Nutrition Care Plan – Flashcards
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Nutrition care plans are fundamental roles of a clinical dietitation. What are 5 important aspects?
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- specific for each patient - Nutrition assessment of patient - specific goals for patient - action plans to meet each goal - evaluation measures should be indicated
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What were the 3 original skills of a nutritional care plan?
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- assessment skills - planning implementation skills - evaluation skills
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What are the 4 phases of the ADA Nutrition care plan?
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- Assessment - Nutrition diagnosis - nutrition intervention - nutrition monitoring & evaluation
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ADA - Nutrition Assessment
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- obtain/collect timely and appropriate data - analyze/interpret with evidence-based standards - document
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ADA - Nutrition Diagnosis
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- identify and label problem - determine cause/contributing risk factors - cluster signs and symptoms/defining characteristics - document
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ADA - Nutrition Intervention
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- plan nutrition intervention - formulate goals and determine a plan of action - implement nutrition intervention - care is delivered and action is carried out - Document
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ADA - Nutrition Monitoring and Evaluation
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- Monitor progress - measure outcomes indicators - evaluate outcomes - document
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Why assess nutrition status in hosptial?
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- frequent cases of malnutrition in hospitalized patients - nutrition status affects treatment and recovery from illness/surgery - baseline health status allows us to determine changes while in care
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Malnutrition in hospitalized patients - chronic disease
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- associated with - increased morbidity - increased mortality - extended hospital stays
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Morbidity
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- condition of being diseased - proportion of disease to health in a community
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Mortality
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frequency of death in a certain population or caused by a particular disease
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Incidence
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rate of occurance - # of new cases of a disease during a certain period
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Prevalence
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where we are at right now - # of cases of a specific disease in existence in a given population at a certain time
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Nutrition assessments need to be
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ongoing as disease/condition/treatment change
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Iatrogenic Malnutrition
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- physician-induced malnutrition - treatment, cure can have more of an effect on nutritional status than disease/condition itself
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Causes of Hospitial Malnutrition
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- failure to observe suboptimal intake - withholding meals because of tests - issues with dentition/depression - delayed or inadequate nutrition support
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How does disease affect nutritional requirements?
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- metabolic rate (increase or decrease) - fever (increase) - catabolism - medication effect - food intake - food/nutrient intolerance - malabsorption - primary concern in GI pt Losses - fluids, nutrients, electrolytes (input/output)
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Consequences of Under/inadequate-nutrition
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- loss of organ mass and function - atrophy of GI tract allowing bacterial translocation - reduced immunocompetence - weight loss (esp. muscle) - poor wound healing/decubitus ulcers - increase LOS and cost to system
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Decubitus ulcers
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pressure sore from laying so long
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Purpose of a Nutrition Assessment
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1. identifies nutrition related problems 2. proviides justification for the nutrition care plan 3. forms the basis for evaluating teh nutrition care plan
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Nutrition Assessment - Purpose - Identifies nutrition related problems
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- assessment often preceded by screening for individuals with specific risk factors - objective and subjective
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Objective Measures
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nutritional status confirmed by professional
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Subjective Information
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provided by patient or caregivers
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Nutrition Assessment - Purpose - Provides Justification for the nutrition care plan
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- basis for the formulation of goals (made with patient/client, family, health care team) - goals should be realistic and measurable (ongoing monitoring required, outcome based) - specific action plans for each goal should be developed
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Nutriition Assessment - Purpose - Forms the basis for evaluating nutrition care plans
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- baseline measures to compare goals/outcomes to need to compare changes for individuals
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Nutrition Assessment of Patients: MABCDE
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Medical and social history Anthropometry & body composition Biochemical Data Clincial/physical examination Diet History Estimation of Requirements
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Two Phases of Nutrition assessment of patients
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Screening - patient at nutritional risk - high, mod, low risk Assessment - 48 hrs, 72 hrs, re-access im 7d
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Medical History
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- diagnosis if known (primary and secondary) - all diseases and conditions an individual has had over their lifetime - all surgical procedures and individual has undergone over their lifetime - all symptoms an indiviual is experiencing - thorough medical history obtrained upon admission to hospital
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Social History
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- living arrangements - cooking/shopping ability - religion (food restrictions) - socioeconomic status/food security
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Method of diet history/assessment determined by
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capabilities of pt time constraints information from secondary source
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24 hr recall
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- fast, random - retrospective for previous 24 hrs - likely not usual intake/not typical
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Daily food records
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- prospective for set time periods - record or weigh food intake - increase accuracy with increase time period - can be used in the hospital - typical days (1d, 3d, 7d)
