Download Diet Instruction: Enteral Tube Feeding Etiology: Enteral nutrition is

Diet Instruction: Enteral Tube Feeding
Etiology:
Enteral nutrition is used when a patient is severely underweight and/or
malnourished. It can only be prescribed if the patient has a fully or partially functioning
gastrointestinal tract. If not, the patient must be placed on parenteral nutrition. There are
three different types of feeding tubes for enteral nutrition. These include the nasogastric,
gastrostomy, and jejunostomy tubes. The type of tube that a patient receives depends on if
the tube will be temporary or permanent. It also depends on which part of the
gastrointestinal tract is functioning. Enteral tube feedings can be safely and effectively
performed at home if the patient is given instruction by a health professional
(www.nestle-nutrition.com).
Some health conditions that can require enteral nutrition are gastrointestinal
disorders, cardiopulmonary disorders, hyper-metabolism, and neuromuscular disorders
(www.nutritioncare.org). My patient has Dysphagia and she is placed on enteral tube
feedings to ensure that she is getting her necessary daily caloric and nutrient intakes.
Dysphagia is more prevalent in the elderly population (www.nidcd.nih.gov). It is
usually seen as a symptom caused by a variety of disorders instead of as a disease state
(Nelms 354-355). Dysphagia is defined as “any condition that weakens or damages the
muscles and nerves used for swallowing (www.nidcd.nih.gov). Diseases of the nervous
system such as cerebral palsy, multiple sclerosis, and Parkinson’s disease can cause
dysphagia (www.nlm.nih.gov). Stroke or head injury can affect the ability of the
necessary muscles for swallowing or they can reduce sensations in the individual’s mouth
or throat. Some forms of cancer and even some treatments of cancer can cause dysphagia
as well (www.nidcd.nih.gov).
Diagnostic Measures:
Dysphagia is first diagnosed with a clinical bedside evaluation and a bedside
swallowing assessment. A healthcare team usually performs the diagnosis. The team
typically consists of physicians, nurses, a speech language pathologist, a physical
therapist, and an occupational therapist. The diagnosis is confirmed by performing either
a videofluoroscopy swallowing study or a fiber optic endoscopic swallowing evaluation.
For either diagnostic procedure, barium is added to a range of foods and beverages with
differing textures. Barium can be viewed by fluoroscopy or x-ray. This makes it possible
to monitor the movement of the food or beverage with barium. Barium is used to pinpoint
the specific location of dysphagia. Knowing the location makes it possible for the
healthcare team to establish an appropriate treatment plan (Nelms 355-356).
In Rose’s case, she has been diagnosed with inadequate oral food and beverage
intake related to her dysphagia. She has also been diagnosed with difficulty swallowing
and malnutrition.
Treatment:
Medical, surgical and/or psychological treatment:
The patient had a gastrostomy to insert a permanent gastric tube. The gastric tube
is being used for enteral tube feedings. The patient could receive treatment from a variety
of health professionals. The patient can be referred to a psychiatrist since she is going
through depression due to her inability to swallow and chew food. She can see a speech
pathologist or an occupational therapist in order to improve her chewing and swallowing
abilities. This can sometimes be attained by practicing muscle exercises to strengthen
facial muscles or to improve muscle coordination (www.nidcd.nih.gov).
Medical Nutrition Therapy:
The medical nutrition treatment therapy for the patient with dysphagia depends on
the cause and the severity. In Rose’s case, her dysphagia is preventing her from receiving
adequate oral intake. In order to bypass the passage of foods or beverages through the
esophagus, Rose is placed on enteral tube feeding. She is placed on enteral nutrition
because she had severe weight loss in the past 6 months. Enteral nutrition is chosen
instead of parenteral nutrition because Rose has a functioning gastrointestinal tract. A
gastrostomy was performed because Rose will need to be on long-term enteral nutrition.
Gastric tube feeding will also allow for bolus feedings, which mimic a regular eating
schedule (Nelms 85).
Before determining Rose’s enteral prescription, her fluid and electrolyte balance
must be restored. Her poor skin turgor and dry skin are evidences of dehydration. Her
electrolyte values are all elevated and this is common in individuals with dehydration.
Her hydration status has to return to normal in order for the electrolyte level readings to
be accurate.
Enteral formulas are typically the primary source of water for patients so it is
important to maintain an adequate fluid intake (Nelms 87). It is also recommended that
the patient consumes 2 cups of water per day to make sure that she is getting enough
fluid. Her enteral formula has 85% free water. Rose will use Nutren 1.0 and she will give
herself 5 bolus feedings a day. She will use 6 ½ cans of formula each day; this is
approximately 1 can and 1/3 cup of formula per feeding. She will be instructed on the
syringe method for bolus feeding at home. In order to make sure that there are no
complications with enteral feeding at home, she will monitor her weight once a week, her
