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Nutrition Support
? Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status
? Two types:
enteral - delivery of nutrients into GI tract through a tube
parenteral - delivery of nutrients into blood steam intravenously
Why enteral support is thought to be better (than parenteral)
? By putting the nutrients into the gut, the gut mucosa keeps toxic substances from getting into the bloodstream & causing sepsis
1.GALT (gut associated lymphoid tissue) is part of immune system - provides 70% of body antibodies & contains lymphocytes
2. Maintain healthy bacteria in gut
3. Can give probiotics (lactobacillus)
4. Can give prebiotics (fiber & fructooliogosaccharides FOSs)
Enteral Feeding:
indications for use
? impaired food ingestion: dysphagia, unconscious, fractured mandible, respiratory failure, inability to suck (premature infants)
? impaired digestion of whole (intact) foods: chronic pancreatitis, Crohn's disease, short bowel syndrome
? cannot meet nutritional requirements: major burn, trauma, anorexia nervosa, severe wasting
When the gut works, use it!
? safer - less risk of infection
?less expensive
?more easily done at home
than parenteral
Understand figure 23-1
Routes (access sites) for tube feeding depend:
? How long will feeding be needed?
? Risk for aspiration of feeding into lungs
? Surgical risk or no risk
? Sites:
1. Nasal gastric (NG) Nasalduodenal or
Nasojejunal
2.Postpyloric-
Gastrostomy-most common is PEG
Jejunostomy- PEJ
Tubes in nasal cavity
? NG - nasogastric: short-term 3-4 wks, pt has low-risk of aspiration (intact gag), normal digestion
? NJ - nasojejunal (postpyloric): short-term, pt with high risk of aspiration, gastric or duodenal surgery or disease
? X Ray to verify placement of a tube
Gastrostomy (G Tube): for long-term feedings
? Need functioning stomach & intestines
? more comfortable, for long term use > 4 weeks
? PEG (Percutaneous endoscopic Gastrostomy)a procedure usingendoscope to put special tube down intostomach & out abdominal wall
? other "G" tubes surgically placed
? may use jejunum - jejunostomy, PEJ
Reasons not to use Enteral Support
? ileus - no bowel sounds
? small bowel obstruction - SBO
? severe diarrhea or vomiting
? refusal of nutrition support by patient or through Advance Directive
? high-output fistula (>500 cc/day)
? acute pancreatitis
? can eat adequate amount by mouth
Choices for Enteral Formula
3 major types
Is GI tract functioning normally?
?YES = intact or polymericformula
?NO = hydrolyzed formula (monomeric)with polypeptides or amino acids & some MCT oil
? when disease specific formulas warrented: renal, diabetes, hepatic, pulmonary, severe stress & trauma
Immune Boosting Properties in Enteral Feedings
Impact, Perative, Crucial (p 1233)
? Glutamine: primary energy source for rapidly ÷ cells; increases T cell production
? Arginine: increases T cells
? Omega-3-fatty acids: causes less inflammation in cells, increases N balance
? Nucleotides: used to form DNA
Enteral Formula Selection: other factors to consider
? Age -special formulas for pediatrics
? Caloric density 1 kcal/cc to 2 kcal/cc
? Protein density of formula (g/liter)
? Na, K, Mg, P content?
? Would fiber be beneficial?
? CHO sources in formulas: hydrolyzed corn starch, maltodextrin, soy fiber, corn syrup solids - all lactose-free
Enteral Formula Selection
? Osmolality (size and number of nutrient particles in a solution). If high (600 - 900 mOsmol/kg) fluid drawn into gut ? diarrhea
? Example: Osmolite = 1.06 kcal/cc, 14% pro, 57% CHO, 29% fat, Cal:N 178, Osmol 300, 1887 cc to get RDA,80% free water, casein & soy pro, maltodextrin, safflower, canola, MCT
Tube Feedings
? at home, person with healthy immune system, could use home made blenderized tube feeding
? water is used to "flush" or clean the tube - this water is part of individual's fluid requirement & given during the day
How are tube feedings given?
? Continuous drip using a pump
? Intermittent drip using a pump
if person eats some food during the day tube feeding may be given at night
3. Bolus using gravity instead of pump; given as a bolus 4-6 bolus times/day
How is a patient on tube feeding monitored?
? gastric residuals (checked by RN)
? stool frequency and consistency
? urine output adequate (I and 0)
?change in wt ? ↓
? Na, K, BUN, creatinine, glucose
? albumin or prealbumin, Ca, P, Mg
? seen/charted by RD every 3-7 days
Complications
of Tube Feeding
? diarrhea
? high gastric residuals
? constipation
? aspiration pneumonia - tube feeding into lungs
? pt pulls out tube
Complications
in patient on tube feeding
? hyperkalcemia
? azotemia (?BUN, ? Cr due to ?ECF)
prerenal azotemia: BUN > Cr 10:1
? hyponatremia
? hyperglycemia
? hypoglycemia
How much tube feeding does one give?
? Determine the number of kcal pt needs during nutrition assessment
? Decide site for access & type of tube feeding needed
? Kcal needed day kcal ÷ ml of feeding = cc needed/ 24 hrs
Example:
? use NG tube, Nutren 1.0 with fiber
? pt needs 1629 kcal/day÷ 1.0 kcal/cc
? 1629 ÷ 24 (hr) = 68 cc/hr continuous drip
Parenteral Nutrition - indications for use
GI tract is not functioning well enough to meet nutritional needs of patient so nutrients put in bloodstream intravenously
examples:
? small bowel resection
? small bowel obstruction
? large output fistula below enteral feeding site
Parenteral Nutrition - access sites (where it can go into the bloodstream)......（后略) ......
