Chapter 36: Enteral Feedings

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Enteral Nutrition
- involves passing a tube into the GI tract to administer a formula containing adequate nutrients
- allows the stomach to be a natural reservoir
- regulates the amount of foods and liquids released into the small intestine
- may deliver total or supplemental nutrition over a short-term period or for longer intervals
Short-Term Nutritional Support
- less than 4 weeks
- usually NG or nasointestinal route
(NG Tube) How is it placed?
through the nose and into the stomach
(NG Tube) Contraindications
- dysfunctional gag reflex
- high risk of aspiration
- gastric stasis
- gastroesophageal reflex
- nasal injuries
- unable to have the head of the bed elevated during feedings
(NG Tube) Levin Tube
- flexible rubber or plastic single-lumen tube with holes at the stomach end and a connector at the opposing end
- the connector allows for attachment to a feeding apparatus and medication administration
(NG Tube) Polyurethane Tube
- smaller and more pliable
- provides more patient comfort
- Dobbhoff tube
- makes checking tube placement and medication administration more difficult
What are ways to check placement of tube?
- radiographic examination
- measurement of tube length
- measurement of tube marking
- measurement of aspirate pH, visual assessment of aspirate
- monitoring of carbon dioxide
Radiographic Examination
- standard procedure
- expose the patient to radiation
- must be interpreted by a physician
- costly
- may be inaccessible
- the tube may have moved in the time after the picture was taken
- placement must be checked frequently
Measurement of Tube Length
- measure length of the exposed tube after insertion and document
- once placement is confirmed by radiograph, mark the exit site on the nostril
- observe for a change in the external tube length
Measurement of Aspirate pH- observe for a change in the volume of fluid withdrawn from a tube at 4-hour intervals during continuous feedings or before each intermittent feeding - a sharp increase in fluids may indicate displacement - consistent inability to withdraw fluid may indicate displacementMonitoring CO2- involves the use of capnograph or a colorimetric end-tidal CO2 detector - presence of CO2 indicates tube positioning in the patient's airway - cannot determine where a feeding tube's tip ends(NI Tube) Where is it placed?through the nose and into the upper portion of the small intestine(NI Tube) Indications- increased risk for aspiration due to a diminished gag reflex or slow gastric motility - delayed gastric emptying - gastric tumor(NI Tube) What does it reduce the risk of?gastric reflex(NI Tube) What can happen if formula is delivered directly into the small intestine?a type of dumping syndrome may develop because the pyloric valve in the stomach, which normally slows transit of food into the intestine, is bypassed(NI Tube) What should the pH be?less than 6(NI Tube) What color is gastric fluid?- clear - colorless - grassy green(NI Tube) What color are small-bowel secretions?- bile-stained - light to golden yellow - brownish-greenLong-Term Nutritional Support- enterostomal tube - PEG tube - low-profile gastronomy device(Enterostomal Tube) How is it placed?- stomach (gastrostomy) - jejunum (jejunostomy)What is the preferred route to deliver enteral nutrition to a patient who is comatose?gastrostomyHow are PEG tubes placed?passage of an endoscope into the stomach, a small incision or stab wound through the skin of the abdomen, pushing a cannula through the small incision, insertion of a guide wire or suture material through the cannula, and introduction and placement of the PEG tube through one of several methodsJejunostomycreation of an opening in the jejunumLow-Profile Gastrostomy Device (LPGD)- for patients who are active yet require long-term continuous or intermittent feedings - used in children - external apparatus is minimal and consists of a button or skin disk that is stable, less irritating to the skin, and has no external tubing, making it easier to conceal with clothing - can be immersed in water - less likely to migrate or become dislodged - has a cap to access the feeding tube and connect with the administration setWhat is a feeding schedule based on?- physical condition - medical condition - nutritional conditionContinuous Feedings Prosallow gradual introduction of the formula into the GI tract, promoting maximal absorptionContinuous Feedings Cons- require an enteral feeding pump, which limits the patient's mobility and increases cost - has a risk for reflux and aspirationWhy are feedings into the intestine always continuous?to avoid triggering dumping syndromeWhat causes dumping syndrome?overdistention of the small intestineIntermittent Feedings Pros- preferred method for gastric feeding - delivered at regular intervals in equal portions - resemble a more normal pattern of intake - allow freedom of movement between feedingsIntermittent Feedings Consbolus feedings pose aspiration risksCyclic Feedings Pros- involves administering continuous feedings for a portion of the 24-hour period - feed patient for 12-16 hours, often overnight - allows the patient to attempt eating regular meals during the dayWhat does the composition of enteral feeding formulas depend on?