Nutrition Topic of the Week: Enteral Nutrition

What is Enteral Nutrition?

As we all know, everyone needs food to survive.  In some cases, individuals are not able to intake any or enough food on their own.  One way to provide nourishment for these individuals is with “enteral nutrition” or more commonly known as “tube feedings.”  Another way to provide nourishment to individuals who cannot orally ingest food is through “parenteral nutrition,” which is providing nutrients through a vein directly into the blood stream.  These two methods are very different and as the saying goes, “use it – or lose it.” In this instance I am referring to the gut and digestive system – if the gut works, then use it!

Tube feeding formulas are in a liquid form that contains protein, carbohydrates, fats, vitamins and minerals.  They are many varieties of formulas to meet different needs and the dietitian performs a variety of calculations to determine which formula will be best for the patient. This formula is given through a tube and then normal digestion can occur in the stomach and intestines.

What Conditions Require Enteral Nutrition?

Any condition that alters a patients’ ability to swallow can lead to the implementation of enteral nutrition as long as the gastrointestinal (GI) system is still working.  Also, if a patient cannot take in adequate nutrition due to impaired nutrient ingestion, digestion, absorption, or metabolism then enteral nutrition can be used.  Common conditions include:

  • Neurological disorders
  • Facial/oral/esophageal trauma
  • Respiratory failure (the need for a ventilator)
  • Traumatic brain injuries
  • Cystic fibrosis
  • Dysphasia (common after a stroke)
  • Major burns, trauma, or wounds

What are the Considerations when Choosing a Formula?

  • Digestibility/availability of nutrients
  • Nutrition adequacy to meet needs
  • Osmolality (fluid needs)
  • Ease of use
  • Cost

What are the Different Formula Categories?

  • Standard – these contain nutrients that are intact (most often used)
  • Elemental – partially or completely hydrolyzed (broken down) nutrients
  • Disease specific – designed for a wide variety of disease states (renal, diabetes, etc.)
  • Modular – allows for the addition of nutrient content

How is the Tube Feeding Supplied?

There are multiple different placements options when considering a tube feed depending on the specific needs of each patient. The greater use of the GI system that can be tolerated by the patient is the route that is used in most cases.  Estimated length of time the feeding tube will be required helps to determine the route.  Another important factor is the risk of aspiration. If there is a high risk for aspiration then the patient will need the tube to continue past the pyloric sphincter.

Short Term (<3 weeks):

  • Orogastric – tube enters through the mouth and goes into the stomach
  • Nasogastric – tube enters through the nose and goes into the stomach
  • Nasoduodenal – tube enters through the nose and goes into the duodenum (first part of the small intestine)
  • Nasojejunal  – tube enters through the nose and goes into the jejunum (second part of the small intestine)

Long Term (>4-8 weeks):

  • Gastrostomy – tube enters directly through the skin into the stomach
  • Jejunostomy – tube enters directly through the skin into the jejunum (second part of the small intestine)

 Enteral Nutrition

What are the Delivery Methods of Enteral Nutrition?

Continuous:

  • Delivered at a continuous/steady rate that is controlled via a feeding pump
  • Most often used when feeding into the small bowel (intestine)
  • Preferred for critically ill patients and those unable to tolerate bolus or intermittent feedings

Bolus or Intermittent:

  • Bolus – last from a few minutes to 20 minutes and given via a syringe
  • Intermittent – last 20-60 minutes and given via a gravity drip
  • Preferred type of feeding for gastric routes (into the stomach) but not well tolerated in the intestine
  • Used for ambulatory patients and patients in their home
  • Fluid ranges between 240-480 mL

Cyclic or Nocturnal:

  • Used as a transition from enteral feedings to an oral (normal) diet
  • Rate can reach up to 150 mL/hour
  • Commonly used for patients in their home
  • They are infused continuously for 10-12 hours (typically overnight) to allow for greater oral intake during the day

What are the Complications of Enteral Nutrition?

While tube feeding is a generally safe option, there are potential risks associate with it.  For example, patients may experience abdominal discomfort, nausea, vomiting, abdominal distention, constipation, diarrhea, or aspiration.  There are ways to reduce this risk that health providers should always abide by.

References:

http://www.nutritioncare.org/wcontent.aspx?id=266

http://patients.gi.org/topics/enteral-and-parenteral-nutrition/

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New Rotation – What Does a Clinical Dietitian Do?

This past week I started a new rotation.  This rotation will include the majority of my objectives from Medical Nutrition Therapy II and the Clinical Concentration.  I will be here for about six weeks and am excited to take on a new challenge and get more experience in the clinical setting.

