Feeding Routes Feeding Routes Enteral feeding Parenteral feeding

Feeding Routes

Feeding Routes Enteral feeding Parenteral feeding

Feeding Routes 1 - Enteral feeding: a. Oral feeding: patients meet their needs by consuming oral diets and supplements b. Tube feeding: provides nutrients using the gastrointestinal tract (GI)-directly into the stomach or intestines

Feeding Routes 2 - parenteral feeding: – Used when a patient’s medical condition prohibits the use of the GI tract to deliver nutrients. – Provides nutrients intravenously to patients without adequate GI function to handle enteral feedings – Also called Intravenous feedings

In general, tube feeding or intravenous feeding should be used when : 1. patients nutrients needs are high 2. or their appetites poor 3. or their medical condition makes it difficult to meet nutrients need orally.

Tube feedings – Nutritionally complete formulas are delivered through a tube placed directly into the stomach or intestine. – Used when a patient is unable to eat but may be able to digest foods and absorb nutrients normally.

Feeding Routes • Transnasal (Short-term nutrition) – Nasogastric – Nasoduodenal – Nasojejunal • Enterostomy (Long-term nutrition) – Gastrostomy – Jejunostomy

Nasogastric (NG): Tube is placed into the stomach via the nose. Nasoduodenal (ND): Tube is placed into the duodenum via the nose. Nasojejunal (NJ): Tube is placed into the jejunum via the nose Gastrostomy : An opening into the stomach through which a feeding tube can be passed. Jejunostomy : An opening in the jejunum through which a feeding tube can be passed

Types of enteral formulas

1. 2. 3. 4. Enteral formulas are categorized according to their macronutrient sources: Standard formulas Elemental formulas Specialized formulas Modular formulas

1 - Standard Formulas • Standard formulas, are provided to individuals who can digest and absorb nutrients without difficulty. • They contain intact proteins extracted from milk or soybeans • The carbohydrate sources include modified starches, and sugars. • A few formulas, called blenderized formulas, are made from whole foods and derive their protein primarily from pureed meat or poultry

2 - Elemental Formulas • Elemental formulas are prescribed for patients who can not digest or absorp well • Elemental formulas contain proteins and carbohydrates that have been partially or fully broken down to fragments that require little digestion. • The formulas are often low in fat and may contain medium-chain triglycerides (MCT) to ease digestion and absorption.

3 - Specialized Formulas • Specialized formulas, are designed to meet the specific nutrient needs of patients with particular illnesses. • Products have been developed for individuals with liver, kidney, and lung diseases; glucose intolerance. • Disease-specific formulas are generally expensive.

4 - Modular Formulas • Modular formulas, created from individual single macronutrient preparations • Prepared for patients who require specific nutrient combinations to treat their illnesses. • Vitamin and mineral preparations are also included in these formulas so that they can meet all of a person’s nutrient needs.

Formula Characteristics • Macronutrient Composition • Energy Density • Fiber • Osmolality

Macronutrient Composition • The percentages of protein, carbohydrate, and fat vary among enteral formulas. • The protein content of most formulas ranges from 12 to 20 percent of total kcalories. • Carbohydrate and fat provide most of the energy in enteral formulas; standard formulas generally provide 40 to 60 percent of kcalories from carbohydrate and 30 to 40 percent of kcalories from fat.

Energy Density • The energy density of enteral formulas ranges from 0. 5 to 2. 0 kcalories per milliliter of fluid. • Standard formulas typically provide 1. 0 to 1. 2 kcalories per milliliter and are appropriate for patients with average fluid requirements.

• Formulas that have higher energy densities can meet energy and nutrient needs in a smaller volume of fluid and thus benefit patients who have high nutrient needs or fluid restrictions. • Individuals with high fluid needs can be given a formula with low energy density or be supplied with additional water via the feeding tube or intravenously.

