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discuss the indications and contraindications for the use of parenteral vs enteral nutrition discuss the nursing considerations related to patient care when administering enteral and parenteral nutrition be aware of some of the types of enteral nutrition tubes available discuss some of the possible complications that could arise from both
Parenteral and Enteral Nutrition
Capital District Health
is the intravenous infusion of nutrients, including: amino acids glucose fat emulsions vitamins electrolytes minerals trace elements water
Indications for PN:
Patients who are moderately to severely malnourished, in negative nitrogen balance GI tract is impaired
obstruction, ileus, surgery, fistulas, short bowel syndrome
Acute pancreatitis or GI bleed Acute episodes of Crohn’s/ Colitis Severe burns, trauma, liver or renal disease Radiation enteritis and terminal illness
Modes of Administration
1. Peripheral Parenteral Nutrition [PPN]
Large volume medication Record it as a medication Need to perform a double check to ensure accuracy Requires a 0.22 micron bacterial retentive filter Follow aseptic technique when caring for lines
2. Central Parenteral Nutrition [CPN]
commonly referred to as TPN hypertonic, dextrose>10%
Guidelines: Dietician consultNutritional assessment DR's order sheet [starting/stopping protocols] Guidelines Baseline lab work. & wt. Change needleless connectors [CLC2000] Qwk. Phos. then if needed initiate sliding scale or continue checks PRN) 24hr urine Q wk. TPN/PPN administration tubing. Mag. ALT. INR.22um bacterial retentive filter is required during administration of TPN. Bilir. Creat. Nursing Considerations-TPN Central lines should be removed when: they are no longer medically necessary if the initial site becomes infected if the line is suspected as the source of bacteremia or clinical sepsis Nursing considerations. All TPN -admix only in the pharmacy using aseptic technique. Ca+. Glucose. ht.TPN Between changes of components. CBC. Injection ports to be decontaminated with alcohol swab prior to connecting. E+. -changed Q72hrs [Q24hrs when transfusing with Lipids] Nursing considerations. AST. 2 . BUN. [no additives on floor]. Alk Phos. TPN & Lipid solutions –to be completed within 24hrs of initiation. A 0.TPN: Parenteral nutrition catheters -use exclusively for parenteral nutrition. Change transparent dressing to insertion site once/week & PRN. if required Nursing Considerations-TPN Central cannulas should be inserted and cared for using sterile technique. Pre-Albumin Routine monitoring: lab work (once-twice/week): glucose checks (BID x48hrs. Routine central line changes are currently not recommended. the IV system –to be maintained as a closed system. Albumin. with filter.
do not use. cracks. It is the preferred method for providing nutrition and should be used when the patient’s GI tract is functional. particulate matter. leaks. Complications Catheter-related sepsis meticulous aseptic technique is essential Air embolism Central venous thrombosis Catheter occlusion Hyperglycemia Hypoglycemia Enteral Nutrition/Tube Feeds Enteral Nutrition is the administration of nutrients directly into the gastrointestinal tract. and expiry date before use.partially maintained severe short bowel syndrome intestinal obstruction intractable vomiting & diarrhea acute GI bleed inability to gain enteral access severe IBD severe acute Pancreatitis Deterioration of gut integrity from gut disuse 3 . before considering parenteral nutrition. during fed state Contraindications of Tube Feeds/ Enteral Nutrition minimal GI function.TPN All containers of parenteral fluids – to be checked for visible turbidity. Advantages of EN over TPN/PPN Maintenance of gut structure and function Enhanced use of nutrients Safety of administration Reduced cost Normal intestinal villus.Nursing Considerations. If there is a problem.
flexible feeding schedules weighted & non-weighted need to have an intact gag or cough reflexes and gastric emptying short-term access.Selection of Enteral Access device Considerations: status of GI tract/ diagnosis risk of aspiration estimated duration of EN Types of Feeding Tubes: Nasogastric tubes [usually small bore tubes] preferred . no longer than 6-8 weeks Types of Feeding Tubes: Nasojejunal or Nasoduodenal tubes [usually small bore tubes] decreased risk of aspiration mostly weighted unable to tolerate bolus feeds requires a feeding pump for administration Types of Feeding Tubes: G-Tube & J-Tube Decreased risk of aspiration Feeding schedules are more limited Long-term access: more than 6-8 wks Gastro & Jejunostomy Tubes Surgically & laparoscopic placed G-tubes & J-tubes G-tubes [or J-tubes] placed under U/S Percutaneous endoscopic gastrostomy [PEG] tubes Percutaneous endoscopic jejunostomy [PEJ] tubes Foley catheters 4 .
