chapter 24

Big Picture: Enteral versus Parenteral Nutrition

• Enteral Nutrition: This involves delivering food or formula directly into the Gastrointestinal (GI) tract. The clinical rule of thumb is: "If the gut works, try to use it." This method is preferred as it maintains GI integrity.

• Examples include:

  • Nasogastric (NG) tube: Nose to stomach.

  • Gastrostomy tube: Inserted into the stomach.

  • PEG tube: Percutaneous Endoscopic Gastrostomy tube.

  • J-tube: Jejunostomy tube (nose or incision to small intestine).

• Parenteral Nutrition (PN): This involves delivering nutrition directly into the bloodstream via an Intravenous (IV) line. This is utilized when the GI tract is non-functional or cannot absorb sufficient nutrients.

• Primary Objective: To keep the patient nourished safely while actively preventing complications such as aspiration, infection, fluid/electrolyte imbalances, and skin breakdown.

• ADHD Memory Shortcut: Think "GUT = ENTERAL" and "VEIN = PARENTERAL."

• Essential Tubes and Devices:

  • NG tube (nasogastric): Extends from the nose to the stomach.

  • Nasointestinal / NJ tube: Extends from the nose to the small intestine (jejunum).

  • PEG / Gastrostomy tube: The tube enters the stomach directly through the abdominal wall.

  • Gastrostomy button: A low-profile, discrete device located at the abdominal wall level.

  • J-tube / Jejunostomy tube: The tube enters the small intestine directly.

  • Central line: A specialized IV line often utilized for Total Parenteral Nutrition (TPN).

Enteral Feeding Formulas and Patient Indications

• Standard Formulas: These consist of a balanced mix of proteins, carbohydrates, fats, vitamins, and minerals. They are indicated for patients with a functional GI tract who cannot ingest enough food orally or have swallowing difficulties.

• Hydrolyzed Formulas: These contain nutrients that are already partially broken down or "predigested." They are indicated for patients with poor digestion or nutrient absorption issues.

• High-protein Formulas: These provide standard nutrition supplemented with extra protein. They are indicated for patients with significant healing needs, such as burns, open wounds, or severe malnutrition.

• Diabetic Formulas: These are specifically formulated with reduced simple carbohydrates. They are used for patients with Type 1 or Type 2 diabetes.

• Renal Formulas: These contain lower levels of potassium, sodium, and specific mineral/protein components. They are indicated for patients with renal insufficiency or renal failure.

• Pulmonary Formulas: These feature a higher fat content, which results in less carbon dioxide ($CO_2$) production during metabolism. They are used for patients with major pulmonary disease.

• Fiber-containing Formulas: These have a higher fiber content. They are indicated for constipation prevention, long-term care settings, and certain bowel disorders.

• Memory Tricks for Formulas:

  • Hydrolyzed = "Already Handled" by the manufacturer.

  • High-protein = "Healing."

  • Renal = "Reduced minerals."

  • Diabetic = "Cut down simple sugars."

Methods and Safety of Tube Feeding

• Intermittent Feeding: Formula is administered several times per day over a period of approximately $30-60\,\text{minutes}$. This method mimics natural meal times more closely than continuous infusion.

• Bolus Feeding: Formula is administered via syringe or gravity in a large volume over a very short duration. This is the fastest method but is not tolerated by every patient.

• Continuous Feeding: Formula is delivered slowly via an infusion pump over many hours (often $8-24\,\text{hours}$). This is generally the best-tolerated method and significantly lowers the risk of aspiration.

• Critical Tube Feeding Safety Protocols:

  • Verify Tube Placement: This must be done before every use. Initial placement is confirmed by X-ray; subsequent checks follow specific facility policies.

  • Head of Bed (HOB): Must be maintained at $30-45^{\circ}$ during all feedings.

  • Post-Feeding Positioning: After intermittent or bolus feeds, keep the HOB elevated for at least $30-60\,\text{minutes}$ (many protocols require a full $1\,\text{hour}$).

  • Temperature: Use room-temperature formula to minimize the risk of abdominal cramping.

  • Flushing: Flush the tube with water according to policy—specifically before and after every feeding and medication administration.

  • Handling Formula: Label, cover, and refrigerate formula properly. Discard per guidelines to prevent bacterial contamination.

  • Equipment Maintenance: Do not leave formula hanging for excessive periods. Replace feeding bags and tubing according to policy (commonly every $24\,\text{hours}$).

  • Monitoring: Watch for nausea, vomiting, abdominal distention, diarrhea, coughing, choking, and signs of respiratory distress.

• Memory Tool: UP • CHECK • FLUSH • WATCH (Keep HOB UP, CHECK placement, FLUSH the tube, and WATCH the patient).

