By Mary Ellen Posthauer RDN, CD, LD, FAND
During the wound healing process, aggressive nutritional support can reverse the body's hypermetabolic state, which occurs when lean body mass is used for energy rather than tissue repair. When energy stores are rapidly depleted in a healthy adult, this can lead to acute malnutrition. In the already compromised individual, however, it can lead to severe protein-calorie malnutrition. Malnutrition increases the risk of morbidity and mortality, and decreases function and quality of life. When the return to the previous quality of life is anticipated, individuals with continued compromised intake along with the burden of increased nutrient needs from stress and chronic wounds may benefit from enteral nutrition (tube feeding). Parenteral nutrition should be used only when the GI tract is not functional, cannot be accessed, or when the individual cannot be adequately nourished by enteral nutrition.
Before initiating an enteral regimen, the interprofessional team should discuss the risk and benefit of tube feedings, including any potential cost, with the individual and/or their caregiver. A tube feeding may result in increased cost, both in terms of equipment as well as caregiver time, for individuals who reside at home. Cultural and religious issues should also be considered when discussing initiating a tube feeding. Health care professionals must respect and honor the preferences of the individual who may not choose a tube feeding even when it is medically appropriate.
Older adults with Alzheimer's or dementia, which is considered a terminal illness, usually lose interest in food, refuse to eat or drink, or become too distracted to focus on eating. Numerous studies report that there is no evidence that tube feedings are beneficial in terms of preventing, improving or reducing the incidence of pressure ulcers or improving nutritional status.
The registered dietitian (RD) should assume the role of primary advocate for all aspects of nutritional care for the individual. The RD should conduct initial and periodic nutrition assessments, establish the individual's nutrient needs, recommend the appropriate enteral formula (product, rate of delivery, mL of flush) evaluate the individual's tolerance to the regime initiated and suggest changes when the desired outcome is not achieved. An individual may receive total enteral feedings or bolus feedings to supplement their meals. Regardless of the type of tube feeding administration, the tolerance and management of enteral feeding complications must be carefully monitored.
When the individual's wounds are healing and the decision is made to transition back to oral feeding, the interprofessional team should develop a plan for gradually reducing the tube feeding rate prior to discontinuing the feeding. It may be appropriate to run the tube feeding nocturnally for a week or more until the individual is consuming adequate calories/fluid orally. The RD should review the individual’s weekly weights, food and fluid intake, and any other pertinent nutritional parameters. The decision to remove the tube should be based on adequacy of the diet, weight stabilization, and healing of the wound.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.