Transcript Lecture 5a powerpoint

Feeding Patients: Oral Diets and
Enteral Nutrition
Chapter 15
Feeding Patients: Hospital Food and
Enteral and Parenteral Nutrition
• The prevalence of malnutrition among hospitalized adults is
estimated at 15% to 60%, depending on the patient population
and how malnutrition is defined (Mueller et al., 2011).
• 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.)
• 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.)
• Normal, regular, and house diets
– Regular diets are used to achieve or
maintain optimal nutritional status.
– Regular diets are adjusted to meet agespecific needs throughout the life cycle.
– Diet as tolerated (DAT)
Oral Diets—(cont.)
• Modified consistency diets
– Modified consistency diets include
o Clear liquid
o Mechanically altered diets
– Clear liquid diets may be used.
o To maintain hydration during gastrointestinal illness
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.
Oral Diets—(cont.)
• Modified consistency diets—(cont.)
– 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.)
• Therapeutic diets
– Therapeutic diets differ from a regular diet.
– Used for the purpose of preventing or
treating disease or illness
Oral Diets—(cont.)
• Nutritional supplements
– Some patients are unable or unwilling to eat
enough food to meet their requirements.
– Categories of supplements include
o Clear liquid supplements
o Milk-based drinks
o Prepared liquid supplements
o Specially prepared foods
Oral Diets—(cont.)
• Nutritional supplements—(cont.)
– 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.)
• Nutritional supplements—(cont.)
– Liquid supplements—(cont.)
oAllow the patient to taste test several
options available
oExplain the rationale for adding
supplements and closely monitor
acceptance
oGiven on a rotation schedule
Oral Diets—(cont.)
• Modular products
– Less frequently used option for maximizing a
patient’s oral intake
– Generally composed of a single nutrient
– Disadvantages
o Ineffective 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.)
• 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.)
• 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
Enteral Nutrition—(cont.)
• 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.)
• Feeding route—(cont.)
– Ostomy feedings are preferred for permanent or
long-term feedings.
– Percutaneous endoscopic gastrostomy (PEG)
tubes are placed with the aid of an endoscope.
Enteral Nutrition—(cont.)
• Formula characteristics
– Are designed to provide complete nutrition
Enteral Nutrition—(cont.)
• 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/L
Enteral Nutrition—(cont.)
• Protein—(cont.)
– 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.)
• Protein—(cont.)
– 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.)
• 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 1000 to 1500 mL/day
Enteral Nutrition—(cont.)
• Water content
– Varies with the caloric concentration
– Formulas that provide 1.0 cal/mL provide
850 mL of water per liter.
– High-calorie formulas are lower at 690 to
720 mL/L.
– Adults generally need 30 to 40 mL/kg/day.
– Need additional free water
Enteral Nutrition—(cont.)
• 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.)
• Fiber and residue content
– Terms fiber and residue are frequently used
interchangeably.
o Fiber
 Stimulates peristalsis, increases stool
bulk, and is degraded by
gastrointestinal bacteria
 Combines with undigested food,
intestinal secretions, and other cells to
make residue
Enteral Nutrition—(cont.)
• 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.)
• 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.)
• Equipment
– Tubing size and pump availability impact formula
selection.
– High-fiber formulas have a high viscosity and require a
large bore tube (8 French 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.)
• 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.)
• Intermittent feedings—(cont.)
– Gastric residuals are checked before each feeding.
– Residual volumes of 200 mL or more on two
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.)
• Continuous drip method
– Given at a constant rate over a 12- 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.)
• 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 10 to 40 mL/hour
and advance by 10 to 20 mL/hour every 8 to 12
hours as tolerated until the desired rate is
achieved.
Enteral Nutrition—(cont.)
• Initiating and advancing the feeding(cont.)
– Commonly recommended maximum flow rate for
gastric feedings is 125 mL/hour.
– 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.)
• 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.)
• 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 six
small oral feedings are accepted.
Enteral Nutrition—(cont.)
• 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.