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Specialized Nutrition Support:
Enteral & Parenteral Nutrition

Chapter 16
Nutrition & Diet Therapy (7th Edition)

Need for Nutrition Support
• Nutrition support: delivery
• Nutrition support may be of formulated nutrients by
required to meet patient’s feeding tube or
nutritional needs intravenous infusion
– Patients often too ill to • Enteral nutrition:
obtain energy & nutrients
by consuming foods supplying nutrients using
– Or illness may interfere GI tract, including tube
with eating, digestion or feedings & oral diets
absorption • Parenteral nutrition:
intravenous provision of
nutrients, bypassing the GI
tract

Enteral Nutrition
• If GI function is normal and a poor
appetite is the primary nutrition
problem, patients may be able to
improve their diets by using oral
supplements.
• If patients are unable to meet their
nutrient needs by oral intakes alone,
tube feedings can be used to deliver
the required nutrients.
Selecting a Feeding Route

Oral Supplements
• Patients who are weak or debilitated
may find it easier to consume oral
supplements than to consume meals.
• A patient who can improve nutrition
status with supplements may be able
to avoid the stress, complications,
and expense associated with tube
feedings.

• Hospitals usually stock a variety of
nutrient-dense formulas, milkshakes,
fruit drinks, and snack bars to
provide to patients at risk of
becoming malnourished.
• In pharmacies too.
• examples of popular liquid
supplements include Ensure, Boost,
and Carnation Breakfast essential.

• These types of products can add
energy and protein to the diets of
patients and be a reliable source of
nutrients.

• When a patient uses an oral
supplement, taste becomes an
important consideration. Allowing
patients to sample different products
and select the ones they prefer helps
to promote acceptance.

Candidates for Tube Feedings
• Tube feedings are typically
recommended for patients at risk of
developing protein-energy
malnutrition who are unable to
consume adequate food and/or oral
supplements to maintain their
health.

• The following medical conditions or
treatments may indicate the need for
tube feedings

• Severe swallowing disorders
• Impaired motility 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 for tube feedings
include severe GI bleeding, high-
output fistulas, intractable vomiting or
diarrhea, and severe malabsorption.
• The procedure may also be
contraindicated if the expected need
for nutrition support is less than 5 to 7
days in a malnourished patient or less
than 7 to 9 days in an adequately
nourished patient.

Tube Feeding Routes
• The feeding route chosen depends
on the patient’s medical condition,
the expected duration of tube
feeding, and the potential
complications of a particular route.

1.Gastrointestinal Access
• When a patient is expected to be
tube fed for less than four weeks, the
feeding tube is generally routed into
the GI tract via the nose (nasogastric
or nasoenteric routes).
• The patient is frequently awake
during transnasal (through-the-nose)
placement of a feeding tube

• While the patient is in a slightly
upright position with head tilted, the
tube is inserted into a nostril and
passed into the stomach (nasogastric
route), duodenum (nasoduodenal
route), or jejunum (nasojejunal
route).
• The final position of the feeding tube
tip is verified by abdominal X-ray or
other means.

• In infants, orogastric placement, in
which the feeding tube is passed into
the stomach via the mouth, is
sometimes preferred over transnasal
routes; this placement allows the
infant to breathe more normally
during feedings.

• When a patient will be tube fed for longer
than four weeks, or if the nasoenteric
route is inaccessible due to an obstruction
or other medical reasons, a direct route to
the stomach or intestine may be created
by passing the tube through an
enterostomy, an opening in the abdominal
wall that leads to the stomach
(gastrostomy) or jejunum (jejunostomy).
An enterostomy can be made by either
surgical incision or needle puncture.

Selecting a Feeding Route
• Gastric feedings (nasogastric and
gastrostomy routes) are preferred
whenever possible. These feedings
are more easily tolerated and less
complicated to deliver than intestinal
feedings because the stomach
controls the rate at which nutrients
enter the intestine.

• Gastric feedings are not possible, if
patients have gastric obstructions or
motility disorders that interfere with
the stomach’s ability to empty.
• Gastric feedings are also avoided in
patients at high risk of aspiration, a
common complication in which
substances from the GI tract (either
GI secretions or refluxed stomach
contents) are drawn into the lungs,
potentially leading to pneumonia

• Table 16-1 summarizes the
advantages and disadvantages of the
various tube feeding routes.

