Alternate Feeding Patterns

Enteral Nutrition
- administration of nourishment via the GI tract.
This includes administration of liquid diets, soft and solid food diets, and special nutritionally
formulas

Enteral feeding by tube

 Nutrients can be provided via feeding tubes placed into the alimentary tract.

Conditions warranting tube feeding

¤ severe dysphagia
¤ major burns
¤ a short gut from small bowel resection
¤ intestinal fistulas

Conditions under which enteral tube feeding is helpful but not routine
¤ major trauma
¤ radiation therapy
¤ chemotherapeutic regimens
¤ acute or chronic liver failure
¤ severe renal dysfunction

Types of Formulas

¤ Standard intact formulas – (polymeric formulas) are composed of intact nutrients that require
a functioning GI tract for digestion and absorption of nutrients.
o Blenderized food products
o Milk-based products
o High-kcalorie lactose-free products
o Normocaloric lactose-free products
 Isotonic - having the same concentration of solute as another solution
 Hypertonic- having greater concentration of solute than another solution
 High-nitrogen- are designed to meet increased protein demands at usual or
increased energy needs
 Fiber containing – used for patients with abnormal bowel regulation, contain
fiber from natural food sources

Special Formulas

¤ Elemental formulas – (predigested or hydrolyzed formulas) are composed of partially or

fully-hydrolized nutrients that can be used for patients with a partially functioning GI tract or
those who have impaired capacity to digest foods or absorb nutrients, pancreatic insufficiency, or
bile salt insufficiency. They are not palatable and are best suited for administration by tube.
¤ Modular formulas – are not nutritionally complete by themselves because they are single
macronutrients such as glucose polymers, protein or lipids. They are added to foods or other
enteral productsto change composition when nutritional needs cannot be met

¤ Specialty formulas – are designed to meet specialized nutrient demands for specific disease
states such as diabetes, renal failure, liver failure, pulmonary disease, or HIV/AIDS.

Feeding Routes

 Nasogastric : Tube is passed through nose to stomach.

 Nasoduodenal : Tube is passed from nose to duodenum (small intestine).
 Nasojejunal : Tube is passed through nose to jejunum (small ontestine).
 Esophagostomy : Tube is surgically inserted into the neck and extends to stomach.
 Gastrostomy : Tube is surgically inserted into stomach.
 Jejunostomy : Tube is surgically inserted into small intestine.

Method of Administration

 Continuous infusion – is generally the preferred method of feeding.

- provides controlled delivery of a prescribed volume of formula at a constant rate over
a continuous period using an infusion pump
-
 Intermittent infusion – involves delivering the total quantity of formulas needed for a 24-
hour period in 3 to 6 equal feedings.
- Each feeding is usually delivered by gravity during a 30- to 90- minute period
- This method presents a more normal feeding pattern, but patients may not tolerate
when feeding rate is too rapid
- Feedings must be closely monitored to ensure proper delivery rate.

 Bolus feeding – involve infusing volumes of formula by gravity or syringe over a short
period of time
- It is requires minimal equipment and time but is associated with increased potential
for aspiration, regurgitation, and GI side effects.
- It should not be used for intestinal feedings.

Home Enteral Nutrition (HEN)

HEN imparts responsibility that nurses and dieticians must assume and risks that must be
anticipated.

Criteria considered for a Home enteral nitrition therapy

> Patient’s nutritional needs cannot be met orally
> Appropriate enteral access is in place and functioning, and patient is tolerating tube
feeding regimen.
> Patient and /or SO is able and willing to perform HEN techniques safely and effectively
 > Underlying disease state is stable, and patient is ready for discharge and can be
monitored in the home setting
> Affordable HEN supplies are available

Possible Tube Feeding Complications

Gastrointestinal complications:
Diarrhea
Nausea and vomiting
Cramping
Distention
Constipation

Mechanical Complications:
Tube displacement
Tube obstruction
Pulmonary aspiration
Mucosal damage

Metabolic complications:
Hyperosmolar dehydration
Overhydration (fluid overload)
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hyperphosphatemia
Hypophosphatemia
Hypomagnesemia
Hypermagnesemia
Increased Respiratory quotient; excess CO2 production; Respiraatory insufficiency
Rapid, excessive weight gain

Parenteral Nutrition
- administration of nutrients by a route other than the GI tract, usually intravenously

¤ Central parenteral nutrition (CPN) or Total parenteral nutrition (TPN)

