Transcript University of Tabuk Faculty of Applied Medical Sciences Department

NUTRITION
Level 3, Academic Year (AY) 1435—1436 H
Ahmad Albalawi, MSN
Lecturer
ENTERAL and
PARENTERAL FEEDING
OBJECTIVES
Learning Objectives
At the end of discussion, you will be able to:
• Distinguish enteral and parenteral tube
feedings and their corresponding
complications
• Use guidelines in caring for patients
receiving parenteral and enteral nutrition
LESSON
TopicOVERVIEW
Outline
•
•
•
•
•
Definition
Indications
Types
Types of formulas
Guidelines in Administration
Complications
Enteral Nutrition
• Form of feeding that brings nutrients
directly into the digestive tract
1. Oral feeding
2. Tube feeding- feeding by tube directly into the
stomach or intensive or via a vein
Enteral Nutrition
• Indicated for patients who have a functioning
GIT but can’t ingest enough nutrients orally
Advantages:
Better preservation of the structure and function of GIT
Lower cost
Fewer complications, particularly infections
Indications:
Prolonged anorexia
Severe protein-energy undernutrition
Coma
Liver failure
Inability to take oral feedings
Critical illnesses
Malabsorption problems
Types of Feeding Tubes
• Nasogastric (NG) tube
– inserted through the nose and into the stomach
and small intestine
– For periods that do not exceed 6 weeks
• Percutaneous Endoscopic Gastrostomy (PEG)
tube
– For periods > 6 weeks
– Opening called an “ostomy” is needed
(esophagostomy, gastrostomy, jejunostomy)
Types of Enteral Formulas
• POLYMERIC FORMULA
Commercially prepared formulas that provides complete,
balanced diet
Contains proteins, carbohydrates, and fats
Requires digestion
Blenderized food and milk-based or lactose free
commercial formula
Types of Enteral Formulas
• ELEMENTAL or HYDROLYZED FORMULAS
Formula containing products of digestion of proteins,
carbohydrates and fats
Used for clients who have difficulty digesting food
Expensive and usually unnecessary
e.g. amino acid formula, calorie- and protein-dense
formula, restricted, fiber-enriched formula
Types of Enteral Formulas
• MODULAR FORMULAS (Feeding modules)
Can be used as supplements to other formulas or for
developing customized formulas for certain clients (e.g.
burn patients)
Usually used in acute setting and for short period of time
(e.g. renal failure, respiratory failure, liver failure)
May contain specific nutrient; used to treat specific
deficiency or combines with other formulas
Three Methods of Administering Tube
Feedings
• Intermittent
Administering tube feedings usually at night; solid foods
eaten during the day
Daily calorie needs are divided into 6 servings/day (< 400
• Bolus
ml); given over 15 mins followed by 25-60 ml of water
• Continuous
Feedings are administered by a continuous pump; 16- to
24-hour period; initially at a rate of 30-50 ml/per
Guidelines in Administering
Tube Feedings
• Nasogastric or nasoduodenal tube feeding
NGT feeding often causes diarrhea
Usually started with small amounts of dilute preparations
Solution may be given undiluted at 50 ml/hour
Water boluses may be given
Note: Higher caloric formula may cause decreased gastric emptying 
higher residual than more dilute formula
• Jejunostomy tube feeding
Requires greater dilution and smaller volumes
Feeding usually begins at < 0.5 kcal/ml and a rate of 25 ml/h
Concentrations and volumes is increased after few days
Complications of Enteral Tube
Nutrition
PROBLEM
CAUSE
EFFECT
1. Presence of tube
Tube irritates tissues
causing them to erode
Damage to the nose,
pharynx or esophagus
2. Blockage of tube
lumen
Thick feedings or pills
can block the lumen
Inadequate feeding
3. Misplacement of
nasogastric tube
intracranially
Tube may be misplaced
Brain trauma, infection
intracranially if the
cribriform plate is
disrupted by severe facial
trauma
Complications of Enteral Tube
Nutrition
PROBLEM
4. Misplacement of
naso- or orogastric
tube in the
tracheobronchial
tree
CAUSE
EFFECT
Responsive
Pneumonia
patients- cough
and gag
Obtunded
patients- may have
few immediate
symptoms
5. Dislodgement of Tube may be
Peritonitis
gastrostomy or
displaced into the
jejunostomy tube peritoneal cavity
Complications of Enteral Tube
Nutrition
PROBLEM
CAUSE
EFFECT
6. Intolerance of one
of the formula’s main
nutrient components
*usually occurs with