Feeding Tubes
• Feeding tubes are made from soft,
flexible materials (such as silicone or
polyurethane) and come in a variety
of lengths and diameters.

• The tube selected largely depends on
the patient’s age and size, the
feeding route, and the formula
viscosity.
• 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.
• The inner diameter depends on the
thickness of the tubing material.
• Double-lumen tubes are also
available; 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.

Enteral Nutrition Support
• Wide selection of enteral formulas, designed to
meet variety of medical & nutritional needs
• May be used alone or in conjunction with other
foods
• Many formulas can provide all of nutrient
requirements if consumed in sufficient volume
• Classified according to macronutrient composition
• Preferred over intravenous feedings
Enteral nutrition
requires intact &
normal GI function

Types of Enteral Formulas
• Standard formula: for patients who can digest &
absorb nutrients without difficulty; contains
protein & carbohydrate sources
• Hydrolyzed formulas: used for patients with
compromised digestive or absorptive functions—
macronutrients are partially or fully broken down
& require little, if any, digestion before absorption
• Disease-specific formulas: designed to meet
nutrient needs of patients with particular
disorders: liver, kidney, lung diseases, glucose
intolerance, metabolic stress
• Modular formulas: contain only one or two
macronutrients; used to enhance other formulas

Macronutrient Composition
• The amounts of protein, carbohydrate, and fat in
enteral formulas vary substantially.
• The protein content of most standard formulas
ranges from 12 to 20 percent of total kcalories.
• note that protein needs are high in patients with
severe metabolic stress, whereas protein
restrictions are necessary for patients with
chronic kidney disease.
• Carbohydrate and fat provide most of the energy
in enteral formulas; standard formulas generally
provide 30 to 60 percent of kcalories from
carbohydrate and 15 to 30 percent of kcalories
from
Nutrition fat.
& Diet Therapy (7th Edition)
Energy Density
• The energy density of most enteral
formulas ranges from 1.0 to 2.0 kcalories
per milliliter of fluid.
• The formulas that have higher energy
densities can meet energy and nutrient
needs in a smaller volume of fluid
• benefit patients who have high nutrient
needs or fluid restrictions

Fiber Content
• Fiber-containing formulas may be helpful
for improving fecal bulk and colonic
function, treating diarrhea or constipation,
and maintaining blood glucose control.
• Conversely, fiber-containing formulas are
avoided in patients with acute intestinal
conditions or pancreatitis and before or
after some intestinal examinations and
surgeries.

Osmolality
• Osmolality refers to the moles of
osmotically active solutes per kilogram of
solvent.
• An enteral formula with an osmolality
similar to that of blood serum (about 300
milliosmoles per kilogram) is an isotonic
formula, whereas a hypertonic formula
has an osmolality greater than that of
blood serum.

• Most enteral formulas have osmolalities between
300 and 700 milliosmoles per kilogram.
• elemental formulas and nutrient-dense formulas
have higher osmolalities than standard formulas.
• Most people are able to tolerate both
isotonic and hypertonic feedings without
difficulty.
• When medications are infused along with
enteral feedings, the osmotic load
increases substantially and may contribute
to the diarrhea experienced by many
tube-fed patients.

Formula Selection

The main factors that influence formula
selection include:
1. GI function.
2. Nutrient and energy needs
3. Fiber modifications.
4. Individual tolerances (food allergies and
sensitivities)-lactose free and gluten free.
patients with food allergies, ingredient
lists should be checked before providing a
formula.

Safe Handling
• Individuals who are ill or malnourished often
have suppressed immune systems, making them
vulnerable to infection from foodborne illness.
• the personnel involved with preparing or
delivering formula should be aware of the specific
protocols at their facility that prevent formula
contamination.
• Hazard Analysis and Critical Control Points
[HACCP] system
• Hazard Analysis and Critical Control Points (HACCP) system: a management system
to identify and correct potential microbial hazards in the preparation, storage,
handling, and administration of food products

• Formulas may be delivered using an open feeding
system or a closed feeding system.
• With an open system, the formula needs to be
transferred from its original packaging to a
feeding container (cans or bottles, concentrates
that need to be diluted, and powders).
• In a closed system, the sterile formula is
prepackaged in a container that can be contected
directly to a feeding tube.
• Closed systems are less likely to become
contaminated, require less nursing time, and can
hang for longer periods of time than open
systems.
• closed systems cost but less expensive in the
long run because they prevent bacterial
contamination
Nutrition and thus avoid the costs of
& Diet Therapy (7th Edition)
treating infections.
Formula Safety Guidelines
• the nursing staff assumes
responsibility for its safe handling.
• Clinicians should carefully wash
hands and put on disposable gloves
before handling formulas and feeding
containers.

