Routes of Nutrition

8/9/2019 Routes of Nutrition

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Routes of nutritionsupport


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Oral diets

Normal diets are intended to maintain health by meeting the RDA for clients ag No foods are excluded & portion sizes are not restricted on a normal diet

Modied diets used for clients !ho are unable to tolerate a normal diet or !ho hnutritional re#uirements

Di$er from normal diets in their consistency% total calorie content% concentration of macronconcentration of one or more micronutrients

ombinations of diet modications necessary to meet clients needs' should beindi"idualized to ensure optimal tolerance & compliance

Oral inta(e resumed after acute illness% surgery% tube feedings% or )*N clear li#uprogressing to full li#uids+soft diet+normal or modied diet , depending on clietolerance & condition% this routine progression may be accelerated by eliminatinof the transitional diets.

lients unable or un!illing to eat enough food to meet at least /-0 of their of thecalorie re#uirements may be gi"en nourishment orally or through a tube to suppinta(e


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1nteral nutrition

supplying nutrients ,li#uid. using 23 tract% including tubefeedings & oral diets

*urposes4 used as a supplement to an oral diet or may pro"ide nutrition to

!ho are unable to consume food orally

easier% safer% better tolerated% & less expensi"e than parentera

should be used !hene"er 23) is functional

has an ad"antage of stimulating the 23) because it helps maintnormal enzyme acti"ity & gut mucosal integrity+nutrients used

helps maintain normal immune function by increasing 3gA !hicpre"ents absorption of enteric antigens


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Oral supplements

plain or fortied mil(% mil( sha(es% instant breaeggnogs are high protein% high calorie 5homemasupplements that are palatable% relati"ely inexpe& suitable for boosting the protein & calorie intaclients !ho are unable to meet their nutritionalre#uirements through food alone7


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Modular products

incomplete formulas that supply a single nutrien8O% 8ON% or fat


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)ube feedings

often used as a transition bet!een parenteral nutritiooral diet

useful for "ariety of clinical conditions & arecontraindicated !hen the 23) is nonfunctional gor intestinal obstruction% paralytic ileus% intracta"omiting% & se"ere diarrhea


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onditions )hat Re#uire OtherNutrition 9upport

1nteral+3mpaired ingestion

+3nability to consume ade#uate nutrition orally

+3mpaired digestion% absorption% metabolism

+9e"ere !asting or depressed gro!th

*arenteral+2astrointestinal incompetency

+8ypermetabolic state !ith poor enteral tolerancor accessibility


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onditions )hat Often Re#uire Nutritional9upport


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onditions )hat Often Re#uire Nutritional9upport :contd


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onditions )hat Often Re#uire Nutritional9upport :contd


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Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimallyinvasive access to the gastrointestinal tract. In Rombea J!,Rolandelli R", editors: Clinical nutrition: enteral and tube

feeding, p #$%, &hiladelphia, #''$, (B )anders* and +li + et al:

tritional spport services, Nutritional Support Algorithms,-$/:#0, Jly #''-.


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ontraindications for 1N

9e"ere acute pancreatitis

8igh output proximal stula 3nability to gain access 3ntractable "omiting or diarrhea Aggressi"e therapy not !arranted

1xpected need less than ;< days ifmalnourished or


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ontraindications for 1N

3nade#uate resuscitation orhypotension' hemodynamicinstability

3leus

3ntestinal obstruction 9e"ere 2737 leed


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Beeding tube placement

)RAN9NA9AC )19 OR NA9O2A9)R3 most commofor feedings of relati"ely short duration

O9)OM319 OR 9)OMA9 surgically created openings mdeli"er feedings directly into the stomach or intestinepreferred method for permanent or longterm feedingbecause they eliminate irritation to the mucous mem

*1R)AN1O9 1NDO9O*3 2A9)RO9)OME )B11D3N29 placed nonsurgically !ith the aid of aendoscope


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)ransnasal tubes

inserted nonsurgically through the nose & exteneither the stomach% duodenum% or FeFunum client can participate acti"ely in the procedure by s!

