ENTERAL NUTRITION

When the dietary needs of the patient cannot be met by a regular well-
balanced diet, alternative means of nutritional support may be recommended.
Nutritional support options range from blended food products to commercial
formulas, which are taken by mouth or by a feeding tube.

Alternative feeding methods to ensure adequate nutrition include both

enteral (through the gastrointestinal system) and parenteral (intravenous)
methods.

Enteral nutrition is an option to provide supplemental or total nutrition by

feeding directly into the gastrointestinal (GI) tract using a tube feeding. Using
enteral nutrition support maintains the GI structure and functional integrity and
allows enhanced utilization of nutrients. Insertion of a feeding tube does not
necessarily mean an end to oral food intake. Tube feeding can be the sole
source of nutrition or as a supplement to inadequate oral nutrition. It can be
administered either temporarily or permanently and allows patients to receive
nutrients otherwise unavailable to their body and should help heal their
underlying illness.

For tube feeding, the physician in collaboration with the dietitian

prescribes the tube-feeding regimen, including the route and type of formula to
be utilized. The selection of the formula type and goal rate for tube feeding is
facilitated by the dietitian. The order should specify the product, either by name
or as standard tube feeding, according to the hospital protocol; volume, rate and
timing, indicating the initial volume and rate, as well as the progression and goal
volume and rate; administration and monitoring including the administration of
extra water to meet the fluid requirements of patient and water to flush the tube.

The choice of the kind of tube feeding to use depends on the functioning
of the gastrointestinal system. It is important to distinguish between enteral and
parenteral feeding:

 Enteral feeding delivers digestible nutrition formula through a tube

directly into an intact, functioning GI system, bypassing problems with
normal oral ingestion. It is preferred over parenteral feeding, in that it
involves lower cost, convenience, less infectious complications and
improves maintenance of the gastro intestinal mucosal structure and
function which can prevent gut atrophy.

 Parenteral feeding, also referred to as total parenteral nutrition (TPN),

delivers a more elemental formula intravenously, directly into the
circulatory system when the GIT system is compromised or
malfunctioning, bypassing both ingestion and digestion.
Enteral Access Devices

A nasogastric tube is inserted through one of the nostrils, down the

nasopharynx, and into the alimentary tract.
Nasogastric tubes are used for feeding clients who have adequate gastric
emptying, and who require shorter-term feedings. They are not advised for
feeding clients without intact gag and cough reflexes since the risk of accidental
placement of the tube into the lungs is much higher than those clients. These
reflexes are present if a tongue depressor advanced to the back of the throat
elicits retching or coughing responses.

A nasoenteric (or nasointestinal) tube, a longer tube than the nasogastric

tube (at least 40 inches for an adult) is inserted through one nostril down into the
upper small intestine. Some agencies may require specially trained nurses or
primary care providers for this procedure. Nasoenteric tubes are used for clients
who are at risk for aspiration. Clients at risk for aspiration are those who manifest
the following:
 Decreased level of consciousness
 Poor cough or gag reflexes
 Endotracheal intubation
 Recent extubation
 Inability to cooperate with procedure
 Restlessness or agitation

I. ENTERAL FEEDING

A. ENTERAL FEEDING TYPES

The enteral feeding route depends on several factors including the
patient’s concurrent diseases or injuries the presence or risk of impaired
gastric motility of aspiration and the anticipated duration of nutrition support
and the advantages and disadvantages of access routes. The stomach is
traditionally used for delivery of enteral nutrition because it is more
convenient, less costly, and less labor intensive than others. The small bowel
however, may be preferred in patients with pancreatitis, severe
gastroesophageal reflux disease, and gastroparesis as well as patients who
have consistent high gastric residual volumes or who are at greater risk of
aspiration. The types of enteral tube feeding are classified according to the
point from which the tube enters the body and the point to which the nutrient
formula is delivered:

1. Orogastric feeding has the tube inserted through the mouth, with
the tip in the stomach.
Traditional firm, large-bore nasogastric tubes (those larger
than 12 Fr in diameter) are placed in the stomach. Examples are
the Levin tube, a flexible rubber or plastic, single-lumen tube with
holes near the tip, and the Salem sump tube, with a double lumen.
 The larger lumen of the Salem sump tube allows delivery of liquids
to the stomach or removal of gastric contents.

