Feeding Routes
Feeding Routes
Enteral feeding
Parenteral feeding
Feeding Routes
1- Enteral feeding:
a. Oral feeding: patients meet their needs by consuming oral diets and
supplements
b. Tube feeding: provides nutrients using the gastrointestinal tract (GI)directly into the stomach or intestines
2- parenteral feeding:
a) Used when a patient’s medical condition prohibits the use of the GI
tract to deliver nutrients.
b) Provides nutrients intravenously to patients without adequate GI
function to handle enteral feedings
c) Also called Intravenous feedings
In general, tube feeding or intravenous feeding should be used when :
1. patients nutrients needs are high
2. or their appetites poor
3. or their medical condition makes it difficult to meet nutrients need
orally.
Tube feedings
-Nutritionally complete formulas are delivered through a tube placed
directly into the stomach or intestine.
-Used when a patient is unable to eat but may be able to digest foods and
absorb nutrients normally.
1-Transnasal
(Short-term nutrition)
 Nasogastric
 Nasoduodenal
 Nasojejunal
2-Enterostomy
(Long-term nutrition)
 Gastrostomy
 Jejunostomy
Nasogastric (NG):

Tube is placed into the stomach via the nose.
Nasoduodenal (ND):

Tube is placed into the duodenum via the nose.
Nasojejunal (NJ):

Tube is placed into the jejunum via the nose
Gastrostomy :

An opening into the stomach through which a feeding tube can be
passed.
Jejunostomy :

An opening in the jejunum through which a feeding tube can be
passed
Types of enteral formulas:
1. Standard formulas
2. Elemental formulas
3. Specialized formulas
4. Modular formulas
1- Standard Formulas
• Standard formulas, are provided to individuals who can digest and
absorb nutrients without difficulty.
• They contain intact proteins extracted from milk or soybeans
• The carbohydrate sources include modified starches, and sugars.
•
A few formulas, called blenderized formulas, are made from whole
foods and derive their protein primarily from pureed meat or poultry
2- Elemental Formulas
• Elemental formulas are prescribed for patients who can not digest
or absorp well
•
Elemental formulas contain proteins and carbohydrates that have
been partially or fully broken down to fragments that require little
digestion.
•
The formulas are often low in fat and may contain medium-chain
triglycerides (MCT) to ease digestion and absorption.
3 - Specialized Formulas
• Specialized formulas, are designed to meet the specific nutrient
needs of patients with particular illnesses.
• Products have been developed for individuals with liver, kidney, and
lung diseases; glucose intolerance.
• Disease-specific formulas are generally expensive.
4 - Modular Formulas
• Modular formulas, created from individual single macronutrient
preparations
• Prepared for patients who require specific nutrient combinations to
treat their illnesses.
• Vitamin and mineral preparations are also included in these formulas
so that they can meet all of a person’s nutrient needs.
Formula Characteristics
• Macronutrient Composition
• Energy Density
• Fiber
• Osmolality
Macronutrient Composition
• The percentages of protein, carbohydrate, and fat vary among
enteral formulas.
• The protein content of most formulas ranges from 12 to 20 percent
of total kcalories.
• Carbohydrate and fat provide most of the energy in enteral formulas;
standard formulas generally provide 40 to 60 percent of kcalories
from carbohydrate and 30 to 40 percent of kcalories from fat.
Energy Density
• The energy density of enteral formulas ranges from 0.5 to 2.0
kcalories per milliliter of fluid.
• Standard formulas typically provide 1.0 to 1.2 kcalories per milliliter
and are appropriate for patients with average fluid requirements.
• Formulas that have higher energy densities can meet energy and
nutrient needs in a smaller volume of fluid and thus benefit patients
who have high nutrient needs or fluid restrictions.
•
Individuals with high fluid needs can be given a formula with low
energy density or be supplied with additional water via the feeding
tube or intravenously.
Fiber Content
• Fiber-containing formulas can be helpful for normalizing intestinal
function, treating diarrhea or constipation, and maintaining blood
glucose control.
• Conversely, fiber-containing formulas are avoided in patients with
acute intestinal conditions, pancreatitis, or procedures involving the
intestines
Osmolality
– A formula with an osmolality similar to that of blood serum (about
300milliosmoles per kilogram) is an isotonic formula.
– A hypertonic formula has an osmolality greater than that of blood
serum.
– Most enteral formulas has osmolalities between 300 and 700
milliosmoles per kilogram
Formula Selection
•
•
•
•
Nutrient and energy needs
Fluid requirements
Need for fiber modifications
Individual tolerances
– Food allergies & sensitivities
Enteral nutrition benefits
– Maintain normal GI function
– Causes fewer complications
– Less costly
Indications for Tube Feedings
Include people with:
• Severe swallowing disorders
• Impaired motility in the upper GI tract
• Gastrointestinal obstructions that can be bypassed with a feeding
tube
• Certain types of intestinal surgeries
• Mechanical ventilators, coma
• Extremely high nutrient requirements
• Little or no appetite for extended periods, especially if malnourished
Administration of Tube Feedings
• Open feeding system: requires formula to be transferred from
original packaging to feeding container
• Closed feeding system: formula prepackaged in ready-to-use
containers
Administration of Tube Feedings
• At the Nursing Station
• Check expiration date on label
• Wash hands
• Clean the can opener and the lid
• Label can with date and time opened
• Store opened cans or mixed formulas in clean, closed
containers & refrigerate
• Discard opened containers not used within 24 hours
• At the Bedside
• Open system :Hang no more than 8 hour supply of formula
and discard any formula that remains after that.
• Closed system: Hang no more than 24 hour supply of formula
and discard any formula that remains after that.
Contraindications for Tube Feedings
•
•
•
•
Severe GI bleeding
Intractable vomiting or diarrhea
Complete intestinal obstruction
Severe malabsorption
Transition to Table Foods
• Tube feedings are gradually tapered off – as oral intake increases
• The steps in the transition depend on the patient’s medical condition
and the type of feeding the patient is receiving.
• Are discontinued when client consuming 2/3 of nutrient needs by
mouth
PARENTERAL NUTRITION SUPPORT
Parenteral Support used with patients who:




