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Enteral and parenteral feeding Katherine D. Olpindo / BSN - RN By:

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ENTERAL NUTRITION promotes the importance of nutritional support in order to improve the nutritional status of patients in hospital and the community. is the administration of nourishment via the GI tract. This includes liquid diets, soft and solid food diets, and special nutritionally complete formulas administered orally or via tubes Objective:

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–are when nutrients are provided via feeding tubes placed into the alimentary tract. Presence of intestinal fistulas (abnormal passages between the intestines) Tube Feeding Indication: Protein-calorie malnutrition resulted from inadequate/reduced oral intake Severe dysphagia Major burns Short gut from small bowel resection

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Severe renal dysfunction Conditions under which Enteral tube feedings are helpful, but not routine: Major trauma Radiation therapy Chemotherapy Acute or chronic liver failure

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If tube feeding will be used for short term, for periods that do not exceed 6 weeks, non-surgical placement can be made. These are preferred for patients who will resume oral feeding. Feeding Routes: If feeding tube will be long term or permanent, it can be surgically made.

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Nasojejunal Intubation –insertion of a tube into the nasal passages to the jejunum If tube feeding will be used for short term. Nasogastric Intubation –refers to the insertion of a long, soft, polyethylene tube called the nasogastric tube (NGT) through the nasopharynx into the stomach. Nasoduodenal Intubation –insertion of a tube into the nasal passages to the duodennum

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If feeding tube will be long term or permanent, it can be surgically made. Jejunostomy / PEJ (Percutaneous Endoscopic Jejunostomy) –feeding tube inserted into the jejunum using an endoscopic technique. Esophagostomy –insertion of a feeding tube into the esophagus using an endoscope Gastrostomy / PEG (Percutaneous Endoscopic Gastrostomy) –insertion of a feeding tube into the stomach which uses an endoscope and pulling the tube through a small incision in the abdominal wall.

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Gastrostomy / PEG

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Jejunostomy / PEJ

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METHOD OF ADMINISTRATION Continuous Infusion -provides controlled delivery of a prescribed volume of formula at a constant rate over a continuous (usually 16-24 hrs period) period using an infusion pump.

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METHOD OF ADMINISTRATION 2. Intermittent Infusion -delivering the quantity of formula needed for a 24-hr period in 3-6 equal feedings. -delivered by gravity during a 30-90 minute period

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3. Bolus Feeding METHOD OF ADMINISTRATION -infusing volumes of formula by gravity or syringe over a short period of time (not to exceed 400 cc at a time)

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GI problem -diarrhea -distention -N/V -constipation -cramping Mechanical problem -displacement -pulmonary aspiration -obstruction -mucosal damage Metabolic difficulties -dehydration, overhydration -hyperglycemia -rapid wt. gain Possible Complications

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-Irrigate tubes every 6-8 hrs with 40-50 ml of warm water(continuous feeds) -For intermittent or bolus feedings, irrigate tubes after each feeding with 40-50 ml of warm water -If tubing clogs, flush with 30-50 ml of warm water -Administer solutions infused by continuous drip chilled -Administer intermittent and bolus feedings at room temperature to decrease incidence of GI side effects Temperature -Use closed feeding containers -Never add new formula to old formula -Do not hang feedings for longer than 4-8 hrs Prevention of bacterial contamination -Check tube placement before administration -HOB should be elevated 30-45 degrees Prevention of aspiration Patency of tubing

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- Medications administered through the feeding tube should be in the liquid form Flush tubing before and after giving the medication with 20cc of water to prevent clogging If medication is not available in liquid form, consult the pharmacist before crushing or diluting the medication(some medications are pharmacologically altered by mechanical manipulation) Do not mix together multiple medications and deliver simultaneously unless the compatibility of the medications is known - Monitor patient response to medications given through the feeding tube Because hyperosmolar liquid medications(KCl) may cause gastric irritation or diarrhea, dilute with water before administration - If feeding into the duodenum or jejunum instead of the stomach, check the effect of the medication absorption Medications

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- Confirm tube placement before initiation of feeding and before each intermittent feeding - Record gastric residuals every 4 hrs (gastric feedings only) - Record bowel movement and consistency - Record tolerance to feedings - Record daily: weight, intake and output - Record weekly: Serum electrolytes and blood counts Chemistry profile(including liver function test, phosphorus, calcium, magnesium, total protein and albumin) Nitrogen balance, if appropriate Monitoring

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PARENTERAL NUTRITION -provision of energy and nutrients intravenously; when tube feedings are contraindicated.

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CPN / Central Parenteral Nutrition -when feeding is infused into a large-diameter vein such as the superior vena cava or subclavian vein. Other name: TPN / Total Parenteral Nutrition -when smaller peripheral vein is used such as the vein in forearm Other names: Hyperalimentation Central Venous Nutrition Peripheral Venous Nutrition 2. PPN / Peripheral Parenteral Nutrition

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Contains: CHO –most common CHO is dextrose monohydrate. Used as energy source, it yields 3.4 kcal/g because of its hydrated form. Dextrose sol’n available in 5% - 70% AA –for protein synthesis not a source of kcal; mixture of essential and nonessential crystalline amino acids with or without added electrolytes Fats –used as a concentrated energy source and to prevent the development of essential fatty acid deficiency. A 10% fat emulsion yields 1.1 kcal/ml or 550 kcal per 500 ml bottle and a 20% solution yields 2 kcal/ml or 1000 kcal per 500 ml bottle -administration lipid emulsion should not exceed 2.5g of lipid/kg(adults). Baseline serum triglyceride level should be confirmed before administration. The patient should not have received lipid emulsion for 12 hrs before blood is drawn. Electrolyte –Mg, Phosphate, K Vitamins –except vit. K for adult (given IM/IV) Trace elements –Zn, Cu, Mn, Cr, Se

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Technical complications -malposition of catheter -subclavian artery puncture -carotid artery puncture -air embolism -thrombosis Septic complication -catheter related sepsis -septic thrombosis Metabolic complications -hyperglycemia -hyperkalemia -hypocalcemia -hyperphosphatemia COMPLICATIONS

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Monitoring of total parenteral nutrition (TPN) Strict I/O Urinary glucoseElectrolytes BUN Ca, P, Mg Alkaline phosphatase Albumin Triglycerides Prealbumin *First 3-7 days, depending on the patient‘s stability I/O = input and output BUN = blood urea nitrogen

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