2. Nasoenteral feeding:
a. Nasogastric (NG) feeding has the tube inserted from the nose
with the tip resting in the stomach. Nasogastric (NG) is a longer
tube than the nasogastric tube (at least 40 inches for an adult) is
inserted through one nostril down into the upper small intestine.
Some agencies may require specially trained nurses or primary
care providers for this procedure. Nasoenteric tubes are used
for clients who are at risk for aspiration.
This is the most common type of enteral feeding and used in
patients with functional lower esophageal sphincter, normal
gastric emptying and lack of involvement of the stomach by the
primary disease process. The stomach having a large capacity
is an advantage for their use.
b. Nasoduodenal feeding has the tube inserted from the nose with
the tip resting in the duodenum (immediately below the
stomach, the upper part of the small intestine).
c. Nasojejunal feeding has a feeding tube inserted from the nose
with the tip resting in the jejunum (middle part of the small
intestine and before the ileum). Both the nasoduodenal and
nasojejunal feedings are used in patients who cannot tolerate
gastric feedings and who need to lie flat as in critically ill
patients.
d. Esophagostomy had the feeding tube inserted through a
surgical opening in the neck and passed through the
esophagus, with the tip resting in the stomach.
A nasoenteric (or nasointestinal) tube, Gastrostomy (GT) has a
feeding tube inserted through the abdominal wall directly into the
stomach. GT is used when a patient cannot or will not eat for longer
than four weeks and has a functional gut. The procedure of placing
GT is known as percutaneous endoscopic gastrostomy (PEG). It
may also be placed surgically and more recently via computed
tomography-guided procedure.

3. Jejunostomy (JT) has a feeding tube inserted through the

abdominal wall via percutaneous endoscopic guidance (PEG) and
directly into the jejunum. This is the type of feeding tube used for
patients who need long time enteral nutrition generally more than 6
to 8 weeks and suffers from chronic aspiration, gastric outlet
obstruction, or duodenal and stomach disease or for patients with
prior gastrectomy. Direct endoscopic techniques are used to place
the tube or it may use a jejuna extension of a feeding tube through
an existing PEG.
Indications for Enteral feeding:

Indications for Feeding Example

Insufficient oral intake Severe malnutrition, hydration crisis
Unconscious patient Head injury, ventilated patient
Swallowing disorder Post stroke, multiple sclerosis, motor
neuron disease
Upper gastrointestinal obstruction Post operative ileus, inflammatory
bowel disease, short bowel
syndrome
Partial intestinal failure Post operative ileus inflammatory bowel
disease, short bowel syndrome
Hyper metabolic conditions Burns, some form of cancer
Neuromuscular disorders Muscular dystrophy, cerebral palsy,
spinal cord defects
Physiological anorexia Liver disease (particularly with ascites)
Increased nutritional requirements Cystic fibrosis, renal disease
Psychological problems Severe depression, anorexia nervosa

Contraindications for enteral nutrition include:

 Inability to gain access
 Gastrointestinal obstruction (depending on location)
 Severe diarrhea or vomiting
 Insufficient absorptive capacity of intestinal tract such as short-bowel
syndrome with less than 100 cm jejunum and 150 cm ileal length of
functioning small bowel
 High output enterocutaneous fistula (>500 ml/day)
 Acute stage of inflammatory bowel disease or due to radiation or
chemotherapy.
 Upper gastrointestinal hemorrhage such as portal hypertension, cirrhosis
or esophageal varices
 Short bowel syndrome (<100 cm of small bowel remaining)
 Prognosis that does not require aggressive nutrition support

Complications and Problems

An understanding of the complications and the necessary intervention can

reduce the incidence of complications and enhance the care of the patient.
Complications are grouped into these categories:

