Routes of nutrition

support

Oral diets
Normal diets are intended to maintain health by meeting the RDA for clients age & sex
No foods are excluded & portion sizes are not restricted on a normal diet

Modified diets- used for clients who are unable to tolerate a normal diet or who have altered
nutritional requirements
Differ from normal diets in their consistency, total calorie content, concentration of macronutrients, or
concentration of one or more micronutrients

Combinations of diet modifications- necessary to meet clients needs; should be

individualized to ensure optimal tolerance & compliance
Oral intake resumed after acute illness, surgery, tube feedings, or TPN- clear liquids
progressing to full liquidssoft dietnormal or modified diet ( depending on clients
tolerance & condition, this routine progression may be accelerated by eliminating one/more
of the transitional diets)
Clients unable or unwilling to eat enough food to meet at least 2/3 of their of their protein &
calorie requirements may be given nourishment orally or through a tube to supplement
intake

Enteral nutrition
supplying nutrients (liquid) using GI tract, including tube
feedings & oral diets
Purposes:
used as a supplement to an oral diet or may provide nutrition to clients
who are unable to consume food orally
easier, safer, better tolerated, & less expensive than parenteral nutrition
should be used whenever GIT is functional
has an advantage of stimulating the GIT because it helps maintain
normal enzyme activity & gut mucosal integritynutrients used better
helps maintain normal immune function by increasing IgA which
prevents absorption of enteric antigens

Oral supplements
- plain or fortified milk, milk shakes, instant breakfast, &
eggnogs are high protein, high calorie homemade oral
supplements that are palatable, relatively inexpensive,
& suitable for boosting the protein & calorie intake of
clients who are unable to meet their nutritional
requirements through food alone.

Modular products
incomplete formulas that supply a single nutrient, either
CHO, CHON, or fat

Tube feedings
often used as a transition between parenteral nutrition & an
oral diet

useful for variety of clinical conditions & are

contraindicated when the GIT is nonfunctional- gastric
or intestinal obstruction, paralytic ileus, intractable
vomiting, & severe diarrhea

Conditions That Require Other

Nutrition Support
Enteral
Impaired ingestion
Inability to consume adequate nutrition orally
Impaired digestion, absorption, metabolism
Severe wasting or depressed growth

Parenteral
Gastrointestinal incompetency
Hypermetabolic state with poor enteral tolerance
or accessibility

Conditions That Often Require Nutritional

Support

Conditions That Often Require Nutritional

Support contd

Conditions That Often Require Nutritional

Support contd

Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimally

invasive access to the gastrointestinal tract. In Rombeau JL,
Rolandelli RH, editors: Clinical nutrition: enteral and tube
feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:
Nutritional support services, Nutritional Support Algorithms,
8(7):13, July 1998.

Contraindications for EN
Severe acute pancreatitis
High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
Expected need less than 5-7 days if
malnourished or 7-9 days if normally
nourished

ASPEN. The science and practice of nutrition support. A case-based core

Contraindications for EN

Inadequate resuscitation or
hypotension; hemodynamic
instability
Ileus
Intestinal obstruction
Severe G.I. Bleed

Feeding tube placement

TRANSNASAL TUBES OR NASOGASTRIC- most common; used
for feedings of relatively short duration
OSTOMIES OR STOMAS- surgically created openings made to
deliver feedings directly into the stomach or intestines;
preferred method for permanent or long-term feedings
because they eliminate irritation to the mucous membranes

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE

FEEDINGS- placed nonsurgically with the aid of an
endoscope

Transnasal tubes
inserted nonsurgically through the nose & extended into
either the stomach, duodenum, or jejunum
client can participate actively in the procedure by swallowing
small sips of water as the tube is passedminimize discomfort
& speed its passage
have potential to irritate the nose & esophagus if used fro
prolonged periods or if the tube is too large

uncooperative clients- are able to withdraw transnasal

tubes

Nasogastric Tubes

Nasogastric Tubes
Definition
A tube inserted through the nasal
passage into the stomach
Indications:
Short term feedings required
Intact gag reflex
Gastric function not compromised
Low risk for aspiration