Do not have functioning GI tracts and are:
Malnourished
At risk for becoming malnourished
Could be harmed if GI tract used (require bowel rest)
There are two types of parenteral nutrition
1- Total Parenteral Nutrition (TPN)
a. Uses larger, central veins
b. Volume is greater and nutrient concentrations are not limited
c. Can reliably meet complete nutrient requirements
2- Peripheral parenteral nutrition (PPN)
a. Used for short-term nutrition support (7-10 days)
b. for clients who do not have high nutrient needs or fluid
restrictions
-Can only provide limited amounts of energy & protein
Parenteral Solutions Nutrients:
• Protein :Amino acids
• Carbohydrates : glucose
• Lipids : triglycerides
• Fluids and electrolytes (Sodium, potassium, chloride, calcium,
magnesium, and phosphorus)
• Vitamins and trace minerals : Multivitamin and trace minerals added
Important notes
-There are disease specific solutions – for patients with: liver failure, kidney
failure and hyper-triglyceridemia, coagulation diseases
-Iron excluded – alters stability of other ingredients – given by injection
-Daily lab tests to monitor electrolyte status
Parenteral Formulation
 Depends on patient’s:
–
–
–
–
Medical condition
Nutritional status
PPN or TPN
May need to be recalculated daily
Parenteral Preparation
• Careful attention to solution preparation and handling
– Prepared in pharmacy under aseptic conditions
– Shielded from light
– Refrigerated
– Prior to hanging infusion
• Solutions removed from refrigerator
• Allowed to reach room temperature
– During feedings – solution and catheter checked frequently for
sign of contamination
Discontinuing intravenous feedings
• Transitional feedings
– Taper off parenteral feedings as enteral feedings are begun
Potential benefits of enteral nutrition over PN include:
1. Physiologic
o Nutrients are metabolized and utilized more effectively
via the enteral than the parenteral route.
o The gut and liver process enteral nutrients before their
release into systemic circulation.
o The gut and liver help maintain the homeostasis of the
amino acid pool as well as the skeletal muscle tissue.
2. Immunologic
o Gut integrity is maintained by enteral nutrients through
the prevention of bacterial translocation from the gut,
sytemic sepsis, and potential increased risk of multiple
organ failure.
o Lack of GI stimulation may promote bacterial
translocation from the gut without concurrent enteral
nutrition.
o Provision of early enteral nutrition may minimize risk of
gut related sepsis.
3. Safety (avoid complications related to intravenous access):
o
o
o
o
Catheter sepsis
Pneumothorax
Catheter embolism
Arterial laceration
4. Cost
o
o
Cost of EN formula is less than PN.
Cost of equipment and personnel for preparation and
administration is less