Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition

•  Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition
Chapter 15

•  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)

•  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 Diets

•  Easiest and most preferred method of providing nutrition

•  Oral diets may be categorized as:

–  “Regular”

–  Modified consistency

–  Therapeutic

–  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)

•  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

o  Oral Diets (cont’d)

•  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

•  Oral Diets (cont’d)

•  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

–  Oral Diets (cont’d)

•  Nutritional supplements (cont’d)

–  Categories of supplements include:

o  Clear liquid supplements

o  Milk-based drinks

o  Prepared liquid supplements

o  Specially prepared foods

•  Oral Diets (cont’d)

•  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

•  Oral Diets (cont’d)

•  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)

•  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 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 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)

•  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

•  Enteral Nutrition (cont’d)

•  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

•  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

•  Enteral Nutrition (cont’d)

•  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

•  Enteral Nutrition (cont’d)

•  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

o  Enteral Nutrition (cont’d)

•  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)

•  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

•  Enteral Nutrition (cont’d)

•  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)

•  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

•  Enteral Nutrition (cont’d)

•  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)

•  Fiber and residue content

–  Terms fiber and residue are frequently used interchangeably

o  Fiber

q  Stimulates peristalsis, increases stool bulk, and is degraded by gastro-intestinal bacteria

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

o  Enteral Nutrition (cont’d)

•  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

•  Enteral Nutrition (cont’d)

•  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

•  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

–  Enteral Nutrition (cont’d)

•  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

•  Enteral Nutrition (cont’d)

•  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

•  Enteral Nutrition (cont’d)

•  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)

•  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

•  Enteral Nutrition (cont’d)

•  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)

•  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

•  Enteral Nutrition (cont’d)

•  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

•  Enteral Nutrition (cont’d)

•  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

•  Parenteral 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)

•  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)

•  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)

•  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)

•  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

–  Parenteral Nutrition (cont’d)

•  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

•  Parenteral Nutrition (cont’d)

•  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)

•  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

•  Parenteral Nutrition (cont’d)

•  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

–  Parenteral Nutrition (cont’d)

•  Administration

–  Administered according to facility protocol

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