The following steps can reduce the risk of
formula contamination when using open
feeding systems
1. Before opening a can of formula, clean the lid with a
disposable alcohol wipe and wash the can opener (if needed)
with detergent and hot water. label the can with the date and
time it was opened.
2. Store opened cans or mixed formulas in clean, closed
containers. Refrigerate the unused portion of formula promptly.
Discard unlabelled or improperly labelled containers and all open
containers.
3. 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.
• For closed systems, the hang time should be no longer than 24
to 48 hours.
Administration of Tube
Feedings
• Preparing for Tube Feedings Before
starting a tube feeding, health
practitioners can ease fears by fully
discussing the procedure with the
patient and family members, who
may feel anxious about the use of a
feeding tube.

• Serious complications can develop if a transnasal
tube is accidentally inserted into the respiratory
tract or if formula or GI secretions are aspirated
into the lungs.
• To minimize the risk of incorrect tube placement,
clinicians use X-rays to verify the positon of the
feeding tube before a feeding is initiated.
• Tube placement can also be monitored by testing
the pH of a sample of body fluid drawn into the
feeding tube, as the pH in the stomach (5 or
lower) is lower than the pH in the small intestine
or respiratory tract (6 or higher).

• 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.

Formula Delivery Methods
• Nutrient needs may be met by
delivering relatively large amounts of
formula several times per day
(intermittent feedings) or smaller
amounts continuously (continuous
feedings).

• Intermittent feedings are best tolerated when
they are delivered into the stomach (not the
intestine). Generally, a total of about 250 to 400
milliliters of formula is delivered over 30 to 45
minutes using a gravity drip method or an
infusion pump
• The exact amount is determined by dividing the
required volume of formula into several daily
feedings

• Due to the relatively high volume of
formula delivered at one time, intermittent
feedings may be difficult for some patients
to tolerate, and the risk of aspiration may
be higher than with continuous feedings.
An advantage of intermittent feedings is
that they are similar to the usual pattern
of eating and allow the patient freedom of
movement between meals.

• Rapid delivery of a large volume of
formula into the stomach (250 to
500 milliliters over 5 to 15 minutes)
is called a bolus feeding. This type of
feeding may be given every 3 to 4
hours using a syringe.

• Bolus feedings are convenient for patients and
staff because they are rapidly administered, do
not require an infusion pump, and allow greater
independence for patients.
• However, bolus feedings can cause abdominal
discomfort, nausea, and cramping in some
patients, and the risk of aspiration is greater than
with other methods of feeding.
• For these reasons, bolus feedings are used only
in patients who are not critically ill.

• Continuous feedings are delivered slowly
and at a constant rate over a period of
8 to 24 hours, and are most often used for
intestinal feedings. The slower delivery
rate is easier to tolerate, so continuous
feedings are generally recommended for
critically ill patients or patients who cannot
tolerate intermittent feedings.

• An infusion pump is usually used to
ensure accurate and steady flow rates;
consequently, the feedings can limit the
patient’s freedom of movement and are
also more costly. Continuous feedings
conducted for shorter periods (8 to 16
hours; called cyclic feedings) allow greater
patient mobility and GI rest and may be
used to help patients transition to
intermittent feedings or an oral diet.

Initiating and Advancing
Tube Feedings
• Formula administration techniques
vary widely among institutions, so
protocols should be reviewed
carefully before working with
patients.
• In addition, patient tolerance must
be considered when adjusting
formula delivery rates.

Some general guidelines
include the following
• Formulas are typically provided full-strength;
diluting them is not recommended because this
reduces the nutrients provided and increases
contamination risk.
• Intermittent feedings can start with 60 to 120
milliliters at the initial feeding and be increased
by 60 to 120 milliliters every 8 to 12 hours until
the goal volume is reached.
• Continuous feedings may start at rates of about
10 to 40 milliliters per hour and be increased by
10 to 20 milliliters per hour every 8 to 12 hours
until the goal rate is reached.
• If the patient cannot tolerate an
increased rate of delivery, the
feeding rate is slowed until the
person adapts.

