1. ENTERAL FEEDING & parenteral feeding

2. Objectives of lecture By the end of this lecture you will be able to:
Discuss the components of enteral feeding parenteral feeding .

3. Introduction
Definition of Enteral Nutriion: Administration of nutrients directly into the stomach, duodenum, or jejunum through a tube is more physiologically beneficial and cost-effective than parenteral feeding.

4. Clinical Indications
Increased metabolic needs and inability to take adequate oral diet e.g: trauma, burns, cancer, sepsis.
Coma or mechanical ventilation.
Head/neck surgery.
Malabsorption.
Obstruction of esophagus or oropharynx.
Severe anorexia nervosa.
Dysphagia.

5. Sites of Tube Insertion
1- Short-Term Nutritional Support:
a) Nasogastric (NG) feeding tubes are passed through the nose or mouth (orogastric) into the stomach and secured in place.
Tube placement must be verified before use by:
X-ray.
aspiration of contents for pH and bilirubin concentration.(stomach pH below 3 )
or auscultation of air injected through tube.
The best method is X-ray.

6. Con….
If there is a question about tube placement in the respiratory tract, the tube should be removed.
b) Nasoduodenal or nasojejunal is tube passed through the nose into duodenum or jejunum and secured in place. X ray is usually needed to verify correct tube placement.

7. Con… 2- Long-Term Nutritional Support:
Gastrostomy is insertion of a tube either surgically or by a percutaneous endoscopic procedure into the stomach.
Jejunostomy is insertion of a tube directly into the jejunum either surgically or by a percutaneous endoscopic procedure.

8. Types of Tubes
Large-bore NG polyurethane tube -size 12 to 18F, used very short-term.
Small-bore NG tube -made of polyurethane, silicone, or polyvinyl chloride with a tungsten-weighted tip or nonweighted tip, size 6 to 12F and 30 to 36 inches (76 to 91.5 cm) long.
Nasointestinal tube - made of silicone, polyurethane, or polyvinyl chloride with tungsten-weighted tip or a nonweighted tip, size 6 to 12F and 40 to 60 inches (101.5 to cm) long.

9. Con…
Gastrostomy tube- catheter made of silicone, polyurethane, polyvinyl chloride, or latex; a balloon on the distal end to stabilize tube may be used and ranges from 5 to 30 mL capacity.
Gastrostomy button-silicone; ranging from 18 to 28F and 1 inch (2.5 cm) long; useful for person wanting minimal alteration in body image.

10. Con….
Jejunostomy tube -size ranging from 5 to 14F with or without a balloon (a balloon may obstruct lumen of jejunum). A plain red rubber catheter is occasionally used as a short-term jejunostomy tube, and some gastrostomy tubes may be used for jejunostomy.

11. Enteral Formulas
Nutrients administered through tubes are liquefied so they can be easily digested and absorbed. Commercially prepared formulas are available and used in most health care settings. There are three basic types of formulas, which differ in osmolality, digestibility, kilocalories, lactose content, viscosity, and fat content.

12. Delivery Systems for Feeding Solution
(Intermittent feeding are delivered at regular interval, continuous feeding for a portion of 24 –hour period usual routine is hours often over night).
1) Intermittent or continuous infusion of feeding solution by gravity is accomplished by hanging container of feeding solution from an I.V. pole and adjusting delivery rate by flow regulator.

13. Con…
2) Continuous feeding by controller feeding pump allows uniform flow, particularly of viscous solutions. 3) Bolus feeding involves enteral formula poured into barrel of a large (60 mL) syringe attached to a feeding tube and allowed to infuse quickly by gravity ( my place the patient at risk for aspiration and distention ).

14. Complications & Nursing Interventions
1-Tube displacement: CAUSES:
Tube migration into esophagus.
NURSING INTERVENTIONS:
Observe for eructation of air when injecting air to test for tube placement in stomach.
Aspirate gastric contents; if none is obtained, suspect esophageal placement.