Tube Feeding Administration Methods Continuous [via infusion pump or gravity] Intermittent [via infusion pump or gravity] Bolus intermittent [via syringe or bulb] Cyclic intermittent [via infusion pump or gravity flow] 5 . increased redness or warmth. dry dressings Occasionally sutured in place Vomiting. leakage or pain may be signs of device malposition Standard Starter Regimen: Standard Continuous Feeding Schedule via a pump will be initiated full strength at 10cc/hr x 8 hrs. Increase rate by 10 cc’s q8h to a final rate of ____cc/h.PEJ and PEG Gastrostomy Devices: Low profile devices Button Replacement Gastrostomy tubes G-Tube & J-Tube Insertion Site Care After 24 hours remove initial dressing and leave open to air Cleanse site daily with normal saline or mild soap and warm water Rotate the external bumper 90 degrees Assess the site for purulent drainage. rashes and site tenderness Maintenance of Feeding Tube Position Measure and mark the tube Secure the tube with tape.
to maintain patency Flushing is also required before & after: infusion of any med via feeding tube. & have residuals checked every 4-8 hrs and tube placement verified at that time Enteral feeding con’t If formula is infusing continuously over 24 hours.and Tracheobronchial pH>7 Gastric residuals –check color Enteral Device Patency Flush tube with 30-50 cc of sterile water (only use water) every 4-6 hours. intestinal pH >7. use a pressure no greater than 40 psi Syringes smaller than 60mL for Gtubes or J-tubes should not be used Clogged Tubes Best approach: Prevent clogs from occurring by flushing before and after meds.Administering Enteral Feedings Place patient in high Fowler’s position or elevate head of bed 30 degrees Check tube placement [Xray if initiating] Advance tube feeding rate gradually Continuous feedings should be flushed with sterile water. and G-tubes when formula is infusing continuously over 24 hours Checking Tube Placement: X-ray prior to initiating feeds & when unsure of position Listening for a “whooshing” or “gurgling” sound when air is inserted is no longer considered totally reliable by itself Measuring the pH (inject 30 mls of air into the tube and aspirate GI contents with a syringe and measure the pH) Gastric pH 1-4. the refillable delivery sets must be changed every 24 hours Formula is not to hang at room temperature for more than 6-8 hours Infusion pumps must be used for all J-tubes. each interruption in feeding. fill the syringe with 5-10 mls of warm water and attach it to the end of the enteral device and instill over 1 minute Clamp tube for 5-15 minutes 6 . and q4-6h. If a clog occurs: attach 60 ml syringe to the end of the enteral device and attempt to aspirate for G-tube only If unsuccessful. and each period in intermittent feeding Use a pump for continuous feeds Prevent bacteria contamination in formula Enteral Tube Rupture To prevent tube rupture.
cardiomegaly) significant debilitation or difficult tube placement. tracheostomy.check bowel sounds Assess frequency and consistency of bowel movements Observe patient for nausea. may try: Pancreatic enzymes Mix with sodium bicarb Assessing Tolerance to Feeds Assess bowel function. Residuals?? Physician should specify how much residual should be present in order to hold feeds Check residual with a 60 mL Try insufflating 20 mls of air into tube initially Return residual volume to stomach.e. Hoskins.High Risk Patients High risk patients include: those with absent or diminished cough or gag refluxes decreased level of consciousness anatomical abnormalities along the placement pathway (i. endotracheal intubation. 1987) Residuals General Rule for maximum residuals: 2 times the hourly rate for continuous feeds One half of the volume of the intermittent feeding for intermittent feeds with an upper limit of 200 mls 7 . fluids and electrolytes If residual exceeds limit.Clogged Tubes: If no success. or symptoms of aspiration Measure abdominal girth Assess for bloating and distention Check gastric residuals q4-6hrs or before each intermittent feeding Mineral water Other Pharmacy preparations Pop Risk of bacterial contamination Contributes to future clogs Blue Dye for Aspiration Monitoring Warning from Health Canada: Do not use blue food coloring to check for aspiration or leakage of enteral feeds. Artman.. (Bohnker.contains nutrition. Flush tube with 10-30mls of water following residual checks Residuals. Evaluate rate. hold feeds & recheck in 1 hour.vomiting.
