Chapter 14

Hospital Nutrition: Defining
Nutrition Risk and Feeding

Patients
Chapter 14
Feeding Patients: Hospital Food and
Enteral and Parenteral Nutrition
• The prevalence of malnutrition among hospitalized
adults is estimated at 30% to 50%, depending on the
patient population and how malnutrition is defined
(Mueller et al., 2011).
• Starvation related
• Chronic disease related
• Acute disease or injury related
Copyright © 2018 Wolters Kluwer · All Rights Reserved

Enteral and Parenteral Nutrition—(cont.)
• Hospital food may be refused because

– It is unfamiliar
– Tasteless (e.g., cooked without salt)
– Inappropriate in texture (e.g., pureed meat)
– Religiously or culturally unacceptable
– Served at times when the patient is unaccustomed to eating

Enteral and Parenteral Nutrition—(cont.)
• Meals may be withheld or missed.
• Inadequate liquid diets may not be advanced in

a timely manner.
• Giving the right food to the patient is one thing;

getting the patient to eat (most of it) is another.

Oral Diets
• Easiest and most preferred method of providing

nutrition
• Oral diets may be categorized as
– “Regular”
– Modified consistency
– Therapeutic

Oral Diets—(cont.)
• Normal, regular, and house diets
– Regular diets are used to achieve or

maintain optimal nutritional status.
– Regular diets are adjusted to meet age-

specific needs throughout the life cycle.
– Diet as tolerated (DAT)

• Modified consistency diets

– Modified consistency diets include
o Clear liquid
o Mechanically altered diets
– Clear liquid diets may be used.
o To maintain hydration during gastrointestinal illness
o In preparation for bowel surgery or procedures
o When oral intake resumes after a prolonged period
o Most patients can tolerate a regular diet for their
second postoperative meal.

• Modified consistency diets—(cont.)

– Mechanically altered diets contain foods
that are chopped, ground, pureed, or soft.
– Diets prepared in a blender provide food in
liquid form.
– Dysphagia diets are another variation of
modified consistency diets.

• Therapeutic diets
– Therapeutic diets differ from a regular diet.
– Used for the purpose of preventing or treating
disease or illness
• Nutritional supplements
– Some patients are unable or unwilling to eat
enough food to meet their requirements.

• Nutritional supplements—(cont.)
– Categories of supplements include
o Clear liquid supplements
o Milk-based drinks
o Prepared liquid supplements
o Specially prepared foods

– Liquid supplements are
o Easy to consume
o Are generally well accepted
o Tend to leave the stomach quickly
o A good choice for between-meal snacks

Question
• What type of diet is a dysphagia diet?
a. Prepared in a blender
b. Liquid
c. Modified consistency
d. Mechanically ground

Answer
c. Modified consistency
Rationale: Dysphagia diets are another variation

of modified consistency diets.

– Liquid supplements—(cont.)
o Allow the patient to taste test several options
available
o Explain the rationale for adding supplements
and closely monitor acceptance
o Given on a rotation schedule

• Modular products (formulas)

– Less frequently used option for maximizing a
patient’s oral intake
– Generally composed of a single nutrient
– Disadvantages
o Ineffective quality control (calculation errors)
o Bacterial contamination
o Higher costs than standard formulas

Enteral Nutrition
• A way of providing nutrition for patients who are

unable to consume an adequate oral intake but
have at least a partially functional GI tract that
is accessible and safe to use
• Enteral nutrition (EN) may augment an oral diet

or may be the sole source of nutrition.

Candidates for Tube Feeding
• Patients who
– Have problems chewing and swallowing
– Have prolonged lack of appetite
– Have an obstruction, fistula, or altered motility in
the upper gastrointestinal tract
– Are in a coma
– Have very high nutrient requirements

Enteral Nutrition—(cont.)
• Contraindicated when the gastrointestinal tract is

nonfunctional
• Patients who receive enteral nutrition experience
less septic morbidity and fewer infections and
complications than patients who receive parenteral
nutrition.
• Significantly less costly than parenteral nutrition
• Has not been proven to reduce the length of the
hospital stay and improve mortality

• More high-quality trials are needed.

