Enteral Nutrition Flashcards
Background
´ Malnutrition can affect up to 45% of acutely ill
patients
´ 1 in 5 malnourished patients will return to hospital
´ Malnutrition at admission is independently associated with increased length of stay
´ Malnutrition increases infections, morbidity,
complications and health care costs while
decreasing quality of life and wound healing
*Canadian Malnutrition Task Force look at effects of malnutrition in patients
poor appetite, loss of taste or smell, depression
caused by
medication use
´ Subjective Global
Assessment
Nutrition assessment
tool
´ Predictive of nutrition associated complications
´ Assists in identifying those who would benefit from nutrition support
dietary intake over last 2 wks
weight changes, intentional or not
difficult eating. nausea, vomiting
functional capacity: can they do activities of daily living
metabolic requirement: what is current disease state
SGA A
SGA B
SGA C
´ SGA A - Well nourished
´ SGA B - Mildly/moderately malnourished, muscle wasting
´ SGA C - Severely Malnourished, no muscle or fat mass, catabolic illness, affects ability to take med
´ Malnutrition in hospital is exacerbated by several
factors including:
can get worse in hospital
´Prolonged use of “NPO” or “Nothing by Mouth”
for medical procedures & tests (no nutrition)
´Late identification of those at risk on admission
´Conditions such as sepsis & multisystem organ failure
´Medical therapies/medications which increase
catabolism and/or affect tolerance to
gastrointestinal feeds
´ Ideal process:
´ Multidisciplinary team consult
´ Dietitian, Pharmacist, OT/PT, Nursing
´ If required: Speech Pathologist, Respiratory Therapist
´ Dietitian’s Role:
´ Nutritional Assessment
´ Consider:
´ Medical history, Biochemical data, Medications,
Anthropometrics, Allergies
´ Functionality of GI tract
´ Oral nutrition - can pt eat, can they meet nutrition needs orally
´ Enteral nutrition (? Access) - if GI is working, but can’t take orally
´ Parenteral nutrition (?Access)
´ Formulation of nutritional care plan
What is Nutrition Support?
´Nutrition Support
´Provision of nutrition via non-volitional
means
´Required when patients are unable to meet
their needs in the presence of an increased
metabolic demand
´2 routes:
´ Enteral (oral/tube feeding) or Parenteral route
Enteral being the preferred route when possible
Goals of Nutrition Support
– Assist with maintaining or restoring nutritional status
– Minimize effects of hypermetabolism
– Promote wound healing
– Assist with the body’s defense against infection
– Reduce complications/mortality
– Reduce hospital stay
Enteral Nutrition basics
´The system of providing nutrition directly into the GI tract bypassing the oral cavity
´Delivery is through an Enteral Access
Device (EAD)
´The Enteral Nutrition Process requires a multidisciplinary approach
Enteral Nutrition Process….
see slide 11
- assess pt
Indications for EN
´ Existing malnutrition & poor intake
´ Catabolic patients (trauma/burn)
´ Inability to eat (e.g.: stroke/brain injury)
´ Impaired digestion/absorption (e.g.: Cystic
Fibrosis
Contraindications for EN
´ Nonoperative GI obstruction
´ Intractable nausea/vomiting refractory to medical
management
´ Severe short bowel syndrome or malabsorption
´ Distal high output fistulas
´ Severe GI bleed
´ Inability to gain enteral access
´ Need for EN is <7-9 days (dependent on baseline
nutrition status)
´ Aggressive nutrition not warranted or desired
EN Access and Medications
Prescribing medications to enterally fed patients, must consider:
´ Anatomic site of delivery
´ Size of feeding tube
Anatomic site of tube:
´ Tolerance to medication
´ Stomach is able to tolerate more concentrated or hypertonic
medications than the small bowel
´ Optimal site of absorption of the medication (e.g.: some
medications are targeted for gastric delivery such as antacids)
EN Access
Short Term:
A. NG (Nasogastric)
´ Larger in diameter
´ Less likely to become occluded by meds
´ Need to clarify if the tube is for feeding or suction
´ Med administration contraindicated if NG being used for suctioning gastric contents Corpak®/Kaofeed®
´ Small in diameter
´ Gastric or jejunal
Higher risk of tube becoming occluded with
medications due to smaller diameter
EN Access
Short Term:
B. NJ/ND
´ Nasojejunal/duodenal (or post pyloric)
´ Indications:
´ High risk of aspiration
´ Gastric motility difficulties
´ Typically smaller diameter tube (increased chance of occlusion)
´ If access is quite distal may affect absorption of medications even targeted to the small bowel
Corpak Feeding Tube
G-J Tube Feeding Ports
Corpak Feeding Tube
(2 ports-both will flow to same site)
G-J Tube Feeding Ports
(2 ports to stomach and 1 port to small
bowel, gastric for suctioning, jejunal port for feeding)
´ Tube occlusion in the setting of permanent tubes:
´ G and J-tubes can be difficult to replace
´ Pay close attention to medication delivery to minimize
risk of tube occlusion
´ Possible solutions:
´Liquid meds whenever possible
´Alternative route if liquid N/A and alternative route practical
