Transcript Modified Diets Dietary Modifications

Feeding Routes
Feeding
Routes
Enteral
feeding
Parenteral
feeding
Feeding Routes
1- Enteral feeding:
a. Oral feeding: patients meet their needs
by consuming oral diets and supplements
b. Tube feeding: provides nutrients using
the gastrointestinal tract (GI)-directly into
the stomach or intestines
Feeding Routes
2- parenteral feeding:
– Used when a patient’s medical condition
prohibits the use of the GI tract to deliver
nutrients.
– Provides nutrients intravenously to patients
without adequate GI function to handle enteral
feedings
– Also called Intravenous feedings
In general, tube feeding or intravenous
feeding should be used when :
1. patients nutrients needs are high
2. or their appetites poor
3. or their medical condition makes it
difficult to meet nutrients need orally.
Tube feedings
– Nutritionally complete formulas are delivered
through a tube placed directly into the
stomach or intestine.
– Used when a patient is unable to eat but may
be able to digest foods and absorb nutrients
normally.
Feeding Routes
• Transnasal
(Short-term nutrition)
– Nasogastric
– Nasoduodenal
– Nasojejunal
• Enterostomy
(Long-term nutrition)
– Gastrostomy
– Jejunostomy
Nasogastric (NG):
Tube is placed into the stomach via the nose.
Nasoduodenal (ND):
Tube is placed into the duodenum via the nose.
Nasojejunal (NJ):
Tube is placed into the jejunum via the nose
Gastrostomy :
An opening into the stomach through which a
feeding tube can be passed.
Jejunostomy :
An opening in the jejunum through which a
feeding tube can be passed
Types of enteral formulas
1.
2.
3.
4.
Enteral formulas are categorized
according to their macronutrient
sources:
Standard formulas
Elemental formulas
Specialized formulas
Modular formulas
1- Standard Formulas
• Standard formulas, are provided to individuals
who can digest and absorb nutrients without
difficulty.
• They contain intact proteins extracted from milk
or soybeans
• The carbohydrate sources include modified
starches, and sugars.
• A few formulas, called blenderized formulas,
are made from whole foods and derive their
protein primarily from pureed meat or poultry
2- Elemental Formulas
• Elemental formulas are prescribed for patients
who can not digest or absorp well
• Elemental formulas contain proteins and
carbohydrates that have been partially or fully
broken down to fragments that require little
digestion.
• The formulas are often low in fat and may
contain medium-chain triglycerides (MCT) to
ease digestion and absorption.
3 - Specialized Formulas
• Specialized formulas, are designed to
meet the specific nutrient needs of
patients with particular illnesses.
• Products have been developed for
individuals with liver, kidney, and lung
diseases; glucose intolerance.
• Disease-specific formulas are generally
expensive.
4 - Modular Formulas
• Modular formulas, created from individual
single macronutrient preparations
• Prepared for patients who require
specific nutrient combinations to treat
their illnesses.
• Vitamin and mineral preparations are also
included in these formulas so that they
can meet all of a person’s nutrient needs.
Formula Characteristics
• Macronutrient Composition
• Energy Density
• Fiber
• Osmolality
Macronutrient Composition
• The percentages of protein, carbohydrate,
and fat vary among enteral formulas.
• The protein content of most formulas
ranges from 12 to 20 percent of total
kcalories.
• Carbohydrate and fat provide most of the
energy in enteral formulas; standard
formulas generally provide 40 to 60
percent of kcalories from carbohydrate
and 30 to 40 percent of kcalories from fat.
Energy Density
• The energy density of enteral formulas
ranges from 0.5 to 2.0 kcalories per
milliliter of fluid.
• Standard formulas typically provide 1.0 to
1.2 kcalories per milliliter and are
appropriate for patients with average fluid
requirements.
• Formulas that have higher energy
densities can meet energy and nutrient
needs in a smaller volume of fluid and
thus benefit patients who have high
nutrient needs or fluid restrictions.
• Individuals with high fluid needs can be
given a formula with low energy density
or be supplied with additional water via
the feeding tube or intravenously.
Fiber Content
• Fiber-containing formulas can be helpful
for normalizing intestinal function, treating
diarrhea or constipation, and maintaining
blood glucose control.
• Conversely, fiber-containing formulas are
avoided in patients with acute intestinal
conditions, pancreatitis, or procedures
involving the intestines
Osmolality
• A formula with an osmolality similar to
that
of
blood
serum
(about
300milliosmoles per kilogram) is an
isotonic formula.
• A hypertonic formula has an osmolality
greater than that of blood serum.