• Factors that influence how and what is used to feed
patients enterally include
– The patient’s calorie and protein requirements
– Ability to digest nutrients
– Feeding route
– Characteristics of the formula
– Equipment available
– Method of delivery

Question
• Enteral nutrition is a way of providing nutrition for

people who have an inadequate oral intake. What is
the other criteria for enteral nutrition?
a. Partially functioning GI tract
b. Nonfunctioning GI tract
c. Obstructed GI tract
d. Patient is comatose.

Answer
a. Partially functioning GI tract
Rationale: Enteral nutrition (EN) is a way of

providing nutrition for patients who are unable
to consume an adequate oral intake but have
at least a partially functional GI tract that is
accessible and safe to use.

• Feeding route
– Depends on the patient’s medical status and the
anticipated length of time the tube feeding will be
used
– Transnasal tubes
o Nasogastric (NG) tube is the most common.
o Generally used for tube feedings of relatively
short duration

• Feeding route—(cont.)
– Ostomy feedings are preferred for permanent or
long-term feedings.
– Percutaneous endoscopic gastrostomy (PEG)
tubes are placed with the aid of an endoscope.
• Formula characteristics
– Formulary of various enteral products available
within major categories
– Are designed to provide complete nutrition

• Protein
– Enteral formulas are classified by the type
of protein they contain.
– Standard formulas
o Made from whole proteins or protein
isolates
o Provide 34 to 43 g protein/L

• Protein—(cont.)
– Variations
o High in protein
o High in calories
o Fiber enriched
o Disease-specific formulas designed for patients
with diabetes, immune system dysfunction,
renal failure, or respiratory insufficiency

• Protein—(cont.)
– Hydrolyzed protein formulas
o Completely hydrolyzed formulas contain only free
amino acids as their source of protein.
o Partially hydrolyzed formulas contain proteins that
are broken down.
o Intended for patients with impaired digestion or
absorption
o Disease-specific formulas are available for liver
failure, HIV/AIDS, and immune system support.

• Calorie and nutrient density

– Calorie density of a product determines the
volume of formula needed.
– Routine formulas provide 1.0 to 1.2 cal/mL.
– High-calorie formulas provide 1.5 to 2.0 cal/mL.
– Nutrient density
o Varies among formulas
o Ranges from 1000 to 1500 mL/day

• Water content
– Varies with the caloric concentration
– Formulas that provide 1.0 cal/mL provide
850 mL of water per liter.
– High-calorie formulas are lower at 690 to
720 mL/L.
– Adults generally need 30 to 40 mL/kg/day.
– Need additional free water

• Other nutrients
– High-fat formulas are available for patients
with respiratory disease.
– Modified-fat formulas are designed for
patients with malabsorption.
– Diabetic formulas are available.
– Electrolyte-modified formulas for renal
disease

• Fiber and residue content

– Terms fiber and residue are frequently used
interchangeably.
o Fiber
 Stimulates peristalsis, increases stool
bulk, and is degraded by
gastrointestinal bacteria
 Combines with undigested food,
intestinal secretions, and other cells to
make residue

• Fiber and residue content

– Residue content of enteral formulas varies
greatly.
– Hydrolyzed formulas are essentially residue
free.
– Most standard formulas are low in residue.
– Formulas prepared in a blender are a natural
source of fiber.

• Osmolality
– Determined by the concentration of sugars,
amino acids, and electrolytes
– Isotonic formulas have approximately the
same osmolality as blood.
– Some patients develop diarrhea when a
hypertonic formula is infused.

Question
• Is the following statement true or false?
Routine formulas provide 1.5 to 2 cal/mL.

Answer
False.
Rationale: The calorie density of a product

determines the volume of formula needed to
meet the patient’s estimated needs. Routine
formulas provide 1.0 to 1.2 cal/mL, whereas
high-calorie formulas provide 1.5 to 2.0 cal/mL.

