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NUTRITIONAL

SUPPLEMENTS

Chapter 55
Nutritional Supplements
Enteral nutrition
Dietary Provision of food or
nutrients through
products used the gastrointestinal
to provide (GI) tract
nutritional Parenteral nutrition
Delivery of
support
nutrients directly
Malnutrition
into the circulation
The bodys by means of an
nutritional needs intravenous (IV)
are not met by solution
nutrient intake

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Nutritional Supplements

Nutritional Support

Enteral Nutrition
Gastrointestinal tract

Parenteral Nutrition
Circulation

3
Enteral Nutrition
Also known as tube feeding
Administration of
nutritionally balanced
liquefied food or formula
through tube inserted into:
Stomach
Duodenum
Jejunum
Enteral Nutrition
Provides nutrients alone or
supplement to oral or
parenteral nutrition
Easily administered
Safer than parenteral
More physiologically efficient
than parenteral
Less expensive than parenteral
Routes of EN

Esophagostomy
Gastrostomy
Jejunostomy
Nasoduodenal
Nasojejunal
Nasogastric
Oral

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Mechanism of Action
Provide basic building
blocks for anabolism
Supply complete dietary
needs through the GI tract
by oral route or by feeding
tube
Neurologic or
psychiatric
conditions
Enteral Nutrition
Extensive burns
Critical illness
Chemotherapy
Indications Radiation
include those therapy
with:
Supplement
insufficient PO
diet
Sole use: meet
all of nutritional
needs
Enteral Nutrition

Feeding tubes are used for those


with:
Abnormal esophageal or
stomach peristalsis
Altered anatomy secondary to
surgery
Depressed consciousness
Impaired digestive capacity

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Enteral Nutrition:
Adverse Effects
GI intolerance: Diarrhea
Feeding too fast
Infection
Medications
Low-fiber formula
Tube moving distally
Contaminated formula
Dumping syndrome
From rapid feeding or bolus
Aspiration pneumonia
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Enteral Nutrition
Variety of formulas
Special formulas for patients with
diabetes, liver, kidney, and lung disease
Elemental
Polymeric
Modular
Carbohydrate formulations
Fat formulations
Protein formulations
Altered amino acid formulations
Impaired glucose tolerance
Osmolarity, amount of protein, sodium,
and fat vary
Other Problems
Dehydration
Excessive diarrhea/vomiting
Poor fluid intake
High protein formula
Hyperosmotic diuresis
Other Problems
Constipation
Formula components
Poor fluid intake
Drug
Impaction
Inactivity

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Problems
Vomiting
Improper placement
Delayed gastric emptying
Increased residual volume
Enteral Nutrition:
Interactions
Various nutrients can interact with
drugs to produce significant food-
drug interactions.
Enteral nutrition can delay absorption
of some medications (phenytoin).
Enteral nutrition may inactivate some
medications (e.g., tetracycline and
nutrient formulations that contain
calcium).
Corticosteroids or vitamins A and D:
an increased absorption rate
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Nutritional Support
Algorithm

(Adapted from Ukleja A, Freeman KL, Gilbert K, and the ASPEN Board of Directors:
Standards for nutrition support: adult hospitalized patients, Nutr Clin Pract 25:403, 2010.)

Copyright 2017, Elsevier Inc. All Rights Reserved.


Enteral Formulation Group:
Polymeric
Type
Complete, Ensure, Ensure Plus,
Isocal, Osmolite, Portagen, Jevity,
Sustacal
Preferred over elemental formulations for
patients with fully functional GI tracts and
few specialized nutrient requirements;
cause fewer GI problems
Most closely resemble normal dietary
intake
Less hyperosmolar than elemental
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Enteral Formulation Group:
Elemental
Peptamen, Vital HN, Vivonex Plus,
Vivonex TEN
Minimal digestion needed; residual is
minimal
Used for malabsorption, partial bowel
obstruction, irritable bowel disease,
radiation enteritis, bowel fistulas,
short bowel syndrome
Hyperosmolarity of formulas may
cause GI problems

18
Enteral Formulation Group:
Modular
Three types
Carbohydrate: Moducal, Polycose
Fat: MCT Oil, Microlipid
Protein: Casec, ProMod, Propac,
Stresstein
Single nutrient formulas
No need for prescription
No pregnancy category

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Enteral Formulation Group:
Altered Amino Acid
Amin-Aid, Hepatic-Aid, Travasorb
Renal, Traum-Aid HBC
Contain varying amounts of specific amino
acids
Used for patients with diseases associated
with altered metabolism
capabilities/genetic errors of metabolism
Phenylketonuria (PKU), homocystinuria, MSUD
Supply nutritional support for clients with
Renal impairment, eclampsia, HF or liver
failure
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Enteral Formulation Group:
Impaired Glucose Tolerance
Glucerna
Contains proteins,
carbohydrates, fat, sodium,
potassium
Used in patients with impaired
glucose tolerance (e.g.,
diabetes)