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Food Frequency Questionnaire
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- food intake over a specific time period - food lists - consumption frequency - can include portion size - better for assessing groups
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Direct Observations
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- time and labour consuming - can only be down in a controlled setting - frequency used in hospital setting where there is concern about pts
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Dietary Assessment Evaluation
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- comparing intake to Canada's Food Guide recommended servings - give an approximation of quality of intake (ex: missing a good group)
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Nutrient Analysis
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- food composition tables - nutrient analysis software - individual nutrients - individual analysis must be compare to reference values
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DRI
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Daily Recommended intake - all DRI values (RDA, EAR, AI, UL) are for healthy individuals/populations and are specific for age and gender
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Recommended Daily Allowance
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RDA - amount that is adequate for 97-98% of healthy population - goal is for optimum nutrition - NOT used to assess diets of individuals or groups
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Estimated Average Requirement
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EAR - would be used as reference values for nutrient analysis programs - estimated requirement adequate in 50% of the population - MAY be used to assess diets of individuals and groups
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Adequate intake
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AI - used when RDA and EAR exists due to lack of scientific evidence - MAY be used to assess diets of individuals and groups - used as REFERENCE VALUES for nutrient analysis programs when no EAR exists
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Tolerable Upper Intake
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UL - maximum nutrient intake NOT associated with adverse side effects (folate, Ca, iron)
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Diet History/Assessment: In hospital
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- a combo of many methods - needs to determine any changes to diet with disease/symptom onset
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Clinical/Physical Assessment
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- examine the patient for clinical signs and symptoms reflecting malnutrition - physical signs do not usually appear until deficiency level is severe - physical signs are often not specific
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Dietitians generally examine for
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Protein, Energy Deficiencies
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if concerned about __________________ lab tests are done
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micronutrients
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Protein, Energy Deficiencies are apparent in Hair, Face, Skin, and musculoskeletel by
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Hair: dry, dull, alopecia Face: drawn in Skin: delayed wound healing, skin breakdown, decubitus ulcers musculoskeletel: wasting, decreased strength
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Edema
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- may be a sign of protein deficiency - may be a sign of very low activity level/immobilization - may indicate poor renal function (chronic or acute) - can contribute to skin breakdown
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Antropometry - used to determine body size and proportions
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- height - weight - circumferences
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Antropometry - Height
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- used for energy requirement calculations - used for BMI - used for height/weight tables - measure if possible - can be used by other members of health care team to determine drug dosages
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Supine Measurement
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- used if pt is to ill to stand - should be lying flat/straight - measure both sides
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Antropometry: Frame Size
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- Wrist circumference - elbow breadth
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Wrist Circumference
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- smallest point distal to ulna/radius styloid process - r = height(cm) / wrist cir (cm) - compared to reference values
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Elbow Breadth
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- distance between epicondyles or humerous - compared to reference values
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Antropometry: Body Weight
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- most important - requires measurement (standing, chair, bed scales available) - take amputations into account - fluid status - needs to be measured on an ongoing basis
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Fluid Status
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- edema can affect weight (wet weight) - attempt to determine dry weight
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BMI
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- evaluates weight independent of height - interpretations - different values at age 65 - evaluation of obesity - association with health risks
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BMI Pros
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- easy to use - correlates with body fat measures - not influenced by height - high correlation with specific diseases - permits comparison between groups
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BMI Cons
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- not as useful (children, elderly >65, atheletes, pregnancy) - doesn't take body composition into consideration
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Ideal Body Weight (IBW)
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- calculation (Hamwii Method) - not all acct for age, race, frame size - healthy weight range (USDA) - reference populations - use desireable BMI ranges for specific age groups
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%IBW
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= current wt/IBW x 100
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Usual Body Wt (UBW)
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- used to determine weight changes - rapid or unintentional change in UBW
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Rapid or unintentional change in UBW
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- may indiciate nutritional risk - used for some differential diagnoses - can be a nutrition screening tool - can indicate - decreased energy intake - increased energy requirement
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%UBW
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= current wt/UBW x 100
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% weight change
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= (UBW - current wt) / UBW x 100
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Most important weight assessments
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% UBW % Wt Change
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Body Shapes
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android - apple (more at risk) pear gynoid (in butt)
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Unplanned weight loss indicating risk of malnutrition
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> 5% of UBW over one month > 10% of UBW over 6 month
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What does a weight gain of more than 1 kg/week likely indicate?
