Diet Instruction: Enteral Tube Feeding

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Bryan Grant
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1 Diet Instruction: Enteral Tube Feeding Etiology: Enteral nutrition is used when a patient is severely underweight and/or malnourished. It can only be prescribed if the patient has a fully or partially functioning gastrointestinal tract. If not, the patient must be placed on parenteral nutrition. There are three different types of feeding tubes for enteral nutrition. These include the nasogastric, gastrostomy, and jejunostomy tubes. The type of tube that a patient receives depends on if the tube will be temporary or permanent. It also depends on which part of the gastrointestinal tract is functioning. Enteral tube feedings can be safely and effectively performed at home if the patient is given instruction by a health professional ( Some health conditions that can require enteral nutrition are gastrointestinal disorders, cardiopulmonary disorders, hyper-metabolism, and neuromuscular disorders ( My patient has Dysphagia and she is placed on enteral tube feedings to ensure that she is getting her necessary daily caloric and nutrient intakes. Dysphagia is more prevalent in the elderly population ( It is usually seen as a symptom caused by a variety of disorders instead of as a disease state (Nelms ). Dysphagia is defined as any condition that weakens or damages the muscles and nerves used for swallowing ( Diseases of the nervous system such as cerebral palsy, multiple sclerosis, and Parkinson s disease can cause dysphagia ( Stroke or head injury can affect the ability of the necessary muscles for swallowing or they can reduce sensations in the individual s mouth

2 or throat. Some forms of cancer and even some treatments of cancer can cause dysphagia as well ( Diagnostic Measures: Dysphagia is first diagnosed with a clinical bedside evaluation and a bedside swallowing assessment. A healthcare team usually performs the diagnosis. The team typically consists of physicians, nurses, a speech language pathologist, a physical therapist, and an occupational therapist. The diagnosis is confirmed by performing either a videofluoroscopy swallowing study or a fiber optic endoscopic swallowing evaluation. For either diagnostic procedure, barium is added to a range of foods and beverages with differing textures. Barium can be viewed by fluoroscopy or x-ray. This makes it possible to monitor the movement of the food or beverage with barium. Barium is used to pinpoint the specific location of dysphagia. Knowing the location makes it possible for the healthcare team to establish an appropriate treatment plan (Nelms ). In Rose s case, she has been diagnosed with inadequate oral food and beverage intake related to her dysphagia. She has also been diagnosed with difficulty swallowing and malnutrition. Treatment: Medical, surgical and/or psychological treatment: The patient had a gastrostomy to insert a permanent gastric tube. The gastric tube is being used for enteral tube feedings. The patient could receive treatment from a variety of health professionals. The patient can be referred to a psychiatrist since she is going

3 through depression due to her inability to swallow and chew food. She can see a speech pathologist or an occupational therapist in order to improve her chewing and swallowing abilities. This can sometimes be attained by practicing muscle exercises to strengthen facial muscles or to improve muscle coordination ( Medical Nutrition Therapy: The medical nutrition treatment therapy for the patient with dysphagia depends on the cause and the severity. In Rose s case, her dysphagia is preventing her from receiving adequate oral intake. In order to bypass the passage of foods or beverages through the esophagus, Rose is placed on enteral tube feeding. She is placed on enteral nutrition because she had severe weight loss in the past 6 months. Enteral nutrition is chosen instead of parenteral nutrition because Rose has a functioning gastrointestinal tract. A gastrostomy was performed because Rose will need to be on long-term enteral nutrition. Gastric tube feeding will also allow for bolus feedings, which mimic a regular eating schedule (Nelms 85). Before determining Rose s enteral prescription, her fluid and electrolyte balance must be restored. Her poor skin turgor and dry skin are evidences of dehydration. Her electrolyte values are all elevated and this is common in individuals with dehydration. Her hydration status has to return to normal in order for the electrolyte level readings to be accurate. Enteral formulas are typically the primary source of water for patients so it is important to maintain an adequate fluid intake (Nelms 87). It is also recommended that the patient consumes 2 cups of water per day to make sure that she is getting enough