1. Gastrointestinal Complications
 Diarrhea. It is the most common complication of tube feeding usually
caused by protein-energy malnutrition, medications, motility, infection,
impaction, infusion rate, osmolality and bacterial contamination of formula.
Medications containing sorbitol, magnesium, non-steroidal anti-
 inflammatory drugs, H2 blockers, proton pump inhibitors and antibiotics
are common offenders. Careful hand washing can minimize
contamination, feeding bags and tubing should be changed daily and
opened formulas should be refrigerated. Decreasing the feeding flow rate
may alleviate diarrhea by allowing time for intestinal mucosa adaptation to
occur when the GIT has not been used for extended periods. If lactose
intolerance is present, switch to a lactose-free formula. A change to
elemental or predigested feeding formula is rarely needed unless
significant impairment in GIT function and absorption is well documented.
 Nausea, vomiting, or abdominal bloating. Nausea may be due to smell,
abdominal bloating and cramps. Cramps and abdominal bloating is
caused by excess feed administration rates, decreased bowel motility
often present in frail elderly and delayed gastric emptying. Assess
abdominal distention and fecal impaction. If receiving intermittent feeds,
change feedings to slower rate of continuous feeds. Using calorie-dense
formula may also decrease the total volume and rate infused.

2. Respiratory Complications

Aspiration of formula is the most dangerous complication of enteral feeding

and is among the leading causes of death in tube-fed patients due to
aspiration pneumonia. Older adults with low level of consciousness, those on
mechanical ventilation, gastroesophageal reflux, prior history of aspiration or
pneumonia, poor oral hygiene, those with delayed gastric emptying and those
with poor cough and gag reflexes are at greater risk of aspiration.
Treatment includes stopping the feed, attempts of aspirating the feed from
the lungs and antibiotics if infection is evident. Administering feeding
continuously rather than intermittently, using small-bore feeding tubes and
elevating the head of the bed at least 30-45 degrees for at least one hour
after feeding is completed, may reduced the risk of aspiration. Iso-osmotic
feeds may be preferred since high osmolality feeds can delay gastric
emptying.

3. Metabolic Complications

a. Electrolyte imbalances are common complications associated with enteral

feeding. Specific imbalances are related to different levels of sodium,
phosphorous, potassium, zinc, copper, magnesium, vitamins, trace
elements and water. Electrolyte imbalances and fluid balance alteration
can be avoided with carefully monitored fluid management.
b. Hyperglycemia . High calorie intake may also unmask glucose intolerance
or diabetes leading to hyperglycemia. Acute illness, over feeding and low
insulin can also account for hyperglycemia.
c. Refeeding syndrome is a potential complication which occurs with rapid
replacement of large amounts of nutrients especially for those who are
chronically ill and receiving IV fluids without nutrients for 7-10 days. To
 avoid this syndrome, one must estimate the nutritional needs of the patient
and then initiate feeding slowly and carefully follow serum electrolyte and
mineral levels.

4. Mechanical Problems
a. Failed insertion and complications of insertion. Insertion of a nasoenteral
tube may cause discomfort, rhinitis, esophageal reflux and strictures,
esophagitis and perforation of the pharyngeal or esophageal pouch, and
accidental bronchia insertion and perforation. The risk is minimized with
the use of flexible polyurethane or silicone tubes.
b. Tube obstruction and displacement . Obstruction is the common
mechanical problem of enteral feeding, commonly caused by medication
fragments, formula residue adhering to the tube, and incompatibility
between the formula and medications. Flushing the tube with at least from
30-60 ml of water every 4 hours during continuous feedings, before and
after medication administration, after intermittent feeding and using liquid
medication can help reduce the incidence of tube obstruction.
c. Leakage is another complication that can cause severe skin tearing and
major hygiene problem. Lowering the acidity of the gastric contents may
decrease gastric secretions. A larger replacement tube may also help.

5. Drug-Enteral Feeding Complications

Drug-enteral feeding interaction involves drugs that interact with food or
electrolytes , or when multiple drugs in liquid form are given concomitantly
with enteral feeds. Inability to recognize these interactions, may lead to
toxicity, life-threatening adverse effects and failure of treatment. These
interactions may be prevented by not administering the feedings for two hours
before and after the administration of medications.

