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Enteral Nutrition

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Enteral Nutrition. Lynn Thomas, DrPH, RD. Basic Diet Orders. NPO. Nothing by ... Clear Liquids - ginger ale, gelatins, Popsicles, strained ... Lynn Thomas, DrPH, ... – PowerPoint PPT presentation

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Title: Enteral Nutrition


1
Enteral Nutrition
Lynn Thomas, DrPH, RD
2
Basic Diet Orders
  • NPO
  • Nothing by mouth
  • NPO x meds
  • Sips
  • Clear Liquids - ginger ale, gelatins, Popsicles,
    strained juices, sherbet, slushes, tea or decaf
    coffee

3
Diet Orders
  • Full Liquids - milk, cream soups, milk shakes,
    pudding, custard, everything on clear liquids
  • Soft diet - mashed potatoes, pasta, casseroles,
    cooked vegetables, canned fruits, liquids

4
Types of Diets
  • Pureed
  • Dysphagia
  • Electrolyte or fluid restriction
  • High fiber or low fiber
  • Low CHOL or low fat

5
Supplements
  • Milk based or lactose free.
  • Clear liquid protein boosters.

Oral supplements to boost kcal and protein.
6
Diet Orders
  • Diet orders written by MD.
  • Nurses per verbal orders.
  • RD per verbal orders.
  • Standard diet varies in each hospital
  • Providence AHA Heart Healthy Diet
  • VA average male 2400 kcal/85 g protein

7
Doctors Orders
  • Diet orders written with admission orders
  • DX/Condition
  • Diet Orders including NPO
  • Tests/Labs
  • Meds/IV Fluids
  • Consults
  • Separate orders for additional changes

8
Tube Identification
  • Nasogastric
  • Nasoduodenal
  • Nasojejunal
  • Oral placement
  • Should be small
  • in diameter and soft

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Tube Identification
  • Surgical Esophagostomy
  • Surgical or Percutaneous endoscopic gastrostomy
    tube
  • Surgical or Percutaneous endoscopic jejunostomy
    tube

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Delivery Methods
  • Continuous Drip
  • 24 hours or cyclic
  • Intermittent Delivery
  • over 24 hours
  • no night feedings at home
  • Bolus Delivery
  • only for the alert and oriented

15
Delivery Formulas
  • Intermittent into the gut
  • Continuous into small bowel.
  • Isotonic formulas best tolerated in small bowel.
  • Hypertonic formulas into gut. Dilute into small
    bowel.

16
Osmolality
  • Measure of concentration of molecular and ionic
    particles in a solution.
  • Isotonic formulas 300 mOsm/kg
  • same as blood serum
  • 300 400 well tolerated
  • Hypertonic Formulas
  • 400 mOsm/kg

17
How much Formula?
  • Energy needs- start with 25 -35 kcal/kg actual or
    dry weight. Order metabolic cart analysis if
    available.
  • Protein needs- start with 1.0-1.2 g/kg and
    increase or decrease as needed. Lower in
    encephalopathy and acute renal. Higher in stress
    and trauma.

18
Other Common Restrictions
  • Fluid restriction is generally most limiting in
    product selection.
  • All are low sodium.
  • Potassium restriction common with renal.
    Generally 2-3 g/day or 55-80 mEq.
  • fat and kind of fat varies.

19
Order Writing
  • Intermittent Delivery
  • 1 can Ensure Plus with 240 cc H20 q4 hours.
  • Continuous Drip
  • FS Osmolite HN _at_ 40 ml/hr with 100 cc H20 q6
    hours as tube flush.

20
Supplemental Water
  • Dont forget to water your enteral feeding
    patients!
  • Tubes need to be flushed on a schedule before
    and after meds before and after feedings.

21
Do the Math- 60 kg patient
  • Want to feed 30 kcal/kg
  • 60 kg x 30 1800
    kcal/day
  • 1 kcal/ml formula
  • 1800 ml to meet needs
  • Pump FS
  • 1800/24 hours 75 ml/hr
  • FS Isocal_at_75ml/hr with 100 ml H20 q6 hours
  • 1.5 kcal/ml formula
  • 1800 kcal/1.5 1200 ml to meet needs
  • Intermittent
  • Divide volume by number of feedings
  • 240 ml (can) with
  • 240 ccs H20 q 4 hours, omit 2 am feeding

22
Medication Delivery
  • Liquid form when available
  • Dilute thick medications
  • Crush pills, etc., and mix with water to form a
    slurry
  • Order tubes flushed with water before and after
    giving meds
  • Medications are not put in the in the feeding

23
Parenteral Nutrition
Lynn Thomas, DrPH, RD
24
Indications
  • Patients with an inability to absorb nutrients
    via the gastrointestinal tract.
  • Patients whose nutrient needs cannot be met with
    enteral feedings within 7 to 10 days.
  • Patients with severe malnutrition or catabolism
    where the GI tract is not usable within 3-5 days.

25
Contraindications
  • Patients with a functional and usable GI tract
    capable of absorption.
  • Less than 5 days of treatment anticipated.
  • When prognosis does not warrant aggressive
    nutrition or when not wanted by patient or family.

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Central sites Internal
jugular Subclavian vein Femoral vein
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15- 30
33
Limitations
  • Determine any special requirements such as higher
    fat and lower carbohydrate.
  • Check for additional electrolyte adjustments.
  • Decide if a fluid restriction is necessary.

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Pharmacy Label
  • Dextrose 70 450 ml
  • Amino Acids 10 900 ml
  • Fat emulsion 20 225 ml
  • MVI-12 10 ml Trace Elements 3 ml
  • Hyperlyte 45 ml sterile H20 167 ml
  • 75 ml/hr
  • Final Conc Dex 17.5 and AA 5

37
Another Example
  • Volume of 3000 ml
  • Run at 125 ml/hr
  • Dextrose 7, AA 3
  • 115 ml 20 lipids/liter
  • Standard lytes, MVI TE
  • 40 CHO, 20 AA, 40 Fat

38
Keep in Mind
  • Plan any tubefeedings or parenteral nutrition
    around diet restrictions.
  • IF the nutrient would be restricted on the
    oral diet, then it needs to be considered when
    planning any kind of nutrition support.
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