- feeding route - patient's ability to digest and absorb nutrients - patient's nutrient and fluid requirementsWhat else should you consider?- availability and cost of formula - medical conditions that require diet modifications - food intolerance - allergiesWhat do standard enteral feeding formulas contain?- protein - carbohydrates - fatsWhat does this require?patient must have normal digestion and absorptionWhat do hydrolyzed enteral feeding formulas contain?- proteins - other nutrientsWho are they used for?- require little or no digestion - impaired digestion or absorptionWhat other components do formulas contain?- high in calories - fiber - protein - can be specially formulated for patients with respiratory, renal, or other health problemsHow are feedings initiated?at full strengthWhat does rate of infusion begin at?- 10-40 mL/hour - advanced by 10-20 mL/hr every 8-12 hours until desired rate is achievedWhat is rate advancement based on?patient toleranceWhat does progressing rate slowly do?improves toleranceWhat criteria should you consider when evaluating patient feeding tolerance?- absence of nausea, vomiting - minimal or no gastric residual - absence of diarrhea and constipation - absence of abdominal pain and distention - presence of bowel sounds within normal limitsEnteral Feeding Pumps- regulates the amount of feeding solution that is required to the patient - should be used when slow rates are required - can be used in both institutions and at home(Enteral Feeding Pump) Safety Features- automatic tube flush - cassettes that prevent free flow of formula - safety tips that prevent accidental attachment to an IV setup - various audible and visible alarms(Enteral Feeding Pump) What are ways to promote patient safety when using these?- check tube placement - check gastric residual (feeding remaining in the stomach) before each feeding or every 4-6 hours during a continuous feeding - evaluate other indicators for GI tolerance - use sterile water to flush tubes in an immunocompromised or critically ill patients - check guidelines for holding feedings - assess the abdomen for abnormalities - assess for bowel sounds at least once a shift to check for peristalsis(Enteral Feeding Pump) What are high gastric residual volumes associated with?- aspiration risks - aspiration-related pneumonia(Enteral Feeding Pump) What might acutely ill patients have?- delayed gastric emptying - delaying feeding because of hypoactive bowel sounds may cause malnutrition(Enteral Feeding Pump) What are indicators for how well a patient is tolerating a tube feeding?- gastric distention - abdominal girth - nausea and vomiting - bloating - painHow far should you keep the head of bed elevated during feedings?30-45 degrees(Enteral Feeding Pump) Closed Systems- sterile, prefilled container - reduces opportunity for bacteria(Enteral Feeding Pump) Open Systemformula from can/bottle added to a feeding setup(Enteral Feeding Pump) What should you disinfect?opening and rim of any cans before opening(Enteral Feeding Pump) What should you label the container with?- patient identifiers - time the feeding was hung(Enteral Feeding Pump) How often should reusable feeding systems be cleaned?every 24 hours with soap and hot water(Enteral Feeding Pump) How often should disposable feeding apparatuses be disposed of?- open systems: every 24 hours - closed systems: every 48 hours(Enteral Feeding Pump) Why shouldn't you administer medications while tube is being infused?may cause clogging(Enteral Feeding Pump) When should you flush the tube?before, between, and after administering medsWhat should you use for medication administration?sterile water(Enteral Feeding Pump) What are common causes of clogged or obstructed tubes?- aspirated stomach contents - residue from medications - slow feeding flow rate - infrequent or inadequate addition of water to the system - using a tube with a small lumen(Enteral Feeding Pump) How much water should you use to flush tubes after medication administration/feeding?30-50 mL(Enteral Feeding Pump) What should you document?intake/output from tube flushing(Enteral Feeding Pump) Comfort Measures- oral hygiene every 2-4 hours to prevent drying of tissues and to relieve thirst - rinse mouth with warm water and mouthwash solution - lubricate lips - keep nares clean - control local irritation from the tube in the throat - encourage patient to verbalize concerns - ensure tube is secure(Enteral Feeding Pump) Education- inform on administration of feedings, operation of the pump, formula, instructions regarding rate, and how to check for tube placement - what to do if tube becomes dislodged - care for the tube insertion site - complications - proper preparation, cleaning, and disposal of equipment - emergency phone numbers - arrangements for follow-up from the home health care nurseWhat can NG tubes be used for besides feeding?