• Equipment
– Tubing size and pump availability impact formula
selection.
– High-fiber formulas have a high viscosity and require a
large-bore tube (8 French or greater) to prevent clogging.
– Hydrolyzed formulas have very low viscosity.
• Delivery methods
– Formulas may be given intermittently or continuously over
a period of 8 to 24 hours.
– Type of delivery method to be used depends on the type
and location of the feeding tube, the type of formula being
administered, and the patient’s tolerance.

• Intermittent feedings
– Administered throughout the day
– Generally used for noncritical patients, home
tube feedings, and patients in rehabilitation
– More closely resemble a normal intake
– Allow the client freedom between feedings

• Intermittent feedings—(cont.)
– Gastric residuals are checked before each feeding.
– Residual volumes of 200 mL or more on two
successive assessments suggest poor tolerance.
• Bolus feedings
– Variation of intermittent feedings
– Large volume of formula delivered relatively quickly
– Often cause dumping syndrome

• Continuous drip method

– Given at a constant rate over a 12- to 24-hour period
– Recommended for feeding of critically ill clients
– Continuous feedings should be interrupted every 4
hours.
• Cyclic feedings
– Variation of continuous drip feedings
– Cyclic feedings are usually well tolerated.

• Initiating and advancing the feeding

– Before initiating a feeding, tube placement is
verified ideally by radiography, and bowel sounds
are confirmed to be present.
– Regardless of the access route, tube feeding
formulas are initiated at full strength.
– Initial feedings may begin at 10 to 40 mL/hour
and advance by 10 to 20 mL/hour every 8 to 12
hours as tolerated until the desired rate is
achieved.

• Initiating and advancing the feeding—(cont.)

– Commonly recommended maximum flow rate for
gastric feedings is 125 mL/hour.
– Using a standard feeding progression schedule helps
to ensure timely progression of feedings to the goal
rate.
– Tolerance may be a problem for patients who are
malnourished, who are under severe stress, or who
have not eaten in a long time.

• Tube-feeding complications
– GI, metabolic, and respiratory complications
are possible.
– Aspiration is the most serious potential
complication.
– More common than large-volume aspirations
is a series of clinically silent small aspirations.
– Increases the risk of aspiration-related
pneumonia

• Giving medications by tube

– Should never be given while a feeding is
being infused
– Some drugs become ineffective if added
directly to the enteral formula.
– Ensure the tube is flushed with 15 to 30 mL
of water before and after the drug is given.

• Transition to an oral diet
– Goal of diet intervention is to ensure an

adequate nutritional intake while promoting
an oral diet.
– Gradually increase meal frequency until six

small oral feedings is accepted.

Question
• What is the commonly recommended initial

flow rate for gastric feedings?
a. 10-40 mL/hour
b. 40-80 mL/hour
c. 80-120 mL/hour
d. 120-150 mL/hour

Answer
a. 10-40 mL/hour
Rationale: The commonly recommended

maximum flow rate for gastric feedings is 10-
40 mL/hour.

Parenteral Nutrition
• Developed in the 1960s

• Infusion of a nutritionally complete, hypertonic formula
• Life-saving therapy in patients who have a
nonfunctional GI tract
– Also used for other clinical conditions such as
critical illness, acute pancreatitis, liver
transplantation, AIDS, and in patients with cancer
receiving bone marrow transplants

Parenteral Nutrition—(cont.)
• Overfeeding can cause a life-threatening complication

known as the refeeding syndrome.
• PN is expensive, requires constant monitoring, and
has potential infectious, metabolic, and mechanical
complications.
• Used only when an enteral intake is inadequate or
contraindicated and when prolonged nutritional
support is needed
• Should be initiated when oral intake has been or is
expected to be inadequate over a 7- to 14-day period

• Catheter placement
– Patient’s anticipated length of need influences
placement of the catheter.
– For short-term central PN in the hospital, a temporary
central venous catheter is placed percutaneously into
the subclavian vein.
– If PN is expected to be more than a few weeks, these
are the catheters of choice:
o A Hickman catheter or Port-A-Cath
o Peripherally inserted central catheter (PICC)

• Composition of PN
– Provide protein, carbohydrate, fat, electrolytes,
vitamins, and trace elements in sterile water.
– “Compounded” or mixed in the hospital pharmacy
– Two-in-one formula (dextrose and amino acids)
o Used by most hospitals
o Lipids given separately
– Three-in-one formula (dextrose, amino acids, and
lipids)

• Protein
– Provided as a solution of crystalline essential
and nonessential amino acids
– Amino acid formulations are available with
and without electrolytes.
– Providing adequate protein is a primary
concern when formulating PN.
– Nitrogen balance study can be used to
determine adequacy of protein intake.

