Transcript File - Medical Nutrition Therapy Portfolio

Methods of Nutrition Support
KNH 411
Oral diets
 “House” or regular diet
 Therapeutic diets
 Maintain or restore health & nutritional status
 Accommodate changes in digestion, absorption, or organ
function
 Provide nutrition therapy through nutrient content changes
 usually soft
 texture change
 consistency change
 manipulating nutrients
Oral diets
 Changes from the house diet
 Caloric level (calculated through mifflin equation)
 Consistency (anywhere from regular diet to soft diet to
pured diet
 Single nutrient manipulation--ex: low fat diet
 Preparation--look at nutrients and how you will manipulate
them
 Food restriction
 Number, size, frequency of meals
 Addition of supplements
Oral diets
 post surgery/post procedure
 Texture modifications
 Soft diets
 Liquid diets
 Clear liquid
 Full liquid
 Consider osmolality
 Preparation for a specific medical test
Oral Supplements
 status post any GI surgery
 Goal: Increase nutrient density without increasing
volume
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Snacks
Liquid meal replacement formulas
Modular products
Commercial supplements
Appetite Stimulants
 Drugs that stimulate appetite
 Prednisone
 Megestrol acetate
 Dronabinol--derivative of marijuana (creates the munchies)
Specialized Nutrition Support (SNS)
 Administration of nutrients with therapeutic intent
 Enteral--if the gut works, use it
 Parenteral--gut doesn’t work; zero GI tolerance; use the
veins
 Ethical considerations
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Enteral Nutrition
 Feeding through the GI tract via tube, catheter or stoma delivering
nutrients distal to oral cavity
 “Tube feeding”
 Indicated for patients with functioning GI but unable to self-feed-altered mental status; swallowing dysfunction
 Contraindications
 Advantages / Disadvantages?
 very cost effective; decreased rate of infection; improved wound
healing and surgical intervention; helps maintain GI function
 difficult to administer; poor tolerance(patient may pull out tube);
placement of the tube(have to keep checking on it);
vomiting/diarrhea;
Enteral Nutrition
Decisions for the nutrition prescription
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GI access
Formula
Feeding technique--bolus or continuous
Equipment needed
Enteral Nutrition
GI Access
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Access route described by where it enters the body and
where the tip is located
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Nasogastric--nose into stomach
Orogastric--mouth into stomach
Nasointestinal--nose into small intestine (ND tube or NJ
tube)
Typically used for short term
Disadvantages?
Enteral Nutrition
GI Access
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– “Ostomy”
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Gastrostomy
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Jejunostomy
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PEG
More permanent
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Enteral Nutrition
Formulas
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Based on substrates, nutrient density, osmolality,
viscosity
Protein
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Soy or casein 10-25% kcal
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Elemental or chemically defined
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Specialized amino acid profiles
Enteral Nutrition
Formulas
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Carbohydrate
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Monosaccharides, oligosaccarides, dextrins, maltodextrins
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Lactose & sucrose free
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FOS
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Fiber ?
Enteral Nutrition
Formulas
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Lipid
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Corn or soy oil
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Long- and medium-chain TG
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Omega-3 fatty acids
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Structured lipids
Enteral Nutrition
Formulas
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Vitamins and minerals
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Meet DRI
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Supplemental amounts
Fluid and nutrient density
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1.0-2.0 kcal per mL
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Difference depends on water content
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Ensure adequate fluid - 80% water for 1 kcal per mL
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Osmolality and osmolarity
Enteral Nutrition
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Formulas
 Other considerations
 Considered medical food – not drug
 No test for efficacy or benefit
 Cost
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Enteral Nutrition
 Feeding techniques/ delivery
methods
 Bolus feedings
 Intermittent feedings
 Continuous feedings
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Enteral Nutrition
 Equipment
 Feeding tubes - french size
 Cans or sealed containers
 Pumps
Enteral Nutrition
 Determining the nutrition prescription
- clinical application
 Determine dose weight, calorie goal
 adjust injury/activity factor that would increase needs
 identify calories from protein, lipids, and carbs
 consider electrolyte needs
 consider vitamins and minerals
 look at fluids--are they fluid restricted or can they recieve
normal amount
Enteral Nutrition
 Complications
 Mechanical complications
 Clogged or misplaced tubes
 GI complications
 Diarrhea
 Aspiration
Enteral Nutrition
 Monitoring for complications
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Dehydration
Tube Feeding Syndrome
Electrolyte Imbalances
Underfeeding or Overfeeding
Hyperglycemia
Refeeding Syndrome
 Monitor serum phosphorus, mg, potassium
Parenteral Nutrition
 Administration by “vein”
 7-14 days
 a.k.a. – PN, TPN, CVN, IVH
 TPN vs. PPN
 Indicated if unable to use oral diet or enteral nutrition
 Certification of medical necessity
Parenteral Nutrition
 Venous access
 Short-term access
 CVC inserted percutaneously
 Using subclavian, jugular, femoral veins
 PICC
 most common
 can be used bedside
 Long-term access
 Tunneled catheters
 Implantable ports(lie completely below the skin)
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Parenteral Nutrition
 Solutions
 Compounded by pharmacist using “clean room”
 Two-in-one
 Dextrose & amino acids
 Lipids added separately
 Clear - easier to identify precipitates
 Three-in-one
 Dextrose, amino acids & lipids
 Single administration
Parenteral Nutrition
 Solutions
 Protein
 Individual amino acids
 Modified products for renal, hepatic and stress
 Commercial amino acids 3.5-20%
 3%--peripheral; 20%--kidney or heart patients needing
smaller volume
 .8- 1.8 g/kg is desired amount depending on condition
 1.5-1.8--status post surgery, burn patients, trauma, healing of
wounds
 restrict with renal; look at BUN and creatine and fluid status
Parenteral Nutrition
 Solutions
 Carbohydrates
 Energy source – dextrose monohydrate
 3.4 kcal/g
 1 mg/kg/min minimum
 5%, 10%, 50%, 70% concentrations
 peripheral is normally 10%
 >10% will need TPN or central line
 concerns--hyperglycemia, excessive CO2, fatty liver
Parenteral Nutrition
 Solutions
 Lipids
 10% solution--1.1 kcal/cc of solution (.1 extra comes from glycerin
 20% solution--2 kcal/cc of solution
 30% solution--3 kcal/cc of solution (rarely used)
 Emulsion of soybean or safflower oil
 Essential fatty acids need to be present
 Source of energy
 Minimum of 10% kcal
 1-1.2 g/kilo
 shouldn’t go above 60% of daily kcals (very high; normally 20-30%)
Parenteral Nutrition
 Solutions
 Electrolytes
 sodium and potassium--1-2 g/kilo
 Chloride--as needed
 magnesium--4-10 milequivalents per kilo
 phosphorus--20-40 millequivalents per kilo
 DRI standards used
 Vitamins/Minerals
 A, C, D, E, K, and compliment of B vitamins
 Trace minerals--zinc, copper, chromium, iodide, molibdium
 Medications
 may add more insulin; albumin to support blood pressure
 need to be looking at drug/nutrient interaction
© 2007 Thomson - Wadsworth
Parenteral Nutrition
 Determining the nutrition prescription
– clinical application
- sample form
Parenteral Nutrition
 Administration techniques
 Initiate 1 L first day; increase to goal volume on day 2
 Patient monitoring
 Intake vs. output
 Laboratory monitoring
Parenteral Nutrition
 Complications
 GI complications
 cholestasis
 Infections
 can occur at site where TPN is being delivered