small sips of !ater as the tube is passed+minimize d& speed its passage

ha"e potential to irritate the nose & esophagus if use

prolonged periods or if the tube is too large

uncooperati"e clients are able to !ithdra! trantubes


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Nasogastric )ubes


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Nasogastric )ubes

Denition

A tube inserted through the nasalpassage into the stomach

3ndications4

9hort term feedings re#uired

3ntact gag reGex 2astric function not compromised

Co! ris( for aspiration


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Brench nits+)ube 9ize

Diameter of feeding tube is measured inBrench units

?B H 00 mm diameter

Beeding tube sizes di$er for formula types aadministration techni#ues

2enerally smaller tubes are more comfortab

and better suited to N2 or NI feedings May be more li(ely to clog !ith "iscousformula or formula mixtures


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Nasogastric )ubes

Ad"antages4

1ase of tube placement

9urgery not re#uired

1asy to chec( gastric residuals

Accommodates "arious administration

techni#ues


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Nasogastric )ubes

Disad"antages4

3ncreases ris( of aspiration ,maybe.

Not suitable for patients !ithcompromised gastric function

May promote nasal necrosis andesophagitis

3mpacts patient #uality of life


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Nasoduodenal-IeFunal

Ad"antages4

Allo!s for initiation of early enteralfeeding

May decrease ris( of aspiration

9urgery not re#uired


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Nasoduodenal-IeFunal

Disad"antages4

)ranspyloric tube placement may bediJcult

Cimited to continuous infusion

May promote nasal necrosis andesophagitis

3mpacts patient #uality of life


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Orogastric

)ube is placed through mouth an

into stomach Often used in premature and sminfants as they are nasal breathe

Not tolerated by alert patients'

tubes may be damaged by teeth


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19O*8A2O9)OME

a surgical opening made in the esophagus throu!hich a feeding tube is passed into the stomach commonly used for clients !ith head & nec( cancer

generally !ell tolerated because the stomach is used& release food at a controlled rate pre"ents 5dumpinsyndrome6

ris( or aspiration is high & danger of hemorrhagto the thoracic duct exists


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ostomyosotomy


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1nterostomy *lacement

2astrostomy

IeFunostomy


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2astrostomyDenition

A feeding tube that passes into the stomachthrough the abdominal !all7 May be placedsurgically or endoscopically

3ndications4

Congterm support planned

2astric function not compromised

3ntact gag reGex present


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2astrostomy

Disad"antages4

May re#uire surgery

9toma care re#uired

*otential problems for lea(age or tubedislodgment

2 t t


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2astrostomy


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IeFunostomy

Denition

A feeding tube that passes into theFeFunum through the abdominal !all7May be placed endoscopically orsurgically

3ndications4

Congterm feeding option for patientshigh ris( for aspiration or !ithcompromised gastric function


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IeFunostomy

Ad"antages4

*ostop feedings may be initiatedimmediately

Decreased ris( of aspiration

9uitable option for patients !ithcompromised gastric function

9table patients can tolerate intermittefeedings


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IeFunostomy

Disad"antages4

Re#uires stoma care *otential problems related to lea(age

tube dislodgement-clogging may arise

May restrict ambulation

olus feedings inappropriate ,stablepatients may tolerate intermittentfeedings.

D t i i M th d f


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Determining Method ofAdministration

Beeding site linical status of patient

)ype of formula used

A"ailability of pump

Mobility of patient


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Administration

olus

3ntermittent

ontinuous

yclic


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olus Beedings

Denition

3nfusion of up to ;>> ml of enteral formula ithe stomach o"er ; to /> minutes% usually bgra"ity or !ith a largebore syringe

3ndications4

Recommended for gastric feedings

Re#uires intact gag reGex

Normal gastric function


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olus Beedings

Ad"antages4

More physiologic 1nteral pump not re#uired

3nexpensi"e and easy administration

Cimits feeding time so patient is free to ambulat

participate in rehabilitation% or li"e a more normin the home

Ma(es it more li(ely patient !ill recei"e full amoformula

olus


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olusBeeding


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olus Beeding

Disad"antages4

3ncreases ris( for aspiration 8ypertonic% high fat% or high ber

formulas may delay gastric emptying result in osmotic diarrhea


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ontinuous Beedings

3ndications4

3nitiation of feedings in acutely illpatients

*romote tolerance

ompromised gastric function

Beeding into small bo!el 3ntolerance to other feeding techni#u


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ontinuous Beedings

Denition

1nteral formula administration into thegastrointestinal tract "ia pump or gra"ity%usually o"er ?K to /@ hours per day

