NUTRITIONAL SUPPORT

NUTRITION SUPPORT

The delivery of nutrients

using a feeding tube or
intravenous infusions (can
meet a patient’s
nutritional needs)
 ENTERAL NUTRITION

The provision of nutrients

using the gastrointestinal
(GI) tract, usually refers to
the use of tube feedings,
which deliver nutrient-
dense formulas directly to
the stomach or small
intestine via a thin,
flexible tube.
PARENTERAL NUTRITION

It provides nutrients
intravenously to
patients
who do not have
sufficient GI function
to handle enteral
feedings.
PARENTERAL NUTRITION

PAR – BESIDE
ENTERO - INTESTINE
PARENTERAL NUTRITION

PREFERRED?
PATIENT WITH POOR APPETITE?

MANAGE?
IMPROVE THEIR DIETS?
EXAMPLE OF ORAL SUPPLEMENTS?
 TUBE FEEDINGS
• Typically recommended for patients

at risk of developing
protein-energy malnutrition

unable to consume adequate food

unable to consume oral supplements to maintain their health.

 DEFINITION OF TERMS
• Orogastric Tube (OGT) - Thin soft tube passed
through a child’s mouth, through the oropharynx,
through the oesophagus and into the stomach
 DEFINITION OF TERMS
• Nasogastric Tube (NGT) – Thin soft tube passed
through a child’s nose, down the back of the
throat, through the esophagus and into the
stomach.
 DEFINITION OF TERMS
• Gastrostomy tube - a feeding tube which is
inserted endoscopically or surgically through the
abdominal wall and directly into the stomach.
 DEFINITION OF TERMS

• Temporary balloon device (G-Tube) – a

gastrostomy tube
 DEFINITION OF TERMS
• Percutaneous endoscopic gastrostomy tube (PEG)
– a gastrostomy tube which is held in place with an
internal fixator
 DEFINITION OF TERMS
• Gastrostomy-Button (Mickey-Button) - skin level
button gastrostomy tube inserted into a pre-
formed stoma.
 DEFINITION OF TERMS
• Gastric Residual Volume (GRV’s) – the amount of
fluid aspirated from the stomach via an enteral
tube to monitor gastric emptying, tolerance to
enteral feeding and abdominal decompression.
Once removed it may be returned to the patient or
discarded.
 DEFINITION OF TERMS
• Trans-Anastomotic Tube (TAT tube) - Utilized after
surgery to repair esophageal atresia (absence or
abnormal narrowing of an opening or passage in
the body) inserted by surgeons in the Neonatal
patient population.
 CANDIDATES FOR TUBE FEEDINGS
• Severe swallowing disorders
• Impaired motility (the ability of the muscles of the digestive
tract to undergo contraction in the upper GI tract)
• GI obstructions and fistulas that can be bypassed with a feeding
tube
• Certain types of intestinal surgeries
• Little or no appetite for extended periods, especially if the
patient is malnourished
• Extremely high nutrient requirements
• Mechanical ventilation
• Mental incapacitation due to confusion, neurological disorders,
or coma
 CONTRAINDICATIONS
• severe GI bleeding
• high-output fistulas
• intractable vomiting or diarrhea
• severe malabsorption
• if the expected need for nutrition support is
less than 5 to 7 days in a malnourished patient
• if the expected need for nutrition support is
less than 7 to 9 days in an adequately
nourished patient
 ROUTES

https://www.google.com/search?q=gastrointestinal+access+feeding&tbm=isch&ved=2ahUKEwj-0aaS3Y_zAhWyNKYKHa_mCmEQ2-
cCegQIABAA&oq=gastrointestinal+access+feeding&gs_lcp=CgNpbWcQAzoECAAQQzoFCAAQgAQ6CwgAEIAEELEDEIMBOggIABCABBCxAzoICAAQsQMQgwE6BwgAELEDEEM6B
ggAEAgQHjoECAAQGFCdgSNYgs4jYKXRI2gAcAB4AIABhwKIAc8nkgEGMC4zMC4xmAEAoAEBqgELZ3dzLXdpei1pbWfAAQE&sclient=img&ei=ZqJJYf6GI7LpmAWvzauIBg&bih=573
&biw=1366&client=firefox-b-d#imgrc=H3FaqL8OzoI1VM
FEEDING TUBES