resistance related to Vit K Antibiotics. Examples of drug interactions with enteral feeds Medication-Type of Interaction Ciprofloxacin. Promote 1 calorie per cc Higher caloric formulas available at 1.Absorption decreased by a possible 25 per cent due to interaction with feeds.Decreased absorption and concentration Sulcrate. if available by IV route. cephalexin. bloating. ranitidine b/c enteral feed has to be stopped for a total of 12 hr/per day Monitor INR closely The sorbitol content and osmolality of liquids can be associated with GI adverse effects such as sudden-onset osmotic diarrhea. Hydralazine.May interact with vitamin K content of feed Suggestion Stop enteral feed for one hour before and two hours after dose or administer higher doses or use IV treatment in severe infections. Drugs that may be affected by this include digoxin.5-2 cal per cc Special formulas available for: Low volume High fibre High protein High calorie Low sugar/CHO High nitrogen Nutritionally complete formula with vitamins & minerals for renal failure patients Medication Administration Whenever possible. dilute it with 60 mls of water Possible Drug Interactions: Dilantin. Monitor changes in blood pressure Use alternatives. Jevity. eg. and delayed gastric emptying because of the regulatory role of osmoreceptors in the duodenum. medications should be taken p. Use liquid medication whenever possible Don’t mix meds with feeding formula Don’t use enteric coated or time-release tablets or capsules Don’t use excess force Crush tablet finely and dissolve it in at least 30 mls warm water Medication Administration Do not mix meds together & give at once Flush the tube with at least 10 mls of warm water between doses Flush the tube with 30 mls of water using a 60 ml syringe before and after administration of medications Consider tube placement in relation to the drug’s optimal absorption Before administering a thick liquid medication. phenytoin and other anticonvulsants. Isocal. stomach cramps. 8 .Binds to the protein in the feed Warfarin.Cipro binds with the formula Sinemet.high protein feeds may impair onset Enteric coated drugs Sustained/extended release drugs Adverse Effects with Meds There are more likely to be problems with absorption when the tube is placed beyond the stomach such as with percutaneous endoscopic jejunostomy (PEJ) tubes.o. or. Osmolite.Formulation Supplements: Ensure. ketoconazole. Peptamen.impaired absorption Warfarin.
heart rate. redness.occurs when feeding provides less than 1500 calories daily Possible Complications Mechanical Tube occlusion Tube displacement Irritation or erosion Hypergranulation and discharge at site 9 . & phlegm [note color].elevated head of bed Diarrhea. cough. triglycerides Hyperglycemia-due to high carbohydrate load Vitamin deficiency.Nursing Considerations Assess patient’s tolerance to therapy: Ask patient how they are doing [any cramping.. bleeding. difficulty swallowing [assess gag reflex]. creatinine.may need to be supplemented Possible Complications Possible metabolic complications (if enteral product is not appropriate choice for pt’s diagnosis): Dehydration. elevated serum urea.supplement as needed Elevated serum electrolytes. & tenderness Assess patency & position of tube Q shift Nursing Considerations Observe for signs of aspiration: Watch for increased SOB.usually caused by antibiotics or bacterial contamination of feeds Constipation. diarrhea.will occur if tube not placed properly or if gastric retention. pressure sores.should not happen with proper hydration and formula choice . or constipation] Examine the abdomen [assess for distention] Auscultate for bowel sounds Evaluate stool pattern Q shift Check residuals Q6-8 hrs Nursing Considerations Laboratory tests are ordered on a regular basis to assess tolerance to feeds Assess insertion site for drainage.elevate head of bed Nausea and vomiting. and increased temp. residuals Aspiration. and respiratory rate Ensure head of bed elevated Possible Complications GI Gastroesophageal reflux. decreased serum electrolytes.
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