Ch 16 enteral nutrition

what is enteral nutrition (EN)?

nutrition provided through the GI tact via tube, catheter, or stoma

preferred method of feeding if PO diet not possible

what does EN do?

reduces disease severity by attenuating metabolic response to stress

diminishes complications by preventing oxidative cellular injury

favorably modulates immune response showing trends of decreasing ICU length of stay

favorably impacts pt outcomes

what are the benefits of EN?

supports components of gut barrier

presence of nutrients in SI maintains normal gallbladder function by stimulating release of cholecystokinin

maintains normal digestive and absorptive capabilities

sig less costly than parenteral nutrition

what are the indications of EN?

functioning GI tract

PO intake deemed unsafe

PO intake deemed insufficient

PO intake deemed impossible

what are contraindications for EN?

less than 5-7 days in malnourished adults

less than 7-9 days in nourished adults

severe short bowel syndrome

severe GI malabsorption

distal high-output fistula

intractable vomiting and/or diarrhea refractory to medial management

paralytic ileus

inability to gain access to GI tract

What determines EN access?

based on several factors: disease state, GI function, disease

where the tip terminates is important for the dietitian to make tube feeding recommendations

short term: NG, ND, and NJ

long term: g, g-j, and j tube

describe the short term tubes

Nasogastric: terminates in stomach

Nasoduodenal: terminates in duodenum

Nasojejunal: terminates in jejunum

what are the long term tubes like?

Gastrostomy (G): percutaneous endoscopic gastrostomy (PEG) is most common, end in stomach

Gastrojejunal (G-J): used when stomach decompression is required

Jejunostomy (J): placed directly into SI

what are the different formulas?

classified by type of protein they contain

usually provide adequate vitamins/minerals

types: standard, hydrolyzed, modular, specialty

what are the different types of standard formulas?

polymeric: unaltered molecules of protein, carb, and fats. best for those w/ no digestion or absorption deficits

routine: nutren 1, osmolite 1 and 1.2

high protein: isosource HN, promote

high calorie: osmolite 1.5, neutron 1.5 2, isosource 1.5, two cal HNFiber enriched: Levity 1 1.2, and Nutren 1 fiber

describe hydrolyzed formulas

predigested proteins (only free amino acids) and simple carbs

small amount of oil or MCT oil

used for pts who lack ability to digest or have small absorptive ability

contain little residual and are better suited for pts that need bowel rest

pts w/feeding tubes in lower GI tract may benefit from these formulas

what are modular formulas?

incomplete liquid or powder supplements that contains specific nutrients

usually single macro, can be combined to provide complete nutrition source

complex to design, may fail to meet 100% needs

not common in adult EN support

what are some specialty formulas?

renal disease, lung disease, liver disease, diabetes, malabsorption, trauma

what is fiber content like in EN?

stimulates peristalsis, increase stool bulk, and degraded by gut bacteria

combine w/ undigested food, intestinal secretions, and other cells to make residue

hydrolyzed are residue free, most standard are low

fiber containing formula recommended for long term EN

describe En osmolality

determined by concentrations of sugars, amino acids, and electrolytes

isotonic formulas have approximately the same osmolality as blood

some patients develop diarrhea when a hypertonic formula is infused

what equipment is needed for EN?

tubing sizing and pump availability impact formula selection

high-fiber formulas have a high viscosity and require a large bore tube (8 French or greater) to prevent clogging

how is a tube feed regimen calculated?

calculate calorie and protein needs

determine type of tube feeding formula

calculate total volume of formula needed to meet needs: divide needed calories by amount in formula, check to make sure protein needs meet

determine most appropriate schedule

calculate regimen using formula total volume and schedule chosen

what is the continuous schedule like?

22-24 hrs

admin through a pump or gravity

tip location: G, D, J

critically ill, least amount at one time

max 125 ml/hr

anytime change in feeding, go back to this

describe a cyclic schedule

amount of formula given over specified amount of time (8-20 hrs)

can be continuous (night cycle) or intermittent (medication)

administered through pump

tip location: g, d, j ( <125ml/hr)

transitioning to PO, ambulatory during day, medication

what is an intermittent schedule like?

large volume of formula (250-500ml) given over 60-75 min 5-8x per day

administered through gravity or pump

tip only G (if >125 ml/hr)

stable pts

describe a bolus schedule

large formula volume (250-500ml) given over 10-20 min 4-6x per day

admin through large syringe or gravity

tip: only g

stable, ambulatory pts

GI intolerance: abd cramping, nausea, dumping syndrome

acute patient may be pump assisted

what should be done before initiating En and to advance EN?

initiating: tube placement verified, bowel sounds present, formulas at full strength, initial feeds begin at 10-40 ml/hr

advance: increase volume by 10-20 ml/hr every 8-12 hrs, monitor tolerance until goal rate is reached

how should feeding tubes be flushed?

should be done: before and after med admin, before starting EN, and after stoping EN

should be flushed with water

never flush with: hot coffee/water, carbonated beverages, pipe cleaners, and meat tenderizer

how do you unclog a feeding tube?

start with gentle back and forth flush of warm water, using 30 or 60 ml syringe, not smaller. allow sit for 5 min and repeat flush actions

if this does not work, tube may need to be replaced

what are EN complications?

can have GI, metabolic, and respiratory complications

aspiration is most serious potential complication

more common than large-volume aspiration is a series of clinically silent aspirations

what is medication administration like to tube feedings?

never infuse during TF

should flush feeding tube w/ 15-30 ml water before and after med is given

some drugs become ineffective if added to EN formula

some drugs require that the tube feed be held 1-2 hrs before and after admin

what is the transition like to PO intake?

may change type of En to help promote PO intake

calorie counts to determine if pt is meeting needs orally

oral nutrition supplements may be necessary in order to maintain adequate nutrition