• Goal rates can usually be achieved over
24 to 48 hours, although in some patients,
formula delivery can be started at the goal
rate immediately.
• Slower rates of delivery may be better
tolerated by critically ill patients, when
concentrated formulas are used, or in
patients who have undergone an extended
period of bowel rest due to surgery,
intestinal disease, or the use of parenteral
nutrition.
Checking the Gastric Residual
Volume
• To ensure that the stomach is
emptying properly, the nurse may
measure the gastric residual volume,
the volume of formula and GI
secretions remaining in the stomach
after feeding.

• In this procedure, 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.

• Although the practice is
controversial,some experts
recommend that feedings be
withheld and an evaluation be
conducted if the gastric residual
volume exceeds 500 milliliters.
• If the tendency to accumulate fluids
persists, the physician may
recommend intestinal feedings or
begin drug therapy to stimulate
gastric emptying.
Meeting Water Needs
• Although water needs vary, many patients
require about 30 to 40 milliliters of water per
kilogram body weight daily.
• Additional water is required in patients with
severe vomiting, diarrhea, fever, excessive
sweating, high urine output, high-output
ostomies, blood loss, or open wounds. Fluids may
be restricted in persons with kidney, liver, or
heart disease.

• The water in formulas meets a
substantial portion of water needs:
most enteral formulas contain about
70 to 85 percent water, or about 700
to 850 milliliters of water per liter of
formula. In addition to the water in
formulas, water can be provided by
flushing water separately through the
feeding tube

• Water flushes are also conducted to
prevent feeding tubes from clogging;
the water used for flushes (20 to 30
milliliters before and after
intermittent feedings and about
every 4 hours during continuous
feeding) should be included when
estimating fluid intakes.

Medication Delivery during
Tube Feedings
• diet-drug interactions must be
considered.
• Medications can also cause feeding
tubes to clog.

Medications and Continuous
Feeding
• Continuous feedings are ordinarily stopped before
and after medication administration to prevent
interactions that may clog the feeding tube or
interfere with the medication’s absorption.
• Some medications may require a prolonged
formula-free interval; for example, feedings need
to be stopped for at least one hour before and
after administering phenytoin, a medication that
controls seizures
• In such cases, the formula’s delivery rate needs
to be increased so that the correct amount of
formula can be delivered.
Diarrhea
• Medications are a major cause of the
diarrhea that frequently accompanies tube
feedings. Diarrhea is especially associated
with the administration of sorbitol
containing medications, laxatives, and
some types of antibiotics. The high
osmolality of many liquid medications can
also cause diarrhea, so dilution of
hypertonic medications may be helpful.

Tube Feeding Complications
• Table 16-2 , page 451

Transition to Table Foods
• After the patient’s condition improves, the
volume of formula can be tapered off as the
patient gradually shifts to an oral diet.
• Individuals receiving continuous feedings are
often switched to intermittent feedings initially.
• Patients using elemental formulas may begin the
transition by using a standard formula, either
orally or via tube feeding.
• Oral intake should supply about two-thirds of
estimated nutrient needs before the tube feeding
is discontinued completely.
Enteral Nutrition in Medical
Care
• Oral use • Patients can drink enteral
– Supplement diet when formulas when they are
food consumption does unable to consume enough
not meet need food from a conventional diet
– Reliable source of
nutrients & energy
– Taste important
consideration
• Tube feedings
– Used when patient
cannot consume enough
food or formula orally
– Feeding delivered
directly to stomach or
intestine

Care (con’t)
• Candidates for tube feedings:
– Severe swallowing difficulties
– Little or no appetite for extended periods, especially if
malnourished
– GI obstructions, impaired motility of the upper GI tract
– After intestinal resection, beginning enteral feedings
– Mentally incapacitated due to confusion, dementia,
neurological disorders
– Individuals in coma
– Individuals with extremely high nutrient requirements
– Individuals on mechanical ventilators

Care (con’t)
• Feeding routes
– Selected on basis of medical condition,
expected duration, potential complications of a
particular route
– Main routes:
• Transnasal (temporary)
– Nasogastric
– Nasoduodenal
– Nasojejunal
• Gastrostomy
• Jejunostomy