4 fluid. Her enteral formula has 85% free water. Rose will use Nutren 1.0 and she will give herself 5 bolus feedings a day. She will use 6 ½ cans of formula each day; this is approximately 1 can and 1/3 cup of formula per feeding. She will be instructed on the syringe method for bolus feeding at home. In order to make sure that there are no complications with enteral feeding at home, she will monitor her weight once a week, her hydration status at least 3 times a week, and her vital signs at least 3 times a week. She will have her blood glucose levels measured every 2 weeks (Nelms 91). She will be monitored closely for aspiration because her unstable mental state puts her at a higher risk of developing it. Description of patient and diagnosis: Patient name: Rose Bush DOB: 07/10/1942 Age: 72 y/o Height: 5 4 Weight: 120 lbs. Sex: Female Education: Bachelor s Degree Occupation: Retired business owner Household members: daughter age 40, son-in-law age 41, granddaughter age 10 Ethnic background: Caucasian/ white Chief Complaints

5 Patient: I am embarrassed to eat in front of my friends and family members because I take a long time to chew my food and my food does not always make it into my mouth. Sometimes I drool and I think it is impolite to do that. Patient s mother: Lately she pushes her food around on her plate more than she eats it. She is getting very thin and she seems depressed. She is very quiet during meals. Patient History Onset of disease: Rose is a 72 year old female who had a stroke 7 months ago. She has recovered from the stroke, but she had severe weight loss. In 6 months, she dropped from 145 pounds to 120 pounds (17.2% weight loss). She was admitted to the hospital for tests. Rose complained of pain while swallowing and difficulty chewing. She was diagnosed with Dysphagia and the doctor recommended a gastrostomy to insert a permanent feeding tube. Rose is recovering from the gastrostomy and she has been administered enteral tube feedings. Rose will be released from the hospital tomorrow. She will continue enteral tube feedings at home. She needs instruction from a R.D. on how to perform the tube feedings at home. Physical Exam Upon Admission General appearance: tired-looking woman, c/o fatigue and difficulty swallowing Vitals: HEENT Heart: tachycardia

6 Eyes: sunken, membranes dry Ears: membranes dry Nose: dry mucous membranes Throat: dry, inflamed Neurologic: irritable, confused Skin: poor turgor, dry skin Chest/lungs: deep, rapid respiration Biochemical Lab Values 1 day post-op Electrolyte Current Serum Level Normal Serum Level Sodium 151 meq/l meq/l Potassium 5.5 meq/l meq/l Chloride 110 meq/l meq/l Glucose 160 mg/dl mg/dl 5 days post-op Electrolyte Current Serum Level Normal Serum Level Sodium 140 meq/l meq/l Potassium 4.0 meq/l meq/l Chloride 108 meq/l meq/l Glucose 122 mg/dl mg/dl

7 Patient 24- hour recall breakfast: ½ mashed banana, 8 oz. whole milk, 1/3 c. instant oatmeal snack: 1 c. applesauce lunch: ¾ c. mashed potatoes with gravy, 16 oz. water, ½ c. creamed corn snack: skipped because her throat was very sore dinner: 3 oz. meatloaf with gravy, 8 oz. Coca-Cola, ¼ rolled biscuit snack: ½ c. pudding, 8 oz. water Enteral Nutrition Prescription Adjusted Body Weight Calculation: AdBW=.25 (120 lbs.-145 lbs.) lbs. AdBW=139 lbs. 139 lbs./2.2=63.2 kg dosing wt. =63.2 kg Mifflin-St. Jeor calculation for women: wt=63.2 kg ht= cm age=72 yrs. 10 (63.2 kg) (162.6 cm) 5 (72 yrs.) 161 1,127 kcal/day PAL=1.4 (some seated work)

8 1,127 kcal*1.4= 1,578 kcal/day Protein Goal: RDA for older adults is 1.0 g/kg so Rose needs 63 kg protein/ day 63 kg pro *4=252 kcal 252 kcal/1,580 kcal*100=16 % pro Electrolyte Needs: There are no abnormal electrolyte losses so electrolyte needs should follow the RDA for adults over 70 years old. Sodium: 1,200 mg Potassium: 4,700 mg Chloride: 1,800 mg Vitamin and Mineral Needs: DRIs for adults 70 years and older Vit. A: 700 mcg/day Vit. C: 75 mg/day Vit D: 15 mg/day Calcium: 1,200 mg/day Iron: 8 mg/day

9 Fluid Needs: Patient s hydration status has been restored 1,580 kcal* 1 ml=1,580 ml osmolality should be about 300 mosm/kg water Enteral Formula Prescription: The patient will receive 1,580 ml or Nutren 1.0 daily Nutren 1.0: 1.0 kcal/ml 16% pro 51% CHO 33% fat osmolality=370 mosm/kg water meets 100% for 20 key micronutrients Continuous Feeding: 1,580 kcal/24 hrs.=66 ml/hr. Bolus feedings 5 times/day: 1,580 ml/4=316 ml 250 ml/can of Nutren ml/250 ml=1.3 cans