15. Con… 1-Tube displacement: CAUSES:
b) Tube placement into respiratory tract
NURSING INTERVENTIONS:
Observe for gagging, dyspnea, inability to speak, coughing when tube insertion attempted.
Aspirate gastric contents; if pH > 6, suspect respiratory tract placement.
Obtain chest X-ray.*
Withdraw tube and attempt reinsertion with patient's head flexed forward.*

16. Complications 2- Tube obstruction: CAUSES: a) Tube kinking.
NURSING INTERVENTIONS:
Obtain chest X-ray to confirm and withdraw and reinsert new tube.*

17. Complications Tube obstruction : CAUSES: b) Tube clogging
NURSING INTERVENTIONS:
Flush tube every 4 hours with 30 ml of water and after administration of intermittent feeding and medication administration.
Administer medications in liquid form if possible. Crush medications finely (if crushable).
Administer pancreatic enzyme/bicarbonate mixture to unclog tube. ( according to physician's order).

18. Complications 3-Vomiting: ( may cause aspiration ) CAUSES:
a) Tube migration into esophagus.
NURSING INTERVENTIONS:
See interventions for tube displacement above.

19. Complications 3-Vomiting : CAUSES: b) Decreased absorption.
NURSING INTERVENTIONS:
Auscultate for decreased bowel sounds, observe for abdominal distention.
Consider decreasing amount of tube feeding.*
Consider administration on a continuous basis.*
Check residual volume per policy.

20. Complications 3-Vomiting : CAUSES: c) Rapid rate of infusion.
NURSING INTERVENTIONS:
Administer no faster than ml during minutes to 30 minutes.
Consider administration on a continuous basis.*

21. Complications 3-Vomiting : CAUSES: d) Excessive infusion of air.
NURSING INTERVENTIONS:
If giving a bolus feeding, pinch tubing off when refilling syringe with formula.
If giving continuous feeding, make certain bag does not empty before closing off tubing.

22. Complications 3-Vomiting : CAUSES: e) Patient position.
NURSING INTERVENTIONS:
Maintain patient at degree angle of head elevation during and minutes after feeding. If administering continuous feeding, maintain head elevation at all times.

23. Complications 3- vomiting: CAUSES: f) Nausea. NURSING INTERVENTIONS:
Antiemetics ( according to physician's order).
g) Obstruction.
Assess for distention and decreased bowel sounds; obtain X-ray.

24. Complications 3- vomiting: CAUSES: h) Constipation.
NURSING INTERVENTIONS:
Assess for impaction and review frequency of bowel movements.

25. Complications 4- Diarrhea : CAUSES: Drug therapy.
High osmolarity of formula.
Lactose intolerance.
Bacterial contamination of formula.
Rapid infusion rate.
Fecal impaction.
NURSING INTERVENTIONS:
Begin administration of formula at slow rate, Maintain strict medical asepsis, Manually clear the impaction.

26. Complications 5-Constipation : CAUSES: Lack of fiber.
Decreased fluid intake.
Drug therapy.
NURSING INTERVENTIONS:
Ensure that patient is not impacted and administer formula with fiber.*

27. Complications
6- electrolyte and metabolic disorders called(refeedig syndrome)
a) Hyperglycemia : CAUSES:
Diabetes impaired metabolism
NURSING INTERVENTIONS:
Monitor serum glucose, assess for dehydration observe for symptoms of hyperglycemia, including polyuria, polydipsia.
Administer insulin.* ( according to physician's order)
Observe for hypercapnia (increased respirations, elevated Pco2).