Care (con’t)
• Formula selected after assessment of the
diagnosis, patient’s age, medical
problems, nutritional status, ability to
digest & absorb nutrients
• Nutrition-related factors influencing
formula selection
– Energy, protein & fluid requirements
– Need for fiber modifications
– Individual tolerances (food allergies &
sensitivities)

Care (con’t)
• Administration of tube • Open feeding system:
feedings requires formula to be
– Safe handling transferred from original
• Open feeding system packaging to feeding
• Closed feeding system container
• Safety guidelines • Closed feeding system:
– Review of procedure formula prepackaged in
with patient & family ready-to-use containers
– Verification of tube • Intermittent feeding: delivery
placement (Xray) of prescribed volume over 20-
– Formula delivery 40 minutes
• Intermittent feedings • Continuous feeding: slow
(bulk over 20-40 min) delivery at constant rate over
• Continuous feedings 8-24 hour period
(pump) • Bolus feeding: delivery of
• Bolus feeding (one or prescribed volume in less than
several “shots”)
15 minutes

Care (con’t)
• Formula volume & strength
– Procedures vary by institution
– Almost all patients can receive undiluted isotonic or hypertonic
formulas
– Generally started slowly and volume gradually increased
• Rate & amount of increase depend on patient’s tolerance
• Continuous feedings may be better tolerated than
intermittent feedings
• Checking gastric residual volume (vol. of formula in stomach after fdg.)
– Volume of formula remaining in stomach from previous feeding
– Evaluate if gastric residual >200 mL
– If tendency to retain persists, physician may consider intestinal
feedings or drug therapy to stimulate gastric emptying

Care (con’t)
Meeting water needs
• Adults require about 2000 mL of
water daily
– Fluid intake may be restricted for Estimating fluid
patients with kidney, liver or
heart disease requirements
– Fluid intake may be increased
with fever, high urine output, Adults: 30-40 mL/kg;
diarrhea, excessive sweating, 30 mL/kg for older
severe vomiting, fistula drainage, adults
high-output ostomies, blood loss,
open wounds
Children: 50-60 mL/kg
• Standard formulas contain about Infants: 150 mL/kg
85% water (about 850 mL/liter);
nutrient-dense formulas contain
about 69-72% water
• Meet fluid needs with additional
water flushes

Care (con’t)
• Transition to table foods
– Volume of formula is tapered off as
condition improves
– Gradual shift to oral diet
• Begin drinking same formula that is
delivered by tube
• Oral intake should supply about 2/3 of
nutrient needs before tube feedings
discontinued

Care (con’t)
• Giving Medication through feeding tubes
– Potential for diet-drug interactions must be
considered before administration
– Continuous feeding halted for approximately
15 minutes before & 15 minutes following
medication delivery (longer for some
medications)
– Type of medication may make tube
administration impossible—require change to
alternate route
• Generally best to administer medications by
mouth whenever possible

Care (con’t)
• Complications of tube feedings
– Gastrointestinal problems: nausea, diarrhea
– Mechanical problems related to tube feeding process
– Metabolic problems: biochemical alterations & nutrient
deficiencies
• Many complications preventable with appropriate
feeding route, formula & delivery method
• Close attention to patient’s medical condition &
medication use is important (follow up/reassessment)
– Monitor weight, hydration status
– Verify lab test results

Parenteral Nutrition Support
• Indicated for patients who do not have functioning GI
tract & who are malnourished (or likely to become so)
• Used when enteral formulas cannot be used or
intestinal function is inadequate
• Life-saving option for critically-ill persons
• Costly and combined with many complications
• Two main access sites: central or peripheral vein

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
Venous Access
• The access sites for parenteral
nutrition fall into two main
categories: the peripheral veins
located in the hand or forearm, and
the large-diameter central veins
located near the heart

Venous Access
• Peripheral parenteral nutrition (PPN)
– Can only provide limited amounts of energy &
protein
– Peripheral veins can be damaged by overly
concentrated solutions
– phlebitis may develop - characterized by
redness, swelling, and tenderness at the
infusion site.
– To prevent phlebitis, the osmolarity of
parenteral solutions used for PPN is generally
kept below 900 milliosmoles per liter
Peripheral parenteral nutrition
– (PPN)
Limited to patients who do not have high
nutrient needs or fluid restrictions
– Used most often for short-term nutrition
support less than 2 weeks (7-10 days).
– The use of PPN is not possible if the peripheral
veins are too weak to tolerate the procedure
– Rotation of vein sites may be necessary

Venous Access (con’t)
• Total Parenteral Nutrition
-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.

