Enteral Nutrition
Implement
Page Contents
Interdisciplinary Team
There are many healthcare professionals involved in the interdisciplinary team. Depending on the patients medical plan and condition, there may be other team members involved. However, the list below represents a usual inpatient team. Their roles are discussed as it pertains to enteral nutrition.
- Registered Dietitian: primarily responsible for enteral nutrition, transition to oral diet.
- Speech Language Pathologist (SLP): assess safety of oral diet & texture recommendation.
- Pharmacist (RPh): drug and nutrient interactions, medication dosing/ indications.
- Registered Nurse (RN): implement nutrition care plan, provide clinical information.
- Physiotherapist (PT): ambulation, positioning, assist with obtaining weights.
- Occupational therapist (OT): cognitive assessment to determine if patient can provide accurate information, modified eating equipment, positioning.
- Medical Doctor (MD) or Nurse Practitioner (NP): medical update, enter orders for IVF, labs, imaging, medications, consults.
- Social Worker (SW): provide counselling, disposition planning and identify sources of emotional support for patients and their families.
Liaising With Carson’s Team
In Carson’s case, you will want to liaise with:
- The SLP regarding Carson’s dysphagia. Often, the RD will wait for an SLP assessment to determine the safest diet texture before optimizing the patient’s diet for nutritional adequacy. If the SLP recommends a patient be NPO, the RD will implement enteral feeding orders.
- The MD and/or NP regarding enteral nutrition for Carson. Provide an update on your nutrition care plan including refeeding risk, enteral regime, water flushes, and request the addition of a multivitamin and thiamine as well as daily bloodwork. The MD/NP may need to enter some or all of your orders depending on your institution’s medical directives.
- The bedside RN, once you have finalized your nutrition care plan and the orders have been entered. The RN will be implementing Carson’s regime.
- Other team members throughout Carson’s stay depending on what his needs are. For example:
- The SW for discharge planning/ support/ resources for enteral feeding at home
- The PT for an updated weight
- The OT for modified feeding utensils
Monitoring Enteral Feeds
During implementation of the enteral feeding plan, consider monitoring:
- GI tolerance: nausea, vomiting, bowel movements (odour, colour, frequency, consistency), abdominal cramping/distension, reflux, fistula/ostomy output.
- Bloodwork: electrolytes, renal profile, calcium profile, liver function tests (LFTs), amylase, blood glucose, complete blood count (CBC), lactate, arterial blood gases (if applicable).
- Weight: bi-weekly weight measurements are common for assessment of dietary strategies (or more/less frequently as indicated).
- Daily intake and output: fluid balance, actual volume of feed received.
- Medications: assess drug-nutrient interactions, add supplements if indicated, adjust insulin if needed.
Reassess based on changes in tolerance or medical condition.
Enteral Nutrition Complications
The tables below outline potential gastrointestinal, metabolic, and mechanical complications associated with enteral nutrition.
| Gastrointestinal Problem | Possible Causes | Treatment |
|---|---|---|
| Nausea / Vomiting |
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| Malabsorption (unexplained weight loss, steatorrhea, diarrhea) |
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| Abdominal Distension |
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| Constipation |
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| Metabolic Problem | Possible Causes | Treatment |
|---|---|---|
| Hypertonic Dehydration |
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| Overhydration |
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| Hypokalemia |
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| Hyperkalemia |
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| Hyponatremia |
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| Hypernatremia |
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| Hypophosphatemia |
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| Hyperphosphatemia |
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| Hyperglycemia |
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| Hypoglycemia |
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| Hypercapnia |
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| Mechanical Problem | Possible Causes | Treatment |
|---|---|---|
| Incorrect tube placement |
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| Tube blockage |
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| Irritation from tube |
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| Aspiration |
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Monitoring for Refeeding Syndrome
Below is important information to know for patients who are at risk of refeeding syndrome. Having awareness of what symptoms to watch for, knowing when symptoms occur, and what to do can allow you to optimize your patient’s nutritional status as safely as possible.
- Symptoms of refeeding syndrome most often occur within 1-3 days after initiating feeding, but may occur up to 5 days following initiation of feeding.
- Closely monitor your patient’s heart rate and fluid intake/output for changes that happen with initiation of feeding.
- Hypophosphatemia is a classic first sign associated with refeeding syndrome.
- Monitor electrolytes daily (K, PO4, Mg) for a minimum of 3 days – if your patient is at high risk of refeeding syndrome or shows signs of refeeding syndrome, monitor electrolytes for up to 1 week. Correct abnormalities concurrently with feeding and prior to advancing feeds.
- Advance feeding as soon as is safely possible to avoid hypocaloric feeding for prolonged period (advancement of 200-300 kcal every 1-3 days recommended).
Education
Carson’s Education
Carson is asking to speak to the dietitian to understand why he is not receiving meals like his roommate. He complains of being hungry and doesn’t remember why he had a tube inserted in his stomach.
The dietitian will need to use simple language to describe the indications for EN and how EN is administered via his G-tube. The dietitian should explain possible side effects and complications, but also be able to reassure Carson with evidence that this is the best treatment plan for him at this time.
- Think about the possible side effects and complications with EN.
- List 3 benefits of EN that you could share with Carson.
- Create a plain-language explanation of EN to share with Carson.
Pause and answer these questions using the information provided to you so far.
PART 3: IMPLEMENT COMPLETE. Pause to reflect on the implementation strategies discussed. When you’re ready, move on to Part 4: Evaluation.
