copyright © 2010 wolters kluwer health | lippincott williams & wilkins feeding patients: oral...

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition

Chapter 15

Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition

Chapter 15


Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition

Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition

• Up to 40% of hospitalized patients are malnourished

• Hospital food may be refused because:

– It is unfamiliar

– Tasteless (e.g., cooked without salt)

– Inappropriate in texture (e.g., pureed meat)

– Religiously or culturally unacceptable

– Served at times when the patient is unaccustomed to eating


Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition (cont’d)

Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition (cont’d)

• Meals may be withheld or missed

• Inadequate liquid diets may not be advanced in a timely manner

• Giving the right food to the patient is one thing; getting the patient to eat (most of it) is another


Oral DietsOral Diets

• Easiest and most preferred method of providing nutrition

• Oral diets may be categorized as:

– “Regular”

– Modified consistency

– Therapeutic


Oral Diets (cont’d)Oral Diets (cont’d)

• Normal, regular, and house diets

– Regular diets are used to achieve or maintain optimal nutritional status

– Regular diets are adjusted to meet age-specific needs throughout the life cycle

– Diet as tolerated (DAT)


Oral Diets (cont’d)Oral Diets (cont’d)• Modified consistency diets

– Modified-consistency diets include:

o Clear liquid

o Mechanically altered diets

– Clear liquid diets may be used:

o After surgery

o In preparation for bowel surgery or procedures

o When oral intake resumes after a prolonged period

o Most patients can tolerate a regular diet for their second postoperative meal



• Modified-consistency diets (cont’d)

– Mechanically altered diets contain foods that are chopped, ground, pureed, or soft

– Diets prepared in a blender provide food in liquid form

– Dysphagia diets are another variation of modified-consistency diets



• Therapeutic diets

– Therapeutic diets differ from a regular diet

– Used for the purpose of preventing or treating disease or illness

• Nutritional supplements

– Some patients are unable or unwilling to eat enough food to meet their requirements



• Nutritional supplements (cont’d)

– Categories of supplements include:

o Clear liquid supplements

o Milk-based drinks

o Prepared liquid supplements

o Specially prepared foods



• Nutritional supplements (cont’d)

– Liquid supplements are:

o Easy to consume

o Are generally well accepted

o Tend to leave the stomach quickly

o A good choice for between-meal snacks


QuestionQuestion

• What type of diet is a dysphagia diet?

a. Prepared in a blender

b. Liquid

c. Modified consistency

d. Mechanically ground


AnswerAnswer

c. Modified consistency

Rationale: Dysphagia diets are another variation of modified-consistency diets.



• Liquid supplements

– Allow the patient to taste test several options available

– Explain the rationale for adding supplements and closely monitor acceptance

– Given on a rotation schedule


Oral Diets (cont’d)Oral Diets (cont’d)• Modular products

– Less frequently used option for maximizing a patient’s oral intake

– Generally composed of a single nutrient

– Disadvantages:

o Quality control (calculation errors)

o Bacterial contamination

o Higher costs than standard formulas


Enteral NutritionEnteral Nutrition

• A way of providing nutrition for patients who are unable to consume an adequate oral intake but have at least a partially functional GI tract that is accessible and safe to use

• Enteral nutrition (EN) may augment an oral diet or may be the sole source of nutrition


Candidates for Tube FeedingCandidates for Tube Feeding

• Patients who:

– Have problems chewing and swallowing

– Have prolonged lack of appetite

– Have an obstruction, fistula, or altered motility in the upper gastrointestinal tract

– Are in a coma

– Have very high nutrient requirements


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)

• Contraindicated when the gastrointestinal tract is nonfunctional

• Patients who receive enteral nutrition experience less septic morbidity and fewer infections and complications than patients who receive parenteral nutrition

• Significantly less costly than parenteral nutrition

• Has not been proven to reduce the length of the hospital stay and improve mortality



• More high-quality trials are needed

• Factors that influence how and what is used to feed patients enterally include:

– The patient’s calorie and protein requirements

– Ability to digest nutrients

– Feeding route

– Characteristics of the formula

– Equipment available

– Method of delivery


QuestionQuestion

• Enteral nutrition is a way of providing nutrition for people who have an inadequate oral intake. What is the other criteria for enteral nutrition?

a. Partially functioning GI tract

b. Nonfunctioning GI tract

c. Obstructed GI tract

d. Patient is comatose


AnswerAnswer

a. Partially functioning GI tract

Rationale: Enteral nutrition (EN) is a way of providing nutrition for patients who are unable to consume an adequate oral intake but have at least a partially functional GI tract that is accessible and safe to use.


