Enteral/Parenteral Feeding Calahan

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Enteral/Parenteral Feeding Calahan
2014-04-07 23:08:04

Enteral/Parenteral Feeding
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  1. ORAL
    • •High-calorie supplements
    • •Used when nutritional intake is deficient
    • (no appetite, cancer patients)

    • •Examples include
    •    Milkshakes
    •    Puddings
    •    Ensure, Boost, Glucerna, Pulmocare
    •    Used as snacks not meal replacements
  2. Sites other than stomach are used when there is a problem with motility of the stomach (gastroparesis)
  3. Tube Feedings
    • Nnutritionally balanced formula given through tube inserted into
    •    -Stomach
    •    -G Tube
    •    -—Duodenum
    •    -Jejunum

    —Sole source of nutrition or supplement

    —Easily administered

    —More efficient/safer than parenteral

    —Less expensive than parenteral
  4. Who gets tube feedings?
    • (Trauma, surgery, anatomical reasons)
    • •Anorexia
    • •Orofacial fractures
    • •Head/neck cancer
    • •Burns
    • •Nutritional deficiencies
    • •Neurologic conditions
    • •Psychiatric conditions
    • •Chemotherapy
    • •Radiation therapy
  5. Delivery Options for Tube Feedings
    •Continuous infusion by pump

    •Intermittent by gravity (bolus)

    •Intermittent bolus by syringe

    •Cyclic feedings by infusion pump
  6. Nasogastric Tubes
    •Inserted through the nasal cavity

    •Radiopaque: Allowing visualization from X-ray

    •↓ Likelihood of regurgitation and aspiration when placed in intestine

    •Can be dislodged by vomiting or coughing (must check placement)

    •Can be knotted/kinked in GI tract
  7. Gastrostomy and jejunostomy tubes
    Those needing tube feedings for extended period

    •Patient must have intact, unobstructed GI tract

    • Can be placed surgically, radiologically, or endoscopically

    •Enteral route preferred

    •Preserves integrity of intestinal mucosa

    •Maintains normal pH in the stomach

    •prevents entry of bacteria into the body through GI tract walls
  8. Patient Positioning for Administering Tube Feeding
    —Patient should be sitting or lying with HOB at 30 to 45 degrees

    —HOB remains elevated for 30 to 60 minutes for intermittent delivery
  9. Tube Patency when administering tube feeding
    —Irrigated with water before/after each feeding, drug administration, residual checks

    —Continuous feedings administered on feeding pump with occlusion alarm
  10. Tube Placement
    •Check before each bolus feeding or drug administration

    •Check q8h with continuous feeds

    • •Methods used to check placement:
    •    -Aspiration of stomach contents; also tells us residual
    •    -pH check:: pH less than 5: Indicative of stomach
    •    -Most accurate assessment: X-ray visualization

    •Why do we need to check placement? RISK FOR ASPIRATION
  11. Clinical Signs of Tube Intolerance
    Abdominal Distention, Vomiting, Uncomfortable Pt
  12. Gastric Residual
    •↑ residual volume leads to aspiration

    • •Before feeding::
    •    -Aspirate gastric contents and measure amount

    • •IF Volume > 150 ml and clinical signs of intolerance
    •      -Notify provider
    •      -Hold feeding for 1 hour
    •      -Recheck residual
    •      -More than 110% of hourly rate of pump—hold feeding

    •Residual should be given back to patient
  13. When Administering Feedings:
    •Formula should be room temperature

    •Kangaroo Pump

    • •Gradually increase rate or volume over 24 to 48 hours
    • (Why do we do this?  to build pt tolerance)

    •Intermittent or bolus feedings

    •Volume usually 200 to 500 ml per feeding

    •More closely approximates normal meal

    • •Administer flush water or water boluses
    •    -As ordered
    •    -As patient tolerates
  14. Nursing Responsibilities with Tube Feedings
    •Daily weights

    • •Assess for bowel
    • sounds before feedings

    •Accurate I&O

    •Initial glucose checks

    •Label with date and time started

    •Feedings infusing >8 hours discarded

    •Prefilled bottles are hung for 24 hours

    Pump tubing changed q24h to prevent bacteria growth
  15. Complications of Tube Feedings
    • —Nausea / Vomiting
    • —Diarrhea
    • —Constipation
    • —Dehydration
    • —Skin irritation / breakdown around G-tubes /J-tubes
    • (—why? gastric acid/enzymes leaking out on the skin lead to skin breakdown)
    • —Blood glucose imbalances
    • —Sodium imbalances
    • Potassium Imbalances
  16. Considerations for Older Adult with Tube Feeding
    • •More vulnerable to complications
    • •Fluid and electrolyte imbalances
    • •Glucose intolerance
    • •Decreased ability to handle large volumes
    • •Increased risk of aspiration
  17. Parenteral Nutrition
    —Administration of nutrients by route other than GI tract (bloodstream)