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change in fluid status
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Body Composition
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- body circumferances and areas - skin-fold measurements - bio-electrical impedance - DEXA
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Body Circumferences/Areas
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- used to estimate skeletal muscle mass (somatic protein stores and body fat stores) - Waist Circumference - Waist-to-hip ratio - mid-upper-arm curcumference
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Waist Circumference
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- correlates with visceral fat stores - increase risk for CVD and Type 2 Diabetes males > 40in/102cm females >35in/88cm
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Waist-to-hip ratio
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- estimates distribution of subcutaneous and intra-abdominal adipose and muscle tissue - possible increased risk for morbidity and mortality with ratios men >1.0 women >0.8
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Mid-upper-arm circumference
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- measure skeletal muscle within the arm - sequential measure can be used to monitor nutrition intervention
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Skinfold Thickness
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- measurement of subcutaneous adipose tissue stores - measured with calipers - adipose stores vary with age, sex, race - need to be done by trained individuals (measured in triplicate
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Four Measurements of Skinfold thickness
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- Triceps Skinfold (TSF) - Subscapular skinfold (triangle on back) - Biceps skinfold - Supraillac skinfold (3 fingers below waist) measure in triplicate
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Bioelectrical Impedance Analysis (BIA)
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- estimates body composition - total body water - fat-free mass and fat mass - body cell mass - Low level electrical current passes through the body - fat free mass = electrical conductor - fat mass = insulator
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Dual-energy X-Ray Absorptiometry (DEXA)
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- estimates body composition - fat tissue - lean tissue - bone mass - low levels x-ray passes through the body - Accuracy - accurate and reproducible
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Biochemical Analysis
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- can detect sub-clinical deficiencies - usually measured by blood or urine samples - Pt result compared to reference values
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Common Specimens of Biochemical Analysis
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Blood - whole blood - serum or plasma - blood cells (erythro (RBC)), leucko (WBC)) - blood spots - Urine - Feces - Other tisses (scraping of biopsy)
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Difference between serum and plasma
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Serum - without coaggulating factor Plasma - with coaggulating factor
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Serum Total Protein
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- composed of mostly albumin and 4 types of globulin (half life 20 days) - not always representative of protein status - low sensitivity, low specificity - affected by: protein intake, protein metabolism/synthesis, hydration, medications, activity level
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Serum Alb (Albumin)
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- half life ~ 20 days - may show longer term protein status - decrease significanty when overhydrated and with acute illness - most useful for pts being followed long term and without acute illness
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Serum Albumin (g/L) >35 28-35 21-27 <21
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Level of Visceral Protein Depletion None Mild Moderate Severe
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Thyroxin Binding Protein (Prealbumin, Pre Alb)
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- Half life 2 day - may show short term changes in protein status - sensitive to acute nutritional changes - decreased significantly with acute illness - Most useful for patients being followed in hospital and once pt is recovering
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C-Reactive Protein (CRP)
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- serum marker of acute inflammation - increased signficantly by acute phase inflammation and acute illness - most useful for pts with surgery and pts with acute trauma - not protein specific
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Urine Analysis
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- Nitrogen Balance - Creatinine Excretion
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Nitrogen Balance
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- reflects fetal protein mass (urea excreted) - gives a measurement of protein breakdown - requires 24hr urine collection
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Creatinine Excretion
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- reflects muscle mass - increased muscle wasting - bedridden pts - lost faster in males
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3Types of Iron
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- Essential (RBC, myoglobin, enzymes) - Transferrin - Ferritin
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Essential Iron
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- RBC - myoglobin - enzymes
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Transferrin
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- iron transport protein - Transferrin saturation (T-SAT) - higher value - Total iron binding capacity (TIBC) - lower value
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Ferritin
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- storage form of iron - can reflect a deficiency, excess, or normal iron status (liver, bone marrow, spleen)
