Medical Nutrition Therapy — Enteral Nutrition – Flashcards
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Nutrition Support
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Delivery of formulated nutrients / diets to maintain or restore nutritional status
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Enteral nutrition support
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Provision of supplemental or total nutrition by feeding directly into the GI tract using a feeding tube
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Parental nutrition support
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Provision of nutrients intraveneously
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What are the indications for use of EN?
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For patients who can't fulfill their nutrition needs orally, but with a functioning or semi-functioning digestive system - Neurological conditions, e.g., coma - Oral or esophageal complications - Increased need in multitude (AIDS, cancer, trauma, sepsis, and burn, etc)
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What are the advantages of using EN compared with TPN?
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Maintain gut integrity Reduce the risk of complications (less invasion and more regulation of nutrient-intake) More cost effective (treatment cost, personnel, and length of stay)
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How does EN maintain better gut integrity than TPN?
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Nourishing the enterocytes and colonocytes Resulting in better integrity of the GALT (gut associated lymphoid tissues) --> better immunity Maintain microflora Lower risk of infections and complications (avoid infection via IV and re-feeding syndrome, etc)
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Contraindications for use
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Severely malfunctioned GI tract Severe inflammatory bowel diseases Hypermetabolic state along with poor enterotolerance / access to GI tract
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What are the 2 most common access routes of EN?
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Nasal (for 4 weeks)
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What are the advantages of taking the nasal route for EN?
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No surgery needed More regulation (storing and holding) if the stomach not skipped Better digestion with the stomach Normal enzymes and normal enzyme activities in the stomach
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What are the disadvantages of taking the nasal route for EN?
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Risk of aspiration --> risk of pulmonary inflammation and infection Uncomfortable for patient, esp discomfort when breathing, and irritation in the GI tract Not used in low level of consciousness
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What are some types of ostomy for EN?
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Esophagostomy / pharyngostomy Gastrostomy (PEG) Jejunostomy (PEJ)
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What are some advantages of ostomy for EN?
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Lower visibility Not interfering breathing Less complicated administration
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What are the disadvantages of ostomy for EN?
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Surgical risks (anesthesia, local or total) Invasive (increased risk of infections)
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What are the considerations of the selection of routes of administration?
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The duration of feeding If the GI tract is functioning The risk of aspiration (choose post-pyloric to reduce the risk)
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What are the two delivery ways for EN?
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Gravity -- adjustable clamp regulates rate Pump -- electronic device regulates rate
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What are the advantages and disadvantages of using gravity for administration of EN?
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Advantages: Cheap; pt is not trapped with the feeding device Disadvantages: - difficult to control rate - used only for bolus feeding - Not used when the stomach is not participating
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What are the advantages and disadvantages of using pump for administration of EN?
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Advantages: - Higher tolerance (little amount every hour) - More accurate delivery - Keep tract of the feeding Disadvantages: - expensive - Low pt's mobility - Takes a lot longer
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What are the delivery methods for EN?
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Bolus or intermittent feeding Continuous or drip feeding
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What are the advantages and disadvantages when applying bolus feeding?
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Advantages: - Higher pt mobility - Mimmic normal feeding (aka normal hormone and GI tract interaction) - No pumb required - Shorter periods of time Disadvantages: - Risk of GI intolerance - Risk of Aspiration - Possible delayed or missed feedings by healthcare staff
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What are the advantages and disadvantages when applying continuous feeding?
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Advantages: - Better GI tolerance - Ideal for maximizing absorption - Large volume allowed Disadvantages: - Takes 20 hours for feeding each day - Low patient mobility - Costly
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What are the macronutrient distributions and calorie density of typical nutritionally complete formulas?
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Calorie: 1 kcal / ml (or 2 kcal if on fluid restriction) CHO: 45 - 55% Fat: 20 - 25% Protein: 10 - 25%
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What determines the fiber content in an EN formula?
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High when used for pt on long term EN feeding
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What are the considerations for formula selection?
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Nutritional needs Enteral feeding route Digestive and absorptive capacity Formula viscosity Formula Availability Disease state and functions of organs Food allergies and intolerance
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What are the different types of formulas?
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Blenderized Polymeric/intact protein Partially hydrolyzed/peptide-based/semi-elemental Monomeric/free AA/defined Disease-specific Modular
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What are the componets of blenderized formula?
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Home-made blended food with supplemental v/m
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How is the viscosity of blenderized formula?
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High d/t the fiber content
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How should blenderized formulae administered?
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Only intra gastric (dealing with whole food and whole protein)
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How should the GI function of the pt be when considering blenderized formulae?