hydration status at least 3 times a week, and her vital signs at least 3 times a week. She
will have her blood glucose levels measured every 2 weeks (Nelms 91). She will be
monitored closely for aspiration because her unstable mental state puts her at a higher
risk of developing it.
Description of patient and diagnosis:
Patient name: Rose Bush
DOB: 07/10/1942
Age: 72 y/o
Height: 5’ 4”
Weight: 120 lbs.
Sex: Female
Education: Bachelor’s Degree
Occupation: Retired business owner
Household members: daughter age 40, son-in-law age 41, granddaughter age 10
Ethnic background: Caucasian/ white
Chief Complaints
Patient: “I am embarrassed to eat in front of my friends and family members because I
take a long time to chew my food and my food does not always make it into my mouth.
Sometimes I drool and I think it is impolite to do that.”
Patient’s mother: “Lately she pushes her food around on her plate more than she eats it.
She is getting very thin and she seems depressed. She is very quiet during meals.”
Patient History
Onset of disease: Rose is a 72 year old female who had a stroke 7 months ago. She has
recovered from the stroke, but she had severe weight loss. In 6 months, she dropped from
145 pounds to 120 pounds (17.2% weight loss). She was admitted to the hospital for tests.
Rose complained of pain while swallowing and difficulty chewing. She was diagnosed
with Dysphagia and the doctor recommended a gastrostomy to insert a permanent feeding
tube. Rose is recovering from the gastrostomy and she has been administered enteral tube
feedings. Rose will be released from the hospital tomorrow. She will continue enteral
tube feedings at home. She needs instruction from a R.D. on how to perform the tube
feedings at home.
Physical Exam Upon Admission
General appearance: tired-looking woman, c/o fatigue and difficulty swallowing
Vitals:
HEENT
Heart: tachycardia
Eyes: sunken, membranes dry
Ears: membranes dry
Nose: dry mucous membranes
Throat: dry, inflamed
Neurologic: irritable, confused
Skin: poor turgor, dry skin
Chest/lungs: deep, rapid respiration
Biochemical Lab Values
1 day post-op
Electrolyte
Current Serum Level
Normal Serum Level
Sodium
151 mEq/L
136-146 mEq/L
Potassium
5.5 mEq/L
3.5-5.0 mEq/L
Chloride
110 mEq/L
98-106 mEq/L
Glucose
160 mg/dL
70-120 mg/dL
Electrolyte
Current Serum Level
Normal Serum Level
Sodium
140 mEq/L
136-146 mEq/L
Potassium
4.0 mEq/L
3.5-5.0 mEq/L
Chloride
108 mEq/L
98-106 mEq/L
Glucose
122 mg/dL
70-120 mg/dL
5 days post-op
Patient 24- hour recall
breakfast: ½ mashed banana, 8 oz. whole milk, 1/3 c. instant oatmeal
snack: 1 c. applesauce
lunch: ¾ c. mashed potatoes with gravy, 16 oz. water, ½ c. creamed corn
snack: skipped because her throat was very sore
dinner: 3 oz. meatloaf with gravy, 8 oz. Coca-Cola, ¼ rolled biscuit
snack: ½ c. pudding, 8 oz. water
Enteral Nutrition Prescription
Adjusted Body Weight Calculation:
AdBW=.25 (120 lbs.-145 lbs.) + 145 lbs.
AdBW=139 lbs.
139 lbs./2.2=63.2 kg
“dosing wt.”=63.2 kg
Mifflin-St. Jeor calculation for women:
wt=63.2 kg
ht= 162.6 cm
age=72 yrs.
10 (63.2 kg) + 6.25 (162.6 cm) – 5 (72 yrs.) – 161
1,127 kcal/day
PAL=1.4 (some seated work)
1,127 kcal*1.4= 1,578 kcal/day
Protein Goal:
RDA for older adults is 1.0 g/kg so Rose needs 63 kg protein/ day
63 kg pro *4=252 kcal
252 kcal/1,580 kcal*100=16 % pro
Electrolyte Needs:
There are no abnormal electrolyte losses so electrolyte needs should follow the RDA for
adults over 70 years old.
Sodium: 1,200 mg
Potassium: 4,700 mg
Chloride: 1,800 mg
Vitamin and Mineral Needs:
DRIs for adults 70 years and older
Vit. A: 700 mcg/day
Vit. C: 75 mg/day
Vit D: 15 mg/day
Calcium: 1,200 mg/day
Iron: 8 mg/day
Fluid Needs:
Patient’s hydration status has been restored
1,580 kcal* 1 mL=1,580 mL
osmolality should be about 300 mOsm/kg water
Enteral Formula Prescription:
The patient will receive 1,580 mL or Nutren 1.0 daily
Nutren 1.0:
1.0 kcal/mL
16% pro
51% CHO
33% fat
osmolality=370 mOsm/kg water
meets 100% for 20 key micronutrients
Continuous Feeding:
1,580 kcal/24 hrs.=66 mL/hr.
Bolus feedings 5 times/day:
1,580 mL/4=316 mL
250 mL/can of Nutren 1.0
316 mL/250 mL=1.3 cans
1 can and 75 mL per bolus feeding (1.3 cans)
household measurements: approx. 1 can and 1/3 cup
Prognosis:
If the patient’s swallowing ability improves and her throat pain decreases, she will
be able to switch to a diet with partial oral intake (Nelms 358). The oral intake would
follow the NDD (National Dysphagia Diet) Level 1, which includes only pureed foods or
smooth foods with no lumps (www.anfponline.org). The food should have a “puddinglike consistency (Nelms 357).” The patient will be educated by a R.D. on her modified
enteral tube feedings and appropriate foods for NDD Level 1. If the patient has trouble
tolerating the NDD Level 1, she will return to a full enteral tube feeding diet.
(Educational Materials)
At-Home Gastric Tube Feeding Overview
*Patient will decide times for feedings; feedings should be at least 2-3 hours apart
Your Formula: Nutren 1.0
Cans per day: 6 ½
Amount per feeding: 1 can and 1/3 c.
Your feeding schedule: 5 bolus feedings daily (at least 15 min. per feeding)
Times
AM
AM
AM/PM
PM
PM
Amount of formula
1 can and 1/3 cup
1 can and 1/3 cup
1 can and 1/3 cup
1 can and 1/3 cup
1 can and 1/3 cup
Wash your hands thoroughly with soap and water then gather supplies:





formula
syringes
lukewarm water (1 cup)
feeding bag (if using)
feeding pump (if using)
Things to remember:

You must flush the tube before and after administration of formula or
medications.

if the tube becomes clogged, take immediate action to unclog it.

Store unopened cans of formula at room temperature.

When a can is opened, use immediately. Date and refrigerate the unused
portion, but it must be thrown away if it is not used within 24 hours.

Syringes need to be cleaned with warm, soapy water and left to air dry
between each use.
Bolus Feeding: Syringe Method
1. Draw up 60 ml of warm water in the syringe. Gently flush the water
through the tube to make sure the feeding tube is clean and open. Disconnect the
syringe. Recap the end of the feeding tube.
2. Remove the plunger from the syringe.
3. Uncap the feeding tube.
4. Attach the syringe directly to your feeding tube. Pour 1 can and 1/3 cup of
feeding into the syringe, allowing it to flow freely until all of the feeding is given.
5. Take the syringe and draw up 60 ml warm water. Gently flush the water through
the tube again to make sure the tube is clean and open. This water also helps keep
you hydrated.
6. Disconnect the syringe from the feeding tube.
7. Recap the feeding tube.
6. Repeat the procedure 4 more times. If you do not tolerate the prescribed amount
of formula, notify your dietitian.
Helpful Resources:
American Society for Parenteral and Enteral Nutrition (ASPEN)
Nestle Health Science: Medicare Coverage of Enteral Nutrition Therapy
References
Academy of Nutrition and Dietetics. (2014). Nutrition Care Manual. Retrieved from
http://www.nutritioncaremanual.org
American Gastroenterological Association. (1995). American gastroenterological
position statement: guidelines for the use of enteral nutrition. Retrieved from
http://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html
American Society for Parenteral and Enteral Nutrition. (2013). What is enteral
nutrition? Retrieved from
http://www.nutritioncare.org/Information_for_Patients
Cleveland Clinic. (n.d.). Tube-feeding instructions for home. Retrieved from
www.my.clevelandclinic.org./home-enteral-nutrition-booklet.pdf
Dietary Manager. (2004).Understanding and implementing dysphagia diets.
Association of Nutrition & Foodservice Professionals. Retrieved from
http://www.anfponline.org/Publications/articles/2004_03_008Dysphagia
Fletcher, J. (2011). Nutrition: safe practice in adult enteral tube feeding. British
Journal Of Nursing, 20(19), 1234-1239. Retrieved from
http://eds.b.ebscohost.com.proxy.lib.muohio.edu
Lloyd, D. & Powell-Tuck, J. (2004). Artificial nutrition: Principles and practices of
enteral feeding. Clinics in Colon and Rectal Surgery, 17(2), 107–118.
doi: 10.1055/s-2004-828657
National Institutes of Health. (2010). Dysphagia. National Institute on Deafness and
Other Communication Disorders. Retrieved from
http://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx
Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy &
pathophysiology 2/e. Belmont, CA: Wadsworth, Cengage Learning.
Nestle Health Science. (2013). Best practices in enteral feeding safety. Retrieved
from http://www.nestle-nutrition.com/Products