Page 432 - Nutrition Essentials for Nursing Practice

420 U N I T 3 Nutrition in Clinical Practice

KEY CONCEPTS

■ Hospital food is intended to prevent malnutrition and nutrient deficiencies, not to prevent
chronic disease. Regular diets may not be consistent with Dietary Guidelines for Americans,
which recommends limiting intakes of fat, saturated fat, cholesterol, and sodium.

■ Oral diets are classified as “regular,” consistency modified, and therapeutic.
Combination diets (e.g., a low-sodium, soft diet) are often ordered.

■ Patients with altered appetites or increased needs may benefit from supplements given with
or between meals. A variety of supplements are available (clear liquid, milk based, routine,
modified routine, puddings, and bars); they vary in nutritional composition, cost, and taste.

■ Although enteral nutrition is defined as any feeding through the gastrointestinal tract,
it is most commonly used to refer to tube feedings. Tube feedings are preferred to
parenteral nutrition whenever the gastrointestinal tract is at least partially functional,
accessible, and safe to use. Tube feedings may be delivered through transnasal tubes or
through ostomy sites into the gastrointestinal tract.

■ The choice of tube-feeding method depends on the patient’s digestive and absorptive
capacities, where the feeding is to be infused, the size of the feeding tube, the patient’s
nutritional needs, present and past medical history, and tolerance.

■ Standard tube-feeding formulas require normal digestion; they contain intact mol-
ecules of protein, carbohydrate, and fat. Intact formulas come in several varieties:
high protein, high calorie, fiber added, and disease specific.

■ Hydrolyzed formulas are made from partially or totally predigested nutrients; they are
higher in cost and osmolality; and they are used when digestion is impaired. Specially
defined formulas are available for specific metabolic disorders (e.g., renal failure,
hepatic failure).

■ Routine formulas provide 1.0 to 1.2 cal/mL; high-calorie or “plus” formulas range
from 1.5 to 2.0 cal/mL.

■ The volume of formula needed to meet RDIs for vitamins and minerals is available
from the manufacturer.

■ Most patients receiving enteral nutrition need additional free water to meet their
estimated requirements. Free water includes water used to flush the tube and bolus
infusions of water.

■ Most hydrolyzed formulas are low residue or residue free. Intact formulas range from
low-residue to fiber-enriched formulas and may help regulate bowel patterns, but study
results are conflicting.

■ Osmolality, the concentration of particles in solution, does usually not affect tolerance
in most people.

■ Policies for initiating and advancing tube feedings vary among facilities. Generally,
enteral feedings are started at full strength. Stable patients may begin an enteral feed-
ing at the goal rate; enteral feedings in critically ill patients may begin at a rate of 10
to 40 mL/hour and increase by 10 to 20 mL/hour every 8 to 12 hours as tolerated.
A suggested maximum flow rate for gastric feedings is 125 mL/hour; feedings at
140 to 160 mL/hour are usually well tolerated when infused into the intestines.

■ Continuous drip infusion with a pump is the preferred method for delivering tube feed-
ings to critically ill patients and should be used whenever feedings are infused into the
jejunum. Intermittent feedings may be preferable for long-term tube feeding and home
enteral nutrition because they more closely resemble a normal intake and allow the client
freedom between feedings. Bolus feedings into the intestine are not recommended.

■ Enteral nutrition is safe but not without the risk of various GI, metabolic, and respiratory
complications. Aspiration is one of the most serious complications of enteral feedings and
may be related to inhibited cough reflex, delayed gastric emptying, or gastroesophageal