    • —Total Parenteral Nutrition (TPN)
    •    -Hung once every 24hours
    •    -The IV provision of dextrose, amino acids, emulsified fats, trace elements, vitamins and minerals to patients who are unable to assimilate adequate nutrition by mouth

    —Frequent BG monitoring daily

    —(Custom for the patient based on the labs (titrating)
  18. What patients get parenteral nutrition
    • •GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients
    • •Chronic diarrhea and vomiting
    • •Complicated surgery or trauma
    • •Gastrointestinal obstruction
    • •Gastrointestinal tract anomalies and fistulae
    • •Intractable diarrhea
    • •Malnutrition
  19. Composition of TPN
    —Base solutions contain dextrose and amino acids

    • —The addition of electrolytes, vitamins, and trace elements is individualized to the
    • patient

    —Three-in-one solutions contains fat emulsion, dextrose, and amino acids

    —Calories supplied primarily from carbohydrates (dextrose) and fat emulsion
  20. Preparation of TPN
    • —PN solutions prepared by pharmacist or trained
    • technician under strict aseptic techniques

    —Must be refrigerated until 30 minutes before use

    —Must be labeled with nutrient content, all additives, time mixed, date and time of expiration

    —Must be ordered daily

    —Fresh bag prepared every 24 hours
  21. Peripheral TPN
    —Peripheral IV catheter

    —Large peripheral vein

    —Short-term nutritional support

    —Protein and caloric requirements are not high

    —Used when the risk of a central catheter is too great

    —Hypertonic:  up to 20% dextrose
  22. Central TPN
    • —IV catheter whose tip lies in superior vena cava (Subclavian or jugular vein)
    • —Peripherally inserted central catheters (PICCs)
    • —Long-term parenteral support
    • —Hypertonic:  20-50% dextrose; 1600 mOsm/L
    • —Lipids can be administered with less risk of thrombophlebitis
  23. TPN catheter placement
    • —-Catheter placement under sterile conditions by MD/PA/APN
    • -—Placement confirmed by x-ray before use
    • -—Site covered with sterile dressing
    • -—Date marked on dressing
    • -—Sterile dressing change per facility policy
  24. Complications of TPN
    • —Infection
    •    **Must have filter

    —With lipids: Tubing, filter change q24h

    —With amino acids, dextrose: Filter, tubing change q72h or per facility policy

    • —Metabolic problems::
    • Hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid deficiency, electrolyte disturbances, hyperlipidemia, mineral deficiencies


    —Mechanical problems

    —Insertion problems

    —Dislodgement, thrombosis of great vein, phlebitis
  25. Nursing Management for TPN
    • —VS q 4-8 h
    • —Daily weights
    • —Blood glucose
    • —   -Check initially every 4-6 hours
    • Labs at least 3x per week
    •    -—Electrolytes
    •    -—BUN
    •    -CBC
    •    -Hepatic enzymes
    • —Dressing changes: sterile technique
    • —Site observation key
    • Before administering, check label and ingredients against order

    Examine bag for signs of contamination

    Infusion pump must be used

    • If PN bag runs out before next bag is available:
    •    -Central PN= hang 10% dextrose
    •    -Peripheral PN= hang 5% dextrose

    —Infusion rate is slowly titrated based on patient tolerance until the desired rate is achieved

    • —Fat emulsion (Lipids) can be administered separately or can be mixed in the bag with the PN
    •    *—Preferred delivery is a continuous low volume (over 12 hours)

    • —   *Adverse reactions to Lipids
    •      -—Allergic reactions (hypersensitivity to egg products, soybeans or legumes)
    •      -—Dyspnea, cyanosis, fever, flushing
    •      -Phlebitis
    •      -—Chest and back pain
    •      -Pain at the IV site
  26. Manifestations of Infection/Septicemia from TPN
    • —Local manifestations
    • Erythema
    • —Tenderness
    • —Exudate at catheter insertion site
    • Systemic
    • —Fever, chills
    • —Nausea/vomiting
    • —Malaise
    • (if infection is suspected= blod and catheter CULTURES!)