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Anemia
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- RBC synthesis - B12 - Folate - Iron - Pt anemic - all 3 levels should be checked - iron deficiency anemia = clinical deficiency ( once all storage and transport iron used up)
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Single Nutrient in Serum
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- nearly all vitamins and minerals can be measured in serum - may increase/decrease with certain diseases/conditions
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Nutrient Deficiency in Nutrition Assessment: Diet History
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Primary Lack or Secondary Cause - decrease intake - decreased absorption - increased need
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Nutritent Deficiency in Nutrition Assessment: Biochemical Measures
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Declining Stores Abnormal Functions inside the body
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Nutrient Deficiency in Nutrition Assessment: Clinical Exam/Anthropometrics
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Clincial signs and symptoms
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Subjective Global Assessment
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- nutritional assessment based on pts medical hx and physical exam - high correlation to objective measures
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What assessment is useful for the critically ill?
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Subjective Global Assessment
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What assessment method predicts post op infection better than objective measures
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Subjective Global Assessment
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What are the HISTORY features of SGA?
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- weight changes - dietary intake - GI symptoms - functional ability - metabolic demands
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What are the PHYSICAL EXAM features of SGA?
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- loss of subcut. fat - muscle wasting - edema - ascites
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SGA features are based on
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information collected
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SGA features subjectively catergorize pts
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A= well nourished B= moderate or suspected malnutrition C= severe malnutrition
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SGA: Pros
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- less time required - can be taught to a variety of health professionals - all pts in facility rated by some system
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SGA: Cons
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- less detail - harder to establish baselines for individual parameters
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Estimation of Requirements
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- Energy (Kcal) - Protein - Fluid
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Requirement Assessment: Energy: Factors
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- nutritional status - activity - severity of illness - wounds, trauma, ventilation, infection, fever (can increase or decrease requirement) - malabsorption - medications - age, gender, height/weight, body composition
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Energy Estimation Equations
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- Basal Energy Expenditure (BEE) - Harris-Benedict Equation (HBE) - FAO/WHO Equations
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Basal Energy Expenditure
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- maintaining body function - 65% energy needed for functioning
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Harris-Benedict Equation
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- may overestimate BEE - most commonly used - considers ht, wt, gender, age - still used because of data to compare
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FAO/WHO
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considers wt, gender, age
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Activity Factor (AF)
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- physical activity from bed-bound to strenuous activity - BEE is multipled by AF
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Stress Factor (SF)
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- stress from various clinical states - may change over clinical course
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Critical Illness & Severe Malnutrition
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Ireton-Jones Equation
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Ireton-Jones Equation
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- different for ventilated & spontaneously breathing pts - spontaneously breathing - includes for increased obesity - ventilated - includes for increase for burns/trauma
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Obesity and BEE
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- different opinions of what wt to used for HBE - ideal IBW, actual, average of ideal and actual
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Adjusted Wt (ABW >125% of IBW)
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- IBW + actual IBW x 0.25
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Kilocalories/kilogram body wt
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- total energy requirement - 25-35 Kcal/g - 21 Kcal/g for obese pt - quick to calulate w/o formulas
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Indirect Calorimetry
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- actual measurement rather than estimated by calculation - measures O2 consumed, CO2 produced - assumes 1L O2 = 3.9 & 1L CO2 = 1.1
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What does indirect calorimetry calculate?
