ENTERAL and

PARENTERAL FEEDING

Mylin G. Abalus
NUTN 204 Lecturer
OBJECTIVES
LESSON OVERVIEW
 Enteral Nutrition

 Form of feeding that brings nutrients

directly into the digestive tract

1. Oral feeding

2. Tube feeding- feeding by tube directly into

the stomach or intensive or via a vein
 Enteral Nutrition
 Indicated for patients who have a
functioning GIT but can’t ingest enough
nutrients orally
Advantages:
Better preservation of the structure and function of GIT
Lower cost
Fewer complications, particularly infections

Indications:
Prolonged anorexia
Severe protein-energy undernutrition
Coma or depressed sensorium
Liver failure
Inability to take oral feedings
Critical illnesses
Malabsorption problems
 Types of Feeding Tubes
 Nasogastric (NG) tube
 inserted through the nose and into the
stomach and small intestine
 For periods that do not exceed 6 weeks

 Percutaneous Endoscopic Gastrostomy

(PEG) tube
 For periods > 6 weeks
 Opening called an “ostomy” is needed
(esophagostomy, gastrostomy, jejunostomy)
 Types of Enteral Formulas
 POLYMERIC FORMULA
Commercially prepared formulas that provides
complete, balance diet

1-2 calories/ml
Contains proteins, carbohydrates, and fats
Requires digestion

Blenderized food and milk-based or lactose free

commercial formula
 Types of Enteral Formulas
 ELEMENTAL or HYDROLYZED FORMULAS

Formula containing products of digestion of

proteins, carbohydrates and fats

Used for clients who have difficulty digesting

food

Provide 1 cal/ ml; lactose-free

Expensive and usually unnecessary

e.g. amino acid formula, calorie- and protein-

dense formula, restricted, fiber-enriched
formula
 Types of Enteral Formulas
 MODULAR FORMULAS (Feeding modules)

Provides 3.8- 4 cal/ml

Can be used as supplements to other formulas

or for developing customized formulas for
certain clients (e.g. burn patients)

Usually used in acute setting and for short

period of time (e.g. renal failure, respiratory
failure, liver failure)
May contain specific nutrient; used to treat
specific deficiency or combines with other
formulas
 Three Methods of Administering
Tube Feedings
 Intermittent
Administering tube feedings usually at night;
solid foods eaten during the day

 Bolus
Daily calorie needs are divided into 6
servings/day (< 400 ml); given over 15 mins
followed by 25-60 ml of water

 Continuous

Feedings are administered by a continuous

pump; 16- to 24-hour period; initially at a rate
of 30-50 ml/per
 Guidelines in Administering
Tube Feedings
 Nasogastric or nasoduodenal tube feeding
NGT feeding often causes diarrhea
Usually started with small amounts of dilute
preparations
Solution may be given undiluted at 50 ml/hour
Water boluses may be given

Note: Higher caloric formula may cause decreased

gastric emptying  higher residual than more dilute
formula

 Jejunostomy tube feeding

Requires greater dilution and smaller volumes
Feeding usually begins at < 0.5 kcal/ml and a rate of 25
ml/h
Concentrations and volumes is increased after few
days
 Complications of Enteral Tube
Nutrition
PROBLEM CAUSE EFFECT
1. Presence of tube Tube irritates tissues Damage to the
causing them to nose, pharynx or
erode esophagus

2. Blockage of tube Thick feedings or Inadequate feeding

lumen pills can block the
lumen

3. Misplacement of Tube may be Brain trauma,

nasogastric tube misplaced infection
intracranially intracranially if the
cribriform plate is
disrupted by severe
facial trauma
 Complications of Enteral Tube
Nutrition