There are many different types of enteral formulas that can be used for
tube feedings. The actual formula used depends on the individual patient's
needs. There are four basic types of enteral formulas: intact, hydrolyzed,
modular, and nutrient modified and disease-specific formulas

B. TYPES OF ENTERAL FORMULAS

a. Intact formulas are also called “standard” or “polymeric” formulas and

contains unaltered molecules of protein, carbohydrates and fat. They must
be digested into dipeptides and tripeptides, free amino acids, and simple
sugars in the small bowel. They are best for people who can digest and
absorb nutrient without difficulty.
There are two basic types of intact formula: synthetic formulas and
blenderized formulas. Synthetic formulas or Polymeric formulas are
available as standard formulations and are the most commonly used
formulas due to safety and feasibility in an institutional setting. Blenderized
 formulas are used infrequently because they are more likely to clog
feeding tubes since they have high viscosity. There is also great risk for
food borne illness for blenderized formulas.

b. Hydrolyzed formulas are predigested micronutrients. They are either

elemental or semi-elemental formulas. Carbohydrates sources are
oligosaccharides, sucrose or both and protein is present as free amino
acid (monomeric) or as bound amino acids in dipeptides or tripeptides.
Most free amino acids have low-fat content or contain a large
amount of medium-chain triglycerides (MCT) oil. Hydrolyzed formulas are
characterized as having low-residue, hyperosmolar and usually lactose-
free. These formulas are indicated for patients with compromised GIT
function and will be unnecessary for patients with normal digestion and
absorption because it cost more than intact formulas. Monomeric formulas
contain very little residue and are appropriate for patients that require
bowel rest. Patients with feeding tubes in the lower GI tract may also
benefit from these formulas.

c. Modular formulas are individually packaged incomplete liquid supplement

that contains specific nutrients & components that may be combined to
meet the nutritional requirement of the patients. Modular components may
be added to premixed formulas to increase the intake of one or more
macronutrient as needed. Examples include protein powders,
carbohydrate powders, fiber, MCT oils and specific amino acids.

d. Nutrient modified and disease-specific formulas are formulas that have

been altered in one or more nutrients in order to optimize nutrition support
without exacerbating the metabolic disturbances associated with various
diseases. Examples of nutrient modified formulas include formulas
containing omega-3 fatty acids, fiber, arginine, glutamine or branched-
chained amino acids.. Examples of disease-specific formula are formulas
for hepatic disease, GI dysfunction, pulmonary disease, diabetes mellitus,
renal disease and for immune enhancement.(HIV/AIDS)

Nutritional Information
Most intact formulas contain about 1 kcalorie per ml. Some formulas are
designed for those who need more kcalories and protein in a smaller volume of
fluid and contain 1.5 to 2 kcals per ml.

Enteral formulas contain high biological value protein such as casein,

lactalbumin, and soy protein isolate.

Most formulas are available as lactose free preparations to accommodate

patients with lactose intolerance

C. FEEDING ADMINISTRATION
 The type and frequency of feedings and amounts to be administered are
ordered by the primary care provider (physician). Liquid feeding mixtures are
available commercially or may be prepared by the dietary department in
accordance with the primary care provider’s orders. A standard formula
provides 1 Kcal per milliliter (1 Kcal = 1 mL) of solution with protein, fat,
carbohydrate, minerals, and vitamins in specified proportions.

Enteral feeding may be administered by various methods, determined by

the tip location of the feeding tube, the patient’s clinical condition, their
tolerance to the formula, and the overall convenience.

1. Continuous method is the most commonly use (often referred to as a

kangaroo pump). Continuous tube feeding is administered by gravity drip
or with a feeding pump and is usually tolerated better than bolus feeding.
This typed of feeding administration is indicated for patients who are
unable to tolerate high-volume feedings, are suffering from malabsorption
or patients at increased risk of aspiration. Continuous feedings are
administered at a slow, usually administered over at least 30 minutes;
continuous rate over a 16 to 24-hour period with sporadic interruptions for
drug delivery or medical procedures. This is preferred method to start a
patient in enteral feeding, when infusing directly into the small bowel and
when patients are critically ill. This method is however, most problematic
for drug-nutrient interactions.