• Feeding route

– Depends on the patient’s medical status and the anticipated length of time the tube feeding will be used

– Transnasal tubes

o Nasogastric (NG) tube is the most common

o Generally used for tube feedings of relatively short duration




• Feeding route (cont’d)

– Ostomy feedings are preferred for permanent or long-term feedings

– Percutaneous endoscopic gastrostomy (PEG) tubes are placed with the aid of an endoscope

• Formula characteristics

– Formulary of various enteral products available within major categories

– Are designed to provide complete nutrition



• Protein

– Enteral formulas are classified by the type of protein they contain

– Standard formulas

o Made from whole proteins or protein isolates

o Provide 34 to 43 g protein/liter



• Protein (cont’d)

– Variations

o High in protein

o High in calories

o Fiber enriched

o Disease-specific formulas designed for patients with diabetes, immune system dysfunction, renal failure, or respiratory insufficiency


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Protein (cont’d)

– Hydrolyzed protein formulas

o Completely hydrolyzed formulas contain only free amino acids as their source of protein

o Partially hydrolyzed formulas contain proteins that are broken down

o Intended for patients with impaired digestion or absorption

o Disease-specific formulas are available for liver failure, HIV/AIDS, and immune system support



• Calorie and nutrient density

– Calorie density of a product determines the volume of formula needed

– Routine formulas provide 1.0 to 1.2 cal/mL

– High-calorie formulas provide 1.5 to 2.0 cal/mL

– Nutrient density

o Varies among formulas

o Ranges from 1,000 to 2,000 mL/day


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Water content

– Varies with the caloric concentration

– Formulas that provide 1.0 cal/mL provide 850 mL of water/liter

– High calorie formulas is lower at 690 to 720 mL/L

– Adults generally need 30 to 40 mL/kg/day

– Need additional free water



• Other nutrients

– High-fat formulas are available for patients with respiratory disease

– Modified-fat formulas are designed for patients with malabsorption

– Diabetic formulas are available

– Electrolyte-modified formulas for renal disease


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Fiber and residue content

– Terms fiber and residue are frequently used interchangeably

o Fiber Stimulates peristalsis, increases stool

bulk, and is degraded by gastro-intestinal bacteria

Combines with undigested food, intestinal secretions, and other cells to make residue



• Fiber and residue content

– Residue content of enteral formulas varies greatly

– Hydrolyzed formulas are essentially residue free

– Most standard formulas are low in residue

– Formulas prepared in a blender are a natural source of fiber



• Osmolality

– Determined by the concentration of sugars, amino acids, and electrolytes

– Isotonic formulas have approximately the same osmolality as blood

– Some patients develop diarrhea when a hypertonic formula is infused


QuestionQuestion

• Is the following statement true or false?

Routine formulas provide 1.5 to 2 cal/mL.


AnswerAnswer

False.

Rationale: The calorie density of a product determines the volume of formula needed to meet the patient’s estimated needs. Routine formulas provide 1.0 to 1.2 cal/mL, whereas high-calorie formulas provide 1.5 to 2.0 cal/mL.


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Equipment

– Tubing size and pump availability impact formula selection

– High-fiber formulas have a high viscosity and require a large bore tube (8F or greater) to prevent clogging

– Hydrolyzed formulas have very low viscosity

• Delivery methods

– Formulas may be given intermittently or continuously over a period of 8 to 24 hours

– Type of delivery method to be used depends on the type and location of the feeding tube, the type of formula being administered, and the patient’s tolerance



• Intermittent feedings

– Administered throughout the day

– Generally used for noncritical patients, home-tube feedings, and patients in rehabilitation

– More closely resemble a normal intake

– Allow the client freedom between feedings



• Intermittent feedings (cont’d)

– Gastric residuals are checked before each feeding

– Residual volumes of 200 mL or more on 2 successive assessments suggest poor tolerance

• Bolus feedings

– Variation of intermittent feedings

– Large volume of formula delivered relatively quickly

– Often cause dumping syndrome



• Continuous drip method

– Given at a constant rate over a 16- to 24-hour period

– Recommended for feeding of critically ill clients

– Continuous feedings should be interrupted every 4 hours

• Cyclic feedings

– Variation of continuous-drip feedings

– Cyclic feedings are usually well tolerated


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Initiating and advancing the feeding

– Before initiating a feeding, tube placement is verified ideally by radiography, and bowel sounds are confirmed to be present

– Regardless of the access route, tube feeding formulas are initiated at full strength

– Initial feedings may begin at 25 to 50 mL/hour and advance by 10 to 25 mL/hour every 8 to 12 hours as tolerated until the desired rate is achieved



• Initiating and advancing the feeding (cont’d)

– Commonly recommended maximum flow rate for gastric feedings is 125 mL/hr

– Using a standard feeding progression schedule helps to ensure timely progression of feedings to the goal rate

– Tolerance may be a problem for patients who are malnourished, who are under severe stress, or who have not eaten in a long time


Enteral Nutrition (cont’d)Enteral Nutrition (cont’d)• Tube feeding complications

– GI, metabolic, and respiratory complications are possible

– Aspiration is the most serious potential complication

– More common than large-volume aspirations is a series of clinically silent small aspirations

– Increases the risk of aspiration-related pneumonia



• Giving medications by tube

– Should never be given while a feeding is being infused

– Some drugs become ineffective if added directly to the enteral formula

– Ensure the tube is flushed with 15 to 30 mL of water before and after the drug is given



• Transition to an oral diet

– Goal of diet intervention is to ensure an adequate nutritional intake while promoting an oral diet

– Gradually increase meal frequency until 6 small oral feedings are accepted


QuestionQuestion

• What is the commonly recommended maximum flow rate for gastric feedings?

a. 75 mL/hr

b. 100 mL/hr

c. 125 mL/hr

d. 150 mL/hr


AnswerAnswer

c. 125 mL/hr

Rationale: The commonly recommended maximum flow rate for gastric feedings is 125 mL/hr; higher volumes may increase the risk of aspiration.