´Proper water flushes pre and post medications
Enteral Formula
Composition
´ Vary in amounts of: ´Protein, fat, and carbohydrate ´Vitamins and minerals ´Electrolytes ´Free fluid ´Fiber ´ Other possible components: ´Immunomodulating nutrients (e.g.: arginine, omega-3-fatty acids) ´Prebiotics
Types of Enteral Formulas
4
Polymeric
´ Intact macronutrients
´ Generally start with this type of formula for most patients
Elemental/semi-elemental
´ Predigested macronutrients
´ Use if documented/diagnosed malabsorption (e.g.: short bowel syndrome)
Specialty
´ Disease specific (do not necessarily require these as first line therapy)
Modules
´ Protein Powder, MCT Oil
Closed System Tube Feed
´ Ready-to-hang
´ Potentially reduces risk of contamination
´ Less nursing time (hang time of 24- 48 hours)
´ Drawback: increased wastage in higher acuity areas where formula changes can occur more frequently
Open System Tube Feeds
´ Can or Tetrapak
´ Must pour into a feeding bag for delivery
´ Hang time of only 8 hours (requires more nursing care)
´ Potential for increased contamination
Enteral Formula Composition and
Medications
´ Potential for interactions between some medications and enteral nutrition components
´ Can occur within the delivery device or in the gastrointestinal lumen
´ Physiochemical reactions and potential inactivation
between nutrient and drug
´ Primary concern is decreased absorption of the medication
´ Result: therapeutic failure
Multiple considerations when developing a plan to administer a medication while still providing adequate enteral nutrition
Decision to hold nutrition or not and for
how long has 4 perspectives to consider:
- Nutritional Perspective
- Nursing Perspective
- Pharmacotherapeutic Perspective
- PATIENT PERSPECTIVE
Multidisciplinary team
discussion to formulate plan
´ Holding enteral nutrition can affect:
´ Stopping and starting of enteral feeds affects:
Nutritional Perspective: ´ Holding enteral nutrition can affect: ´ Caloric/protein delivery ´ Goal tube feed rate ´ Tube feed tolerance ´ Glycemic control
Nursing Perspective:
´ Stopping and starting of enteral feeds affects:
´ Work flow
´ Gastrointestinal tolerance (resulting in other nursing care issues)
´ Difficulty in spacing of medications if any incompatibilities
Pharmacy Perspective:
PATIENT PERSPECTIVE
´ If NOT holding enteral nutrition:
´Concern that absorption pattern and
bioavailability of medication are altered
´Efficacy of medication is decreased leading to therapeutic failure
PATIENT PERSPECTIVE
Most effective treatment
Safest treatment
Quality Care
Medications of concern:
´ Ciprofloxacin, Levofloxacin ´ Dilantin ´ Alendronate ´ Synthroid Sometimes patient dependent and pharmacist dependent
Dietitian Solutions:
´ Use a more concentrated enteral
feed to lower the goal rate
´ Adjust goal rate to meet daily caloric needs
´ Monitor feed tolerance daily to ensure adequate nutritional delivery
´ Consider intermittent or night feeds (if noncritically ill)
Other Solutions (in practice):
´ Discussions with pharmacy:
´ Frequency of medication dosing
´ Alternate route of medication if QID dosing required
´ Dosing based on therapeutic monitoring without holding of enteral feeds
Daily team communication to ensure everyone knows the plan and patient care is optimized
Delivery Methods (3)
´ Continuous ´Infused via feeding pump ´Preferred method for: ´ Critically ill/intubated ´ Refeeding risk ´ Poor glycemic control ´ Demonstrated intolerance to intermittent feeds
´ Intermittent (bolus)
´Infused via pump or gravity drip
´Large volumes over 20 minutes to 2 hours 4-6 times per day
´Mimics regular meal times
´ Cycled
´ Infused via pump for 6-24 hours
´ Often infused overnight
´ Used when transitioning to oral intake in an effort to
increase volitional intake during the day
Enteral Nutrition Order
´ Several critical elements:
´ Patient identifiers
´ EN formula name
´ Delivery site/route
´ Administration method and rate
Enteral Nutrition Monitoring
´ Biochemical parameters: ´ Respiratory parameters ´ Gastrointestinal tolerance ´ Consistency of goal rate provision ´ Fluid balance (hydration status)
´Review medications with Pharmacist for: ´Interactions with EN ´Contributing factors for GI symptoms ´Affects on biochemical parameters - E.g.: Diuretics and potassium levels/fluid status - Basal bolus insulin therapy**** ´Additional catabolic effects ´Additional micronutrient requirements - E.g.: chronic steroids and increased calcium/vitamin D
Enteral Nutrition Dispensing &
Administration
Food Services delivers tube feed to patient room or specified unit
Nursing verifies access, patient information, enteral formula, titration, and goal rate
Nursing sets up administration set and pump for enteral infusion
Enteral feed set is connected to patient’s feeding access and initiated
Other precautions:
• HOB > 30° (unless contraindicated)
Enteral Nutrition Reassessment
´Options:
´Continue with current enteral regime
´Change current tube feed formula/regime if
indicated
´Change to bolus/intermittent tube feeds
´Transition to oral intake
Each option may impact med administration