- when infused into a large-diameter vein, such as the superior vena cava or
subclavianvein
- preserved for severely malnourished patients undergoing chemotherapy and major
surgery
¤ Peripheral parenteral nutrition (PPN)
- when a smaller , peripheral vein is used, usually the forearm
Other terms are also used to characterize parenteral nutrition
¤ Central venous nutrition (CVN)
¤ Peripheral venous nutrition (PVN)
¤ Hyperalimentation (hyperal)

Components of Pareneral Nutrition Solutions

Carbohydrates
- dextrose monohydrate is the most common carb used
- used as an energy source, yields 3.4kcal/g

Amino acids
- Protein is provided in PN sol’n as a mixture od essential and non-essential crystalline
amino acids that are available with or without added electrolytes.
- Amino acid sol’n are available for specialized protein needs such as renal failure,
liver failure, stress and trauma, but their efficacy is controversial.

Fats
- IV lipid emulsions are used as concentrated energy source and to prevent the
development of essential fatty acid deficiency.
- Commercial lipid emulsions are formulations of safflower oil, soybean oil, or
combination of the two, with glycerol added for isotonicity and egg phospoholipid
added for emulsifying agent.

Total Nutrient Admixtures

- When lipid emulsions are added to dextrose and amino acid mixtures, the resulting
sol’n is called a three-in-one mixture
- It allows lipid infusion over 24 hours, decreasing CO2 production and reducing
hepatic accumulation of fat induced by long term glucose use.

Electrolytes
- Electrolytes and minerals can be provided by the general amino acid sol’n, as a
combined electrolyte concentrate, or added separately as individual salts.
- Electrolytes and minerals are essential for normal body function and to accommodate
excesses and deficiencies of minerals resulting from underlying disease processes.

Vitamins
- Adult and pediatric multivitamin formulations for IV use are available commercially.
- In the event of frank vitamin deficiency, multiples of daily doses can be given in
accordance with clinical status
- Vit. K is not included in adult preparations and must be given either IM or as an IV
injectable added to to the PN sol’n.

Trace Elements
- They are another essential component of PN sol’n.
 - Formulations that include zinc, copper, manganese, chromium, and selenium are
available from commercial sources already combined, or institutional pharmacies
may develop their own IV injectable formula.

Home Parenteral Nutrition (HPN)

HPN enables selected patients who depend on PN to return to reasonably normal lifestyle.
A specialized catheter is placed through a tunnel under the skin and exits the chest at a place
where the patient or caretaker can care for it conveniently. HPN requires the patient and SO to be
willing and able to perform daily procedures involved in administering the PN, which include
monitoring laboratory values, temperature, weight, glucose measurements, and fluids.

Complications of Parenteral Nutrition

Technical Complications
Pneumothorax
Malposition of catheter
Subclavian artery puncture
Carotid artery puncture
Catheter embolism
Air embolism
Catheter obstruction
Thrombosis

Septic complications
Catheter-related sepsis
Septic thrombosis

Metabolic complications
Hyperglycemia
Hyperglycemic hyperosmolar nonketoic dehydration
Hypoglycemia
Hyperkalemia
Hypophosphatemia
Hypocalcemia

Transitional Feedings
 A period of adjustment or weaning, is necessary before discontinuing nutritional support or
when converting from one form of nutritional support to another.
 Patients with who have been receiving TPN usually have decreased appetites and may take 1
to2 weeks after complete cessation of TPN before they feel hungry and may experience
early satiety. This necessitates gradual weaning from PN as enteral feeding (oral or tube)
progresses to ensure continued adequate intake.
 Stopping TPN to quickly can result in hypoglycemia.

Parenteral to Oral or Tube Feeding

o Long periods of PN wihtout enteral feedings result in atrophy of the GI tract.
o Before weaning, assessment of GI function is needed to prevent problems with
delayed gastric emptying, nausea, vomiting, or diarrhea.
o It is important to document actual enteral intake.
o If oral feedings or isotonic formulas are not well tolerated, elemental formula may be
needed.

Tube to Oral Feeding

o Documentation of intake per tube and orally is important.
o Assess patient’s swallowing ability before offering oral feedings.
o Full liquids are usually offered first, followed by pureed or soft foods.
o Tube feedings should be stopped at least 1 hour before and after mealtime to promote
appetite.
o As oral intake increases, tube-feeding volume.

Reference:

Grodner, M., et al. 2005. Foundations and Clinical Applications of Nutrition: A

Nursing Approach. 3rd edition. Elsevier (Singapore) PTE LTD. Philippines