Download TF and TPN

Chapter 15
Enteral &
Parenteral
Nutrition
Support
© 2007 Thomson - Wadsworth
Nutrition Support
• Enteral
• Parenteral
• Means “within or by
means of the
gastrointestinal tract.”
 Oral
 Known as tube
feedings
 Preferred route if
have adequate GI
function
 Uses the veins
 Persons with
inadequate GI
function
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
If you choose enteral
nutrition support…
• Must have
• Types
functional GI tract
 Standard (1.0-1.2cal/ml)
• Tolerated by most patients
 Bowel sounds
• Can be used
alone or as a
supplement
• Variety of kinds of
formulas
 Hydrolyzed
• Partially or fully broken down
• Persons with compromised GI
functioning
 High calorie
 Disease-specific
 Modular
• contain 1-2 macronutrients
© 2007 Thomson - Wadsworth
Enteral Nutrition Support
• Provide Pro, CHO
and Fat
• Nutrient Density
 Protein = 8-29% of
total kcalories
 Standard formulas
• Carbohydrates = 4050% total kcalories
• Fat = 30-45% total
kcalories
• Energy Density
 0.5-2.0 kcalories per mL
 Standard formulas
• 1.0-1.2 kcalories per mL
• Patients with average fluid
requirements
 Formulas with higher
energy density
• Smaller amount of fluid
• Good for fluid restrictions
© 2007 Thomson - Wadsworth
Feeding Routes
• Tube feeding less
than 4 weeks
• Tube feeding more than
4 weeks
• Enterostomy
 Nasogastric
• Postplorically
 Gastrostomy
 Jejunostomy
 Nasoduodenal
 Nasojejunal
 These tubes are weighted
or non-weighted with
stylets to guide placement
• Orogastric
 Mouth to stomach
 Good for vent patients
• Gastric feedings are the
preferred route
 Easily tolerated & less
complicated
 Not good for patients at
risk for aspiration
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
Osmolality
• A solution’s tendency to shift from one
fluid compartment to another across a
semipermeable membrane
• Range: 300-700 milliosmoles per kilogram
• Isotonic: osmolality similar to blood
• Hypertonic: osmolality greater than blood
© 2007 Thomson - Wadsworth
Enteral Nutrition in
Medical Care
• Preferred over
parenteral
• Can fully meet
nutrient needs
 Helps maintain gut
• Good for weak &
 Fewer complications
debilitated patients
 Less costly
• Oral preferred over • Nurses help
patients find
tube feedings
appealing flavors
 Less stress
 Less complications
 Less costly
© 2007 Thomson - Wadsworth
Candidates for Tube Feedings
• Severe swallowing
problems
• Little or no appetite
• GI obstructions,
impaired GI motility
• Intestinal
resections
• Mentally
incapacitated
• Coma
• Extremely high
nutrient
requirements
• Mechanical
ventilators
© 2007 Thomson - Wadsworth
Feeding Tubes
• Soft & flexible
• Variety of lengths & diameters
• Outer diameter measured in
French units
© 2007 Thomson - Wadsworth
Formula Selection
• Need to assess
 Age
 Medical problems
 Nutritional status
 Ability to digest &
absorb nutrients
• Choose the one
 With the lowest risk
of complications
 Lowest cost
• Nutrition-related
factors
 Energy, protein, &
fluid requirements
 Need for fiber
modification
 Individual tolerances
(food allergies &
sensitivities)
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
What Formula?