PROBLEM CAUSE EFFECT

4. Misplacement of Responsive patients- Pneumonia
naso- or orogastric cough and gag
tube in the Obtunded patients-
tracheobronchial may have few
tree immediate
symptoms
5. Dislodgement of Tube may be Peritonitis
gastrostomy or displaced into the
jejunostomy tube peritoneal cavity
 Complications of Enteral Tube
Nutrition
PROBLEM CAUSE EFFECT
6. Intolerance of *usually occurs with Diarrhea, GI
one of the formula’s bolus feedings discomfort, nausea,
main nutrient *lactose vomiting
components
7. Osmotic diarrhea High osmolality of Weakness, diarrhea
the solution

*Sorbitol- often
contained in liquid
drug preparations

*Clostridium difficile
8. Nutrient Specific formulas Electrolytes
imbalances disturbances,
hyperglycemia,
 Complications of Enteral Tube
Nutrition
PROBLEM CAUSE EFFECT
9. Reflux of Clogged tube or ASPIRATION
solutions tube may be pulled
out
 Parenteral Nutrition
 Provision of nutrients intravenously
 Used if GIT is not functional or normal feeding is
not adequate
 Compared with enteral feeding, it causes more
complications, does not preserve GIT structure and
function and more expensive
 Solutions- prescribed by physician and dietitian and
prepared by pharmacist
 Administered via CENTRAL or PERIPHERAL VEIN
 Parenteral Nutrition
Peripheral Vein Central Vein
 2 weeks or less  > 2 weeks
 Subclavian or superior
vena cava is used

Indications:
Some stages of Crohn’s disease or ulcerative colitis
Bowel obstruction
Certain pediatric GI disorders (congenital anomalies, prolonged
diarrhea)
Short bowel syndrome
 Types of Parenteral Nutrition
1. Partial Parenteral Nutrition
 Supplies only part of daily nutritional
requirements, supplementing oral intake
 Dextrose or amino acids solutions

2. Total Parenteral Nutrition

(Hyperalimentation)
 Supplies all daily nutritional requirements
 TPN solutions are highly concentration-
central vein is used
 Parenteral Nutrition Content
water 30-40 ml/kg/day
energy 30-60 kcal/kg/day
(depending on energy
expenditure)
Amino acids 1-2 g/kg/day
Essential fatty acids
Vitamins
minerals

Standard TPN solution- 2 L

Most calories are supplied by CHO (25% dextrose)
May also have lipid emulsions to supply essential fatty acids
and triglycerides
20-30% of total cal supplied from lipids
Electrolytes may be added
Modified based on results, d/o
 Parenteral Nutrition Solutions
 Reduced protein content and high
percentage of essential amino acid-
renal failure or liver failure
 Limited volume (liquid) intake- heart or
kidney failure
 Lipid emulsion (provides non-CHON
calories minimize CO2 production by CHO
metabolism)- respiratory failure
 Guidelines in Caring for Patient
having Parenteral Nutrition
 Strict sterile technique during insertion and
maintenance of central venous catheter
 TPN line should not be used for any other
purpose
 External tubing should be change every 24
hours
 Dressing should be kept sterile and
changed every 48 h using strict sterile
technique
 Guidelines in Administering
Parenteral Nutrition
 Solution is started slowly at 50% calculated
requirements + 5% dextrose

 Energy and nitrogen given simultaneously

 Amount of regular insulin (added directly to

the TPN solution) depends on the serum
glucose level (e.g. level is normal; 25% dextrose=
5-10 units of regular insulin)
 Guidelines in Caring for Patient
having Parenteral Nutrition
 Monitor weight, CBC, electrolytes and BUN
 Serum glucose monitored every 6 h until
stable
 Monitor intake and output
 Monitor liver function test
 Measure plasma CHONs (albumin),
prothrombine time, plasma and urine
osmolality, Ca, Mg and phosphate twice a
week
 Full nutritional assessment (BMI) every 2
weeks
 Complications of
Parenteral Nutrition
 Catheter related sepsis
 Phlebitis/thrombosis
 Glucose abnormalities
 Hepatic complications
 Abnormalities of serum electrolytes and
minerals
 Volume overload
 Bone demineralization
 Gallbladder complications