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- BEE (awake, fasted, supine) - REE (after 30 min rest, 4 hrs after a meal - RQ = VCO2/VO2
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RQ values
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CHO - 1 Fat - 0.7 Pro - 0.82 Alcohol - 0.67
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Indirect Calorimetry: Pros
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- accurate measurement of calorie requirements - information on substrate utilization - can see acute changes - can be used on ventilated pts
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Indirect Calorimetry: Cons
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- expensive - trained professional - exact testing criteria
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Requirement Assessment: Protein Estimation: Healthy Adult
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FAO/WHO = 0.75g/kg body wt Canada = 0.86g/kg body wt DRI (RDA >19 yr) = 0.8g/kg body wt
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Protein Estimation: In Hospital
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- moderately stressed: 1.0-1.5g/kg body wt - severely stressed: 1.5-2.0g/kg body wt
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DRI Macrpnutrient Distribution Ranges: Adult
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CHO: 45-65% PRO: 10-35% Fat: 20-35%
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DRI Macrpnutrient Distribution Ranges: Young Children
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CHO: 45-65% PRO: 5-20% Fat: 30-40%
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DRI Macrpnutrient Distribution Ranges: Older Children
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CHO: 45-65% PRO: 10-30% Fat: 25-35%
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Conditions that may change protein requirement
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- renal disease - increase in dialysis - liver disease - increase or decrease - pregnancy/lactation - trauma
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Requirement Assessment: Fluid/Hydration Estimation
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- total body water = 55-65% of body wt
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Hydration status affects other areas of nutrition
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- biochemical measurements - physical exam - anthroprometrics
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Fluid Inputs
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- food and drink - IV fluids - irrigation
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Fluid Outputs
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- urine and stool - insensible losses - sweating/fever - wound output - vomitting - diarrhea - medications (diuretics)
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Fluid Calculation based on
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- Wt - Age & Wt
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Weight fluid calculaton
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1st 10 kg = 100ml/kg next 10 kg = 50ml/kg >20 kg = 20ml/kg
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Age and Weight fluid calculation
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16-30 active = 40ml/kg/d 20-55 = 35ml/kg/d 66-75 = 30ml/kg/d >75 = 25ml/kg/d
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Energy Fluid calulation
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1ml per kcal
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fluid balance
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urine output + 500 ml
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Nutrition Diagnosis (Dx)
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- nutritional problem that the dietitian is responsible for treating - identifies and describes the problem
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PES Statement
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- Problem, Etiology, Signs/Symptoms - writting for a Nutrition diagnosis using standardized language
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Nutrition Intervention
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= nutrition plan + implement - purposely planned actions designed with the intent of changing a nutrition-related behaviour, risk factor, environmental condition, or aspect of health status for an individual, a target group, or population at large
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Nutrition intervention should be targeted at the
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etiology
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Plan
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= formulate and determine a plan of action - prioritize the nutrition Dx (most current issue first) - select specific strategies - define intervention plan - determine expected outcomes - define time and frequency of care - identify resources
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Implementation
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= action phase of the nutrition care plan
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how do you carry out (implement) the plan?
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- communicate with pts and other health professional team - continue data collection & modify the plan of care as needed - follow-up and verify that implementation occurs - evaluate food-drug interactions: counsel accordingly - educate pts
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Nutrition Care Process/Plan
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Assessment Nutrition Dx - articulated as etiology Nutrition Intervention - Addresses etiology or signs/symptoms Nutrition Monitoring & evalution
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Planning Nutrition Support: How will we provide the requirements?
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- Diet/Nutrition prescription: type, amt, frequency, route of feeding - P.O. intake = regular/general diet or modified - enternal nutrition (EN) - tube feeding - parenteral nutrition (PN) - iv feeding
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Diet Classifications
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Ideal - pt can safely tolerate oral feeding - can feed themselves - pt has not disease or illness that require modification of diet - Regular/Full - diet provided with no modifications
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What is a therapeutic diet?
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- modification of the normal diet to treat the disease, illness or physical symptoms
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Why might someone need a therapeutic diet?
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- swallowing problem - lactose problem - diabetes - religion - vegan - recoverying from surgery
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What is the purpose of a modified diet?
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- maintain and restore nutritional status - rest an affected organ - adjust ability to digest, metabolize or excrete - improve tolerance of food intake - adjust for mechanical difficulties - increase or decrease body wt - eliminate specific foods
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What is a diet prescription?
