1. ENTERAL and PARENTERAL FEEDING
Mylin G. Abalus
NUTN 204 Lecturer

2. OBJECTIVES

3. LESSON OVERVIEW

4. Enteral Nutrition
Form of feeding that brings nutrients directly into the digestive tract
Oral feeding
Tube feeding- feeding by tube directly into the stomach or intensive or via a vein

5. 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 or depressed sensorium
Liver failure
Inability to take oral feedings
Critical illnesses
Malabsorption problems

6. 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)

7. Types of Enteral Formulas
POLYMERIC FORMULA
Commercially prepared formulas that provides complete, balance diet
1-2 calories/ml
Contains proteins, carbohydrates, and fats
Requires digestion
Blenderized food and milk-based or lactose free commercial formula

8. 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
Provide 1 cal/ ml; lactose-free
Expensive and usually unnecessary
e.g. amino acid formula, calorie- and protein-dense formula, restricted, fiber-enriched formula

9. Types of Enteral Formulas
MODULAR FORMULAS (Feeding modules)
Provides cal/ml
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

10. Three Methods of Administering Tube Feedings
Intermittent
Bolus
Continuous
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 ml of water
Feedings are administered by a continuous pump; 16- to 24-hour period; initially at a rate of ml/per

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

12. 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 intracranially if the cribriform plate is disrupted by severe facial trauma
Brain trauma, infection

13. Complications of Enteral Tube Nutrition
PROBLEM
CAUSE
EFFECT
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

14. 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
*Sorbitol- often contained in liquid drug preparations
*Clostridium difficile
Weakness, diarrhea
8. Nutrient imbalances
Specific formulas
Electrolytes disturbances, hyperglycemia,

15. Complications of Enteral Tube Nutrition
PROBLEM
CAUSE
EFFECT
9. Reflux of solutions
Clogged tube or tube may be pulled out
ASPIRATION

16. 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

17. Parenteral Nutrition Peripheral Vein Central Vein 2 weeks or less
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

18. Types of Parenteral Nutrition
Partial Parenteral Nutrition
Supplies only part of daily nutritional requirements, supplementing oral intake
Dextrose or amino acids solutions
Total Parenteral Nutrition (Hyperalimentation)
Supplies all daily nutritional requirements
TPN solutions are highly concentration- central vein is used

19. Parenteral Nutrition Content
water
30-40 ml/kg/day
energy
30-60 kcal/kg/day (depending on energy expenditure)
Amino acids
1-2 g/kg/day
Essential fatty acids
Vitamins
minerals
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

20. 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

21. 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

22. Guidelines in Administering Parenteral Nutrition
Solution is started slowly at 50% calculated requirements + 5% dextrose
Energy and nitrogen given simultaneously
Amount of regular insulin (added directly to the TPN solution) depends on the serum glucose level (e.g. level is normal; 25% dextrose= units of regular insulin)

23. 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

24. 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