2. Cyclic feeding administration involves delivery using continuous drip

method over a period of 8-20 hours per day using a pump to control
delivery. It is usually administered at night, thus allowing independence
from feeding equipment during the day and stimulates appetite in the
daytime. Like continuous administration, this delivery method may be used
when feeding into the stomach or small intestine. This method usually
requires a higher infusion rate which requires closer monitoring for formula
and delivery tolerance. It is usually well-tolerated and effective for
malnourished patients especially for the ambulatory elderly population.

3. Bolus feedings allow for more mobility than continuous drip feedings
because there are breaks in the feedings, allowing the patient to be free
from the tube feeding apparatus or activities such as physical therapy. It
closely mimics usual eating pattern and involves shorter period of infusion
at specified intervals – usually four to six times a day. It is characterized
by rapid administration of the formula usually less than 15 minutes into the
GI tract by syringe or feeding bag. Although not well tolerated by patients
with small bowel access, it offers the advantage of offering medications
separate from the feeding. It also poses an increased risk of aspiration.
 4. Intermittent delivery uses a similar technique to that of bolus feeding, but
it is used over a longer duration, which may help improve tolerance. This
delivery method cannot be used when feeding into small bowel.

5. Combination of continuous drip (at night) and bolus feeding (during the
day) can also be used.

Enteral feedings are administered to clients through open or closed systems.

Open systems use an open-top container or a syringe for administration. Enteral
feedings for use with open systems are provided in flip-top cans or powdered
formulas that are reconstituted with sterile water. Sterile water, rather than tap
water, reduces the risk of microbial contamination. Open systems should have no
more than 8 to 12 hours of formula poured at one time. At the completion of this
time, remaining formula should be discarded and the container rinsed before new
formula is poured. The bag and tubing should be replaced every 24 hours.
Closed systems consist of a prefilled container that is spiked with enteral tubing
and attached to the enteral access device. Prefilled containers can hang safely
for 48 hours if sterile technique is used.
Before administering a tube feeding, the nurse must determine any food
allergies of the client and assess tolerance to previous feedings. The nurse must
also check the expiration date on a commercially prepared formula or the
preparation date and time of agency-prepared solution, discarding any formula
that has passed the expiration date or that was prepared more than 24 hours
previously.
Feedings are usually administered at room temperature unless the order
specifies otherwise. The nurse warms the specified amount of solution in a basin
of warm water or leaves it to stand for a while until it reaches room temperature.
Because a formula that is warmed can grow microorganisms, it should not hang
longer than the manufacturer recommends. Continuous-feeding formulas should
be kept cold; excessive heat coagulates feedings of milk and egg, and hot liquids
can irritate mucous membranes. However, excessively cold feedings can reduce
the flow of digestive juices by causing vasoconstriction and may cause cramps.

II. PARENTERAL FEEDING

Parenteral nutrition (PN), also referred to as “total parenteral nutrition”

(TPN), and “central venous nutrition” (CVN) or intravenous hyperalimentation
(IVH), is the delivery of nutrients for assimilation and utilization by a patient
whose sole source of nutrients is via solutions administered intravenously,
subcutaneously, or by some other non-alimentary route. It is provided when the
gastrointestinal tract is nonfunctional because of an interruption in its continuity
or because its absorptive capacities is impaired. Parenteral nutrition is
administered intravenously such as through a central venous catheter into the
superior vena cava.
The basic components of TPN solutions are protein hydrolysates or free
amino acid mixtures, monosaccharides, and electrolytes. Components are
selected for their ability to reverse catabolism, promote anabolism, and build
structural proteins. It is in contrast to enteral nutrition, which encompasses oral
and tube feeding into the digestive tract. The general rule of thumb for deciding
whether to use parenteral or enteral feeding is “if the gut works, use it”. Always
use a working gastrointestinal tract to prevent atrophy. Because TPN solutions
are hypertonic (highly concentrated in comparison to the solute concentration of
blood), they are injected only into high-flow central veins, where they are diluted
by the client’s blood.

Parenteral Nutrition Indications.

