Patient Care and Monitoring

1. Assess the patient's condition to estimate the amount of time he or she is expected to be unable to eat adequately to meet nutritional requirements. If inadequate intake has occurred or is anticipated for 7 to 14 days, start SNS. The threshold for starting SNS is lower for previously malnourished patients than for previously well-nourished patients. Also, critically ill patients should generally be started on EN within 24 to 48 hours of ICU admission.

2. Assess whether the GI tract is functional. If not, then PN is the first SNS therapy of choice. If the GI tract is functional and no contraindication to EN exists, then EN is the SNS therapy of choice.

3. Does the patient have any condition precluding gastric feeding? If so, then postpyloric feeding should be started.

4. Choose the appropriate type of enteral access device based on the expected duration of SNS.

5. Choose an appropriate feeding formula based on patient-specific factors. This necessitates assessing nutritional requirements. Standard polymeric formulas are appropriate for the majority of patients.

6. Choose the method of feeding administration (e.g., intermittent or continuous) based on the type of feeding access (i.e., gastric versus postpyloric) and other patient factors. For example, in a patient with a gastric access, starting with or later transitioning to intermittent feedings may be preferred if it is anticipated that the patient still receiving these feedings will be discharged to a long-term care facility or to home.

7. Develop a plan to include monitoring at appropriate intervals for metabolic, GI, technical, and infectious complications.

8. Start the tube feeding at full strength and at a low rate, and increase the rate as tolerated to the goal that will meet the patient's nutritional requirements.

9. Develop a monitoring plan for adequacy of the nutritional regimen.

10. If the patient is to be discharged to home on EN, educate the patient or caregiver on

• Enteral access device care

• Feeding delivery

• Troubleshooting

• Complications to observe for (e.g., fluid overload, dehydration) Abbreviations Introduced in This Chapter

ARDS Acute respiratory J i sire sä syndrome

A;S.RE,Nf American Society for Parenteral anil Enteral Nutrition

BCAA Branched-chain amino acids

BUN Blood urea nitrogen

CRP C-reaciive protein

DHA Docosahexenoic acid

EAAs Essential amino adds

EFAs Essential fatty acids

EN Enteral nutrition

EPA Eicosapenlaenoic acid

ESPEN European Society for Clinical Nutrition and

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