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Enteral Formulation for
Respiratory Ailments
Pulmocare
COPD, Cystic fibrosis or Respiratory
failure
High calorie modified CHO and fat
formula
Can help reduce diet-induced CO2
production
Supplement or sole-source nutrition
Enteral Nutrition
Delivery options include:
Continuous infusion by pump
Cyclic feedings by pump
Intermittent by gravity
Intermittent bolus by syringe
Enteral Nutrition
Polyurethane or silicone
tube
Soft and flexible
Radiopaque
Placement in small intestine
Stylet may be used for
placement (comatosed
patient)
Likelihood of regurgitation
Enteral Nutrition
Nasogastric and
nasointestinal tubes
Can clog easily
Can be dislodged by vomiting
or coughing
Can be knotted/kinked in GI
tract
Tube Feeding
Gastrostomy and
jejunostomy tubes
May be used when a patient
requires tube feedings for an
extended time
Patient must have intact,
unobstructed
GI tract that can result from using a stylet is
A complication
increased risk for perforation.
Can be placed surgically,
radiologically, or
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Placement of Gastrostomy
Tube

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Percutaneous Endoscopic
Gastrostomy

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Enteral Nutrition
Percutaneous endoscopic
gastrostomy (PEG)
placement requires
esophageal lumen wide
enough for endoscope
PEG and radiologically
placed gastrostomy
Fewer risks than surgical
placement, lower cost,
Percutaneous Endoscopic
Gastrostomy
Gastrostomy tube
placement via
percutaneous endoscopy
Using endoscopy, a
gastrostomy tube is
inserted through
esophagus into stomach
and then is pulled through
Tube Feeding & Safety
Most important safety
concerns
Aspiration
Dislodgement of
Case Study
(Jupiterimages/Photos.com/Thinkstock)

J.W. comes to the


outpatient surgery unit for
placement of a
gastrostomy tube.
What will you need to teach
him and his wife for
discharge?
Enteral Nutrition
Feedings can be started
when bowel sounds are
present, usually 24-48
hours after placement
Most PEG tube feedings can
start within 2 hours of
insertion
Enteral Nutrition
Tube feeding administration
Aspiration risk
Ensure proper position of tube
Maintain head-of-bed elevation
Check gastric residual volume:
every ____hours in 1st 48 hours
Promotility drugs-improve
gastric emptying to reduce risk
Metocloperamide
Erythromycin
Nursing Management
1. Check tube placement
before feeding and before
each drug administration.
2. Assess for bowel sounds
before feeding.
3. Use liquid medications
rather than pills. Dilute
viscous liquid medications.
Do not add medications to
Nursing Management
If using tablets, crush drugs to a fine
powder and dissolve in water to
avoid clogging feeding tubes.
5. Follow measures to decrease
aspiration risk: Keep head of bed
elevated to 30- to 45-degree angle.
Check for residual volumes per
facility policy.
6. Assess regularly for complications
(e.g., aspiration, diarrhea,
abdominal distention,
Enteral Nutrition
Tube feeding
administration
Patient position
Patient should be sitting or
lying with HOB at 30 to 45
degrees (Preferable)
Prevent aspiration
HOB remains elevated for 30 to
60 minutes for intermittent
delivery
Enteral Nutrition
Tube position
Check gastric residual
volumes
Every 4 hours during first 48
hours
Volume leads to aspiration
Promotility drugs may be
ordered
Enteral Nutrition
Tube position
_______ confirmation for new
nasal or orogastric tubes
Mark exit site of tube
Check placement before each
feeding/drug administration or
every 8 hours with continuous
feeds
Check insertion length
Enteral Nutrition
Tube position
Methods used to check
placement
Aspiration of stomach
contents
pH check
pH <5, which is indicative
of stomach contents
Most accurate assessment: x-
ray visualization
Enteral Nutrition
Site care
Assess the skin around tube
daily
Monitor bumper tension
Apply a dressing until site is
healed
After healed, wash with soap
and water
Protective ointment or skin
Enteral Nutrition
Tube feeding
administration
Tube patency
Flush with water before/after
each feeding, drug
administration, residual check
Continuous feedings
administered on feeding pump
with occlusion alarm
Enteral Nutrition
Misconnection
Inadvertent connection
between an enteral feeding
system and a nonenteral
feeding system
Severe patient injury or
death can result
Enteral Nutrition
Administration of feedings
Pump
Gradually increase rate or
volume over
24 to 48 hours
Intermittent feedings
Volume usually 200 to 500 mL
per feeding
Administer flush water or
water boluses as tolerated
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Enteral Nutrition

General nursing
considerations
Daily weights
Assess for bowel sounds
before feedings
Accurate I&O
Initial glucose checks
Label with date and time
started
Enteral Nutrition
Complications
Vomiting
Dehydration
More calorically dense, less
water formula contained
Check for high protein content
Diarrhea
Constipation
Enteral Nutrition
Gastrostomy or jejunostomy
feedings
Two potential problems
Skin irritation
Skin assessment and care
Pulling out of tube
Teach patient/family about
feeding administration, tube
care, and complications
Enteral Nutrition
Gerontologic
Considerations
More vulnerable to
complications
Fluid and electrolyte balances
Glucose intolerance
Decreased ability to handle
large volumes
Increased risk of aspiration
Parenteral Nutrition
Totally digested nutrients
are given intravenously,
directly into the circulatory
system
Hyperalimentation
Total parenteral nutrition
(TPN)
Carbohydrates

Carbohydrates are usually supplied to


patients through dextrose:
Peripheral parenteral nutrition (PPN)
dextrose concentrations are usually kept
below 10% to decrease the possibility of
phlebitis
Central TPN dextrose concentrations can
range from 10% to 50%, but they are
commonly 25% to 35%.
Supplemental insulin may be given
simultaneously in nutritional
supplements. 50
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