• RED FLAG ALERT: Immediately stop the feeding and reassess the patient if they develop coughing, choking, a "wet" voice, shortness of breath, cyanosis, or other signs of feed intolerance.

Managing Residuals, PEG/J-Tube Care, and Complications

• Residual Gastric Volume: Checks are performed to determine if the stomach is emptying effectively. For continuous feedings, facilities often check every $4\,\text{hours}$. For intermittent feedings, residuals are typically checked before each feed. Always adhere to facility or school policy regarding volume cutoffs for holding or reducing feeds.

• PEG / J-Tube Site Care:

  • Inspect the insertion site daily.

  • Clean the skin and dry it thoroughly.

  • Monitor for signs of infection/irritation: redness, swelling, drainage, pain, odor, bleeding, or skin breakdown.

  • Secure the tube effectively to ensure it does not pull or cause trauma.

• Common Complications: Aspiration, clogged tubing, diarrhea, constipation, dehydration, abdominal cramping/distention, tube displacement, insertion site infection, and formula contamination.

• Measures to Prevent Aspiration:

  • Verify placement before use.

  • Maintain HOB at $30-45^{\circ}$ during and after feedings.

  • Regular residual checks.

  • Monitor bowel sounds and assess for distention.

  • Control the rate: Do not force formula quickly.

• ADHD Trick: Aspiration risk increases when the patient is FLAT, FULL, or FORCED. Keep them UP, TOLERATING, and SLOW.

• Contamination Prevention: Shake the can well, clean the top before opening, use clean containers, cover/refrigerate unused formula, rinse equipment, and replace bags/syringes per policy.

Parenteral Nutrition (PN) and Safety Protocols

• Partial Parenteral Nutrition (PPN): Administered through a peripheral IV. It is less concentrated than TPN and used for short-term support when the patient needs extra calories but not total replacement.

• Total Parenteral Nutrition (TPN): Highly concentrated nutrition delivered via a central line. Used when the patient cannot use the GI tract at all or requires complete nutritional support.

• Conditions Requiring PN: Severe malnutrition, bowel obstruction, severe GI disease, major burns or trauma, severe pancreatitis, and intractable vomiting or diarrhea.

• PN Safety Rules:

  • Accuracy: Always use an infusion pump.

  • Hypertonicity: TPN is hypertonic and must usually be infused via a central line to prevent vein damage.

  • Infection Control: Aseptic technique is mandatory due to the high risk of central-line-associated bloodstream infections (CLABSI).

  • Monitoring: Regularly check blood glucose, fluid balance, electrolytes, daily weights, and laboratory values.

  • Discontinuation: Never stop TPN abruptly unless directed; sudden cessation can trigger severe hypoglycemia.

  • Interruptions: if the bag runs out or is interrupted, follow provider orders/policy immediately.

• Memory Tool: TPN Problems = SUGAR + SEPSIS + SITE (Glucose issues, infection risk, central-line complications).

• RED FLAG ALERT: Watch for fever, chills, hyperglycemia or hypoglycemia, sudden shortness of breath, fluid overload, or signs of catheter-related infection.

Clinical Skill Checklists: Feeding and Intake/Output

• Skill 24.1 — Assisting a Patient with Feeding:

  • Assess: Swallowing/chewing ability, vision, appetite, diet order, food preferences, pain levels, and current need for assistance.

  • Action: Sit patient upright ($90^{\circ}$ if possible), place items within reach, protect clothing, cut food, and open containers. Give small bites and encourage independence.

  • Observation: Watch for choking, pocketing of food in the cheeks, wet voice, or fatigue.

  • Documentation: Record the amount eaten/drank and any problems encountered.

  • Memory: Feeding is about SAFETY + DIGNITY + INDEPENDENCE.

• Skill 24.2 — Recording Intake and Output (I&O):

  • Intake: Measure all oral liquids, tube feedings, IV fluids, and irrigations.

  • Output: Measure all urine, emesis, liquid stool, drainage from tubes, and NG suction.

  • Process: Use the unit $mL$. Document promptly. Add totals carefully at the end of every shift and compare.

  • Purpose: Early identification of fluid imbalances.

Clinical Skill Checklists: Nasogastric (NG) Tube Procedures

• Skill 24.3 — Inserting a Nasogastric Tube:

  • Procedure: Explain to the patient; position in High-Fowler’s; check nares for patency.

  • Measurement: Measure from the nose to the earlobe to the xiphoid process.

  • Insertion: Lubricate the tip; insert gently through the naris; have the patient flex the head slightly and swallow sips of water. Advance as the patient swallows.

  • Completion: Verify placement and secure the tube to the nose.

• When to STOP advancing the tube:

  • Persistent coughing or gagging.

  • Choking, cyanosis, or severe respiratory distress.

