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PATIENT CARE PROCESS

Patient Care Process for the Use of Enteral Nutrition

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Collect

  • Patient characteristics (e.g., age, race, sex)

  • Patient history (past medical, surgical, family, social—alcohol use)

  • Nutrition history (dietary history, weight history, dietary intolerance, prior enteral or parenteral nutrition therapy)

  • Procedures related to enteral access placement

  • Current medications (including nutritional supplements)

  • Objective data

    • Height, weight, BMI

    • Fluid balance (intake and output)

    • Labs (e.g., serum electrolytes, Scr, BUN, glucose, albumin)

    • Other diagnostic tests when indicated (e.g., gastric emptying study, swallow study)

Assess*

  • Appropriate time to initiate enteral nutrition

  • Presence of altered GI anatomy or function (e.g., bariatric surgery, delayed gastric emptying, pancreatic insufficiency)

  • Nutritional status and risk of refeeding syndrome (e.g., unintentional weight loss, prolonged time period with poor nutritional intake, BMI <18, low visceral proteins, muscle wasting; see Tables 141-2, 141-5, 141-7)

  • Nutrition requirements (goal protein, calories, fluid, and micronutrient intake; see Tables 141-9, 141-10, 141-14)

  • Appropriate enteral access (see Table 143-3)

Plan*

  • Enteral nutrition regimen including specific enteral feeding formulation, method of administration (continuous, bolus), and initiation and advancement guidelines (see Tables 143-5 and 143-6)

  • Monitoring parameters for efficacy (weight, growth in children, enteral intake), GI tolerance (gastric residual volumes, stool output, nausea, vomiting, abdominal distention), and metabolic complications (serum electrolytes, Scr, BUN, glucose, LFTs; see Table 143-7)

Implement*

  • Initiate enteral nutrition when the oral route fails or is not possible, the GI tract is functional, and enteral access can be safely achieved

  • Patient education when home enteral nutrition is indicated

Follow-up: Monitor and Evaluate*

  • Determine nutrition goal attainment

  • Provide adjustments to the enteral nutrition regimen when nutrition goals are not achieved and consider transition to parenteral nutrition if repeated adjustments fail or intolerance develops

  • Transition off enteral nutrition when nutrition needs are safely met by oral dietary intake

  • Presence of adverse effects and GI intolerance

  • Plan for transitioning off enteral nutrition

*Collaborate with patient, caregivers, and other health professionals

KEY CONCEPTS

KEY CONCEPTS

  • Image not available. The gastrointestinal (GI) tract defends the host from toxins and antigens by both immunologic and nonimmunologic mechanisms, collectively referred to as the gut barrier function. Whenever possible, enteral nutrition (EN) is preferred over parenteral nutrition (PN) because it is associated with a lower risk of metabolic and infectious complications and is less expensive and invasive.

  • Image not available. Candidates for EN are those with a sufficiently functioning GI tract to allow adequate nutrient absorption who cannot or will not eat and in whom enteral access can be safely obtained.

  • Image not available. The most common route for both short- and long-term EN access is directly into the stomach. The method of delivery may be continuously via an infusion pump, intermittently via a pump or gravity drip, or bolus administration via gravity or syringe.

  • Image not available. Patients unable to tolerate tube feeding into the stomach because of impaired gastric motility may benefit from feeding tube placement into the duodenum or jejunum. When feeding into the small bowel, the continuous method of delivery ...

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