• Because the central veins carry a
large volume of blood, the parenteral
solutions are rapidly diluted; thus,
patients with high nutrient needs or
fluid restrictions can receive the
nutrient-dense solutions they
require.

Venous Access (con’t)
• Total parenteral nutrition (TPN)
– Can reliably meet complete nutrient
requirements because of that called TPN
– Provides nutrient-dense solutions for
patients with high nutrient needs or fluid
restrictions
– Preferred for long-term intravenous
feedings
– Inserted directly into a large central vein

• To access central veins, the tip of a central
venous catheter can either be placed
directly into a large-diameter central vein
or threaded into a central vein through a
peripheral vein

• catheter: a thin tube placed within a
narrow lumen (such as a blood
vessel) or body cavity; can be used
to infuse or withdraw fluids or keep a
passage open

Parenteral Solutions
• pharmacies are often responsible for
preparing parenteral solutions; this
because the pharmacist can
customize the solutions to meet
patients’ nutrient needs and because
the solutions have a limited shelf life.
•

Parenteral Solutions
• Customized formulations to meet patients’
nutrient needs
• Prescriptions for parenteral solutions
Highly individualized; often recalculated
on daily basis until patient’s condition
stabilizes
• Contents:
– Amino acids (both essential and non-essential for protein)
– Carbohydrates (dextrose)
– Lipid emulsions
– Fluid & electrolytes
– Vitamins & trace minerals

Amino Acids
• Parenteral solutions contain all of the essential
amino acids and various combinations of the
nonessential amino acids.
• The amino acid concentrations in commercial
solutions range from 3 to 20 percent
• Disease-specific products are available for
patients with liver disease, kidney disease, and
metabolic stress, but lack of evidence of their
benefit

Carbohydrate
• Glucose is the main source of energy in
parenteral solutions.
• It is provided in the form dextrose monohydrate,
in which each glucose molecule is associated with
a single water molecule.
• Dextrose monohydrate provides 3.4 kcalories per
gram, slightly less than pure glucose, which
provides 4 kcalories per gram.
• Commercial dextrose solutions are available in
concentrations between 2.5 and 70 percent;
concentrations greater than 10 percent are
usually used only in TPN solutions.
Lipids
• Lipid emulsions supply essential fatty acids and
are a significant source of energy.
• The emulsions available in the United States
contain triglycerides from either soybean oil or a
mixture of olive oil and soybean oil, egg
phospholipids to serve as emulsifying agents, and
glycerol to make the solutions isotonic.

• Lipid emulsions are available in 10, 20, and 30
percent solutions, containing 1.1, 2.0, and 3.0
kcalories per milliliter, respectively. Therefore, a
500-milliliter container of 10 percent lipid
emulsion would provide 550 kcalories; the same
volume of a 20 percent lipid emulsion would
provide 1000 kcalories
• the 30 percent lipid emulsion can be used for
preparing mixed parenteral solutions but is not
approved for direct infusion into patients

• Lipid emulsions are often provided daily and may
supply 20 to 30 percent of total kcalories.
• Including lipids as an energy source reduces the
need for energy from dextrose and thereby
lowers the risk of hyperglycemia in glucose-
intolerant patients.
• Lipid infusions must be restricted in patients with
hypertriglyceridemia

Fluids and Electrolytes
• Daily fluid needs range from 30 to 40 milliliters
per kilogram body weight in stable patients.
• The amount of fluid provided is adjusted
according to daily fluid losses and the results of
hydration assessment
• The electrolytes added to parenteral solutions
include sodium, potassium, chloride, calcium
magnesium, and phosphate.
• The amounts infused differ from DRI values
because they are not influenced by absorption, as
they are when consumed orally.
In the parenteral nutrition order, most electrolyte
concentrations are expressed in milliequivalents
(mEq), which are units that indicate the number
of ionic charges provided by the electrolyte.
The body’s fluids and parenteral solutions are
neutral solutions that contain equal numbers of
positive and negative charges.