• Most enteral formulas has osmolalities
between 300 and 700 milliosmoles per
kilogram
Formula Selection
• Nutrient and energy needs
• Fluid requirements
• Need for fiber modifications
• Individual tolerances
– Food allergies & sensitivities
Enteral nutrition benefits
– Maintain normal GI function
– Causes fewer complications
– Less costly
Indications for Tube Feedings
Include people with:
• Severe swallowing disorders
• Impaired motility in the upper GI tract
• Gastrointestinal obstructions that can be
bypassed with a feeding tube
• Certain types of intestinal surgeries
• Mechanical ventilators, coma
• Extremely high nutrient requirements
• Little or no appetite for extended periods,
especially if malnourished
Administration of Tube Feedings
• Open feeding system: requires formula to
be transferred from original packaging to
feeding container
• Closed
feeding
system:
formula
prepackaged in ready-to-use containers
Administration of Tube Feedings
• At the Nursing Station
– Check expiration date on label
– Wash hands
– Clean the can opener and the lid
– Label can with date and time opened
– Store opened cans or mixed formulas in clean,
closed containers & refrigerate
– Discard opened containers not used within 24 hours
Administration of Tube Feedings
• At the Bedside
– Open system :Hang no more than 8 hour supply of
formula and discard any formula that remains after
that.
– Closed system: Hang no more than 24 hour
supply of formula and discard any formula that
remains after that.
Contraindications for Tube
Feedings
Include:
•
•
•
•
Severe GI bleeding
Intractable vomiting or diarrhea
Complete intestinal obstruction
Severe malabsorption
Transition to Table Foods
• Tube feedings are gradually tapered off
– as oral intake increases
• The steps in the transition depend on the
patient’s medical condition and the type
of feeding the patient is receiving.
• Are discontinued when client consuming
2/3 of nutrient needs by mouth
PARENTERAL NUTRITION
SUPPORT
Indications for Parenteral
Support
Patients who:
• Do not have functioning GI tracts and are:
– Malnourished
– At risk for becoming malnourished
• Could be harmed if GI tract used (require
bowel rest)
Indications for Parenteral
Support
-1 Total Parenteral Nutrition (TPN)
– Uses larger, central veins
– Volume
is
greater
and
concentrations are not limited
– Can reliably meet complete
requirements
nutrient
nutrient
Peripheral parenteral
nutrition (PPN)
– Used for short-term nutrition
support (7-10 days)
– for clients who do not have
high nutrient needs or fluid
restrictions
-Can only provide limited
amounts of energy & protein
Accessing Central Veins for
Total Parenteral Nutrition
Parenteral Solutions:
Nutrients
•
•
•
•
Protein :Amino acids
Carbohydrates : glucose
Lipids : triglycerides
Fluids
and
electrolytes
(Sodium,
potassium, chloride, calcium, magnesium,
and phosphorus)
• Vitamins and trace minerals : Multivitamin
and trace minerals added
Important notes
– There are disease specific solutions – for
patients with: liver failure, kidney failure and
hyper-triglyceridemia, coagulation diseases
– Iron excluded – alters stability of other
ingredients – given by injection
– Daily lab tests to monitor electrolyte status
Parenteral Formulation
• Depends on patient’s:
– Medical condition
– Nutritional status
– PPN or TPN
– May need to be recalculated daily
Parenteral Preparation
• Careful attention to solution preparation and
handling
– Prepared in pharmacy under aseptic conditions
– Shielded from light
– Refrigerated
– Prior to hanging infusion
• Solutions removed from refrigerator
• Allowed to reach room temperature
– During feedings – solution and catheter checked
frequently for sign of contamination
Discontinuing intravenous
feedings
• Transitional feedings
– Taper off parenteral feedings as
enteral feedings are begun
Potential benefits of enteral
nutrition over PN include:
Physiologic
1.Nutrients are metabolized and utilized more effectively via
the enteral than the parenteral route.
1.The gut and liver process enteral nutrients before their
release into systemic circulation.
1.The gut and liver help maintain the homeostasis of the amino
acid pool as well as the skeletal muscle tissue.
•Immunologic
1.Gut integrity is maintained by enteral nutrients
through the prevention of bacterial translocation
from the gut, sytemic sepsis, and potential
increased risk of multiple organ failure.
2.Lack of GI stimulation may promote bacterial
translocation from the gut without concurrent
enteral nutrition.
3.Provision of early enteral nutrition may
minimize risk of gut related sepsis.
•Safety (avoid complications related to
intravenous access):
1.Catheter sepsis
2.Pneumothorax
3.Catheter embolism
4.Arterial laceration
•Cost
1.Cost of EN formula is less than PN.
2.Cost of equipment and personnel
for preparation and administration is
less