Parenteral nutrition is indicated for patients with a non-functioning GIT and
unable to tolerate oral and enteral feeding. It is prescribed to patients whose
prognosis warrants aggressive nutrition therapy and at nutritional risk of
developing nutrition-related co-morbidities. Other indications include:
1. Patients who cannot be fed via GIT for more than a few days
2. Patients who are malnourished or at risk of malnutrition
3. Non-functional, inaccessible or perforated (leaking) GIT
4. Persistent GI hemorrhage
5. Enteral feeding not possible or failed trial
6. Short bowel syndrome
7. Mesenteric Ischemia
8. High output gastrointestinal fistula
9. Gut failure or malabsorption
10. Renal failure
11. Chronic hepatic disease
12. Acute pancreatitis
13. Eating disorder

Parenteral Nutrition Contraindications:

 Functional gastrointestinal; tract
 Anticipated treatment is less than 7 days in patients without severe
malnutrition
 Patients with poor peripheral access
 A prognosis that does not warrant aggressive nutrition support
 When the anticipated risk outweighs the potential benefits.

TPN is not risk-free. Infection control is of utmost importance during TPN

therapy. The nurse must always observe surgical aseptic technique when
changing solutions, tubing, dressings, and filters. Clients are at risk of fluid,
electrolyte, and glucose imbalances and require frequent evaluation and
modification of the TPN mixture.
TPN solutions are 10% to 50% dextrose in water, plus a mixture of amino
acids and special additives such as vitamins (e.g., B complex, C, D, K), minerals
(e.g., potassium, sodium, chloride, calcium, phosphate, magnesium), and trace
elements (e.g., cobalt, zinc, manganese). Additives are modified to each client’s
nutritional needs. Fat emulsions may be given to provide essential; fatty acids to
correct and/or prevent essential fatty acid deficiency or to supplement the
calories for clients who, for example, have high calorie needs or cannot tolerate
glucose as the only calorie source. Note that 1,000 mL of 5% glucose or dextrose
contains 50 grams of sugar. Thus a liter of this solution provides less than 200
calories!
Because TPN solutions are high in glucose, infusions are started gradually to
prevent hyperglycemia. The client needs to adapt to TPN therapy by increasing
insulin output from the pancreas. For example, an adult client may be given 1
liter (40 mL/hour) of TPN solution the first day; if the infusion is tolerated, the
amount may be increased to 2 liters (120 mL/hr) within 3 to 5 days. Glucose
levels are monitored during the infusion.
When TPN therapy is to be discontinued, the TPN infusion rates are
decreased slowly to prevent hyperinsulinemia and hypoglycemia. Weaning a
client from TPN may take up to 48 hours but can occur in 6 hours as long as the
client receives adequate carbohydrates either orally or intravenously.
Enteral or parenteral feedings may be continued beyond hospital care in the
client’s home or may be initiated in the home.

