Download Chapter 7 Oral, Enternal, parenteral nutrition

Nutritional care of clients
Dr. Reham Khresheh
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OBJECTIVES
After studying this chapter, you should be able to:
 Describe how illness and surgery can affect the nutrition of
clients
 Identify and describe three or more nutrition-related health
problems that are common among elderly clients needing
long-term care
 Demonstrate correct procedures for feeding a bed-bound
client
 Explain the importance of adapting the family’s meal to suit
the client’s nutritional requirement
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Introduction
 Illness can have a significant impact on nutritional status by
altering nutrients’
 Requirement
 Intake
 Absorption
 Metabolism
 Excretion
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 Diagnostic procedures, medical treatment, drug therapy &
emotional stress of hospitalization can create nutritional problem
 Hospital food which may be vital component of treatment may
be rejected for social, religious or personal reasons
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Hospital food
 Hospital food is intended to prevent nutrient
deficiencies, not to prevent chronic disease
 Regular diets may not be consistent with Dietary
Guidelines which recommends limiting intakes of
fat, saturated fat, cholesterol, and sodium
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ORAL DIETS:
 Depending on the needs of the individual patient,
oral diets may be modified in their
 consistency
 concentration of certain nutrients
 dietary components
 Combination diets (e.g., a low-sodium, soft diet)
are often ordered
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ORAL DIETS:
 Are the easiest, least expensive, least risky, & preferred method
of delivering nutrients
 Normal diets are intended to maintain health by meeting the RDA
for the client's age & sex
 Modified diets are used for the clients who are unable to tolerate a
normal diet or who have altered nutritional requirement (liquid,
soft, low residue, high fiber)
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ORAL DIETS (cont’d)
 Modified diet differ from normal diet in their consistency
(liquid or pureed), total calorie amount (high or low calorie),
concentration of macronutrients (high protein, low fat),
 When oral diet resumed after acute illness, surgery, tube
feeding, TPN, clear liquid may be ordered & progressed to full
liquid
soft
normal diet depending on client tolerance
& condition
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Types of diet 1
 Clear liquid: eg.
 Tea
 Coffee
 Soft drink
 Gelatin
 Grape & apple juice
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Types of diet 2
 Full liquid: eg.
 Ice cream
 Milk
 Pudding
 Custard
 Vegetable juice
 Refined cereal
 Cream
 margarine
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Types of diet 2
 Soft diet:
 Cooked vegetable
 Lettuce
 Cooked & canned fruit
 Avocado
 Banana
 Melon
 Potatoes, cakes, cookies
 Rice, fish, egg,
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Enteral nutrition = tube feedings
 The delivery of nutrients by mouth or tube into the GI tract. In
practice it is used interchangeably with tube feeding
 Tube feeding may be (homemade) blenderized or commercial
formula
 Compared to Parenteral nutrition, enteral nutrition is safer & less
costly. & should be used when GI is functioning
 Using the GI tract helps prevent gut atrophy, & reduce risk of sepsis
by preventing bacteria translocation (movement of gut bacteria
from GIT into lymph nodes or other organs
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Choice of tube feeding method depends on:
 patient’s digestive and absorptive capacities
 where the feeding is to be infused
 size of the feeding tube
 patient’s nutritional needs
 present and past medical history
 tolerance
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Feeding Tube Replacement:
 Transnasal tubes: used for short duration (<3-4 weeks)
 Tube Enterscopy: inserted through a surgical in the stomach,
esophagus or jejunum
 Esophagostomy: surgical opening in the esophagus through
which a feeding tube is passed into the stomach. Commonly
used for pt with head & neck cancer
 Gastrostomy: inserting tube directly into the stomach
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Common indications for tube feeding:
1. neurologic/psychiatric:
 post CVA
 neoplasm
 trauma
 inflammation
 demyelinating disease
 depression, psychosis
 anorexia nervosa
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Common indications for tube feeding:
2. gastrointestinal
 severe Dysphagia
 Pancreatitis
 inflammation bowel disease
 Malabsorption
 Prolonged lack of appetite
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Common indications for tube feeding:
3. others:
 Chemotherapy
 Radiotherapy
 Sepsis
 Head & neck trauma, surgery, cancer
 Ventilator- dependent clients
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Types of Formula:
1. Intact protein formulas: made from whole proteins (milk, meat, eggs). Or
protein isolates (semipurified, high value proteins that have been extracted
from milk, soybean or eggs). Because they contain protein, CHO, fat, they
require normal digestive & absorptive capacity , they are several categories:
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Blenderized formula: provide 1 cal/ml, made from regular foods (beef, milk, fruits,
vegetables)
Standard formulas: provide 1 - 1.2 cal/ml, lactose free, low in residue. Example, Isocal,
osmolite
High caloric formulas: provide 1.5 – 2 cal/ml, intended for patient who need to gain
weight
High protein formulas: provide 1 – 2 cal/ml, low residue,
Formulas enriched with fiber: provide 1 – 1.5 cal/ml, for pts with diarrhea or constipation
from low residue formulas
Intact specialty formulas: for diabetes (Gluerna), pulmonary disorder (Respolar), fat
malabsorption (Lipisorb), renal disorder (Suplena).