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- specific type of therapeutic diet ordered - states what modifications to the regular diet will be used
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5 Diet Modifications
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- Consistency - Texture - Energy - Nutrients - Seasoning
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Consistency Diet Modifications
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- Clear fluids - Full Fluids
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Clear Fluids
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- clear - minimal or no residue in GI tract - foods that are liquid at room temp (consumee, ginger ale, jello) - used in transition diet following IV feeding - intended for short use 24-48 hrs - supplements can be included
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Full Fluids
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- liquid at body temp - easily digested foods (cream soup, ice cream, pudding, cooked cereals) - used in pts with - swallowing difficulties, esophgeal problems - transition from CF to full diet - severe chewing problems - decreased appetite / severe vomitting - nutritionally adequate - can be monotonous/bland
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Texture Diet Modifications
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- pureed -> minced -> diced (soft to chew) - progressive consistency Used for - chewing difficulties - mechanical (teeth, ENT surgery) - neurological (stroke, brain injury)
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Energy Diet Modifications
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- can be specific kcal lever - weight loss, weight gain, diabetes - Cen be high/increased calorie/energy diet - wt maintenance, weight gain
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Nutrient Diet Modification
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- can be specific nutrient - specific level - high/low - often met with supplements - a diet may incorporate/restrict several
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Bland/Light Nutrient modification
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- based on tradition - foods are mildly seasoned, low in fiber, low in fat - often transition diet to regular
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Nutrition Monitoring and Evaluation Components
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monitor progress, measure outcomes, evaluate outcomes
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Monitor Progress
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- check pts's understanding and adherance - determine if intervention is being implemented as planned - determine if pt's status is or is not changing - identify other positive or negative outcomes - gather information indicating reasons for any lack of progress
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Measure Outcomes
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- select outcome indicators that re relevant to signs or symptoms, nutrition goals, medical diagnosis and outcomes or quality management goals
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Evaluate Outcomes
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- compare current findings with previous status, intervention goals, and or reference standards
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Enteral Nutrition - Definition
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- provision of supplemental or total nutrition by feeding directly into the GI Tract - Oral feeding cannot be tolerated
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what are some occasions where oral feeding cannot be tolerated
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- swallowing problem - nerve damage - trauma - Pt is unconscious - stroke - severe burn
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Indications for enteral feeding
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- insufficient to meet estimated need by oral food intake > 5 days an PEM < 50% requirements 5-10 days - GI tract is functional
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What are the benefits of enteral feeding
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- maintenance of GI integrity, decreasing atrophy - decrease gastric ulceration - enhance nutrient utlilization - safe a less costly
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Contraindications for enteral support
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- non-functional GI - bowel obstruction (physical or paralytic ileus) - extended bowel rest
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Enteral Feeding Route - non-surgical (<6 weeks)
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- Nasogastric (NG) - Nasoduodenal (ND) - Nasojejunal (NJ)
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Enteral Feeding Route- NS - Aspiration Risk
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NG - med ND - low NJ - low
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Enteral Feeding Route- NS - Dumping Risk
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NG - low ND - med NJ - high
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Enteral Feeding Route - NS - Ease of Removal
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NG, ND, NJ - easy
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Enteral Feeding Route - NS - long term tolerance
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NG, ND, NJ - fair
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How can you tell when non-surgical Enteral feeding tubes are in the correct place?