Nutrition Support
? Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status
? Two types:
enteral - delivery of nutrients into GI tract through a tube
parenteral - delivery of nutrients into blood steam intravenously
Why enteral support is thought to be better (than parenteral)
? By putting the nutrients into the gut, the gut mucosa keeps toxic substances from getting into the bloodstream & causing sepsis
1.GALT (gut associated lymphoid tissue) is part of immune system - provides 70% of body antibodies & contains lymphocytes
2. Maintain healthy bacteria in gut
3. Can give probiotics (lactobacillus)
4. Can give prebiotics (fiber & fructooliogosaccharides FOSs)
Enteral Feeding:
indications for use
? impaired food ingestion: dysphagia, unconscious, fractured mandible, respiratory failure, inability to suck (premature infants)
? impaired digestion of whole (intact) foods: chronic pancreatitis, Crohn's disease, short bowel syndrome
? cannot meet nutritional requirements: major burn, trauma, anorexia nervosa, severe wasting
When the gut works, use it!
? safer - less risk of infection
?less expensive
?more easily done at home
than parenteral
Understand figure 23-1
Routes (access sites) for tube feeding depend:
? How long will feeding be needed?
? Risk for aspiration of feeding into lungs
? Surgical risk or no risk
? Sites:
1. Nasal gastric (NG) Nasalduodenal or
Nasojejunal
2.Postpyloric-
Gastrostomy-most common is PEG
Jejunostomy- PEJ
Tubes in nasal cavity
? NG - nasogastric: short-term 3-4 wks, pt has low-risk of aspiration (intact gag), normal digestion
? NJ - nasojejunal (postpyloric): short-term, pt with high risk of aspiration, gastric or duodenal surgery or disease
? X Ray to verify placement of a tube
Gastrostomy (G Tube): for long-term feedings
? Need functioning stomach & intestines
? more comfortable, for long term use > 4 weeks
? PEG (Percutaneous endoscopic Gastrostomy)a procedure usingendoscope to put special tube down intostomach & out abdominal wall
? other "G" tubes surgically placed
? may use jejunum - jejunostomy, PEJ
Reasons not to use Enteral Support
? ileus - no bowel sounds
? small bowel obstruction - SBO
? severe diarrhea or vomiting
? refusal of nutrition support by patient or through Advance Directive
? high-output fistula (>500 cc/day)
? acute pancreatitis
? can eat adequate amount by mouth
Choices for Enteral Formula
3 major types
Is GI tract functioning normally?
?YES = intact or polymericformula
?NO = hydrolyzed formula (monomeric)with polypeptides or amino acids & some MCT oil
? when disease specific formulas warrented: renal, diabetes, hepatic, pulmonary, severe stress & trauma
Immune Boosting Properties in Enteral Feedings
Impact, Perative, Crucial (p 1233)
? Glutamine: primary energy source for rapidly ÷ cells; increases T cell production
? Arginine: increases T cells
? Omega-3-fatty acids: causes less inflammation in cells, increases N balance
? Nucleotides: used to form DNA
Enteral Formula Selection: other factors to consider
? Age -special formulas for pediatrics
? Caloric density 1 kcal/cc to 2 kcal/cc
? Protein density of formula (g/liter)
? Na, K, Mg, P content?
? Would fiber be beneficial?
? CHO sources in formulas: hydrolyzed corn starch, maltodextrin, soy fiber, corn syrup solids - all lactose-free
Enteral Formula Selection
? Osmolality (size and number of nutrient particles in a solution). If high (600 - 900 mOsmol/kg) fluid drawn into gut ? diarrhea
? Example: Osmolite = 1.06 kcal/cc, 14% pro, 57% CHO, 29% fat, Cal:N 178, Osmol 300, 1887 cc to get RDA,80% free water, casein & soy pro, maltodextrin, safflower, canola, MCT
Tube Feedings
? at home, person with healthy immune system, could use home made blenderized tube feeding
? water is used to "flush" or clean the tube - this water is part of individual's fluid requirement & given during the day
How are tube feedings given?
? Continuous drip using a pump
? Intermittent drip using a pump
if person eats some food during the day tube feeding may be given at night
3. Bolus using gravity instead of pump; given as a bolus 4-6 bolus times/day
How is a patient on tube feeding monitored?
? gastric residuals (checked by RN)
? stool frequency and consistency
? urine output adequate (I and 0)
?change in wt ? ↓
? Na, K, BUN, creatinine, glucose
? albumin or prealbumin, Ca, P, Mg
? seen/charted by RD every 3-7 days
Complications
of Tube Feeding
? diarrhea
? high gastric residuals
? constipation
? aspiration pneumonia - tube feeding into lungs
? pt pulls out tube
Complications
in patient on tube feeding
? hyperkalcemia
? azotemia (?BUN, ? Cr due to ?ECF)
prerenal azotemia: BUN > Cr 10:1
? hyponatremia
? hyperglycemia
? hypoglycemia
How much tube feeding does one give?
? Determine the number of kcal pt needs during nutrition assessment
? Decide site for access & type of tube feeding needed
? Kcal needed day kcal ÷ ml of feeding = cc needed/ 24 hrs
Example:
? use NG tube, Nutren 1.0 with fiber
? pt needs 1629 kcal/day÷ 1.0 kcal/cc
? 1629 ÷ 24 (hr) = 68 cc/hr continuous drip
Parenteral Nutrition - indications for use
GI tract is not functioning well enough to meet nutritional needs of patient so nutrients put in bloodstream intravenously
examples:
? small bowel resection
? small bowel obstruction
? large output fistula below enteral feeding site
Parenteral Nutrition - access sites (where it can go into the bloodstream)......（后略) ......
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