1. Enteral & Parenteral Nutrition

2. Enteral Tube Feedings
Enteral nutrition (EN) provides nutrients into the GI tract.
Feedings are provided for patients who can not swallow and have a functioning GI tract.
Feedings can be delivered through a nasogastric (NGT), jejunal (JT) or gastric tube (GT).
When oral feeding assistance is inadequate in providing appropriate nutrition, enteral or parental feeding is required. EN is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally, yet has a functioning GI tract.
[Box on text p lists indications for EN or PN.]
Patients at low risk for gastric reflux receive gastric feedings; however, if risk of gastric reflux, which leads to aspiration, is present, jejunal feeding is preferred.
Types of formulas include
Polymeric: milk-based, blenderized; the patient’s gastrointestinal tract needs to be able to absorb whole nutrients
Modular: single-macronutrient (protein, glucose, polymers, or lipids) formulas are added to other foods to meet patients’ needs
Elemental formulas: predigested nutrients, easier for partially dysfunctional gastrointestinal tract to absorb
Specialty formulas: designed to meet specific nutritional needs in certain illnesses
Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of water to ensure that the tube is clear and patent. Tube feedings typically are started at full strength at slow rates. Increase the hourly rate every 8 to 12 hours per health care provider’s order if no signs of intolerance appear.
Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function.
Tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy).
If for less than 4 weeks total, nasogastric or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding.
A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree, which leads to infection.
[Review Box on text p Advancing the Rate of Tube Feeding.]

3. Enteral Tube Feedings Procedure: Start at full strength Slow rate
Increase every 8-12 hours as ordered
Assess for signs of intolerance
High gastric residuals, nausea, cramping, vomiting and diarrhea
Assess for complications
Aspiration, Diarrhea, Bacterial contamination, Tube occlusion, delayed gastric emptying

4. Tube Placement
The most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination.
Check pH of gastric aspirate, < 4
Observe aspirate color
Do not use auscultation method

7. Nursing Diagnosis Risk for Aspiration r/t NGT feeding
Outcome: Patient will maintain patent airway and clear lung sounds.
Nursing Interventions
Determine if patient is at high risk for aspiration: coughing, hx of GERD, nasotracheal suction, an artificial airway, decreased LOC, and lying flat.
Keep HOB up to degrees at all times
Measure gastric residual volumes every 4-6 hrs.
250 ml or more on 2 consecutive assessments: delayed gastric emptying or if 500 ml on assessment
Discuss follow up with HCP

8. Nursing Diagnosis Risk for Aspiration r/t NGT feeding
Stop feedings if aspiration occurs
Administer metoclopramide (Reglan) if ordered
Monitor for nausea, vomiting, cramping and diarrhea and tube occlusion.
Increase rate per order

9. Parenteral Nutrition
Parenteral nutrition (PN) is a form of specialized nutrition support in which nutrients are provided intravenously.
A basic PN formula is a combination of amino acids, hypertonic dextrose (10-50%), electrolytes, vitamins, and trace elements.
Fat emulsions: provides calories and fatty acids
Delivered through
Central venous catheter
Peripheral line (rarely)
pg 1021

10. Parenteral Nutrition
If using a CVC that has multiple lumens, use a port that is exclusively dedicated for the TPN. Label it!
Verify the HCP’s order
Inspect the solution for particulate matter
Always use an infusion pump
First hrs: delivers 50% of estimated needs and then rate has will be increased (run at 40-50ml)

11. Parenteral Nutrition: Complications
Catheter-related Problems
Pneumonthorax
Sudden sharp chest pain, dyspnea, and coughing
Monitor for 24 hrs
Air embolus
Occurs during insertion of the catheter or when changing the tubing or cap.
Turn pt to left side and have pt perform a Valsalva maneuver (hold breath and bear down during catheter insertion to help prevent air embolus
Keep IV system closed

12. Parenteral Nutrition: Complications
Catheter-related Problems
Catheter occlusion
If sluggish or no flow, stop infusion and flush with NS or heparin (per protocol).
Attempt to aspirate clot or follow protocol for thrombolytic agent (urokinase)
Sepsis
Fever, chills, or glucose intolerance and positive blood culture
Change tubing q 24 hrs
Hang bag for only 24 hr; lipids 12 hrs
Check to see if solution needs a filter

13. Parenteral Nutrition: Complications
Metabolic alterations
Electrolyte and mineral imbalances
Hyperglycemia
Thirst, HA, lethargy, increased urination.
Monitor BS q 6 hrs
Give insulin
Hypoglycemia
Diaphoresis, shakiness, confusion, loss of consciousness
Do not abruptly discontinue TPN
Taper rate
Give IV bolus of dextrose
Dehydration