Enteral Nutrition assignment
Order Description
Answer these questions.

ENTERAL NUTRITION
Note: Download the current ASPEN Guidelines to use as a resource
1. Describe the factors to consider when selecting enteral nutrition formulas.

2. Describe short-term and long-term enteral nutrition feeding administration routes, site advantages, and disadvantages of each.

3. Describe monitoring parameters you would use to evaluate tolerance and progression of Enteral Nutrition.

***Use the below information to assist in answering the above questions.

SELECTION OF APPROPRIATE EN PRODUCTS

The selection of an enteral formula requires solid knowledge of formula composition and digestive and absorptive processes. The selection process can be summarized in several steps.

Assess Digestive and Absorptive Capacity
The first step is to assess the patient’s digestive and absorptive capacity. If digestion or absorption is impaired, an elemental or semi-elemental formula should be considered. Conditions or diseases with possible compromised digestion and/or absorption include celiac sprue, short bowel syndrome, malnutrition, chronic pancreatitis, and pancreatectomy. If a patient’s gastrointestinal tract is fully functional, elemental formulas are not indicated due to high osmolality, cost, and additional preparation required. A formula containing intact nutrients should be used instead.

Estimate Calorie and Protein Requirements
Second, estimate the patient’s total calorie and protein requirements. Determine whether the formula(s) being considered will meet these requirements. Most patient’s calorie and protein needs can be met using a standard formula (1 kcal/ml or 1.2 kcals/ml). A calorie-dense formula is beneficial if a patient requires a large amount of calories in a relatively small volume of formula. Most enteral formulas provide adequate protein for patients without unusual protein requirements. High protein or high nitrogen (HN) formulas are appropriate for patients with elevated protein requirements, such as patients with sepsis, trauma, burns, or wounds.

Consider Physical Characteristics of the Formula to Improve Tolerance
Third, consider what effects the physical characteristics of the formula selected will have on the patient’s gastrointestinal tract and blood chemistries (e.g. osmolality, sodium, and potassium content). Starting feedings at a low rate (20 ml/hr) and increasing slowly may increase tolerance especially when administering EN to very ill or malnourished patients. This is especially important if the formula will be infused directly into the small intestine. An isotonic formula and/or one containing fiber may be an appropriate choice for a patient who experiences diarrhea during tube feeding. The sodium and potassium content of a formula is an important consideration when working with a patient with compromised hepatic, renal, or cardiac function.

ENTERAL NUTRITION ROUTES

Choosing an appropriate enteral route requires an estimation of the length of time for which EN will be required, knowledge of the functional status of the GI tract, estimation of the risk for aspiration, and comprehension of the underlying disease process. EN can be provided through different routes directly into the stomach or small intestine. Feeding into the stomach is the preferred route as tubes are usually easier to place and replace. Conditions that may require feeding into the small intestine include: gastroparesis, gastric ileus, recent abdominal surgery, sepsis, significant gastroesophageal reflux, pancreatitis, and aspiration. Adequate digestion of nutrients is possible when the formula is fed in to the upper part of the small intestine. Formulas made from intact nutrients can be used when feeding into the small bowel.

Nasogastric Tubes
Nasogastric tubes deliver formula directly into the stomach. This allows the digestive process to begin in the stomach. The stomach acts as a reservoir and allows formula to be released into the duodenum at a controlled rate, decreasing the risk of dumping syndrome (diarrhea, fullness, abdominal cramps, and vomiting after feeding). However, the risk of aspiration is higher because only the gastroesophageal sphincter is available to prevent regurgitation. Nasogastric tubes are used for short-term feedings (less than 6 weeks) and can cause permanent damage to the structures of the nose and throat if used for long periods of time. These tubes should be used in patients who are alert with an intact gag reflex. Aspiration precautions should be used in unconscious patients.