Parenteral NutritionParenteral Nutrition

• Developed in the 1960s

• Infusion of a nutritionally complete, hypertonic formula

• Life-saving therapy in patients who have a nonfunctional GI tract

– Also used for other clinical conditions such as critical illness, acute pancreatitis, liver transplantation, AIDS, and in patients with cancer receiving bone marrow transplants


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)• Overfeeding can cause a life-threatening complication

known as the refeeding syndrome

• PN is expensive, requires constant monitoring, and has potential infectious, metabolic, and mechanical complications

• Used only when an enteral intake is inadequate or contraindicated and when prolonged nutritional support is needed

• Should be initiated when oral intake has been or is expected to be inadequate over a 7- to 14-day period


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)• Catheter placement

– Patient’s anticipated length of need influences placement of the catheter

– For short-term central PN in the hospital, a temporary central venous catheter is placed percutaneously into the subclavian vein

– If PN is expected to be more than a few weeks, these are the catheters of choice:

o A Hickman catheter or Port-a-Cath

o Peripherally inserted central catheter (PICC)


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)

• Composition of PN

– Provide protein, carbohydrate, fat, electrolytes, vitamins, and trace elements in sterile water

– “Compounded” or mixed in the hospital pharmacy

– 2-in-1 formula (dextrose and amino acids)

o Used by most hospitals

o Lipids given separately

– 3-in-1 formula (dextrose, amino acids, and lipids)


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)• Protein

– Provided as a solution of crystalline essential and nonessential amino acids

– Amino acid formulations are available with and without electrolytes

– Providing adequate protein is a primary concern when formulating PN

– Nitrogen balance study can be used to determine adequacy of protein intake



• Carbohydrate

– Carbohydrate used in parenteral solutions in the U.S. is dextrose monohydrate

– Minimal amount of carbohydrate needed to spare protein is generally accepted as 1 mg/kg/min

– Hyperglycemia is associated with immune function impairments and increased risk of infectious complications

– High carbohydrate load may also lead to excessive carbon dioxide production



• Fat

– Lipid emulsions

o Made from soybean oil or safflower plus soybean oil with egg phospholipid as an emulsifier

o Isotonic

o Available in 10%, 20%, and 30% concentrations

o Significant source of calories

o Necessary to correct or prevent fatty acid deficiency


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)• Electrolytes, vitamins, and trace elements

– Quantity of electrolytes provided is based on the patient’s blood chemistry values and physical assessment findings

– Parenteral multivitamin preparations usually contain 12 to 13 essential vitamins

– Most adult formulations now contain a small amount of vitamin K

– Trace element preparations contain between 4 to 7 trace elements



• Medications

– Patients receiving PN may have insulin ordered if glucose levels are above 150 to 200 mg/dL

– Heparin may be added to reduce fibrin buildup on the catheter tip

– Medications should not be added to PN solutions because of the potential incompatibilities of the medication and nutrients in the solution



• Administration

– Administered according to facility protocol

– Generally initiated slowly (i.e., 1 L in the first 24 hours)

– Continuous drip by pump infusion is needed to maintain a slow, constant flow rate

– Rapid changes in the infusion rate can cause:

o Severe hyperglycemia or hypoglycemia

o Potential for coma, convulsions, or death



• Administration (cont’d)

– After the patient is stable, PN may be infused cyclically

– Cyclic PN allows serum glucose and insulin levels to drop during the periods when PN is not infused

– To give the pancreas time to adjust to the decreasing glucose load, the infusion rate is tapered near the end of each cycle


Parenteral Nutrition (cont’d)Parenteral Nutrition (cont’d)• Administration (cont’d)

– During the last hour of infusion, the rate may be reduced by one half to prevent rebound hypoglycemia

– When the patient is able to begin consuming food orally, the amount of PN is gradually reduced to prevent:

o Metabolic complications

o Nutritional inadequacies


QuestionQuestion

• Is the following statement true or false?

Medications should not be added to parenteral nutrition solutions because of potential incompatibilities.


AnswerAnswer

True.

Rationale: In general, medications should not be added to PN solutions because of the potential incompatibilities of the medication and nutrients in the solution.

copyright © 2010 wolters kluwer health | lippincott williams & wilkins feeding patients: oral...

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