• Because electrolyte imbalances can
be lethal, Blood tests are
administered daily to monitor
electrolyte levels until patients have
stabilized

Vitamins and Trace Minerals
• All vitamins are usually included in parenteral
solutions, although a preparation without vitamin
K is available for patients using warfarin therapy.
• The trace minerals typically added to parenteral
solutions include chromium, copper, manganese,
selenium, and zinc.
• Iron is often excluded because it can destabilize
parenteral solutions that contain lipid emulsions;
therefore, special forms of iron may need to be
injected separately

Irondextranisnotrecommendedtobeaddedtolipidemulsionsorall-in-oneparenteralmixes
becausethetrivalentcations(Fe**)candestabilisethenegativesurfacechargebetweenlipid
particles.Theimpactcanunitesmalllipidparticlesandformlargeparticles.?Driscolletallshowed
thatthetrivalentcationinirondextrancouldinterferewithlipid-basedparenteralnutrient
mixturesandincreasethefatparticlesizewhichmaybepotentiallydangerous.Onecouldimagine
thattheselargelipiddropletscouldcausefatemboliinhumanorgans,especiallyinneonates.Puntis
andRushtonfoundintravascularlipidsinthesmallpulmonarycapillariesin15liveborninfantsat
necropsy.Thisgrouphadreceivedsignificantlymorefatduringparenteralnutrition(totalamount
g/kgandnumberofdays)comparedwithanothergroupof15infantswhodidnothavelipid
staining.However,theauthorsfoundnoevidencethatitwasclinicallyharmful.]

Medications
• To avoid the need for a separate
infusion site, medications are
occasionally added directly to
parenteral solutions or infused
through a separate port in the
catheter.

Parenteral Formulations
• When a parenteral solution contains dextrose,
amino acids, and lipids, it is called a total nutrient
admixture (TNA), a 3-in-1 solution, or an all-in-
one solution.
• A 2-in-1 solution excludes lipids, and the lipid
emulsion is administered separately, often using
a second port in the catheter. Although the
administration of TNA solutions is simpler
because only one infusion pump is required, the
addition of lipid emulsion to solutions may reduce
their stability.
• s, lipids are often administered separately when
they are not a major energy source and are used
only
Nutrition toTherapy
& Diet provide essential fatty acids
(7th Edition)
Osmolarity
• The osmolarity of PPN solutions is limited to 900
milliosmoles per liter because peripheral veins are
sensitive to high nutrient concentrations.
• 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

