ENTERAL NUTRITION.pptx

Enteral nutrition in geriatric

1. ENTERAL NUTRITION Submitted by: Rabbia Shahid Roll no 2221008 MS HND 2 nd Submitted to: Mam Zunaira

2. Contents Enteral Nutrition Indication and feeding routes Enteral formula and types Formula selection Energy and nutrient requirement Water requirement Drug delivery Other factors effecting tube feeding Case study

3. Enteral Nutrition “The provision of nutrients using the gastrointestinal (GI) tract, the term more often refers to the use of tube feedings, which supply nutrients directly to the stomach or intestine through thin, flexible tube to individuals who are unable to eat or do not eat enough.” In observational study on Medicare beneficiaries 65 and older people, it has been seen 35%–65% hospitalized patients and 15% in ambulatory outpatients, with gastrostomies have percutaneous endoscopic gastrostomy (PEG) tube placements (Mandi MS et al., 2018)

4. Indication for Tube Feeding Neurological Disorders Coma patients , Motor neuron disorder, Dementia, Multiple sclerosis, Parkinson’s disease Unable to Meet Nutritional demands Cystic fibrosis, Extensive burns, cancer Decreased Desire to Eat Severe depression, Chronic medical illnesses Post chemotherapy/radiation Unable to Eat GI obstruction, Severe swallowing disorder, Intestinal failure, Certain types of intestinal surgeries, Ventilated patients, Trauma Contraindications for Tube Feedings Severe GI bleeding, High-output fistulas, Intractable vomiting or diarrhea, Complete intestinal obstruction, and Severe malabsorption

5. Feeding Routes Two types of tube feeding route: Trans-nasal (through-the-nose). When a patient is expected to be tube-fed for less than four weeks Enterostomy (opening to stomach and jejunum). When a patient will be tube fed for longer than four weeks or if the naso -enteric route is inaccessible due to an obstruction or other medical reasons

6. Types of Trans-nasal Route Nasogastric (NG): tube is placed into the stomach via the nose. Nasoenteric: tube is placed into the GI tract via the nose. Nasoduodenal (ND): tube is placed into the duodenum via the nose. Nasojejunal (NJ): tube is placed into the jejunum via the nose. Orogastric: tube is placed into the stomach via the mouth.

7. Types of Enterostomy Gastrostomy: an opening into the stomach through which a feeding tube can be passed. A nonsurgical technique for creating a gastrostomy under local anesthesia is called percutaneous endoscopic gastrostomy (PEG). Jejunostomy: an opening in the jejunum through which a feeding tube can be passed. A nonsurgical technique for creating a jejunostomy is called percutaneous endoscopic jejunostomy (PEJ).

8. Enteral Formulas Most formulas can supply all of an individual’s nutrient requirements when consumed in sufficient volume Use as dietary supplements by people who have trouble meeting nutritional needs Use as replacement of conventional food by healthy people The products are available in ready-to-drink liquid form or in powdered forms

9. Types of Enteral Formula Standard Formulas Also called polymeric formulas, are provided to those who can digest and absorb nutrients without difficulty. They contain intact proteins or a combination of protein isolates The carbohydrate sources are modified starches, glucose polymers and sugars. Elemental Formulas Also called hydrolyzed, chemically defined, or monomeric formula for compromised digestive or absorptive functions. They contain partially or fully broken down proteins and carbohydrates. Low in fat and may contain MCT. Specialized Formulas Also called disease-specific formulas, are designed to meet the specific nutrient needs of patients with particular illnesses like liver, kidney, and lung diseases, glucose intolerance and metabolic stress. Modular Formulas Created from individual macronutrient preparations called modules, are prepared for patients who require specific nutrient combinations to treat their illnesses and can meet all of a person’s nutrient needs.