• Factors to consider
 GI function
 Calorie and protein
density
 Ability to meet needs
 Type of
• Protein, fat, CHO
• Fiber
© 2007 Thomson - Wadsworth
 Electrolytes
 Fluid
 Viscosity
 Osmolality
Administration of
Tube Feedings
• Safe handling
• Safety guidelines
 Clean equipment
 Clean hands
• Open system
 Formula needs to be
transferred from original
packaging to feeding
container
• Closed system
 Formula is prepackaged
 Clean can opener & lid
 Refrigerate unused portions
in clean, closed containers
 Discard unlabeled or unused
within 24 hours
 Open system; hang no
longer than 8-12 hour
supply
 Closed system; hang no
longer than 24-48 hour
supply
© 2007 Thomson - Wadsworth
Tube Feeding
• Formula delivery
• Initiating tube
feeding
 Intermittent
 Discuss with patient
& family
 Check initial
placement with X-ray
 Monitor its position
throughout the day:
can check fluid pH
• Gastric, 2500-400 mL over 2040 minutes
• Risk of aspiration
 Bolus
• Gastric
• Delivery of <500mL every 3-4
hours
 Continuous
• Slowly at constant rate
• 8-24 hours
• Noctural
© 2007 Thomson - Wadsworth
Administering the Feeding
• Formula volume &
strength
 Varies among
institutions
 Hypertonic fluids
usually started slowly
& volume gradually
increased
 Assess patient
tolerance
• Checking gastric
residuals
 Withdraw contents
through feeding
tube with syringe
 Intermittent before
each feeding
 Continuous every 46 hrs
© 2007 Thomson - Wadsworth
Tube Feedings
• Supplemental water
 Formulas are 6985% water
 More water comes
from flushes via
feeding tubes
• Flush before & after
each bolus or
intermittent feeding
• Flush every 4 hours
for continuous
• Count as intake
• Transition to table
foods
 Gradually shift to
oral diet
 Oral needs to be
2/3 of nutrient
intake before
discontinuing the
tube
© 2007 Thomson - Wadsworth
Tube Feedings
• Delivering
medications
• Complications
 Nausea & diarrhea
 Mechanical problems
 Metabolic problems
 Need to consider
diet-drug interactions
 Medications can clog
tubes
• Monitor patient’s
 Continuous: stop
 Weight
feeding 15 minutes
 Hydration status
before & after
 Lab test results
medication
administration
© 2007 Thomson - Wadsworth
Parenteral Nutrition
Support
© 2007 Thomson - Wadsworth
Indications for
Parenteral Nutrition
• Short bowel
syndrome
• Severe
pancreatitis
• Malabsorption
disorders
• Intestinal
obstructions or
fistulas
• Severe burns or
trauma
• Critical illnesses
or wasting
disorders
• Bone marrow
transplants
• Malnourished &
high risk for
aspiration
© 2007 Thomson - Wadsworth
Venous Access
• Peripheral Parenteral
Nutrition (PPN)
 Peripheral veins
 Short-term support
 Patients with average
nutrient needs & no
fluid restrictions
 Veins can be damaged
• Total Parental
Nutrition (TPN)
 Larger, central
veins
 Long-term support
 Patients with high
nutrient needs or
fluid restrictions
• Need solutions under
800-900 mOsm
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
Parenteral Solutions
• Contain amino acids
• Contain lipids
 All essential plus
combinations of nonessential
• Contain carbohydrates
 Dextrose, 3.4
kcalories/gram
 2.5-70%
concentrations
 >10% only for TPN
 Significant source of
energy
 10, 20% solutions
 Often provided daily &
= 20-30% total
kcalories
 Decreases risk of
hyperglycemia from
dextrose
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
Parenteral Solutions
• Fluid
• Contain vitamins
 Need 1500-2500
mL/day for adults
• Contain electrolytes
 All water-soluble plus A,
D, & E
 K must be added
separately
 Sodium, potassium,
• Contain trace minerals
chloride, calcium,
magnesium, &
 Zinc, copper, chromium,
phosphorus
selenium, & manganese
 Expressed in
 Iron is excluded
milliequivalents (mEq)
© 2007 Thomson - Wadsworth
Types of Parenteral Solutions
• Total Nutrient Admixture (TNA)
3-in-1 solution