Made from soft,

flexible materials
(such as silicone
or polyurethane) and
come in a variety of
lengths and diameters
FEEDING TUBES

The tube selected

largely depends on
the patient’s age
and size, the feeding
route, and
the formula
viscosity.
FEEDING TUBES

The outer diameter of

a feeding tube is
measured in French
units, in which each
unit equals 1/3
millimeter;
thus, a “12 French”
feeding tube has a 4-
millimeter diameter
(12 3 1/3 mm 5 4
mm).
FEEDING TUBES

The inner diameter

depends on the
thickness of the
tubing material.
FEEDING TUBES

Double-lumen tubes
these allow a single tube
to be used for both
intestinal feedings and
gastric decompression, a
procedure in which the
stomach
contents of patients with
motility problems or
obstructions are removed
by suction.
Insertion Method or Advantages
Feeding Site
Transnasal Does not require surgery or incisions for
placement; tubes can be placed by a nurse or
trained dietitian.
Nasogastric Easiest to insert and confirm placement; least
expensive method; feedings can often be given
intermittently and without an infusion pump.
Nasoduodenal and Lower risk of aspiration in compromised patients;
nasojejunal allows for earlier tube feedings than
gastric feedings during acute stress; may allow
enteral feedings even when obstructions,
fistulas, or other medical conditions prevent
gastric feedings.
Tube enterostomies Allow the lower esophageal sphincter to
remain closed, reducing the risk of aspiration;
more comfortable than transnasal insertion for
long-term use; site is not visible under clothing.
Gastrostomy Feedings can often be given intermittently and
without a pump; easier insertion procedure
than a jejunostomy.
❚ Jejunostomy Lowest risk of aspiration; allows for earlier
tube feedings than gastrostomy during critical
illness; may allow enteral feedings even when
obstructions, fistulas, or medical conditions
prevent gastric feedings.
Disadvantages
Easy to remove by disoriented patients; long-
term use may irritate the nasal passages, throat, and
esophagus.
Highest risk of aspiration in compromised
patients;
risk of tube migration to the small
intestine.
More difficult to insert and confirm placement;
risk of tube migration to the stomach; feedings
require an infusion pump for administration.
Tubes must be placed by a physician
or surgeon; general anesthesia may be
required for surgically placed tubes; risk of
complications from the insertion procedure;
risk of infection at the insertion site.
Moderate risk of aspiration in high-risk
patients;b
feedings often withheld for 12 to
24 hours before and 48 to 72 hours after the
insertion procedure.
Most difficult insertion procedure; most costly
method; feedings require an infusion pump for
administration.
 ENTERAL FORMULAS
• Most enteral formulas can supply all of an
individual’s nutrient requirements when
consumed in sufficient volume, a necessity for
the patient who is using a tube feeding for
more than a few days.
 ENTERAL FORMULAS
TYPE INDICATIONS CONTENT
1. Standard Individuals who contain intact proteins
Formulas can digest and absorb nutrients extracted from milk or soybeans
(polymeric without difficulty. (called protein isolates) or a
formulas) combination of such proteins.
The carbohydrate sources include
hydrolyzed cornstarch, glucose
polymers (such as maltodextrin
and corn syrup solids), and sugars.

A few formulas, called blenderized

formulas, are produced from
whole foods such as chicken, veg-
etables, fruits, and oil, along with
some added vitamins and
minerals.
 ENTERAL FORMULAS
TYPE INDICATIONS CONTENT
2. Elemental compromised digestive or Elemental formulas contain
formulas absorptive functions. proteins and carbohydrates that
(hydrolyzed, have been partially or fully broken
chemically down to fragments that require
defined, or little (if any) digestion. The
monomeric formulas are often low in fat and
formulas) may provide fat from medium-
chain triglycerides (MCT) to ease
digestion and absorption.
 ENTERAL FORMULAS
TYPE INDICATIONS CONTENT
3.Specialized meet the nutrient needs of Specialized
formulas patients with particular illnesses. formulas are generally expensive,
(disease- Products have been developed for and their effectiveness is
specific or individuals with liver, kidney, and controversial.
specialty lung diseases; glucose intolerance;
formulas) severe wounds; and metabolic
stress
 ENTERAL FORMULAS
TYPE INDICATIONS CONTENT
4. Modular Prepared for patients who require Provides protein, fat, or
formulas specific nutrient combinations. carbohydrate as a single nutrients
or modular mixtures to allow
adjustment of macronutrient mix.
May also contribute to renal
solute load, osmolality.
Vitamin and mineral preparations
are also included in the formulas
so that they can meet all of a
person’s nutrient needs.
 MAIN FACTORS THAT INFLUENCE
FORMULA SELECTION

