1. NUTRITION Level 3, Academic Year (AY) 1435—1436 H Ahmad Albalawi, MSN Lecturer

2. ENTERAL and PARENTERAL FEEDING

3. 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 Learning Objectives

4. LESSON OVERVIEW Definition Indications Types Types of formulas Guidelines in Administration Complications Topic Outline

5. 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

6. Indicated for patients who have a functioning GIT but can’t ingest enough nutrients orally Enteral Nutrition 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

7. 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)

8. 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

9. ELEMENTAL or HYDROLYZED FORMULAS Types of Enteral 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

10. MODULAR FORMULAS (Feeding modules) Types of Enteral Formulas May contain specific nutrient; used to treat specific deficiency or combines with other formulas 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)

11. Intermittent Bolus Continuous Three Methods of Administering Tube Feedings Administering tube feedings usually at night; solid foods eaten during the day Daily calorie needs are divided into 6 servings/day (< 400 ml); given over 15 mins followed by 25-60 ml of water Feedings are administered by a continuous pump; 16- to 24-hour period; initially at a rate of 30-50 ml/per

12. Nasogastric or nasoduodenal tube feeding Jejunostomy tube feeding Guidelines in Administering Tube Feedings  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  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

13. PROBLEMCAUSEEFFECT 1. Presence of tubeTube 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 intracranially if the cribriform plate is disrupted by severe facial trauma Brain trauma, infection Complications of Enteral Tube Nutrition

14. PROBLEMCAUSEEFFECT 4. Misplacement of naso- or orogastric tube in the tracheobronchial tree Responsive patients- cough and gag Obtunded patients- may have few immediate symptoms Pneumonia 5. Dislodgement of gastrostomy or jejunostomy tube Tube may be displaced into the peritoneal cavity Peritonitis Complications of Enteral Tube Nutrition

15. PROBLEMCAUSEEFFECT 6. Intolerance of one of the formula’s main nutrient components *usually occurs with bolus feedings *lactose Diarrhea, GI discomfort, nausea, vomiting 7. Osmotic diarrheaHigh osmolality of the solution *Sorbitol- often contained in liquid drug preparations *Clostridium difficile Weakness, diarrhea 8. Nutrient imbalancesSpecific formulasElectrolytes disturbances, hyperglycemia, Complications of Enteral Tube Nutrition

16. PROBLEMCAUSEEFFECT 9. Reflux of solutions Clogged tube or tube may be pulled out ASPIRATION Complications of Enteral Tube Nutrition

17. 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

18. Peripheral VeinCentral Vein 2 weeks or less > 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

19. 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 Types of Parenteral Nutrition

20. 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

21. 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 Parenteral Nutrition Solutions

22. 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 Caring for Patient having Parenteral Nutrition

23. 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 Administering Parenteral Nutrition

24. 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 Guidelines in Caring for Patient having Parenteral Nutrition

25. Catheter related sepsis Phlebitis/thrombosis Glucose abnormalities Hepatic complications Abnormalities of serum electrolytes and minerals Volume overload Bone demineralization Gallbladder complications Complications of Parenteral Nutrition

26. M Department of Nursing26

27. 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 Nursing27

28. 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 Nursing28

29. References Whitney, W & Rolfes, SR (2008) Understanding Nutrition (11 th 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. 4 th Edition.