There are a variety of hospitals in the area and many dietitians that I will get to work with over the next few months so that I can experience the greatest diversity in patients and conditions. This first week I primarily spent my time with surgical and neuro patients on the floors and in the intensive care unit (ICU).  Due to the severity of these patients’ conditions, many of these patients required tube feedings, which is also known as enteral nutrition – stay tuned for a post specifically about enteral nutrition! In the weeks to come I will have a chance to work with trauma, pediatrics, rehab, cardiac, behavioral medicine, weight loss, cystic fibrosis, diabetes, transplant, and even the wound clinic!

So before I get too far into this rotation I wanted to provide a little background so you can start to understand what exactly it is that a clinical dietitian does!  A clinical registered dietitian (RD) will typically have following responsibilities:

  • Identify patients at nutritional risk
  • Provide nutrition care using the Nutrition Care Process (see below)
  • Determines the nutritional needs and diet restrictions for patients
  • Plans therapeutic diets and implements preparation and service of meals for patients, which includes tube feedings, parenteral nutrition, and modified texture diets.
  • Instructs patients and their families on healthy eating and/or special diets
  • Participates in interdisciplinary discussions and meetings with other health care providers

What is the Nutrition Care Process?

The NCP is a systematic approach to providing quality nutrition-related care.  It is divided into four separated, but interrelated steps: assessment, diagnosis, intervention, monitoring/evaluation.

  • Nutrition Assessments – obtain, verify, and interpret data to identify nutrition-related problems, their causes, and their significance. Five main domains:
    • Food/Nutrition Related History:
      • Examples include:
        • Allergies, intolerance, special diets
        • How has the patient been eating?
        • Access to food
      • Anthropometric Measurements:
        • Examples include:
          • Height and Weight
          • Calculate BMI, Ideal Body Weight, Adjusted/Feeding Body Weight
          • Any weight changes?
          • NOTE: use this information to calculate calorie, protein, and fluid needs
      • Biochemical Data, Medical Tests, and Procedures:
        • Examples include:
          • Lab values, test results, surgeries
      • Nutrition-Focused Physical Findings:
        • Examples include:
          • Edema, skin breakdown, hair loss
      • Client History:
        • Examples include:
          • Previous health conditions
  • Nutrition Diagnosis – describe nutrition related problem using standardized language
    • Commonly referred to as a PES statements
      • Problem, Etiology, Signs and Symptoms
  • Nutrition Intervention – actions used to remedy a nutrition diagnosis/problem
    • Calculate tube feeding prescriptions
    • Calculate parenteral nutrition prescriptions
    • Recommend nutrition supplements to meet calorie/protein needs
    • Modify diet consistency or texture
    • Provide nutrition education or counseling
  • Nutrition Monitoring and Evaluation:
    • Follow the progress of nutrition goals by monitoring weight, labs, intake and/or diet tolerance.

 

Nutrition Care Process

Nutrition Care Process

 

What patients are seen by the dietitian?

Patients of nutrition risk are seen by the RD – This can be determined by:

  • Admitting diagnosis, condition, or chief complaints.  Common examples include:
    • Bowel Obstruction/Ileus
    • Burns
    • Cancer
    • Celiac Disease
    • Cirrhosis
    • Chronic Kidney Disease
    • Cystic Fibrosis
    • Diabetes, new onset
    • Dysphasia
    • Hepatic Encephalopathy
    • Malnutrition
    • Pancreatitis
    • Renal Failure
    • Renal Transplant
    • Spinal Cord or Traumatic Brain Injury
    • And many more…
  • NPO/Clear Liquid greater than 3 consecutive days
  • New tube feeding (enteral nutrition) orders
  • New parenteral nutrition orders
  • Specific lab values:
    • Low albumin (<2.5 mg/dL)
    • Low prealbumin (<16 mg/dL)
    • High blood glucose (≥200 mg/dL X 3 consecutive results)
    • NICU: Phosphorus (>600 U/L)
    • NICU: Bilirubin (<4.5 mg/dL)
    • NICU: Alkaline phosphatase (> 2 mg/dL)
  • Consults made by MD, RN, Pharm D, ancillary or patient’s family.
    • May include a request for: an assessment, visit, calorie count, tube feeing, parenteral nutrition, or education.

 

References:

http://www.eatright.org/HealthProfessionals/content.aspx?id=7077

http://andevidencelibrary.com/ncp/inc/circle.gif