• GI function.
Although the vast majority of patients can use standard
formulas, a person with a functional but impaired GI tract
may require an elemental formula.
 MAIN FACTORS THAT INFLUENCE
FORMULA SELECTION

• Nutrient and energy needs.

• As with patients consuming regular diets, the tube-fed
patient may require adjustments in nutrient and energy
intakes. If fluids are restricted, the formula should have
adequate nutrient and energy densities to provide the
required nutrients in the volume prescribed.
 MAIN FACTORS THAT INFLUENCE
FORMULA SELECTION

• Fiber modifications.
• The choice of formulas is narrower if fiber intake needs
to below or high.
 MAIN FACTORS THAT INFLUENCE
FORMULA SELECTION

• Individual tolerances (food allergies and sensitivities).

• Nearly all formulas are lactose free and gluten free and
can accommodate the needs of patients with lactose
intolerance or gluten sensitivity. For patients with food
allergies, ingredient lists should be checked before
providing a formula.
 FORMULAS MAY BE DELIVERED…
CLOSED FEEDING
OPEN SYSTEM
SYSTEM

the sterile formula is

the formula needs to
prepackaged in a
be transferred from its
container that can be
original packaging to a
connected directly to a
feeding container.
feeding tube.

cans or bottles,
concentrates that
need to be diluted,
and powders that
require reconstitution.
 FORMULA SAFETY GUIDELINES
• Before opening a can of
formula, clean the lid
with a disposable
alcohol wipe.
• Wash the can opener
(if needed) with
detergent and hot
water.
• If you do not use the
entire can at one
feeding, label the can
with the date and time
it was opened.
 FORMULA SAFETY GUIDELINES

• Store opened cans or mixed

formulas in clean, closed
containers. Refrigerate the
unused portion of formula
promptly.
• Discard unlabeled or
improperly labeled containers
and all open containers of
formula that are not used
within 24 to 48 hours.
 FORMULA SAFETY GUIDELINES
• Hang no more than an 8-hour supply of
formula (or a 4-hour supply for newborn
infants) when using liquid formula from a
can.
• Formulas prepared from powders or
modules should hang no longer than 4
hours. Discard any formula that remains,
rinse the feeding bag and tubing, and add
fresh formula to the feeding bag.
• A new feeding container and tubing
(except for the feeding tube itself) is
necessary every 24 hours.
 FORMULA SAFETY GUIDELINES

• For closed systems, the

hang time should be no
longer than 24 to 48 hours.
• Contamination is more likely
with the longer time
periods.
Formula Delivery Methods
INTERMITTENT CONTINUOUS
FEEDINGS FEEDINGS
• delivering • Smaller
relatively large amounts
amounts of continuously
formula
several times
per day
Formula Delivery Methods

INTERMITTENT CONTINUOUS
FEEDINGS FEEDINGS
• best tolerated when
they are delivered • delivered slowly and
into the stomach at a constant rate
(not the intestine). over a period of
• 8 to 24 hours, and
are most often used
for intestinal
feedings.
Formula Delivery Methods
BOLUS FEEDING

Rapid delivery of a large volume

of formula into the stomach
(250 to 500 milliliters over 5 to
15 minutes)

may be given
every 3 to 4 hours using a
syringe.

can cause abdominal discomfort,

nausea, and cramping in some
Bolus feedings are used only in
patients, and the risk of aspiration is
patients who are not critically ill.
greater than with other methods of
feeding.
 COMBINATION
BOLUS FEEDING
(Day time)

