Enteral Feeding Protocol

Information about Ensure

• Ensure is mixed by adding 6 scoops of powder to 196 mL of water, which results in 230 mL of Ensure
• Ensure has 1 kcal/mL

Calculating Nutritional Needs

For most patients, the following is adequate:

• Energy: 25-30 kcal/kg body weight
• Protein: 1-1.2 gm/kg body weight

For most underweight or overweight patients, use Ideal Body Weight:

• Males: IBW = 50 kg + 2.3 kg for each inch over 5 ft (152 cm)
• Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 ft (152 cm) (There are online calculators that you can use to simplify the math)

Adjusting Ideal Body Weight for Amputations

• All 4 limbs amputated = 50 percent;
• entire arm = 5 percent;
• forearm and hand = 2.3 percent;
• just one hand = 0.7 percent;
• entire leg = 16 percent;
• lower leg and foot = 5.9 percent;
• just one foot = 1.5 percent.

Example: Adjusted IBW = 100 kg x 0.84 (loss of entire leg) = 84 kg

Calculating Total Fluid Needs

• 100 mL/kg for the first 10 kg
• 50 mL/kg for the second 10 kg
• 20 mL/kg for everything after that

Initiating Feeds

• Typically order feedings of 100-400 ml administered over 5-30 minutes 3-6 times per day. Free water flushes should be given before and after each feeding (typically 50-250 ml total for each feeding). The total fluid needs determine how much flush to use.
• If the patient has been eating well, order feedings to meet needs. If the patient has been NPO, unstable, or malnourished, order feedings at about half the goal volume and increase to goal over 1-2 days.
• Do not feed a patient who is hemodynamically unstable or is on vasopressors.
• When advancing tube feedings, decrease IV fluids accordingly so that the patient does not become fluid overloaded.

Nursing Orders

• NG and NJ tubes must be replaced every 4-6 weeks.
• The head of the bed should be elevated at least 30 degrees during each feeding and for at least one hour afterward.
• Flush with 30-50 ml sterile water before feeding to clear the tube. Infuse formula via syringe without the plunger (gravity/drip feedings), refilling as needed until total volume is infused.
• Flush with remaining free water to meet fluid needs.
• Store extra prepared formula in the refrigerator promptly. Allow refrigerated formula to come to room temperature over 30 min before feeding. Throw out prepared formula after 24 hours.

Examples of Calculations

Example 1: Well Patient 50 kg patient Calorie needs 50 kg x 25-30 kcal = 1250-1500 calories Fluid needs = 2100 mL Ensure is 1 kcal = 1 mL

• Ensure 230 mL x 6 feeds per day (1380 calories/1380 mL)

• 150 mL water [50 mL before and 100 mL after] x 6 flushes (900 mL)

• Ensure 345 mL x 4 feeds per day (1380 calories/1380 mL)

• 180 mL water x 4 flushes (720 mL)

• Ensure 460 mL x 3 feeds per day (1380 calories/1380 mL)

• 240 mL water x 3 flushes (720 mL)

Example 2: Critically Ill Patient 50 kg patient Calorie needs 50 kg x 25-30 kcal = 1250-1500 calories Fluid needs = 2100 mL Ensure is 1 kcal = 1 mL

• Start at ½ goal
  • Ensure 115 mL x 6 feeds (690 kcal/mL)
  • 150 mL water x 6 flushes (900 mL)

  • Run D5 ½ NS at 40 mL/hr (86.7 kcal/510 mL)
  • Advance to goal feedings over several days and decrease IV fluids

Monitor for Refeeding Syndrome in patients with severe malnutrition. If K, Phos, Magnesium dropping quickly, need frequent lab checks and likely need transfer to a hospital facility that can check these labs and replete them multiple times per day