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Fully functioning GI
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What are the components of polymeric formulae?
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CHO: di-, oligo-, polysaccharides (no lactose) Fat: whole fat from vegetable oils Protein: whole protein (e.g.,soy isolates, caesin, lactoalbumin) Fiber: no fiber typically (added if used long-term)
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How is the viscosity of polymeric formulae?
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Low to moderate depending on fiber content
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What is the osmolality of polymeric formulae?
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300 - 450 (isotonic, same as blood)
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How should the GI function of the patient be when considering using polymeric formulas for EN?
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Intact GI
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Where should polymeric formulas be administered?
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Best used for intragastric Duodenum not the best, but still OK
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What are the components of peptide-based formulas?
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CHO: oligosacharides, disacharides (no poly-) Fat: vegetable oils and medium chain triglycerides Protein: short chain peptides
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How is the viscosity of peptide-based formulas?
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Low (no fiber present)
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What is the osmolality of peptide-based formulas?
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A little bit higher than isotonic
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How is the taste of peptide-based formulas?
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Highly unpalatable
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Where should peptide-based formulas administered?
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Jejunum
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What should the patient profile for feeding peptide-based formulas?
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Patients with no gastric function and impaired absorption
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What are the components of monomeric formulas?
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CHO: disacharide Protein: free amino acids Fat:minimal (just essential fatty acid and medium chain triglyceride) to prevent disorder
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How is the viscosity of monomeric formulas?
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Low (no fiber present)
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What is the osmolality of monomeric formulas?
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Hypertonic
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How is the taste of monomeric formulas?
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Highly unpalatable
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Where should monomeric formulas be administered?
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Jejunum
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What is the patient profile indicating the use of monomeric formulas?
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Severe absorptive dysfunctions
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Give some examples of disease-specific formulas.
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Fluid restriction: high caloric density High nitrogen formulas: increased protein need Diabetes: lowered CHO Kidney / liver diseases: low K, Na, and P
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What are modular formulas?
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Formulas mixed by health-workers to fit specific needs of the patients
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What needs to be monitored for patients on EN?
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Metabolic status: - Serum electrolytes 2-3x weekly, per patient condition, or accord to facility protocol - BG, Ca2+, Ph2+, Mg2+ weekly, per patient condition, or accord to facility protocol GI tolerance: - Stool output amount and consistency daily - Gastric residuals q 4 hours if indicated Intake and output records: - Fluid status daily - Adequacy of enteral intake at least 2x weekly, more often initially Nutritional status: - Serum proteins Clinical: - Signs and symptoms or edema and dehydration daily
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What are the metabolic complications resulted from EN?
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Refeeding syndrome: imbalance of fluid, glucose, electrolyte, acid-base, and minerals
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What are the causes, and prevention and treatment for refeeding syndrome?
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Cause: overfeeding --> hyperglycemia Prevention: - Montoring I & O - Monitoring BG and electrolyte balance Treatment: - Modify formula and rate - Prescribe electrolyte via IV
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What are some examples of gastrointestinal complications resulted from EN?
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N/V, GER, constipation, diarrhea
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What are the causes of gastrointestinal complications?
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Type of formula Administration site Tube migration --> diarrhea Infusion rate Infection --> diarrhea Side effects of medication
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What are the prevention and treatment for EN gastrointestinal complications?
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Keep monitoring for signs and symptoms Rule out the possibility of infection and med side effects Elevated the head of the bed Modify rate/type of formula
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What are some mechanical complications resulted from EN?
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Naso/pharyngeal/esophageal discomfort and/or ulcer Occluded tube
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What causes mechanical complications resulted from EN?
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Tube is not properly flushed Bad tube position
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How to prevent mechanical complications resulted from EN?
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Flush properly Minimize tube size Check the placement If applicable, maintain good oral hygiene. Chew gum to raise salivary flow
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What are some infectious complications resulted from EN?
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Infections at the site of administration Pulmonary infection d/t aspiration GI infection
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What causes infectious complications for EN?
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More common in ostomy -- improperly cleaned site Contaminated formula / equipment Aspiration
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How to prevent infectious complications for EN?
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Monitor stomach distention to avoid aspiration Elevate the head of the bed Reduce the rate Good ostomy care proper treatment of equipment Monitor girth for stomach moving downward
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Institute nutritional support if:
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Patient has been without nutrition for 7 days Expected duration of illness greater than 10 days More than 10% weight loss Patient at high risk Initiate EN or TPN only when patient is hemodynamically stable and electrolytes are normal.