10 1 can and 75 ml per bolus feeding (1.3 cans) household measurements: approx. 1 can and 1/3 cup Prognosis: If the patient s swallowing ability improves and her throat pain decreases, she will be able to switch to a diet with partial oral intake (Nelms 358). The oral intake would follow the NDD (National Dysphagia Diet) Level 1, which includes only pureed foods or smooth foods with no lumps ( The food should have a puddinglike consistency (Nelms 357). The patient will be educated by a R.D. on her modified enteral tube feedings and appropriate foods for NDD Level 1. If the patient has trouble tolerating the NDD Level 1, she will return to a full enteral tube feeding diet.

11 (Educational Materials) At-Home Gastric Tube Feeding Overview *Patient will decide times for feedings; feedings should be at least 2-3 hours apart Your Formula: Nutren 1.0 Cans per day: 6 ½ Amount per feeding: 1 can and 1/3 c. Your feeding schedule: 5 bolus feedings daily (at least 15 min. per feeding) Times AM AM AM/PM PM PM Amount of formula 1 can and 1/3 cup 1 can and 1/3 cup 1 can and 1/3 cup 1 can and 1/3 cup 1 can and 1/3 cup Wash your hands thoroughly with soap and water then gather supplies: formula syringes lukewarm water (1 cup) feeding bag (if using) feeding pump (if using) Things to remember: You must flush the tube before and after administration of formula or medications. if the tube becomes clogged, take immediate action to unclog it. Store unopened cans of formula at room temperature. When a can is opened, use immediately. Date and refrigerate the unused portion, but it must be thrown away if it is not used within 24 hours. Syringes need to be cleaned with warm, soapy water and left to air dry between each use.

12 Bolus Feeding: Syringe Method 1. Draw up 60 ml of warm water in the syringe. Gently flush the water through the tube to make sure the feeding tube is clean and open. Disconnect the syringe. Recap the end of the feeding tube. 2. Remove the plunger from the syringe. 3. Uncap the feeding tube. 4. Attach the syringe directly to your feeding tube. Pour 1 can and 1/3 cup of feeding into the syringe, allowing it to flow freely until all of the feeding is given. 5. Take the syringe and draw up 60 ml warm water. Gently flush the water through the tube again to make sure the tube is clean and open. This water also helps keep you hydrated. 6. Disconnect the syringe from the feeding tube. 7. Recap the feeding tube. 6. Repeat the procedure 4 more times. If you do not tolerate the prescribed amount of formula, notify your dietitian. Helpful Resources: American Society for Parenteral and Enteral Nutrition (ASPEN) Nestle Health Science: Medicare Coverage of Enteral Nutrition Therapy

13 References Academy of Nutrition and Dietetics. (2014). Nutrition Care Manual. Retrieved from American Gastroenterological Association. (1995). American gastroenterological position statement: guidelines for the use of enteral nutrition. Retrieved from American Society for Parenteral and Enteral Nutrition. (2013). What is enteral nutrition? Retrieved from Cleveland Clinic. (n.d.). Tube-feeding instructions for home. Retrieved from Dietary Manager. (2004).Understanding and implementing dysphagia diets. Association of Nutrition & Foodservice Professionals. Retrieved from Fletcher, J. (2011). Nutrition: safe practice in adult enteral tube feeding. British Journal Of Nursing, 20(19), Retrieved from Lloyd, D. & Powell-Tuck, J. (2004). Artificial nutrition: Principles and practices of enteral feeding. Clinics in Colon and Rectal Surgery, 17(2), doi: /s National Institutes of Health. (2010). Dysphagia. National Institute on Deafness and Other Communication Disorders. Retrieved from Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy & pathophysiology 2/e. Belmont, CA: Wadsworth, Cengage Learning. Nestle Health Science. (2013). Best practices in enteral feeding safety. Retrieved from

Amanda Hernandez FND October 17, 2011 Enteral Feeding Case Study

Amanda Hernandez FND October 17, 2011 Enteral Feeding Case Study Amanda Hernandez FND 430-001 October 17, 2011 Enteral Feeding Case Study 1. Nutritional Assessment to determine energy and protein needs Percent Usual Body Weight [(current body weight/usual body weight)