bolus feedings
*lactose
Diarrhea, GI
discomfort, nausea,
vomiting
7. Osmotic diarrhea
High osmolality of the
solution
Weakness, diarrhea
*Sorbitol- often
contained in liquid
drug preparations
*Clostridium difficile
8. Nutrient imbalances Specific formulas
Electrolytes
disturbances,
hyperglycemia,
Complications of Enteral Tube
Nutrition
PROBLEM
9. Reflux of
solutions
CAUSE
EFFECT
Clogged tube ASPIRATION
or tube may be
pulled out
Parenteral Nutrition
• Provision of nutrients intravenously
• Used if GIT is not functional or normal feeding is not adequate
• Compared with enteral feeding, it causes more complications,
does not preserve GIT structure and function and more
expensive
• Solutions- prescribed by physician and dietitian and prepared
by pharmacist
• Administered via CENTRAL or PERIPHERAL VEIN
Parenteral Nutrition
Peripheral Vein
•
2 weeks or less
Central Vein
•
•
> 2 weeks
Subclavian or superior vena cava
is used
Indications:
Some stages of Crohn’s disease or ulcerative colitis
Bowel obstruction
Certain pediatric GI disorders (congenital anomalies, prolonged diarrhea)
Short bowel syndrome
Types of Parenteral Nutrition
1. Partial Parenteral Nutrition
– Supplies only part of daily nutritional
requirements, supplementing oral intake
– Dextrose or amino acids solutions
2. Total Parenteral Nutrition
(Hyperalimentation)
–
–
Supplies all daily nutritional requirements
TPN solutions are highly concentration- central
vein is used
Parenteral Nutrition Content
Standard TPN solution- 2 L
Most calories are supplied by CHO (25% dextrose)
May also have lipid emulsions to supply essential fatty
acids and triglycerides
20-30% of total cal supplied from lipids
Electrolytes may be added
Modified based on results, d/o
Parenteral Nutrition Solutions
• Reduced protein content and high
percentage of essential amino acid- renal
failure or liver failure
• Limited volume (liquid) intake- heart or
kidney failure
• Lipid emulsion (provides non-CHON
calories minimize CO2 production by
CHO metabolism)- respiratory failure
Guidelines in Caring for Patient having
Parenteral Nutrition
• Strict sterile technique during insertion and
maintenance of central venous catheter
• TPN line should not be used for any other
purpose
• External tubing should be change every 24
hours
• Dressing should be kept sterile and
changed every 48 h using strict sterile
technique
Guidelines in Administering
Parenteral Nutrition
• Solution is started slowly at 50% calculated
requirements + 5% dextrose
• Amount of regular insulin (added directly
to the TPN solution) depends on the serum
glucose level (e.g. level is normal; 25% dextrose= 5-10 units
of regular insulin)
Guidelines in Caring for Patient having
Parenteral Nutrition
•
•
•
•
•
Monitor weight, CBC, electrolytes and BUN
Serum glucose monitored every 6 h until stable
Monitor intake and output
Monitor liver function test
Measure plasma CHONs (albumin), prothrombine
time, plasma and urine osmolality, Ca, Mg and
phosphate twice a week
• Full nutritional assessment (BMI) every 2 weeks
Complications of
Parenteral Nutrition
•
•
•
•
•
Catheter related sepsis
Phlebitis/thrombosis
Glucose abnormalities
Hepatic complications
Abnormalities of serum electrolytes and
minerals
• Volume overload
• Bone demineralization
• Gallbladder complications
M
Department of Nursing
26
Post-Lecture Evaluation
Identify the following:
1. It is indicated for patients who have a
functioning GIT but can’t ingest enough
nutrients orally.
2. It is a commercially prepared enteral formula
that provides complete, balanced diet.
3. It is an enteral formula that contain products of
digestion of proteins, carbohydrates and fats.
Department of Nursing
27
Post-Lecture Evaluation
TRUE or FALSE.
• Strict sterile technique should be observed
during insertion of central venous catheter.
• TPN line can be used for giving medications.
• External tubing should be change every week.
Department of Nursing
28
References
Whitney, W & Rolfes, SR (2008) Understanding Nutrition (11th
ed), Thomson Higher Education, Belmont, CA, USA.
Caudal, ML . (2008) Basic nutrition and diet therapy textbook
for nursing students /. Rev. ed. Quezon City : C & E Pub.
Grodner, M. et al. (2009). Foundations and Clinical Application
of Nutrition: A Nursing Approach. 4th Edition.