CONTINUOUS DRIP
(At night)
 ASPIRATION
• To reduce the risk of aspiration,
the patient’s upper body is
elevated to a 30- to 45-degree
• angle during the feeding and for
30 to 60 minutes after the feeding
whenever possible.
• The addition of blue food coloring
to formula was formerly
suggested as a means of
identifying aspirated formula in
lung secretions; however, the
practice was discontinued after it
was found to be associated with
various complications and even
deaths.
 GASTRIC RESIDUAL VOLUME
• Is the stomach emptying properly?
 GASTRIC RESIDUAL VOLUME
• The volume of formula and GI secretions
remaining in the stomach after a previous
feeding.
 GASTRIC RESIDUAL VOLUME
• How?
• The gastric contents are
gently withdrawn through
the feeding tube using a
syringe, usually before
intermittent feedings and
every 4 to 8 hours during
continuous feedings in
critically ill patients.
 WATER NEEDS
• many patients require about 30 to 40
milliliters of water per kilogram body weight
daily.
 WATER NEEDS

Severe vomiting, diarrhea,

fever, excessive sweating, Restricted in persons with
high urine output, high- kidney, liver, or heart
output ostomies, blood disease.
loss, or open wounds.
MEDICATIONS

PHENYTOIN
(Seizure)

Feedings need to be
stopped for at least one
hour before and after
administration of
medication.
 DIARRHEA
• Medications are a major cause of the diarrhea
that frequently accompanies tube feedings.
• Example:

Sorbitol-containing medications, laxatives,

and some types of antibiotics.

The high osmolality of many liquid

medications
Osmolality - the concentration of a solution
expressed as the total number of solute
particles per kilogram.
TUBE FEEDING COMPLICATIONS
TUBE FEEDING COMPLICATIONS
TRANSITION TO TABLE FOODS
CANDIDATES FOR PARENTERAL NUTRITION
• Intractable vomiting or diarrhea
• Severe GI bleeding
• Intestinal obstructions or fistulas
• Paralytic ileus (intestinal paralysis)
• Short bowel syndrome (a substantial portion of
the small intestine has been removed)
• Bone marrow transplants
• Severe malnutrition and intolerance to enteral
nutrition
 PERIPHERAL PARENTERAL NUTRITION (PPN)

• Nutrients are delivered

using only the
peripheral veins
 PERIPHERAL PARENTERAL NUTRITION (PPN)

• Nutrients are delivered

using only the
peripheral veins

• Phlebitis (redness,
swelling, and tenderness
at the infusion site).
 TOTAL PARENTERAL NUTRITION (PPN)

• Most patients meet

their nutrient needs
using the larger central
veins, where blood
volume is greater and
nutrient concentrations
do not need to be
limited.
 TOTAL PARENTERAL NUTRITION (PPN)

• preferred for patients

who require long-term
parenteral nutrition.
PARENTERAL SOLUTIONS
Amino Acids

Carbohydrate

Lipids

Fluids and Electrolytes

Vitamins and Trace Minerals

 PARENTERAL SOLUTIONS
MEDICATIONS??

Can we add medications to parenteral

solutions? or infused through a separate
port in the catheter?

Medications are occasionally added

directly to parenteral solutions or
infused through a separate port in the
catheter.
 CONTINUOUS
CYCLIC PARENTERAL
PARENTERAL
NUTRITION
NUTRITION
• Continuous • Administration of
administration of parenteral solutions
parenteral solutions over a 10-14-hour
over a 24-hour period each day
period
 Parenteral Formulations
A TOTAL NUTRIENT ADMIXTURE (TNA)

3-in-1 solution or all-in-one solution :