French UnitsTube Size

Diameter of feeding tube is measured in
French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types and
administration techniques
Generally smaller tubes are more comfortable
and better suited to NG or NJ feedings
May be more likely to clog with viscous
formula or formula mixtures

Nasogastric Tubes
Advantages:
Ease of tube placement
Surgery not required
Easy to check gastric residuals
Accommodates various administration
techniques

Nasogastric Tubes
Disadvantages:
Increases risk of aspiration (maybe)
Not suitable for patients with
compromised gastric function
May promote nasal necrosis and
esophagitis
Impacts patient quality of life

Nasoduodenal/Jejunal
Definition
A tube inserted through the nasal
passage through the stomach into the
duodenum or jejunum
Indications:
High risk of aspiration
Gastric function compromised

Nasoduodenal/Jejunal
Advantages:
Allows for initiation of early enteral
feeding
May decrease risk of aspiration
Surgery not required

Nasoduodenal/Jejunal
Disadvantages:
Transpyloric tube placement may be
difficult
Limited to continuous infusion
May promote nasal necrosis and
esophagitis
Impacts patient quality of life

Orogastric
Tube is placed through mouth and
into stomach
Often used in premature and small
infants as they are nasal breathers
Not tolerated by alert patients;
tubes may be damaged by teeth

Tube enterostomy
ostomy tubes are inserted through a surgical opening in
the stomach, esophagus, or jejunum, usually under
general anesthesia
more successful in long-term use & more acceptable to
the client because they are hidden under clothing

ESOPHAGOSTOMY
a surgical opening made in the esophagus through
which a feeding tube is passed into the stomach
commonly used for clients with head & neck cancer
generally well tolerated because the stomach is used to hold
& release food at a controlled rate- prevents dumping
syndrome

risk or aspiration is high & danger of hemorrhagic injury

to the thoracic duct exists

rostomynosotomy

Enterostomy Placement
Gastrostomy
Jejunostomy

Gastrostomy
Definition
A feeding tube that passes into the stomach
through the abdominal wall. May be placed
surgically or endoscopically
Indications:
Long-term support planned
Gastric function not compromised
Intact gag reflex present

Gastrostomy
Disadvantages:
May require surgery
Stoma care required
Potential problems for leakage or tube
dislodgment

Gastrostomy

Jejunostomy
Definition
A feeding tube that passes into the
jejunum through the abdominal wall.
May be placed endoscopically or
surgically
Indications:
Long-term feeding option for patients at
high risk for aspiration or with
compromised gastric function

Jejunostomy
Advantages:
Post-op feedings may be initiated
immediately
Decreased risk of aspiration
Suitable option for patients with
compromised gastric function
Stable patients can tolerate intermittent
feedings

Jejunostomy
Disadvantages:
Requires stoma care
Potential problems related to leakage or
tube dislodgement/clogging may arise
May restrict ambulation
Bolus feedings inappropriate (stable
patients may tolerate intermittent
feedings)

Determining Method of
Administration
Feeding site
Clinical status of patient
Type of formula used
Availability of pump
Mobility of patient

Administration
Bolus
Intermittent
Continuous
Cyclic

Bolus Feedings
Definition
Infusion of up to 500 ml of enteral formula into
the stomach over 5 to 20 minutes, usually by
gravity or with a large-bore syringe
Indications:
Recommended for gastric feedings
Requires intact gag reflex
Normal gastric function

Bolus Feedings
Advantages:
More physiologic
Enteral pump not required
Inexpensive and easy administration
Limits feeding time so patient is free to ambulate,
participate in rehabilitation, or live a more normal life
in the home
Makes it more likely patient will receive full amount of
formula

Bolus
Feeding

Bolus Feeding
Disadvantages:
Increases risk for aspiration
Hypertonic, high fat, or high fiber
formulas may delay gastric emptying or
result in osmotic diarrhea

Continuous Feedings
Indications:
Initiation of feedings in acutely ill
patients
Promote tolerance
Compromised gastric function
Feeding into small bowel
Intolerance to other feeding techniques

