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Types of Formulas1. Standard/Intact/Polymeric Formulas
Complete macronutrient molecules:
Pt. must be able to digest/absorb nutrients
3. Modular Formulas e.g. Polycose, Promod
Can be added to existing enteral formula to modify its composition
Can be combined together to create a highly individualized formula (rare)
Formula Composition1. Kcalories
Standard – Concentrated –
2. Residue: contributes to fecal bulk Low residue formula:
3. Fiber
• Fuel:
4. Osmolality: concentration of particles in a solution (mOsm/kg) Osmolality of blood – Isotonic solution: Hypertonic solution:
• –
•
Cost: Standard formulas are cheapest.
Routes of Administration
A. Nasogastric (NG)Passage of the feeding tube transnasally into the stomach
1. Advantages
a.
b.
2. Disadvantages
a. Potentially aspirated:
b. Patient can pull out the tube
c. Nose and esophagus can become irritated
d. Cosmetically unattractive
B. Nasoduodenal/Nasojejunal: Passed nasogastrically into stomach, migrate to
small bowel
1. Advantages
a.
b.
c. Increased chance of hypoglycemia (as in dumping syndrome)
d. Patient can pull out the tube
e. Nose and esophagus can become irritated
f. Cosmetically unattractive
C. Gastrostomy (PEG, G-tube) – Endoscopically placed into stomach, then brought out through abdominal wall (PEG) or surgically placed (GT)
More permanent – for use when TF will be long-term or if tube can’t be passed 2’obstruction, etc.
D. Jejunostomy (PEJ, J-Tube)
1. Advantages
a.
b.
c.
2. Disadvantages
a. Can’t recannulate if the tube comes out
b. Penetrates peritoneum; source of infection
Formula Delivery
** Head of bed should be elevated 300 during and after TF administration to minimize risk of aspiration.
2. Continuous infusiona. Continuous delivery in controlled amounts over
24hours
b. Controlled delivery for enhanced GI tolerance (not much difference if delivered to stomach with functioning pylorus)
c. Begin isotonic formula at FS at a slow rate
d. rate as tolerance allows in stepwise increments until nutrient goals are met
e. Gastric residuals
f. Gravity vs. Pump Gravity method less accurate
• More attention must be paid to tube size, location, and patient mobility.
• Not advisable with closed system delivery Pump – more accurate, enhances GI tolerance,
more expensive
3. Cyclic feedinga. E.g. b. c.
4. All feedings: Supplemental Watera. Water used to flush feeding tube before and
after feeding/when tube/bag are changedb. Pay attention to hydration status of pt.c. Total water should be
d. Typical TF formula is
5. Drugs via Tubea. Can cause drug-nutrient interactions
b. Formula can affect drug absorption
c. Some drugs can clog tubes
Tube Feeding Complications
1. Failure to achieve/maintain adequate nutrition status
a. Check calculations
b.
c.
d.
e. Monitor pt. tolerance of TF
2. Diarrhea
a. May be related to formula, illness, or other treatments
b.
c. Bacterial contamination
d. Infusion rate too high –
e. Hypertonic formula –
f. Malnutrition/low serum albumin – slow rate or continuous drip.
3. Aspiration
4. Nausea
5. Malabsorption
6. Clogged feeding tube
7. Fluid/lyte imbalances
8. Hyperglycemia
9. Refeeding Syndrome (to be discussed in “Stress” chapter)
Calculations1. Caloric Requirements of Patient
H-B/Long’s method or kcals/kg
2. Protein Requirements
a. _____g/kg current weight (or adjusted weight )
b. Kcal:N ratio
200:1 not stress, hospitalized
150:1 moderate stress
100:1 severe stress, such as burns, sepsis, head injury
3. Water Requirements 1ml/kcal, or 30-35ml/kg/day minimum (adults
only).
4. Calculating Tube Feeding: (refer to handout)
Charting
Enteral Order: Date, product, rate, strength, additional fluid, IV fluids if applicable
Nutritional Provisions: Kcals, protein, and fluid provided
Labs: Albumin, BUN, Na, and Glucose
Nutritional Needs: Kcals, protein, and fluids(as calculated with Harris-Benedict equation, etc.)
Assessment: Albumin and wt. status, hydration status, appropriateness/adequacy of enteral order, tolerance, nutrition status of patient.
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