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NG - gastric juices ND - x-ray NJ - x-ray
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Enteral Feeding - surgical (>6 weeks)
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- esophagostomy - gastrostomy - jejunostomy
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PEG
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percutaneous endoscopic gastrostomy
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Enteral Feeding Route- S - Aspiration Risk
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- esophagostomy - high - gastrostomy - low - jejunostomy - low
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Enteral Feeding Route- S - Dumping Risk
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- esophagostomy - low - gastrostomy - low - jejunostomy - high
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Enteral Feeding Route - S - Ease of Removal
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- esophagostomy - diff - gastrostomy - diff - jejunostomy - diff
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Enteral Feeding Route - S - long term tolerance
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- esophagostomy - good - gastrostomy - good - jejunostomy - good
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Selection of Enteral Formula
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- osmolarity - digestability - energy density - lactose content - fat content - viscosity
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Enteral Formula - osmolality
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- fluid imbalance can lead to diarrhea, nausea, GI distress - H20 moves from a dilute sol to a conc. solution
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Enteral formula differs in
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osmolality - by wt, # of osmoloes solute/kg solution osmolarity - by vol, # of osmoles solute/L solution
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Osmolality of body fluid
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~ 300 mOsm/kg
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The great the # of ____________, the smaller the _____
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the greater the # of PARTICLES IN SOLUTION, the smaller the PARTICLE SIZE. increasing OSM
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Osm and CHO, PRO, Fat, Electrolytes
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CHO - if high Mol wt: large particles (low osm effect) - is low Mol wt: smaller particles (high osm effect( PRO - large particle: minimal osm - small particle: high osm Fat - do not form solution in water - very minimal osmotic effect Electrolytes - small particles (K+, Na+): high osm effect
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Types of tube feeding formula
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- blended - elemental (monomeric) - non-elemental (polymeric) - specific nutrient modular - disease-specific formula
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Blended tube feeding
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- blended regular foods - sometimes baby food - rarely used - tubes may plug
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Elemental Diet tube feeding
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- low residue (peptides, glucose, EFA) - lactose free - unpalatable for oral use - basic nutrients "ready to absorb" AA & short peptiides glucose, dextrose no fat, or minimal MCT
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MCT Oil
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- more H20 soluble than most fats - require less bile salts diffuse more rapidly are not re-esterified in the enterocyte - transported as fatty acid bound to albumin through portal circulation - portal blood flow = much greater than the lymphatic system
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Non-elemental diets
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- low residue or with fibre - low osmolality - may contain lactose - oral or enteral feeding - intact macro-nutrients eg) prot - soy, Na or Ca casinate CHO - corn syrup, glucose polymer, corn starch Fat - veg oil
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Nutrient Modules (single nutrient)
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- supply single nutrients - good for diet manipulations eg) PRO - whey, albumin CHO - glucose polymers Fat - TG with MCT or LCFA
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Special Formula Tube Feeding
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- pts have normal GI function but have a metabolic or oral esophageal problem
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Special Formula tube feeding products
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- Glucerna (Diabetes) - 50% fat-high MUFA - 33% CHO - corn starch, fructose - Amin-Aid (Renal Disease) - 4% pro - NPE:N 800:1 - Pulmocare - Pulmonary Disease (COPD) :RQ - 55% fat - 28% CHO - Impact - improve immune function - RNA - increase host immune responsiveness & survival - Arg - increase celluar immune function - Omega 3 fat: alter PG synthetic pathway
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Methods of formula administration
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- continuous drip feeding - intermittent drip feeding - bolus feeding (all at once) - cyclic drip feeding
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Continuous Drip Feeding
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- preferred methods - slow and steady - low complications - 16-24 hrs - pump
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Intermittent Drip
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- not ideal - used in special situations - q4-6 (over 30-60 min) - gravity drip or pump - miminc meal time
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Bolus Feeding
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- rapid feeding syringe or feeding bag - q4-6 (in 15 min) - feed only to stomach - complications: aspiration, digestion
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Cyclic Drip Feeding
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- night feeding only - 8-16 h - pump - used as transition feedings - allow greater mobility - good for home nutrition support
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Isotonic solutions
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- can be started at full strength
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Hypertonic Solutions
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- very slow delivery rate to begin with
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Rate of Feeding
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Start - 25-50ml/h --- max 1200 ml/d Advance - 50-75ml/h --- max 1800 ml/d Upper Limit - 75-150ml/h --- max 3600 ml/d
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Dumping Syndrome