Fiber Content • Fiber-containing formulas can be helpful for normalizing intestinal function, treating diarrhea or constipation, and maintaining blood glucose control. • Conversely, fiber-containing formulas are avoided in patients with acute intestinal conditions, pancreatitis, or procedures involving the intestines

Osmolality • A formula with an osmolality similar to that of blood serum (about 300 milliosmoles per kilogram) is an isotonic formula. • A hypertonic formula has an osmolality greater than that of blood serum. • Most enteral formulas has osmolalities between 300 and 700 milliosmoles per kilogram

Formula Selection • Nutrient and energy needs • Fluid requirements • Need for fiber modifications • Individual tolerances – Food allergies & sensitivities

Enteral nutrition benefits – Maintain normal GI function – Causes fewer complications – Less costly

Indications for Tube Feedings Include people with: • Severe swallowing disorders • Impaired motility in the upper GI tract • Gastrointestinal obstructions that can be bypassed with a feeding tube • Certain types of intestinal surgeries • Mechanical ventilators, coma • Extremely high nutrient requirements • Little or no appetite for extended periods, especially if malnourished

Administration of Tube Feedings • Open feeding system: requires formula to be transferred from original packaging to feeding container • Closed feeding system: formula prepackaged in ready-to-use containers

Administration of Tube Feedings • At the Nursing Station – Check expiration date on label – Wash hands – Clean the can opener and the lid – Label can with date and time opened – Store opened cans or mixed formulas in clean, closed containers & refrigerate – Discard opened containers not used within 24 hours

Administration of Tube Feedings • At the Bedside – Open system : Hang no more than 8 hour supply of formula and discard any formula that remains after that. – Closed system: Hang no more than 24 hour supply of formula and discard any formula that remains after that.

Contraindications for Tube Feedings Include: • • Severe GI bleeding Intractable vomiting or diarrhea Complete intestinal obstruction Severe malabsorption

Transition to Table Foods • Tube feedings are gradually tapered off – as oral intake increases • The steps in the transition depend on the patient’s medical condition and the type of feeding the patient is receiving. • Are discontinued when client consuming 2/3 of nutrient needs by mouth

PARENTERAL NUTRITION SUPPORT

Indications for Parenteral Support Patients who: • Do not have functioning GI tracts and are: – Malnourished – At risk for becoming malnourished • Could be harmed if GI tract used (require bowel rest)

Indications for Parenteral Support 1 - Total Parenteral Nutrition (TPN) – Uses larger, central veins – Volume is greater and concentrations are not limited – Can reliably meet complete requirements nutrient

Peripheral parenteral nutrition (PPN) – Used for short-term nutrition support (7 -10 days) – for clients who do not have high nutrient needs or fluid restrictions -Can only provide limited amounts of energy & protein

Accessing Central Veins for Total Parenteral Nutrition

Parenteral Solutions: Nutrients • • • Protein : Amino acids Carbohydrates : glucose Lipids : triglycerides Fluids and electrolytes (Sodium, potassium, chloride, calcium, magnesium, and phosphorus) Vitamins and trace minerals : Multivitamin and trace minerals added

Important notes – There are disease specific solutions – for patients with: liver failure, kidney failure and hyper-triglyceridemia, coagulation diseases – Iron excluded – alters stability of other ingredients – given by injection – Daily lab tests to monitor electrolyte status

Parenteral Formulation • Depends on patient’s: – Medical condition – Nutritional status – PPN or TPN – May need to be recalculated daily

Parenteral Preparation • Careful attention to solution preparation and handling – Prepared in pharmacy under aseptic conditions – Shielded from light – Refrigerated – Prior to hanging infusion • Solutions removed from refrigerator • Allowed to reach room temperature – During feedings – solution and catheter checked frequently for sign of contamination

Discontinuing intravenous feedings • Transitional feedings – Taper off parenteral feedings as enteral feedings are begun

Potential benefits of enteral nutrition over PN include: Physiologic 1. Nutrients are metabolized and utilized more effectively via the enteral than the parenteral route. 1. The gut and liver process enteral nutrients before their release into systemic circulation. 1. The gut and liver help maintain the homeostasis of the amino acid pool as well as the skeletal muscle tissue.

• Immunologic 1. Gut integrity is maintained by enteral nutrients through the prevention of bacterial translocation from the gut, sytemic sepsis, and potential increased risk of multiple organ failure. 2. Lack of GI stimulation may promote bacterial translocation from the gut without concurrent enteral nutrition. 3. Provision of early enteral nutrition may minimize risk of gut related sepsis.

• Safety (avoid complications related to intravenous access): 1. Catheter sepsis 2. Pneumothorax 3. Catheter embolism 4. Arterial laceration

• Cost 1. Cost of EN formula is less than PN. 2. Cost of equipment and personnel for preparation and administration is less