Also called “all-in-one” solution
Contains dextrose, amino acids, & lipids
• 2-in-1 solution
Dextrose & amino acids
Lipids administered separately to
provide essential fatty acids
© 2007 Thomson - Wadsworth
Administering
Parenteral Nutrition
• Team effort




Physicians
Dietitians
Pharmacists
Nurses: provide direct
care
• IV catheters
 Nurse can place in
peripheral veins
 Physician must place
in central veins
• Problems
 Dislodging
 Air embolism
 Clotting
 Phlebitis
 Infection
• Must use aseptic
technique
© 2007 Thomson - Wadsworth
Parenteral Nutrition
Complications
• Mechanical complications
• Infection and sepsis
• Metabolic Complications
• Gastrointestinal Complications
© 2007 Thomson - Wadsworth
Parenteral Solutions
• Administering
• Discontinuing
 Continuous
• Critically ill
• Malnourished
 Cyclic
• 10-16 hours
• Often provided at
night
 Check tubing &
solution daily for
contamination
 When 2/3-3/4 of
nutrient needs are
provided by enteral
feedings, IV can be
discontinued
 Clear liquids
 Small enteral
feedings to determine
tolerance
© 2007 Thomson - Wadsworth
Managing Metabolic
Complications
• Hyperglycemia
• Hypertriglyceridemia
 Patients who are glucose
intolerant or in severe
metabolic stress
 Provide insulin with
feedings or decrease
dextrose
• Hypoglycemia
 When feedings are
interrupted or
discontinued
 Taper slowly
 Critically ill can’t tolerate
lipid infusions
 Impaired lipid clearance
• Refeeding syndrome
 Re-feed slowly
 Life-threatening
• Abnormal liver function
 Long-term, can lead to
liver failure
 Cause unclear
© 2007 Thomson - Wadsworth
Managing Metabolic
Problems
• Gallbladder disease
 Parenteral for more
than 4 weeks
 Sludge builds up,
leading to gallstones
 Cholecystokinin
injections or remove
gallbladder
• Metabolic bone
disease
 Long-term
parenteral lowers
bone density
 Alterations in
calcium,
phosphorus, &
vitamin D
metabolism
© 2007 Thomson - Wadsworth
Nutrition Support at Home
• Candidates
• Planning Enteral
 Enteral
• Head & neck cancers
• Neurological
impairments affecting
swallowing
 Parenteral
• Portion of small
intestine removed
• Intestinal obstructions
• Malabsorption
conditions
 Nasal tubes or
enterostomies
 Investigate cost &
availability
• Planning Parenteral
 Sterile & aseptically
prepared
 Cyclic best
© 2007 Thomson - Wadsworth
Quality of Life Issues
•
•
•
•
•
Economic impact
Time-consuming
Inconvenient
Disturbed sleep
Activities & work
must be planned
around feedings
• Social issues
 Inability to
consume meals
with friends &
family
 Inability to go to
restaurants &
social events
 Fear, anxiety &
depression
© 2007 Thomson - Wadsworth
Nutrition in Practice
Ethical Issues in Nutrition Care
© 2007 Thomson - Wadsworth
Ethical Principles &
Health Care
• Patient autonomy
 The right to make own
health care decisions
• Disclosure
 Fully informed of
treatment’s risks &
benefits
• Decision-making
capacity
• Treatment benefits
(beneficence) should
outweigh harm
(maleficence)
• Distributive justice
 Would care given to one
patient unfairly limit the
care of other patients?
 Mental capacity to
make appropriate
health care decisions
© 2007 Thomson - Wadsworth
Life-Sustaining
Treatments
• Nutrition support &
hydration
• Cardiopulmonary
resuscitation (CPR)
• Defibrillation
• Mechanical ventilation
• Dialysis
© 2007 Thomson - Wadsworth
Legal Documents for
End of Life Care
• Living will, medical
directive
• Durable power of
attorney
 Written statement
specifying medical
procedures desired or
not desired
• Advanced directive
 Written or oral
instruction regarding
one’s preferences for
medical treatment
 Another person is
appointed to make health
care decisions in the event
of incapacitation
• Do-not-resuscitate (DNR)
 Order to withhold CPR in
the event of a cardiac
arrest
© 2007 Thomson - Wadsworth