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- a complex physiological response to the rapid emptying of hypertonic contents/undigested foods into the duodenum and jejunum (hyperosmolar syndrome)
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Dumping Syndrome Symptoms
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- n/v, weakness, fatigue, sweating, palpitation, diarrhea, syncope - progresses to weakness, sweating, dizziness
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Dumping Syndrome Causes
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- stomach surgery (gastrectomy, gastric bypass surgery) - EN feeding to the jejunum
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Syncope
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fainting Dumping syndrome
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Parenteral Nutrition Definition
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Provision of nutritents directly into the bloodstream intravenously without using the GI tract
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Indications of PN support
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- unavailable functioning GI, Bowel rest *bowel obstruction, fistulas, short bowel syndrome, ileus - inadeuquate enteral nutrition >5-7 to 10 d *variable upon institute - severe malnutrition/preoperative nutrition rehabiliation *anorexia, wt loss >= 10-15%: nutritional repletion
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Contraindications for PN support (reasons to not use)
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- functional GI or recover GI function in 7-10 d - nutrition support is anticipated for < 7 d - ricks of PN exceed potential benefits - inability to obtain venous access - aggressive nutrition support contraindicated
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PN access
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central peripheral
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Central PN access
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- Total Parenteral Nutrition (TPN) - catheter into vena cava - can infuse concentrated (hyperosmolar) formula - less pressure incurred - decreased phlebitis
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Peripheral PN access
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- Peripheral Parenteral Nutrition (PPN) - catheter into vein in arm - cannot provide concentrated nutrients & electrolytes - easy to put in - use less < 7 day
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Central (TPN) Pros
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- long term use > 14 day - hypertonic solutions - meets nutrition requirements
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Central (TPN) Cons
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- ++ risk of infection - invasive - + nursing care time
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Peripheral (PPN) Pros
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- non-invasive/short term 7-14 day - peripheral vein - risk of infection
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Peripheral (PPN) Cons
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- amts limited by Osm - duration of line placement (less)
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TPN Components: Fat
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- lipid emulsions - essential FA included - calorie density: 20% lipid, 1g = 10 kcal - max dose 1-1.5 g/kg/day - soybean oil based (intralipid) - olive oil based (ClinOliec) - glycerine used to make emulsion isotonic
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TPN Components: Vitamins
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- STD vitamin solution -- 9 water soluble and 3 fat soluble vitamins - provides maintenance amt of vitamin - daily requirement: 10 mL of multi-12 - extra vitamins can be added
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Water Soluble vitamins
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B1 B2 B3 B6 B12 folate Vit C biotin pantothenic Acid
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Fat soluble vitamins
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Vitamin A, D, E
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TPN Components: Minerals (TES)
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STD trace element solution I, Zn, Cu, Cr, Mn, Se - provides maintenance amt of minerals: 2ml of trace
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Why is Fe rarely used in TPN
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doesn't mix well with nutrients anaphalatic rxn can occur - extra nutrients can be added
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TPN Components: Electrolytes
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Na, K, PO4, Ca, Mg - individualized and adjusted daily based on serum levels
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TPN and insulin, ranitidine, heparin
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Insulin - hypoglycemia can occur - so not usually used Ranitidine - histamine Heparin - added to help protect the vein
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Total Nutrient Admixture
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- mix all components of TPN into one bag
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Non TNA
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- the AA solution and dextrose are mixed in one bag - lipid is administered in a seperate bag
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Completing PN Requistion
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Pts requirement 1) determine protein (g) to provide 2) determine glucose (g) to provide 3) make up the remainder of Kcal with lipid 4) determine the amt of electrolytes (based on daily IV requirements, serum levels and renal function) 5) include multi vit, TES and any other additives
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PN infusion rate
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- variable -- continuous vs. cyclic infusion - pt dependent - volume dependent - to discontinue - gradual decrease in infusion rate until transition to oral or EN meets minimal nutrient needs - catheter often remains for medications
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PN Complications: Metabolic related
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- hyper/hypoglycemia - hypertriglyceridemia - EFA deficiency - Fluid Overload/dehydration - Prerenal azotemia - hyper/hypo electrolytes - abnormal liver function tests - metabolic acid/base balance - hyperammonemia - iron deficiency
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EFA
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Essential fatty acids linolenic, linoleic acid
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PN Complications
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- placement and positioning of catheter - infection - catheter, site, solution - Phiebitis - irriation of vessel wall by catheter or hyperosmolar solutions - thrombosis - Perforation - Pneumothorax - occlusion
