1. Enteral Nutrition Support Fluid and electrolyte requirements. Calculate enteral and parenteral nutrition formulations.

2. ENS Selecting the formula –Integrity of GI system –Type of protein, fat, CHO, fiber in formula –Kcal & protein density of formula

3. ENS Selecting the formula –Ability of formula as taken to meet pt nutrient needs –Viscosity of formula and TF equipment –Cost of formula

4. ENS Components Intact or polymeric formulas Hydrolyzed or elemental formulas

5. ENS Components Molality and molarity –number of free particles/unit wt or volume –the higher the number the more free particles –the higher the number more osmotic force –mOsm

6. ENS Components Isotonic - –350 mOsm/kg or less Intact formulas –300 - 500 mOsm/kg Hydrolyzed nutrient formulas - hyperosmolar –900 mOsm/kg

7. ENS Components Density of formulas –more nutrients or kcal/ml the more dense –less free water Dense formulas used –restrict water –other source of water

8. ENS Components Protein –polymeric formulas - intact HBV protein What if small intestine can’t digest protein?

9. ENS Components CHO –starch hydrolysates –maltodextrins –sucrose –fructose –glucose

10. ENS Components CHO –osmolality increases as mover towards simple sugars

11. ENS Components Fat –corn, soy, safflower, canola –need 4% of total kcal as linoleic –some have MCT

12. ENS Components Fluid –need to check free water –standard formulas - 80 - 85% –calorie dense - 60%

13. ENS Components Fiber –soy polysaccaharide –fructooligosaccharides –10 - 12 g/L

14. Chart showing narrowing the choice of formulas next

15. Narrowing the choice of formulas

16. ENS Things to consider when selecting –ability to digest –absorption –colonic residue –length of time on TF –risk of aspiration

17. ENS Routes of Admin Nasogastric Nasoduodenal or jasojejunal Enterostomies –percutaneous endoscopic gastrostomy (PEG) –percutaneous endoscopic jejunostomy (PEJ)

18. ENS Admin Bolus administration –maximum bolus - 400-450 ml –4 - 6 times/day Check gastric residual Contraindications? Describe pt this might work?

19. ENS Admin Continuous drip –infusion 18 - 24 hours –start 30 - 50 ml/hr –advance 8 - 12 hr as tolerate –flush with water

20. What steps would you take in planning a tube feeding?

21. Starting ENS 300 mOsm - full strength, full rate >600 mOsm - full strength, low rate & as tolerated advance

22. Monitoring ENS Table 22-5 Mahan What would you monitor?

23. Monitoring ENS Gastric residuals –>150-200 ml without feeding –maintain elevation –wait 30-60 min –check again

24. Monitoring ENS Gastric residuals –if always 150-200 ml –find out why –if have this and greater with feeding - stop feeding or slow rate

25. Complications ENS Dehydration –why dehydrated –increase fluid –lower protein intake

26. Complications ENS Signs of excessive protein –dehydration –inadequate fluid intake –hypernatremia –hypercholremia

27. Complications ENS Signs of excessive protein –azotemia –pt appears confused

28. Complications ENS Aspiration pneumonia –make sure correct tube and placement of end of tube –elevate head 30 degrees –continuous drip 22-24 hrs

29. Complications ENS Diarrhea –lactose intolerance –bacterial contamination –hyperosmolar formula –low serum alb –medication

30. END ENS Questions? Calculations next