Metabolic Complications Associated with Parenteral Nutrition

Complications Possible Cause Symptom Treatment Prevention
Hypervolemia Excess fluid Dyspnea, Restrict fluids, Initiate PN once fluid
administration, renal bounding pulse, use diuretics, balance stable;
dysfunction, CHF, moist rales, hemofiltration monitor serum and
hepatic failure edema, weight in extreme urine osmolality
gain cases
Hypovolemia Inadequate fluid DHN, thirst, dry Increase fluid Monitor daily I&O;
administration, mucus intake monitor serum and
excessive sodium membranes, low urine osmolality,
intake urine output, monitor BUN
weight loss
Hypernatremia Inadequate free Thirst decreased Decreases Na Avoid excess Na
water administration, skin turgor, mild intake, intake; monitor urine
excessive Na intake, irritability in some replenish fluid sodium
excessive water cases, elevated
losses (fever, burns, serum sodium,
hyperventilation) BUN, and hct
Hyponatremia Excessive fluid Confusion, Restrict fluid Avoid over hydration;
administration, hypotension, intake; provide 60-100
nephritis and/or irritability, increase Na mEq/day unless
adrenal lethargy, seizures intake as contraindicated by
insufficiency, dictates by cardiac, renal, or fluid
dilutional states clinical status status; monitor urine
(CHF, syndrome of sodium
inappropriate
secretion of ADH,
cirrhosis of the liver
with ascites,
persistent vomiting
or diarrhea
Hyperkalemia Renal dysfunction, Diarrhea, Decrease K- Monitor serum levels
excessive K tachycardia, intake, K for trends; assess for
 administration; cardiac arrest, binders drug-nutrient
metabolic acidosis, oliguria, interactions,
K-sparing paresthesias especially K-sparing
medications diuretics
Hypokalemia Inadequate K N/V, confusion, Increase PN or Provide 40 mEq K
provisions, arrhythmias, IV K daily unless
increased K losses cardiac arrest, contraindicated; 3
(diarrhea, diuretics, respiratory mEq K/g nitrogen
intestinal fistulas) depression, needed with
muscle cramps, anabolism
constipation
Hyperglycemia Rapid infusion of Blood glucose Administer Slow initiation and
concentrated 200 mg/dl, insulin; reduce advancement of PN;
dextrose solution; metabolic dextrose use mixed substrate
sepsis, pancreatitis, acidosis, concentration solution
post-operative polyuria, in PN
stress; chromium polydipsia
deficiency; use of
steroids; advanced
age; multiple
sources of dextrose
both oral and IV
routes; DM
Hypoglycemia Abrupt Weakness, Administer Taper PN solution
discontinuation of sweating, dextrose with abrupt
PN, insulin overdose palpitations, discontinuation of
lethargy, shallow TPN; hang 10%
respirations dextrose at same rate
as TPN to prevent
rebound
hypoglycemia;
monitor serum
glucose when insulin
is being given
Hypertrigly- Lipid provision Serum Decrease lipid Assess for hx of
cemia exceeds ability to triglyceride level volume hyperlipidemia before
clear lipids from >250 mg/dl 4 hrs administered, initiation of PN; avoid
bloodstream (>4 after lipid lengthen lipid administration
mg/kg/min.), sepsis, stopped; infusion time, >2.5 g/kg/day or
multisystem organ elevated levels in and >60% of total
failure, pathologic previously stable simultaneously calories; suggest
hyperlipidemia, patients (i.e. infuse glucose limiting fat to <1g/kg
lipoid-nephrosis; sepsis); Serum to avoid potential
medication use level >400 mg/dl immunosuppressive
alters fat metabolism during effects
continuous lipid
infusion
Hypercalcemia Renal failure, tumor Confusion, DHN, Provide Encourage weight-
lysis syndrome, muscle isotonic saline, bearing activity;
bone cancer, excess weakness, N/V, inorganic evaluate vit D intake
vit. D administration, coma phosphate
prolonged supplementatio
immobilization and n
stress, hyperpara- costecosteroid
thyroidism s,mithramycin
Hypocalcemia Decreased vit D Paresthesia, Provide Ca Provide Ca, 0.2 – 0.3
intake, tetany, irritability, supplemntation mEq; use caution
hypothyroidism, ventricular when adjusting Ca:P
citrate binding of arrythmias ratio as precipitation
calcium due to may occur
excessive blood
transfusion,
hypoalbuminemia
Hypermagne- Excessive Respiratory Provide Monitor serum levels
semia magnesium paralysis, magnesium for trends
administration, renal hypotension, provision
insufficiency premature
ventricular
contractions(PVC
), lethargy,
cardiac arrest,
coma, liver
dysfunction
Hypomagnese- Refeeding Cardiac Provide Monitor serum levels
mia syndrome, arrhythmias, magnesium for trends; provide
alcoholism, diuretic tetany, supplementatio 0.25-0.35 mEq.
use, increased convulsions, n
losses, diabetic muscle
ketoacidosis, weakness
chemotherapy
Hyperphospha- Excess phosphate Paresthesias Decrease Monitor serum levels
temia administration flaccid paralysis, phosphate for trends
mental confusion, administration,
HPN, cardiac phosphate
arrhythmias, binders
tissue
calcification with
prolonged
elevated levels
Hypophospha- Refeeding Neurologic Provide Monitor serum
temia syndrome, changes phosphate phosphorous and
alcoholism, respiratory supplementatio replete prior to and
phosphate-binding muscle fatigue, n stop during TPN as
antacids, dextrose diaphragmatic phosphate- needed
infusion overfeeding, contractility, binding
secondary erythrocyte antacids, avoid
hyperparathyroidism hemolysis, overfeeding
insulin therapy, vit D leukocyte
deficiency, GI losses dysfunction
Pre-renal DHN, excess CHON Elevated serum Increase fluid Monitor serum BUN
azotemia provision, BUN intake, for trends; perform
inadequate non- decrease nitrogen balance
CHON energy CHON load, study
provision with increase non-
mobilization of own CHON energy
CHON stores
Overfeeding Excess energy Excess CHO; Decrease Avoid excess energy
administration CO2 retention, energy (CHO, administration
liver dysfunction; CHON, fat)
excess CHON, provision as
elevated BUN, needed
 excess nitrogen
excretion,
elevated BUN;
Crea ratio
Essential fatty Inadequate fat Dermatitis, Administer Provide 2-4% of
acids intake alopecia,; lipids energy as linoleic acid
deficiency alterations in or 8-10% of energy
pulmonary, from fat, especially in
neurologic, and patients severely
red cell malnourished or
membranes; expected not to take
diarrhea; anemia food by mouth for >1-
2 weeks
Abnormal liver Excess glucose or Increase in Ensure patient Keep CHO <5
function tests lipid load serum LFT after is not being mg/kg/min. Avoid
(LFT) 1-4 weeks PN overfed (total excess energy.
therapy; energy or Consider cyclic TPN.
transaminases CHO)
may increase 4-
fold