10. FORMULA SELECTION AND NUTRIENT REQUIREMENT

11. Nutrient and Energy Needs Protein content of a formula should be between 12 and 20% of the total calories (can alter according to condition). Elderly patients protein requirement may go up to 1.2 to 1.5g/kg/day. Carbohydrate and fat provide most of the energy in enteral formulas; standard formulas generally provide 40 to 60% of kcalories from carbohydrate and 25 to 40% of kcalories from fat The energy density of enteral formulas ranges from 0.5 to 2.0 kcalories per milliliter of fluid. Formulas that have higher energy densities can benefit patients who have high nutrient needs or fluid restrictions. Individuals with high fluid needs can be given a formula with low energy density

12. Fiber and Osmolarity Fiber -containing formulas can be helpful for normalizing intestinal function, treating diarrhea or constipation, and maintaining blood glucose Osmolarities of most enteral formulas are between 300 and 700 milliosmoles per kilogram Hydrolyzed formulas and nutrient-dense formulas have higher osmolarities than standard formulas

13. Calculating Enteral Feeding Requirements Proteins Maintenance: 1.2–1.5 g/kg/day Stress: 1.5–2.0 g/kg/day Calories Maintenance: 25–30 kcal/kg/day Stress: 30–40 kcal/kg/day Sepsis: 40–50 kcal/kg/day Free water: 30–35 ml/kg/day

14. Water Requirements Fluids may be restricted in persons with kidney, liver, or heart disease. Additional water is required in patients with fever, high urine output, diarrhea, excessive sweating, severe vomiting, fistula drainage, blood loss, or open wounds. Thirst is often a good indicator of water needs but in the elderly, thirst may be slow to develop in response to dehydration. Routinely monitor patients’ weight changes, fluid intake and output, and measure urine specific gravity to evaluate hydration status.

15. Estimate fluid requirements Estimation of fluid intake include Water in formula Water used for flushing and medication Routine Flushes To prevent clogging, 20 to 30 milliliters of warm water before and after each feeding and about every 4 hours when feedings are continued throughout the day . Adults 30 to 40 mL/kg Older adults 25 to 30 mL/kg Children 50 to 60 mL/kg Infants 100 to 150 mL/kg

16. Drug delivery through feeding tube Medications can interact with enteral formula. Some medication can cause feeding tubes to clog like Augmentin Diarrhea is especially associated with the administration of Liquid medications sorbitol, laxatives and some types of antibiotics thus should be diluted with 30 cc of water to decrease the osmolality. Long-acting medications should not be crushed can lead to side effects.

17. Medications and Continuous Feedings Continuous feedings is typically halted for 15 minutes before and 15 minutes after medication delivery to prevent drug nutrient interaction. Some medications may require a longer formula-free interval, during phenytoin administration, feedings need to be stopped for 1 to 2 hours before and after administration In such cases, the formula’s delivery rate needs to be increased so that the correct amount of formula can be delivered.

18. Transition to Table Foods Volume of formula can be tapered off as the patient gradually shifts to an oral diet. The steps in the transition depend on the patient’s medical condition and the type of feeding the patient is receiving. Individuals using continuous feedings are often switched to intermittent feedings initially. Patients receiving elemental formulas may begin the transition by using a standard formula, either orally or via tube feeding. Oral intake should supply about two-thirds of estimated nutrient needs before the tube feeding is discontinued completely

19. Complication Complications Causes Aspiration Compromised lower esophageal sphincter, delayed gastric emptying Clogged feeding tube Formula too thick for tube, Medication given through feeding tube Constipation Low-fiber formula, Lack of exercise Dehydration and electrolyte imbalance Excessive diarrhea, Inadequate fluid intake Carbohydrate intolerance, Excessive protein intake Diarrhea, cramps, abdominal distention Bacterial contamination, Lactose intolerance Hypertonic formula, Rapid formula administration Skin irritation at enterostomy site Leakage of GI secretions and friction cause by tube Nausea and vomiting Obstruction, Delayed gastric emptying, Psychological reaction to tube feeding, Intolerance to concentration or volume