Administering Parenteral
Nutrition
• Many hospitals organize nutrition
support teams, consisting of
physicians, nurses, dietitians, and
pharmacists, that specialize in the
provision of both enteral and
parenteral nutrition.
• The nurse, who performs direct
patient care, plays a central role in
administering and monitoring
parenteral infusions.
Care of Intravenous
Catheters
• Catheter-related problems frequently cause
complications
• 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 develop at the placement site.
• To reduce the risk of complications, nurses 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.
Administration of Parenteral
Solutions
• Infusion protocols vary among institutions.
• One approach is to start the infusion at a slow
rate (with a solution that is either full strength or
nutrient dilute) and increase the rate gradually
over a 2- to 3-day period.
• Another method is to give the full volume of a
nutrient-dilute solution on the first day and
advance nutrient concentrations as tolerated.
• risk of fluid overload, hyperglycemia, or other
complications.
• Parenteral solutions are usually infused
continuously over 24 hours (continuous
parenteral nutrition) in acutely ill patients.
• Patients who require long-term parenteral
nutrition often receive infusions for 10- to 14-
hour periods only (cyclic parenteral nutrition),
more freedom of movement during the day.
• Regular monitoring can help to prevent
complications.
• The parenteral solution and tubing are checked
frequently for signs of contamination.
• Routine testing of glucose, lipid, and electrolyte
levels helps to determine tolerance to
solutions.
• Frequent reassessment of nutrition status may
be necessary until a patient has stabilized.
Discontinuing Parenteral
Nutrition
• 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.
• Transitioning to an oral diet is sometimes
difficult because a person’s appetite
remains suppressed for several weeks
after parenteral nutrition is terminated.
Managing Metabolic
Complications
1- Hyperglycemia (blood glucose levels that exceed
about 180 mg/ dL during parenteral infusions) most
often occurs in patients who are glucose intolerant,
receiving excessive energy or dextrose, undergoing
severe metabolic stress, or receiving corticosteroid
medications.
•It can be prevented by providing insulin along with
parenteral solutions, avoiding overfeeding or overly
rapid infusion rates, and restricting the amount of
dextrose in the solution.
•Dextrose infusions are generally limited to less than 5
milligrams per kilogram of body weight per minute in
critically ill adult patients so that the carbohydrate intake
does not exceed the maximum glucose oxidation rate.
2- Hypoglycemia :uncommon
•occurs when parenteral nutrition is
interrupted or discontinued or if
excessive insulin is given.
•infuse a dextrose solution at the
same time that parenteral nutrition is
interrupted or stopped.
3- Hypertriglyceridemia :may result
from dextrose overfeeding or overly
rapid infusions of lipid emulsion.
•If blood triglyceride levels exceed 400
milligrams per deciliter, lipid infusions
should be reduced or stopped.
• 4- Refeeding Syndrome:
• Severely malnourished patients who are aggressively
fed (parenterally or otherwise) may develop refeeding
syndrome, characterized by electrolyte and fluid
imbalances and hyperglycemia.
• These effects occur because dextrose infusions raise
levels of circulating insulin, which promotes anabolic
processes that quickly remove potassium, phosphate,
and magnesium from the blood.
• The altered electrolyte levels can lead to fluid
retention and life-threatening changes in various
organ systems.
• To prevent refeeding syndrome, start parenteral
infusions slowly and carefully monitor electrolyte and
glucose levels when malnourished patients begin
receiving nutrition support.
5- Liver Disease : Fatty liver often results
from parenteral nutrition, but it is usually
corrected after the parenteral infusions
are discontinued.
•Long-term parenteral nutrition=
progressive liver disease.
•To minimize the risk, avoid giving the
patient excess energy, dextrose, or lipids
(which promote fat deposition in the liver)
and monitor liver enzyme levels weekly.
•Cyclic infusions may be less problematic
than continuous infusions.
6- Gallbladder Disease
•When parenteral nutrition continues
for more than a few weeks, sludge
(thickened bile) may build up in the
gallbladder and eventually lead to
gallstone formation.
•Patients requiring long-term
parenteral nutrition may be given
medications to stimulate gallbladder
contractions or improve bile flow or
may have their gallbladders removed
surgically.
7- Metabolic Bone Disease Long-term
parenteral nutrition is associated
with lower bone mineralization and
bone density, which may be related
to altered intakes or metabolism of
calcium, phosphorus, magnesium,
and vitamin D.
•Interventions may include
adjustments in parenteral nutrients,
medications, and weight-bearing
physical activity.
Nutrition
• Multidisciplinary nutrition support
team of health care professionals
– Physicians
– Nurses
– Dietitians
– Pharmacist
• Potential complications related to
venous line & metabolic problems

Nutrition (con’t)
• Administration procedures
– Insertion & care of intravenous catheters
– Administration of parenteral solutions
• Continuous administration -24 hours/day
• Cyclic administration – 10 to 16 hour periods
– Monitoring patient condition, nutritional status,
complications
– Discontinuing of feedings-when GI function
returns

Nutrition Support at Home
• Continuation of nutritional support (tube feedings
or parenteral nutrition) after medical condition
has stabilized
• Candidates for home nutrition support
– Long-term nutrition care required for chronic conditions
– Users intellectually capable of learning procedures,
monitoring treatment & managing complications
• Planning for home nutrition
– Involvement of users in decision making to ensure long-
term compliance & satisfaction
– Assessment & evaluation of type of feeding, equipment,
resources, ability to perform procedures

Nutrition Support at Home
(con’t)
• Quality of life issues • Portable pumps & convenient
– Lifestyle adjustments carrying cases allow people
may cause struggle for who require home nutrition
patients & families support to move about freely
– Economic impact
– Time & other demands
associated with
treatment
– Physical difficulties,
including disrupted
sleep
– Social issues
– Life-sustaining therapy
associated with serious
complications

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Specialized Nutrition Support:

Enteral & Parenteral Nutrition

Nutrition & Diet Therapy (7th Edition)

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Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)