Types of Formula:
2. Hydrolyzed formulas (elemental): contain partially digested
nutrients (CHO); amino acids, dipeptides & tripeptides
(protein), fat.
They are intended for clients with impaired digestion or absorption
Provide 1 - 1.5 cal/ml
Have 8% - 17% of total calories from protein
Low residue & free lactose, low viscosity
It two types:
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Stress formulas: metabolized in the muscle tissue. Used for energy during stress
Specially defined formulas: for pts with metabolic disorder, such as renal failure,
hepatic failure. These examples lack vitamins, electrolytes
Other characteristics
 The osmolality of these products ranges between 300 – 810
mOsm/kg water. & contraindicated in patients who have normally
functioning GIT.
 Osmolality: the measure of the number of particles in solution
(mos/kg)
 Isotonic formula: have the same osmolality as blood, about 300 mos/kg
 hypertonic: cause dumping syndrome (diarrhea, nausea, cramping)
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Handling formula
Use clean equipment
2. Wash hand before handling the formula
3. Clean the top of formula before opening
4. Cover open cans
5. Refrigerate unused formula promptly
6. Discard unlabeled & all opened within 24 hr
7. Never add new formula to old formula
8. Flush tube with water before & after use
9. Hang feeding solution for < 6 hr
10. Change feeding container tube every 24 hr
1.
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Method of Delivery:
1. Bolus feeding:
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Used only if the tube is placed in the stomach.
Rate regulated by gravity
Usually given 4 – 6 times /day. Is appropriate for pt who want to
feed themselves, & for disoriented pts who require observation
during feeding
Cause dumping syndrome, diarrhea, vomiting, increase risk of
aspiration
Method of Delivery:
2. Continuous drip method:
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Given every 16 – 24 hour period
Recommended for critically ill pts, and feeding through jejunum
Rate regulated by pump
Water for equipment & patient
 Continuous feeding should be irrigated every 6 hr with 50 ml
 Standard formula (1 cal/ml) provide 850 ml
 Formula of 1.5cal/ml provide 775ml/liter
 Formula of 2cal/ml provide 660ml/L
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Giving Medications by Tube
 Drugs should be given orally whenever possible
 Stop the feeding before administering drugs
 Make sure tube is flushed with 15-30 mL of water before and
after the drug is given
 If more than one drug is given, flush the tube between doses
with 5 mL of water
 Drugs absorbed from the stomach should never be given
through a nasointestinal tube
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Giving Medications by Tube (cont’d)
 Liquid form of a medication diluted with 30 mL of
water should be used for feeding tube administration
 If there is no alternative, a drug can be crushed to a
fine powder and mixed with water before it is
administered
 Slow-release drugs should never be crushed
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Potential problems of tube feeding:
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Diarrhea
Aspiration pneumonia
nausea
Distention & bloating
Dehydration
constipation
fluid overload
dry mouth, nose irritation
Tube feedings and diarrhea
 Diarrhea is a frequent complication of tube feedings
 Diarrhea may be caused by
 bacterial contamination
 a feeding rate that is too rapid
 giving too much volume of formula
 hyperosmolar formula
 misplacement of the feeding tube
 hypoalbuminemia
 antibiotic therapy
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PARENTRAL NUTRITION
 Deliver nutrients directly to bloodstream, thereby bypassing the GIT.