Nasoenteric Tubes
Nasoduodenal or nasojejunal routes deliver formula into the small intestine. These tubes should be used short-term for patients who cannot tolerate gastric feedings, such as those with acute pancreatitis and gastric ileus. Nasoenteric tubes are associated with a decreased risk of aspiration since the pyloric and gastroesophageal sphincters work to prevent regurgitation. The risk of dumping syndrome is increased since the stomach is not used as a reservoir. Another disadvantage is that the bactericidal effect of hydrochloric acid in the stomach is bypassed.

Orally placed tubes
Orally placed tubes may be indicated for patients who have had surgery or trauma involving the face or head. In addition, orally placed tubes may be selected to reduce risk of sinusitis or otitis media associated with nasally placed tubes.

Dual lumen tubes
One lumen is used for ongoing gastric decompression while the other lumen is used for transpyloric feeding.

Tube Enterostomy Routes
The surgical placement of a tube into the gastrointestinal tract is indicated when long-term EN is needed. Gastrostomy tubes bypass the upper part of the gastrointestinal tract and deliver formula directly into the stomach. It may be used with patients with esophageal obstruction, dysphagia due to stroke or other neurological disorders, chest trauma, esophageal fistula, neoplasm, radiation esophagitis, and maxillofacial disorders. The major complications that occur are aspiration, peritonitis, and dislodgement of the feeding tube. Gastrostomy tubes offer greater flexibility in designing feeding schedules than do jejunostomy tubes.

Jejunostomy tubes are used when delivery into the small intestine is needed. Patients with gastric cancer, chronic nausea and vomiting, pancreatitis, or extensive peptic ulcer disease may fall into this category. The risk of gastric reflux and aspiration is low. If the location of the tube tip is beyond the upper portion of the jejunum, the use of a partially digested formula may be indicated to enhance absorption.

Confirming Tube Feeding Placement
X-ray (or radiographic verification) is considered the “gold standard” for confirming feeding tube placement.

MONITORING ENTERAL NUTRITION

The dual goals of monitoring EN include: (1) evaluating the adequacy of nutrient provision, and (2) troubleshooting and detecting potential complication as early as possible. EN monitoring should also include procedures designed to promote safety: keeping the head of bed elevated, maintaining correct placement of the feeding tube, irrigating the access device appropriately, providing care for skin adjacent to the feeding tube, and adhering to infection control principles.

Other monitoring parameters include:
• Physical assessment, including clinical signs of fluid and nutrient excess of deficiency.
• Vital signs
• Actual fluid and nutrient intake (oral, enteral, and parenteral)
• Measurement of output (urine, gastrointestinal, wound losses, chest tube drainage)
• Laboratory data
• Markers for nutritional adequacy
• Review of medications
• Changes in gastrointestinal function indicating tolerance of nutrition therapy such as ostomy output, stool frequency and consistency, presence of blood in the stool, presence of abdominal distention/firmness, increasing abdominal girth, nausea, vomiting, amount and appearance of residual volume.

One of the most important issues to monitor once EN orders have been written is to verify that the tube feedings are actually being administered as ordered. Scheduled and unscheduled interruptions, inadequate nutrient prescriptions, or other barriers can contribute to inadequate provision of EN. One strategy used in cases where frequent interruptions occur during EN is to increase the hourly rate of administration to compensate for the time that the tube feeding is stopped.

Hydration
Signs of inadequate hydration are decreased skin turgor, confusion, serum sodium > 145 – 150 mEq/l, elevated temperature, specific gravity > 1.03, dry tongue, diminished urine output < 500 ml/day, elevated BUN and HCT.

Nutrition
Routine, weights, nitrogen balance, and labs- the traditional protein markers (albumin, prealbumin, transferrin, and retinol-binding protein are a reflection of the acute phase response and do not accurately reflect nutritional status in the ICU setting.

Mechanical
Monitoring should include x-ray to confirm tube position, gastric residual checks, changing the tube and feeding bag daily.