• Carbohydrate
– Carbohydrate used in parenteral solutions in the
United States is dextrose monohydrate.
– Minimal amount of carbohydrate needed to spare
protein is generally accepted as 1 mg/kg/min.
– Hyperglycemia is associated with immune function
impairments and increased risk of infectious
complications.
– High carbohydrate load may also lead to excessive
carbon dioxide production.

• Fat
– Lipid emulsions
o Made from soybean oil or safflower plus soybean
oil with egg phospholipid as an emulsifier
o Isotonic
o Available in 10%, 20%, and 30% concentrations
o Significant source of calories
o Necessary to correct or prevent fatty acid
deficiency

• Electrolytes, vitamins, and trace elements

– Quantity of electrolytes provided is based on the
patient’s blood chemistry values and physical
assessment findings.
– Parenteral multivitamin preparations usually contain
12 to 13 essential vitamins.
– Most adult formulations now contain a small amount
of vitamin K.
– Trace element preparations contain between four
and seven trace elements.

• Medications
– Patients receiving PN may have insulin ordered
if glucose levels are above 150 to 200 mg/dL.
– Heparin may be added to reduce fibrin buildup
on the catheter tip.
– Medications should not be added to PN solutions
because of the potential incompatibilities of the
medication and nutrients in the solution.

• Administration
– Administered according to facility protocol
– Generally initiated slowly (i.e., 1 L in the first 24
hours)
– Continuous drip by pump infusion is needed to
maintain a slow, constant flow rate.
– Rapid changes in the infusion rate can cause
o Severe hyperglycemia or hypoglycemia
o Potential for coma, convulsions, or death

• Administration—(cont.)
– After the patient is stable, PN may be infused
cyclically.
– Cyclic PN allows serum glucose and insulin
levels to drop during the periods when PN is
not infused.
– To give the pancreas time to adjust to the
decreasing glucose load, the infusion rate is
tapered near the end of each cycle.

• Administration—(cont.)
– During the last hour of infusion, the rate may be
reduced by one-half to prevent rebound
hypoglycemia.
– When the patient is able to begin consuming food
orally, the amount of PN is gradually reduced to
prevent
o Metabolic complications
o Nutritional inadequacies

Question
• Is the following statement true or false?
Medications should not be added to parenteral

nutrition solutions because of potential
incompatibilities.

Answer
True.
Rationale: In general, medications should not be

added to PN solutions because of the potential
incompatibilities of the medication and nutrients
in the solution.

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Hospital Nutrition: Defining

Nutrition Risk and Feeding

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Hospital food may be refused because

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Meals may be withheld or missed.

• Inadequate liquid diets may not be advanced in

• Giving the right food to the patient is one thing;

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Easiest and most preferred method of providing

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Normal, regular, and house diets

– Regular diets are used to achieve or

– Regular diets are adjusted to meet age-

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Modified consistency diets

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Modified consistency diets—(cont.)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• What type of diet is a dysphagia diet?

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Rationale: Dysphagia diets are another variation

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Modular products (formulas)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• A way of providing nutrition for patients who are

• Enteral nutrition (EN) may augment an oral diet

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Contraindicated when the gastrointestinal tract is

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• More high-quality trials are needed.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Enteral nutrition is a way of providing nutrition for

Copyright © 2018 Wolters Kluwer · All Rights Reserved

a. Partially functioning GI tract

Rationale: Enteral nutrition (EN) is a way of

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Calorie and nutrient density

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Fiber and residue content

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Fiber and residue content

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Is the following statement true or false?

Routine formulas provide 1.5 to 2 cal/mL.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Rationale: The calorie density of a product