20. Factors Effecting Enteral Nutrition Decision-making capacity Surrogate decision maker. Forty-five percent of surrogate decision makers stated that no alternative was offered , and 2% were offered spoon feeding Religion Jewish law states that life-sustaining treatment can be withheld if the person dying is suffering or the treatment would produce suffering Islam suggests that if enteral nutrition prolongs life, it should be done, and if it hastens death, it is not recommended Cost of enteral nutrition in a nursing home

21. Mortality Rate According to one study, the mortality of patients with PEG for 7 days is 48% and risk factors included aspiration, UTI The risk of mortality increase 4% elder people specially people more than 75 years old.

22. CASE STUDY OF STROKE PATIENT

23. Demographic data Name: Mr. Khan Gender: Male Age: 65 years old Height: 72” Weight: 71.2 kg BMI: 21.29kg/m2 Years education: 11 Language: English only Occupation: Unemployed

24. Medical History: Diabetes HTN (hypertension) GERD Current Problem: Protein calorie Malnutrition Hemorrhagic stroke leading to paralysis

25. Vital signs Temperature 100°F Pulse rate 120 bpm Respiratory rate 120 bpm Respiratory rate 140/93 mmHg SpO2 140/93 mmHg

26. Medical Nutrition Therapy Mr. khan is currently paralyzed thus the ENTERAL FEEDING is used Early Enteral feeding start within 24 to 48 hours after hospitalization because: Hypertonia response Decrease the release of catecholamine (that cause high glucose level, blood pressure, heart rate)

27. Energy and Water Requirement : Energy requirement is more than normal person because body is in stress 30kcal/kg of body weight/day 30 x 71.2 = 2136 kcal Water requirement 28mL /kg of body weight 28 x 71.2 = 1993mL approx. 2000mL or 2L

28. Energy sources: Carbohydrate is main source of fuel but for diabetic patient given not more than 5g/kg/day Carbs = 4 × 71.2 = 286g Protein helps in healing process and rebuilding of tissues. Patient body is in stress thus given 1.5 to 2g/kg of body weight Protein= 1.8 × 71.2 = 128g Lipids in limit amount 20% to 35% from nonprotein because high fat increases the risk of diarrhea and suppress immunity

29. Route of Feeding: The nasogastric (NG) route or percutaneous endoscopic gastrostomy (PEG) is used Good for patient who are in stress It reduces the risk of aspiration Mr. joe has GERD this route is good for feeding

30. Type of Formula: Moderate in protein Low in carbs Modified MUFAs Have fiber Example: Glucerna

31. How to determine the formula volume Glucerna is used: Energy required = 2136kcl Volume = total energy requirement ÷ energy given in standard formula = 2136kcal ÷ 1kcl/ml = 2136ml = 2136 / 1000 = 2.136L approx. 2.14L In 2.14L; Protein = 42g/L × 2.14L = 90g Carbs = 102g/L × 2.14L = 218g Fat = 38g/L × 2.14L = 81g Volume mL Energy kcal/ml Protein g/L Carbs g/L Fat g/L Fiber 1420 1.00 42 102 38 14g/L

32. Calories: Protein = 90g × 4kcal/g = 360kcal Carbs = 218g × 4kcal/g = 872kcal Fat = 81g × 9g/kcal = 729kcal Percentage: Protein = 360kcal / 2136kcal × 100 = 17% Carbs = 872kcal / 2136kcal × 100 = 45% Fat = 729kcal / 2136kcal × 100 = 35%

33. Medication and Supplementation Given through tube feeding with proper guidance Vitamin C: 500 mg every 12 hours Vitamin D: 400 IU per 1000 calories Calcium supplement to treat hypocalcemia Supplement of phosphorus and magnesium is given by IV Niacin (B3): 20 to 25 mg/day B12: 2.4 micrograms