- decompress or drain the stomach of fluid - monitor GI bleeding - prevent intestinal obstructionParenteral Nutritionthe administration of nutritional support through the IV route(Parenteral Nutrition) Indications- nonfunctional GI tract - comatose - high caloric and nutritional needs due to illness or injury(Parenteral Nutrition) How can it be administered?- central venous access device - short-term IV access in a peripheral vein(Parenteral Nutrition) Where are solutions less concentrated?peripheral venous access sites(Parenteral Nutrition) Uses- highly concentrated, hypertonic nutrient solution - calories - restores nitrogen balance - replaces essential fluids, vitamins, electrolytes, minerals, and trace elements - can promote tissue and wound healing - promotes normal metabolic function - provides the bowels a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine - may be used to improve a patient's response to surgery(Parenteral Nutrition) Assess- inability to achieve or maintain enteral access - motility disorders - intractable diarrhea - impaired absorption of nutrients from the GI tract - when oral intake has been or is expected to be inadequate over a 7-14 day period(Parenteral Nutrition) Why might peripheral parental nutrition (PPN) be indicated?patients with a malfunctioning GI tract(Parenteral Nutrition) What is there a risk for in PPN?thrombophlebitis(Parenteral Nutrition) What are PPN solutions?- isotonic - contain low concentrations of dextrose and amino acids - provide fewer calories and supplement a patient's inadequate oral intake(Parenteral Nutrition) What are the 3 primary components of the solution?- proteins - carbohydrates - fats(Parenteral Nutrition) What else is included in the solution?- electrolytes - vitamins - trace elements(Parenteral Nutrition) What must you monitor?blood glucose levels (high glucose)(Parenteral Nutrition) How is it administered?using an electronic infusion device with anti-free-flow protection, via continuous or cyclic infusion(Parenteral Nutrition) What is a potential problem that should be addressed?physical incompatibility between the formula and other solutions, especially medications(Parenteral Nutrition) What should be done to prevent incompatibility problems?if the patient has a multilumen catheter in place, use only one lumen for PN(Parenteral Nutrition) Cons- costly - can cause infections and metabolic/mechanical complications - should be used only when enteral intake is contraindicated - should be discontinued as soon as possible(Parenteral Nutrition) Complications- complications related to the use of central venous access devices, such as pneumothorax, thromboembolism, and air embolism - infection - sepsis - metabolic alterations, such as hyperglycemia or hypoglycemia - fluid, electrolyte, and acid-base imbalances - phlebitis - hyperlipidemia - liver and gallbladder disease(Parenteral Nutrition) Who may require long-term PN?- AIDS - advanced cancer - difficulty swallowing - chronic bowel problems(Parenteral Nutrition) How is it often administered in the home setting?cyclic infusion(Parenteral Nutrition) Patient EducationPurpose and expected duration of PN ■ Proper storage of PN containers and supplies ■ Infection prevention measures, including hand hygiene and maintaining sterile components of the infusion system ■ Adverse reactions or catheter complications ■ Signs and symptoms of hypo- and hyperglycemia ■ Signs and symptoms of alterations in electrolytes (e.g., potassium, calcium) (INS) ■ Circumstances that require contacting the primary care provider ■ Basic care of the venous access device used to administer ■ Use and maintenance of equipment ■ Frequency for measuring the patient's weight, intake and output, and monitoring glucose levels(Parenteral Nutrition) Evaluateate: ■ Evaluates the patient's progress toward meeting nutritional outcomes ■ Evaluates the patient's tolerance and adherence to the prescribed diet, when appropriate ■ Assesses the patient's level of understanding of the diet and/or dietary-related interventions and the need for further instruction or reinforcement ■ Communicates findings to other members of the health care team ■ Revises the plan of care, as needed, or terminates nursing carePOWERPOINTShort-Term Support- nasogastric - nasointestinalHow are enterostomal tubes placed?- gastrostomy (opening created into the stomach) - jejunuostomy (opening created into the jejunum)What is a gastrostomy the preferred route for?patient who is comatoseComplications of TPNInsertion problems Infection and sepsis Metabolic alterations Fluid, electrolyte, and acid-base imbalances Phlebitis Hyperlipidemia Liver and gallbladder diseaseSTUDY GUIDEWhere are TPN's usually administered?- subclavian - internal jugular