Ad"antages4

May impro"e tolerance

May reduce ris( of aspiration

3ncreased time for nutrient absorption


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3ntermittent BeedingsDenition

1nteral formula administered at specied times through

day' generally in smaller "olume and at slo!er rate thabolus feeding but in larger "olume and faster rate thancontinuous drip feeding

)ypically />>0>> ml is gi"en o"er 0>K> minutes # @K

*recede and follo! !ith 0>ml Gush of tap !ater

3ndications4 3ntolerance to bolus administration

3nitiation of support !ithout pump

*reparation of patient for rehab ser"ices or discharge toor C) facility

)he A797*717N7 Nutrition 9upport *ractice Manual% /nd1dition />>;


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3ntermittent Beedings

Ad"antages4

May enhance #uality of life Allo!s greater mobility bet!een

feedings

More physiologic

May be better tolerated than bolus


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3ntermittent Beedings

Disad"antages4

3ncreased ris( for aspiration 2astric distention

Delayed gastric emptying


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yclic Beedings

Denition

Administration of enteral formula "ia continuous drip o"dened period of L to ?/ hours% usually nocturnally

3ndications4

1nsure optimal nutrient inta(e !hen4

)ransitioning from enteral support to oral nutrition ,e

appetite during the day. 9upplement inade#uate oral inta(e

Bree patient from enteral feedings during the day


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yclic Beedings

Ad"antages4

Achie"e nutrient goals !ithsupplementation

Bacilitates transition of support to oradiet

Allo!s daytime ambulation

1ncourages patient to eat normal meand snac(s

li di


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yclic Beedings

Disad"antages4

May re#uire high infusion rates+maypromote intolerance

1nteral Beeding ontainers


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1nteral Beeding ontainers

May be rigid or Gexible

9terile or nonsterile nbrea(able% lea(proof%and disposable

onsiderations in hoosing 1nte


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onsiderations in hoosing 1nteBeeding ontainers

1asy to ll% close and hang 1asy to read calibrations and directions

Appropriate size

Adaptable tubing port

ompatible !ith pump Re#uires minimal storage space

Adapted from A9*1N7 )he science and practice of nutrition

support7 A casebased core curriculum7 />>?' ?


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losed 9ystems

1nteral Beeding *umps


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Administration


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before initiating a feeding, tube placement must be veried prefex-ray & bowel sounds must be present

Fluid restriction is required- tube feedings canstarted at 30 ml/r

Feedings sould be at room temperature

!o elp ensure tube patency, intermittent & bolus feedings souldfollowed by an infusion of "0-#0 ml warm water & continuous feedsould be irrigated every sift wit "0-#0 ml of warm water

li$ewise, every time te feeding is interruptedsould be %used wit water

edications- can become terapeutically ine'eadded directly to te enteral formula

(dminister drug in a single bolus troug te etube ma$ing sure tube is %used wit water beafter te drug is administered

)f more tan one drug is given- tube sould be

Reduce ris( of bacterial


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Reduce ris( of bacterialcontamination ?7 closed feeding systems are recommended

/7 changing the extension tubing & bag daily

07 refrigerating prepared formulas until they areneeded

@7 ne"er adding a ne! supply of formula to old

;7 hanging feeding solutions for less than K hou


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)ransition to oral diet


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)ransition to oral diet

)o begin transition process tube feeding should be st

for ? hour before each meal 2radually increase meal fre#uency until K small oral f

are accepted

Actual inta(e recorded & e"aluated daily

hen oral calorie inta(e is consistently ;>> calor

tube feedings may be gi"en only during the night hen client consistently consumes /-0 of 8ON

calorie needs orally for 0; days tube may be todiscontinued

Documents

Routes of Nutrition