Some Common Complications and Interventions

1. Mechanical
a. Nasopharyngeal irritation (ice chips, topical anesthetic and decongestant)
b. Luminal obstruction (flush, replace tube)
c. Mucosal erosions (reposition tube, ice water lavage; remove tube)
d. Tube displacement (replace tube)
e. Aspiration (discontinue tube feeding)

2. Gastrointestinal
a. cramping/distention (change formula; reduce infusion rate)
b. vomiting/diarrhea (dilute formula; reduce infusion rate, antidiarrheal
agents)
c. constipation (promote sufficient fluids and fibers; encourage patient
activity)

3. Metabolic
a. hypertonic dehydration (increase free water)
b. glucose intolerance (reduce infusion rate; give insulin)
c. cardiac failure (reduce sodium content; fluid restriction)
d. renal failure (decrease phosphate, magnesium, potassium, protein
restriction, essential amino acids solution)
e. hepatic encephalopathy (decrease amount of protein)

Complications of Tube Feedings

Dumping Syndrome and Regurgitation

 The delivery site of the TF can influence complications. NG, esophagostomy,
and gastrostomy placement allow for digestion to begin in the stomach. The
stomach empties at a controlled rate so that food has adequate time for digestion
and absorption in the intestines, preventing the dumping syndrome.

Regurgitation of fluids is a possible complication, especially if the formula enters

the stomach much faster than it is emptied. If fluids are regurgitated and enter
the lungs, a fatal infection or aspiration pneumonia, can develop.

Diarrhea & Dehydration

Transpyloric feedings (delivered beyond the pyloric sphincter) to the duodenum

and jejunum are less likely to be regurgitated, but diarrhea and dehydration may
occur if the formula enters the intestines too rapidly.

Regardless of the site of feeding, patients must be monitored closely for

complications.

References:

Caudal, M. C. Basic Nutrition and Diet Therapy: Textbook for nursing students.
2008. C&E Publishing, Inc. Quezon City, Philippines.

Jamorabo-Ruiz, A. et.al. Nutrirtion and Diet Therapy for Nursing.2011. Merriam

Webster Bookstore, Manila, Philippines.

Kozier, et al. Kozier & Erb’s Fundamentals of Nursing, 8th ed. 2008. Pearson
Education, Inc. New Jersey, USA.

Mahan, L.K. & Escott-Stump, S. Krause’s Food, Nutrition & Diet Therapy, 11th ed.
2004. Elsevier PTE Ltd. Singapore.

Parenteral Nutrition Tutorial. Available at:

http://www.csun.edu/~cjh78264/parenteral/

The Hitchhiker’s Guide to Parenteral Nutrition Management for Adult Patients.

Available at:
http://www.healthsystem.virginia.edu/internet/digestive-
health/nutritionarticles/madsenarticle.pdf

Tube feeding tutorial. Available at:

http://www.csun.edu/~cjh78264/tubefeeding/index.html