  • Inability of the patient to speak.

  • Coiling of the tube in the back of the mouth.

  • Unexpected resistance.

• RED FLAG ALERT: If the patient exhibits hard coughing, inability to talk, or cyanosis, the tube is likely in the airway. Stop immediately, withdraw/remove, and reassess.

• Skill 24.4 — Irrigating an NG Tube:

  • Verify the medical order and the tube placement first.

  • Use the prescribed solution (Normal Saline or water).

  • Flush gently without force. Reconnect suction if ordered and document results.

• Skill 24.5 — Removing an NG Tube:

  • Position the patient upright and turn off suction.

  • Flush with air (if policy dictates) to clear the tube.

  • Ask the patient to hold their breath; remove the tube smoothly in one continuous motion.

  • Provide oral care afterward.

• Memory: MEASURE • LUBE • SWALLOW • VERIFY • SECURE.

Clinical Skill Checklists: Administering Feedings and Pumps

• Skill 24.6 — Administering Intermittent / Bolus Enteral Feedings:

  • Verify order, formula type, and tube placement.

  • Ensure HOB is $30-45^{\circ}$.

  • Check gastric residual as ordered and flush the tube before feeding.

  • Administer room-temperature formula at the prescribed rate.

  • Flush again after feeding and keep HOB elevated for at least $30-60\,\text{minutes}$.

• Skill 24.7 — Using a Feeding Pump:

  • Check expiration and load formula into the pump correctly.

  • Label and prime the tubing to remove air.

  • Set the prescribed rate and monitor frequently.

  • Note: Pumps do not replace human assessment. You must still verify placement, residuals, and aspiration risk manually.

• Memory Sequence for Feedings: ORDER \rightarrow POSITION \rightarrow VERIFY \rightarrow RESIDUAL \rightarrow FLUSH \rightarrow FEED \rightarrow FLUSH \rightarrow DOCUMENT.

Nursing Care Plan: Post-Cerebrovascular Accident (CVA) Patient

• Focus: Patients who have suffered a stroke (CVA) often have impaired swallowing, high aspiration risk, and mobility issues.

• Likely Nursing Diagnoses:

  • Impaired swallowing.

  • Imbalanced nutrition or Risk for inadequate nutrition.

  • Risk for aspiration.

  • Impaired physical mobility.

  • Risk for impaired skin integrity.

• Key Interventions:

  • Keep HOB elevated and suction available at the bedside.

  • Monitor PEG placement, site condition, and gastric residuals.

  • Perform frequent oral care.

  • Monitor I&O and daily weights ($kg$).

  • Assist with ROM (Range of Motion) and repositioning to protect the affected side.

• Improvement Indicators: Absence of aspiration, weight stability, healthy tube site, regular bowel elimination, and improved mobility.

• ADHD Shortcut: The 4 P’s: Position, PEG, Prevent aspiration, Protect skin/mobility.

Questions and Discussion

1. Question: If the patient’s GI tract works, which route is preferred: enteral or parenteral?    Answer: Enteral. If the gut works, use the gut.

2. Question: What is the safest initial confirmation of a newly inserted NG tube?    Answer: X-ray confirmation.

3. Question: What position should most patients be in during tube feedings?    Answer: Head of bed elevated about $30-45^{\circ}$.

4. Question: Which formula type is best for a patient with poor digestion/absorption?    Answer: Hydrolyzed.

5. Question: Which formula type is commonly used for a patient with diabetes?    Answer: A diabetic formula with fewer simple carbohydrates.

6. Question: Name the 3 main enteral feeding methods.    Answer: Intermittent, bolus, and continuous.

7. Question: Give 2 signs that a patient may be aspirating during a feeding.    Answer: Coughing, choking, wet voice, shortness of breath, or cyanosis.

8. Question: Why is TPN usually given through a central line?    Answer: It is hypertonic (highly concentrated) and can irritate peripheral veins.

9. Question: Why should TPN not be stopped abruptly?    Answer: It poses a risk for rebound hypoglycemia.

10. Question: What is one major risk of any PEG/J or central-line site?     Answer: Infection.

11. Question: What are the main steps to remember for NG insertion?     Answer: Measure, lubricate, advance while swallowing, verify placement, and secure.

12. Question: What is the purpose of checking intake and output?     Answer: To monitor fluid balance and detect potential issues early.

13. Question: Before giving a bolus feeding, what 3 things should you think about first?     Answer: Position the patient, verify tube placement, and check residual per policy.

14. Question: What makes continuous feeding different from bolus feeding?     Answer: It is given slowly over many hours via a pump rather than a large volume at once.

15. Question: After assisting a patient with meals, what should be documented?     Answer: Amount consumed, degree of assistance required, and any tolerance or swallowing difficulties.