Chapter 23
Enteral and
Parenteral
Nutrition Support
Introduction to Enteral Nutrition
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Enteral Nutrition Definition
Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.
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Oral Supplements
Between meals
Added to foods
Added into liquids for medication pass
by nursing
Enhances otherwise poor intake
May be needed by children or teens to
support growth
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Conditions That Require Other
Nutrition Support
Enteral
—Impaired ingestion
—Inability to consume adequate nutrition
orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth
Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral
tolerance or accessibility
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Considerations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
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Formula Selection
The suitability of a feeding formula should be
evaluated based on
Functional status of GI tract
Physical characteristics of formula (osmolality,
fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte
needs or restriction
Cost effectiveness
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Factors to Consider When Choosing an Enteral
Formula
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Enteral Access: Clinical Considerations
Duration of tube feeding
—Nasogastric or nasoenteric tube for short term
—Gastrostomy and jejunostomy tubes for
long term
Placement of tube
—Gastric
—Small bowel
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Placement Site
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning
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Advantages—Enteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not
possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with
disease state
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More Advantages—
Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial
translocation
Preserves immunologic function of gut
Increased compliance with intake
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Disadvantages—Enteral Nutrition
GI, metabolic, and mechanical complications
—tube migration; increased risk of bacterial
contamination; tube obstruction;
pneumothorax
Costs more than oral diets
Less “palatable/normal”
Labor-intensive assessment, administration,
tube patency and site care, monitoring
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Complications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)
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Protein
From 4% to 26% of kcal is possible
14% to 16% of kcal is usual
18% to 26% of kcal—considered to be
high-protein solution
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Recommended Water
Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to
85% water
Elderly: consider 25 ml/kg with renal, liver,
or cardiac failure; or consider 35 ml/kg if
history of dehydration
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Sources of Fluid (“Free Water”)
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with
water about 3 times daily—include this
amount in estimated needs
—Example: “flush with 200 cc tid”
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Enteral Nutrition Monitoring
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Advantages—Parenteral Nutrition
Provides nutrients when less than
2 to 3 feet of small intestine remains
Allows nutrition support when GI
intolerance prevents oral or enteral
support
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Contraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)
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Protein Requirements
1.2 to 1.5 g protein/kg IBW
mild or moderate stress
2.5 g protein/kg IBW
burns or severe trauma
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Carbohydrate Requirements
Max. 0.36 g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems
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Lipid Requirements
4% to 10% kcals given as lipid meets
EFA requirements; or 2% to 4% kcals
given as lineoleic acid
Usual range 25% to 35% max. 60% of
kcal or 2.5 g fat/kg
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Other Requirements
Fluid—30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements
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Monitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome
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Refeeding Syndrome
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest
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Monitor—cont’d
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration (daily)
WBC and differential (as needed)
Cultures (as needed)
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Pediatric—cont’d
Protein:
Infant
2.4 to 4 g/kg/day <1500 g weight
2.0 to 2.5 g/kg/day 0 to 12 months
normal weight
Child >1 year
1 to 8 years 1.5 to 2.0 g/kg/day
8 to 15 years 1.0 to 1.5 g/kg/day
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Pediatric—cont’d
Carbohydrate
Infant preterm:
4 to 6 mg/kg/minute begin rate
Term infants:
8 to 9 mg/kg/minute begin rate
Fat
Infants:
0.5 to 1.0 g/kg/day min for EFA
needs
2 to 3 g/kg/day max
Vitamins and minerals:
See tables in textbook
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Pediatric—cont’d
Fluid and electrolytes
Infant:
LBW 125 to 150 ml/kg/day
2 to 4 mmol/kg/day for electrolytes
Other infants and children
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