Continuous Feedings
Definition
Enteral formula administration into the
gastrointestinal tract via pump or gravity,
usually over 16 to 24 hours per day
Advantages:
May improve tolerance
May reduce risk of aspiration
Increased time for nutrient absorption

Continuous Feedings
Disadvantages:
May reduce 24-hour infusion
May restrict ambulation
More expensive for home support
Pumps are more accurate; useful for
small-bore tubes and viscous feedings,
but many payers have strict criteria for
approval of pumps for home or LTC use

Intermittent Feedings
Definition
Enteral formula administered at specified times throughout the
day; generally in smaller volume and at slower rate than a
bolus feeding but in larger volume and faster rate than
continuous drip feeding
Typically 200-300 ml is given over 30-60 minutes q 4-6 hours
Precede and follow with 30-ml flush of tap water
Indications:
Intolerance to bolus administration
Initiation of support without pump
Preparation of patient for rehab services or discharge to home
or LTC facility
The A.S.P.E.N. Nutrition Support Practice Manual, 2 nd
Edition, 2005

Intermittent Feedings
Advantages:
May enhance quality of life
Allows greater mobility between
feedings
More physiologic
May be better tolerated than bolus

Intermittent Feedings
Disadvantages:
Increased risk for aspiration
Gastric distention
Delayed gastric emptying

Cyclic Feedings
Definition
Administration of enteral formula via continuous drip over a
defined period of 8 to 12 hours, usually nocturnally
Indications:
Ensure optimal nutrient intake when:
Transitioning from enteral support to oral nutrition (enhance
appetite during the day)
Supplement inadequate oral intake
Free patient from enteral feedings during the day

Cyclic Feedings
Advantages:
Achieve nutrient goals with
supplementation
Facilitates transition of support to oral
diet
Allows daytime ambulation
Encourages patient to eat normal meals
and snacks

Cyclic Feedings
Disadvantages:
May require high infusion ratesmay
promote intolerance

Enteral Feeding Containers

May be rigid or flexible
Sterile or non-sterile
Unbreakable, leakproof,
and disposable

Considerations in Choosing Enteral

Feeding Containers
Easy to fill, close and hang
Easy to read calibrations and directions
Appropriate size
Adaptable tubing port
Compatible with pump
Requires minimal storage space

Adapted from ASPEN. The science and practice of nutrition

support. A case-based core curriculum. 2001; 179

Closed Systems

Enteral Feeding Pumps

Administration
before initiating a feeding, tube placement must be verified preferably by
x-ray & bowel sounds must be present

Fluid restriction is required- tube feedings can be

started at 30 ml/hr
Feedings should be at room temperature
To help ensure tube patency, intermittent & bolus feedings should be
followed by an infusion of 40-50 ml warm water & continuous feeding tubes
should be irrigated every shift with 40-50 ml of warm water

likewise, every time the feeding is interrupted, tube

should be flushed with water
Medications- can become therapeutically ineffective if
added directly to the enteral formula
Administer drug in a single bolus through the enteral
tube making sure tube is flushed with water before &
after the drug is administered
If more than one drug is given- tube should be

Reduce risk of bacterial

contamination
1. closed feeding systems are recommended
2. changing the extension tubing & bag daily
3. refrigerating prepared formulas until they are
needed
4. never adding a new supply of formula to old formula
5. hanging feeding solutions for less than 6 hours

Prevent aspiration
1. head of bed should be elevated at least 45 degrees during the
feeding & for 30-45 minutes afterward
2. feedings should be held if gastric residuals are greater than
100 ml
3. aspirate should be replaced to reduce the loss of electrolytes &
gastric juices
4. better approach for testing pulmonary secretions is to use a
glucose dipstick- unless they are bloody, pulmonary secretions
normally do not contain glucose, whereas enteral formulas do

Transition to oral diet

To begin transition process- tube feeding should be stopped
for 1 hour before each meal
Gradually increase meal frequency until 6 small oral feedings
are accepted
Actual intake- recorded & evaluated daily
When oral calorie intake is consistently 500-750 calories/daytube feedings may be given only during the night

When client consistently consumes 2/3 of CHON &

calorie needs orally for 3-5 days- tube may be totally
discontinued