 Used when a pt physically or psychologically cannot consume enough
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nutrients orally or eternally
The usual fluid given to adults over 24 hours is 1.5- 3L
Examples: IVF, PPN, TPN
Include dextrose, amino acids, lipid emulsion, electrolytes, vitamins, trace
elements, & sterile water
Sterile water, dextrose available in 5%, 10%, 20%, 30%, 50%, 70%
Amino acids 3%, 3.5%, 5%, 7%, 8.5%, 10%
Lipid emulsions 10%, 20%
Peripheral Nutrition:
Solutions that are infused into peripheral veins must be isotonic
(low concentrations of dextrose & amino acids) to prevent
phlebitis & thrombus formation
1. Simple IV Solutions:
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to maintain fluid & electrolytes balance on a short term basis,
Used before & after surgery, after trauma
Contain water dextrose 5%, 10%, electrolytes,
Liter of D5W provides 50 g of dextrose. When given IV, one gram of
dextrose provides 3.4 cal. Therefore, 1 liter provides 170
cal.(50*3.4=170)
Peripheral Parenteral nutrition (PPN)
Delivers complete but not limited nutrition
The final concentration of the solution cannot exceed 10% dextrose, 5%
amino acids, vitamins, electrolytes, trace elements
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suited for 7 – 10 days, but do not require more than 2000 – 2500 cal/day
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contraindicated in pt with abnormal lipid metabolism
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3 liters of 10% dextrose & 5% amino acids solution provides only 1620
cal
10% dextrose = 100g/L * 3L=300g dextrose *3.4 cal/g = 1020 cal dextrose
5% amino acids=50 g/L * 3L=150 g amino acids* 4 cal/g= 600 cal protein
1020 +600= 1620 cal
To increase cal., one 500 ml bottle of a 20% fat solution may be given which represents:
500mL * 2cal/ml = 1000 cal fat
1620 + 1000 = 2620
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Total parenteral nutrition (TPN)
TPN infuses hypertonic nutritional solutions through central
venous catheter (CVC)
used to provide complete long term nutritional support for pts
who cannot or will not consume an adequate oral or enteral
intake. Indication for TPN include:
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severe malnutrition
GI abnormalities (obstruction, peritonitis)
After surgery or trauma, burn, sepsis
Acute renal or liver failure
AIDS
Bone marrow transplantation
Total parenteral nutrition (TPN)
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A typical order of TPN specifies 3 L of solution daily with
a final concentration of 25% dextrose, 3.5% amino acids.
An additional 250 mL of 20% lipid is ordered
25% dextrose= 250g/L * 3= 750g*3.4=2550cal
3.5% protein = 35g/L *3L = 105 g* 4= 420 cal
250mL*2 cal/mL = 500 lipid cal
2550 + 420 + 500 = 3470 total cal
Nursing management
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remove the solution from the refrigerator 1 hour before they are
hung, once hung the solution must be infused or discard within 24
hours
Monitor the flow rate to avoid complication & ensure adequate intake.
Too rapidly infusion cause hyperosmolar diuresis, leading to seizures,
coma, death
observe for side effect: weight gain greater than 1 kg/day (indicative
of fluid overload), elevated temperature or sepsis, high glucose level,
dyspnea, tightness of chest, nausea & vomiting, jaundice,
pneumothorax, cardiac arrhythmias,
begin weaning from TPN to an enteral or oral intake as soon as
possible to reduce the risk of bacterial translocation & sepsis
some pt may feel hungry while receiving TPN & should be allowed to
eat, if oral intake contraindicated give mouth care