Medical Nutrition Therapy Exam 2 Study Guide Nutrition Support Methods Nutrition Support Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status Should be considered when patient is unable to meet their nutritional needs for more than 5 days Enteral Nutrition EN provision of nutrients into the GI tract through a tube or catheter when oral intake is inadequate May include formulas as oral supplements or meal replacements Rationale and criteria o For those who can t eat or can t eat enough o Should be first consideration Proposed Benefits of Enteral vs Parenteral Nutrition o Better GI barrier function o Preserved immunity o Attenuate catabolic response o Better blood glucose control o Decreased rates of infection Conditions that often require enteral Impaired nutrient ingestion o Neurologic disorders dysphagia o facial trauma o oral or esophageal trauma o congenital anomalies o respiratory failure on ventilator o traumatic brain injury o comatose o GI tract surgery e g esophagectomy Inability to consume adequate nutrition orally o Hypermetabolic states such as trauma and burns Severe wasting or depressed growth o Cancer o cystic fibrosis o Cystic fibrosis o Failure to thrive o Cancer o heart failure o anorexia nervosa o HIV AIDS o failure to thrive o Sepsis o Cerebral palsy Impairer digestion absorption and metabolism o Severe gastroparesis o inborn errors of metabolism o Crohn s disease o ulcerative colitis o short bowel syndrome Enteral Nutrition Access Depends on Includes the location of nutrient administration and type of enteral access device o Anticipated length of time of enteral feeding o Risk for aspiration or tube displacement o Patient s clinical status o Presence or absence of normal digestion and absorption o Patients anatomy i e obesity may interfere o Planned surgical intervention Closed enteral system contained or bag prefilled with sterile liquid formula by the manufacturer and ready to administer Open enteral system person administering feeding opens and pours the feeding into Hang time the length of time an enteral nutrition formula is considered to be safe for the container or bag administration to a patient o 4 hours for open systems o 24 48 hours for closed systems TYPES o Nasogastric route Uses nasogastric tube NGT Most commonly used Normal GI fxn Bolus intermittent and continuous infusions Short term up to 3 4 weeks o Nasoduodenal or nasojejunal route Nasoduodenal tube NDT or nasojejunal tube NJT Gastric motility disorders gastroesophageal reflux or persistent nausea Short term up to 3 4 weeks and vomiting o Percutaneous endoscopic gastrostomy PEG or jejunostomy PEJ Nonsurgical technique for placing tube directly into stomach through the abdominal wall using an endoscope and local anesthesia Preferred for longer than 3 to 4 weeks Have a short piece of tubing or button to inject feedings into o Other minimally invasive techniques include Laparoscopic or fluoroscopic techniques Fluoroscopy a radiologic technique in which tubes are guided visually into the stomach or the jejunum and then brought out through the abdominal wall to provide the access route for enteral feedings Laparoscopic is a modern surgical technique in which operations in the abdomen are performed through small incisions usually 0 5 1 5 cm as opposed to the larger incisions needed in laparotomy o Surgically placed enterostomies gastrostomies and jejunostomies o Multiple lumen tubes Prolonged GI decompression and small bowel feeding used for early postoperative feeding Formulas Formula selection should be evaluated based on o Functional status of GI tract o Energy and nutrient content and patients nutritional needs o Type of protein fat and CHO in the formula o Presence of fiber o Digestion and absorption capability of patient o Clinical considerations such as fluid and electrolyte status and organ or system function o Viscosity of formula related to tube size o Cost effectiveness Formula composition o Standard polymeric formulas Lactose free 1 to 1 2 kcal mL with a balanced CHO fat and protein Concentrated standard formulas 1 5 to 2 kcal mL for fluid restriction o High nitrogen formulas 18 25 of kcal from protein Increased protein requirements burns fistulas sepsis trauma o Elemental or predigested formulas When the GI tract is compromised and polymeric formula is not tolerated Fat is primarily MCT Protein fragments dipeptides tripeptides or oligopeptides o Specialized or disease specific formulas Aimed at a specific disease associated problem e g renal products high protein low potassium low phosphorus etc o modular components combining separate nutrient sources or modifying existing formulas Formula components o Protein 6 25 of kcal Generally from casein whey or soy protein isolate Intact standard vs hydrolyzed elemental or predigested affect osmolarity Hydrolyzed proteins di and tripeptides and amino acids Glutamine and arginine o Carbohydrate 30 85 of kcal Generally from corn syrup solids in standard formulas Cornstarch or maltodextrin in hydrolyzed formulas Source and degree of hydrolysis affect osmolarity Lactose is generally not used Addition of fiber and or fructooligosaccharides o Lipid 1 5 55 kcals 15 30 in standard formulas 2 4 as linoleic and linolenic acid remainder is long chain and medium chain triglycerides Usually from corn soy sunflower safflower or canola oils o Vitamins mineral and electrolytes DRIs modified for specific formulas o Fluid Amount of water depends on calorie density 70 in 2 kcal mL formulas Provide additional water via tube as needed consider fluid from feeding tube flushes medications and intravenous fluids 1 kcal mL formulas are about 85 water Administration Method selection is based on patient s clinical status living situation and quality of life considerations Feedings should be room temperature because cold can cause GI discomfort Bolus common in home care Up to 500 mL rapid delivery via a large bore 60 mL syringe three or four times daily Intermittent drip Start with 100 to 150 mL and increase as tolerated 20 to 60 minutes four to six times a day via gravity drip or syringe Continuous drip via infusion pump for those who do not tolerate bolus or intermittent Complications Access problems o Tube displacement or obstruction o Leakage Administration problems o Aspiration o Regurgitation o Microbial contamination GI complications o Nausea and vomiting o Delayed gastric emptying o High gastric residuals o