1. Feeding Routes

2. Feeding Routes
Enteral feeding
Parenteral feeding

3. Feeding Routes 1- Enteral feeding:
Oral feeding: patients meet their needs by consuming oral diets and supplements
Tube feeding: provides nutrients using the gastrointestinal tract (GI)-directly into the stomach or intestines

4. Feeding Routes 2- parenteral feeding:
Used when a patient’s medical condition prohibits the use of the GI tract to deliver nutrients.
Provides nutrients intravenously to patients without adequate GI function to handle enteral feedings
Also called Intravenous feedings

5. In general, tube feeding or intravenous feeding should be used when :
patients nutrients needs are high
or their appetites poor
or their medical condition makes it difficult to meet nutrients need orally.

7. 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.

9. Feeding Routes Transnasal (Short-term nutrition) Nasogastric
Nasoduodenal
Nasojejunal
Enterostomy
(Long-term nutrition)
Gastrostomy
Jejunostomy

11. 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

12. Types of enteral formulas

13. Standard formulas Elemental formulas Specialized formulas
Enteral formulas are categorized according to their macronutrient sources:
Standard formulas
Elemental formulas
Specialized formulas
Modular formulas

14. 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

15. 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.

16. 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.

17. 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.

18. Formula Characteristics
Macronutrient Composition
Energy Density
Fiber
Osmolality

19. 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.

20. 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.

21. 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.

22. 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

23. 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

24. Formula Selection Nutrient and energy needs Fluid requirements
Need for fiber modifications
Individual tolerances
Food allergies & sensitivities

25. Enteral nutrition benefits
Maintain normal GI function
Causes fewer complications
Less costly

26. 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

27. 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

28. 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

29. Administration of Tube Feedings
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.

30. Contraindications for Tube Feedings
Include:
Severe GI bleeding
Intractable vomiting or diarrhea
Complete intestinal obstruction
Severe malabsorption

31. 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

32. PARENTERAL NUTRITION SUPPORT

33. Indications for Parenteral Support
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)

34. Indications for Parenteral Support
1-Total Parenteral Nutrition (TPN)
Uses larger, central veins
Volume is greater and nutrient concentrations are not limited
Can reliably meet complete nutrient requirements

35. Peripheral parenteral nutrition (PPN)
Used for short-term nutrition support (7-10 days)
for clients who do not have high nutrient needs or fluid restrictions
-Can only provide limited amounts of energy & protein

36. Accessing Central Veins for Total Parenteral Nutrition

37. 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

38. 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

39. Parenteral Formulation
Depends on patient’s:
Medical condition
Nutritional status
PPN or TPN
May need to be recalculated daily

40. 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

41. Discontinuing intravenous feedings
Transitional feedings
Taper off parenteral feedings as enteral feedings are begun

42. Potential benefits of enteral nutrition over PN include:
Physiologic
Nutrients are metabolized and utilized more effectively via the enteral than the parenteral route.
The gut and liver process enteral nutrients before their release into systemic circulation.
The gut and liver help maintain the homeostasis of the amino acid pool as well as the skeletal muscle tissue.
Potential benefits of enteral nutrition over PN include:

43. Immunologic
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.
Lack of GI stimulation may promote bacterial translocation from the gut without concurrent enteral nutrition.
Provision of early enteral nutrition may minimize risk of gut related sepsis.

44. Safety (avoid complications related to intravenous access):
Catheter sepsis
Pneumothorax
Catheter embolism
Arterial laceration

45. Cost of EN formula is less than PN.
Cost of equipment and personnel for preparation and administration is less