28. Complications 6- electrolyte and metabolic disorders
b) Hypernatremia: CAUSES:
Dehydration.
NURSING INTERVENTIONS:
Assess for signs and symptoms of dehydration (I&O, daily weight, skin turgor, blood urea nitrogen, CVP, tachycardia, hypotension).
Rehydrate with extra water via the feeding tube or, if patient is severely hypernatremic, use I.V. route. ( according to physician's order)
Rehydrate with D5W or hypotonic saline solutions.*( according to physician's order)

29. Complications 6- electrolyte and metabolic disorders
c) Hyponatremia: CAUSES:
Overhydration
Excessive sodium loss (diaphoresis, nasogastric suction)
NURSING INTERVENTIONS:
Observe for signs and symptoms of hypervolemia (shortness of breath, rales, I&O, daily weight, peripheral edema, elevated CVP).

30. Con….
Observe for signs and symptoms of hyponatremia (lethargy, headaches, mental status change, nausea, vomiting, abdominal cramping).
Replace sodium, administer diuretics or, depending on the cause of hypernatremia, restrict fluids.**( according to physician's order)

31. Complications 6- electrolyte and metabolic disorders
d) Hyperkalemia: CAUSES:
Metabolic acidosis/renal insufficiency.
NURSING INTERVENTIONS:
Observe for signs and symptoms of hyperkalemia (dysrhythmias, nausea, diarrhea, muscle weakness).
Treat underlying cause. .*( according to physician's order)
Choose lower potassium formula. .*( according to physician's order)

32. Complications 6- electrolyte and metabolic disorders
e) Hypokalemia: CAUSES:
Diarrhea
NURSING INTERVENTIONS:
See interventions for diarrhea.
If severe, replace potassium.* *( according to physician's order)

33. Complication 7- Nasal erosion with tube. NURSING INTERVENTIONS:
Check nostrils every shift for signs of pressure.
Clean and moisten nares every 4-8 hours.

34. Nursing care to promote patient safety (summary)
Check tube placement before administering any fluid, medication or feeding.
Check residual( feeding remaining in the stomach)before each feeding or every 4-6 hours during a continuous feeding ( according to institution policy).
Assess for bowel sounds at least once per shift to check for presence of peristalisis and functional intestinal tract.

35. Community and Home Care Considerations
Teach patient and family:
Technique for administration of tube feeding
Signs and symptoms of potential complications.
Need to assess tube placement and residual before each feeding (for gastric feedings only).
Principles of medical asepsis, including careful hand washing, refrigeration of formula, cleaning of equipment with soap and water and thorough drying between feedings.

36. Con…
When the gastrostomy or jejunostomy tube insertion site is well healed, surrounding skin can be cleaned with soap and water.
Gauze dressing can be applied as needed.
Leakage around tube or signs of peristomal skin irritation should be reported.

37. PARENTERAL NUTRITION
Parenteral nutrition is the introduction of nutrients, including amino acids, lipids, carbohydrates, vitamins, minerals, and water, through a venous access device (VAD) directly into the intravascular fluid to provide nutrients required for metabolic functioning of the body either through central vein or peripheral vein .

38. Clinical Indications
1- Patient cannot tolerate enteral nutrition due to:
e.g;
Paralytic ileus.
Intestinal obstruction.
Severe pancreatitis
The enteral feed is contraindicated for them.

39. Con…
2- Hypermetabolic states for which enteral therapy is either not possible or inadequate, such as burns, trauma, sepsis.
3- In these situations additional components are added to the enteral therapy or individualized solutions are developed to meet the nutritional needs of the patient.

40. Conclution
Enteral feeding carries less risk of infection than parenteral feeding and maintains a functional GI tract by preventing mucosal atrophy and biliary and hepatic dysfunction.

41. Reference
Authors/Editors: Nettina, Sandra M.; Mills, Elizabeth Jacqueline
Title: Lippincott Manual of Nursing Practice, 8th Edition
Copyright آ©2006 Lippincott Williams & Wilkins
> Table of Contents > Part Two - Medical-Surgical Nursing > Unit V - Gastrointestinal and Nutritional Health > Chapter 20 - Nutritional Problems

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