When a parenteral solution contains dextrose, amino acids,
and lipids.
2-in-1 solution:
When a parenteral solution contains dextrose and amino
acids.
 NOTE: Osmolarity
• The osmolarity of PPN solutions is limited to 900
milliosmoles per liter because peripheral veins
are sensitive to high nutrient concentrations.
• Whereas TPN solutions may be as nutrient dense
as necessary. Amino acids, dextrose,and
electrolytes contribute the most to a solution’s
osmolarity. Because lipids contribute little to
osmolarity, lipid emulsions can be used to
increase the energy provided in PPN solutions.
 NOTE : Care of Intravenous Catheters
• Catheters may be improperly positioned or may
dislodge after placement. Air can leak into catheters
and escape into the bloodstream, obstructing blood
flow. Catheters in peripheral veins may cause phlebitis,
necessitating reinsertion at an alternate site. A catheter
may become clogged from blood clotting
• or from a buildup of scar tissue around the catheter
tip. Catheters are also a leading cause of infection:
contamination may be introduced during insertion or
may developat the placement site.
NOTE: To reduce the risk of complications:
• Use aseptic techniques when inserting catheters,
changing tubing, or changing a dressing that covers the
catheter site.
• Unusual bleeding or a wet dressing suggests a problem
with catheter placement.
• A change in infusion rate may indicate a clogged
catheter.
• Infection may be indicated by redness or swelling
around the catheter site or by an unexplained fever.
• Routine inspections of equipment and frequent
monitoring of patients’ symptoms help to minimize the
problems associated with catheter use.
NOTE: Discontinuing Parenteral Nutrition
• The patient must have adequate GI function before parenteral
nutrition can be tapered off and enteral feedings begun.
• During the transition to oral feedings, a combination of methods is
often necessary.
• Parenteral infusions are usually tapered off at the same time that
tube feedings or oral feedings are begun, such that the two
methods can together supply the needed nutrients.
• Once about two-thirds to three-fourths of nutrient needs can be
provided by other means, the parenteral infusions may be
discontinued.
• Transitioning to an oral diet is sometimes difficult because a
person’s appetite remains suppressed for several weeks after
parenteral nutrition is terminated.
 PLAN A TUBE FEEDING SCHEDULE
1. Select a suitable formula
2. Determine the volume of formula that meets the
patient’s nutritional needs.
3. Example: a patient needs 2000 kcl/day and is
receiving a standard formula that provides 1.0kcal
per ml. per day
4. Formula:
xml x 1.0kcal/ml = 2000kcal = 2000 ml

xml = 2000 kcal

1.0 kcal/ml
 PLAN A TUBE FEEDING SCHEDULE

5. If the patient is to receive intermittent feedings

six times a day, he will need about ____ ml of
formula at each feeding.
2000 ml
6 feedings

= 333 ml per feeding

 CALCULATE THE
MACRONUTRIENT AND ENERGY CONTENT
OF A PARENTERAL SOLUTION
Example: A patient is receiving 1.25 Liters (1250ml) of a
parenteral solution that contains:
5 percent amino acids and 30 percent dextrose, supplemented with 250 milliliters of
a 20 percent lipid emulsion daily.

How many grams of protein and carbohydrate is the person receiving, and what is the
total energy intake for the day?

Amino acids:
5% amino acids = 5 g amino acids
100 mL
= 62.5g of amino acids x 4.0 kcal/g
5 g amino acids
100 mL x 1250 mL
= 250 kcal
= 62.5g of amino acids
 CALCULATE THE
MACRONUTRIENT AND ENERGY CONTENT
OF A PARENTERAL SOLUTION
Example: A patient is receiving 1.25 Liters (1250ml) of a
parenteral solution that contains:
5 percent amino acids and 30 percent dextrose, supplemented with 250 milliliters of
a 20 percent lipid emulsion daily.

How many grams of protein and carbohydrate is the person receiving, and what is the
total energy intake for the day?

Carbohydrate:
30 % dextrose = 30 g dextrose
100 mL
= 375g of dextrose x 3.4 kcal/g
30 g dextrose
100 mL x 1250 mL
= 1275 kcal
= 375g of dextrose
 CALCULATE THE
MACRONUTRIENT AND ENERGY CONTENT
OF A PARENTERAL SOLUTION
Example: A patient is receiving 1.25 Liters (1250ml) of a
parenteral solution that contains:
5 percent amino acids and 30 percent dextrose, supplemented with 250 milliliters of
a 20 percent lipid emulsion daily.

How many grams of protein and carbohydrate is the person receiving, and what is the
total energy intake for the day?

Lipids:
Recall that a 20 percent lipid emulsion provides 2.0 kcalories per ml

If the patient is given 250 ml of the

emulsion: = 500 kcal
250ml x 2.0 kcal/ml
 CALCULATE THE
MACRONUTRIENT AND ENERGY CONTENT
OF A PARENTERAL SOLUTION

TOTAL ENERGY INTAKE?

Amino Acids + Carbohydrate + Lipid

250 kcal + 1275 kcal + 500 kcal

= 2025 kcal
NEXT LESSON