Transcript NFSC 470 Seminar MNT “Pre-Test”

NFSC 470
Seminar MNT
Review of Clinical Nutrition
What are some signs/symptoms of dysphagia?
What labs might be affected?
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If dysphagia doesn’t resolve and you must
recommend a tube feeding, where would you
recommend it be placed and why?
What are your diet and lifestyle recommendations
for someone who has GERD?
So… for GERD:
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What are the nutrition implications of chronic
gastritis? In other words, the absorption of what
vitamin might be affected, and this would lead to
what condition?
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What are the most common causes of gastric ulcers?
What recommendations would you give to
your patients with ulcers?
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The post-gastrectomy diet is designed to decrease
risk for dumping syndrome. What are the primary
tenets of this diet?
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What are the signs of fat malabsorption? What are
the nutritional implications? What are your
dietary recommendations for someone with fat
malabsorption, in general??
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What are your recommendations for someone with
lactose intolerance?
What is IBD? Name two forms.
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What are the nutritional recommendations for IBD?
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What are the dietary recommendations for
diverticulosis? Diverticulitis?
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Describe the nutrition recommendations for someone
with a colostomy or ileostomy.
What are some causes of hepatic steatosis? What are
your nutrition recommendations?
What are the biochemical indicators for hepatic
steatosis?
Ascites is associated with what disease state? What
are the nutritional recommendations?
Cirrhosis may cause steatorrhea. Why? What’s the
MNT?
Would you expect a change in lab values for
someone with cirrhosis?
What are the hallmark lab indicators of acute
pancreatitis? Hallmark symptoms?
Why would pancreatitis cause steatorrhea?
What’s the MNT for acute pancreatitis?
For someone with acute pancreatitis who requires a
tube feeding, where should it be placed and
why?
Tell me what could cause elevated blood glucose
levels.
What’s albumin and why do we look at it when
assessing nutritional status?
What pair of lab values may indicate dehydration?
(Tell me which way they’d be off, either
elevated or depressed).
What might cause low electrolyte values?
What does it mean, in general, if someone has a low
Hgb and Hct?
What does a high MCV mean, and what dietary
factors could cause it?
What are the two labs that (in general) together
indicate kidney disease?
In renal failure, how would you expect the following
labs to change? (Indicate up, down, or n/c for
no change)
___BUN
___creatinine
___uric acid
___K+ (potassium)
___ PO4 (Phosphorus)
___ Hgb/Hct
__albumin
What is Hgb A1c and what does it indicate?
What are the LDL goals for people with diabetes,
and why?
What does GFR indicate?
What are the dietary restrictions associated with
kidney failure? (pre-dialysis)
Which one of these changes once dialysis is
initiated?
List the “desirable” or “optimal” values:
a.
Total cholesterol (for people age 30+)
____________
b. LDL cholesterol __________
c. HDL cholesterol __________
d. TG (triglycerides) __________
e. Blood pressure ______________
f. Fasting blood glucose (range) ____________
g. Serum albumin ___________
What type of dietary fiber helps reduce serum
cholesterol? How does it do it? What are
some good food sources?
What is the DASH diet? For whom is it appropriate?
What are the main tenets of this diet?
What are the main tenets for the TLC diet?
(Therapeutic Lifestyle Changes)
Nutrient
Saturated fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
Cholesterol
Recommended Intake
Enteral Nutrition
• Indications
– Patient must have a functioning GI tract
– Malnourished patient expected to be unable to
eat >
– Normally nourished patient expected to be
unable to eat >
– (anorexia, comotose, head/neck surgery,
hypermetabolic, adaptive phase of SBS, upper
GI obstruction if TF can be placed beyond it)
• Contraindications
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Intractable vomiting and/or diarrhea
Intestinal obstruction, ileus, or bleed
Early SBS
Fistula
Early short-bowel syndrome
Pt. intolerance
No enteral access/pt. refusal
Pt. expected to eat within reasonable timeframe
Aggressive therapy not warranted
• Types of formulas
– Intact (Standard)
– Hydrolyzed (Elemental)
– Modular
• Kcals:
– Standard
– Concentrated
• Osmolality
• Routes of Administration
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NG
ND
NJ
PEG
PEJ
Enteral Calculations
Volume:
rate (ml/hr) x 24 hours = ml total volume/day
Kcals:
volume x kcal/ml = kcals
Protein:
g_ x volume (L) = g prot/day
L
Water:
volume x %free water (plus flushes) = ml/day
(Review Homework Problems)
Parenteral Nutrition
• TPN = Total Parenteral Nutrition
• Provision of nutrients intravenously
– Central
– Peripheral (PPN)
• For patients who are already malnourished or
have the potential for developing malnutrition
and who are not candidates for enteral nutrition
Indications for TPN
1. NPO for extended period (>10 days)
2. Enteral nutrition support projected to
be inadequate for >14 days
3. Extensive small bowel resections
4. Radiation enteritis
5. Intractable diarrhea/vomiting
6. GI tract obstruction
7. Severe acute pancreatitis
8. Fistula
B. Contraindications
1. Patients for whom EN would meet
requirements
2. Terminally ill patients.
Routes for Parenteral Nutrition
Central Venous Access
Routes for Parenteral Nutrition
Central Venous Access
• PICC Line
– Peripherally inserted central catheter
• Easier to insert than central line
Peripheral Parenteral Nutrition
(PPN)
Utilization of peripheral veins for the
administration of nutrients
Indications for use:
1. Short term PN
2. No access to central vein
3. Malnourished pts with frequent NPO for
procedures/tests
Contraindications:
1. Weak peripheral veins
2. Fluid restrictions (i.e. kidney disease, congestive
heart failure, etc.)
Limitations
Peripheral site more prone to inflammation/infection
Fewer kcals administered
Remember: PPN solution needs to have:
• <10% [dextrose] to avoid phlebitis
• lipids q day to protect the vein
Review of PN Solutions and
Calculations
Intravenous Solutions
Abbreviations:
D: dextrose
W: water
NS: normal saline (0.9% sodium chloride
solution)
D5W:
D10W:
D50W:
D70W:
Calculations
• Dextrose =
• AA =
• Lipid
– 10% lipid provides
– 20% lipid provides
– Lipid can be infused separately or with
dextrose and amino acid (admixture)
• TPN Orders – Several ways they can be
written. Examples:
– Per liter
• Example: 500 ml 70% dextrose, 500 ml 15% AA
@ 50 ml per hour, plus 250 ml 20% lipid/d
– Final concentration
• Example: 20% dextrose, 6% AA at 85 ml/hr plus
500 ml 10% lipid/d
– Per Day:
• 960ml 8.5% Aas, 960ml D50W at 80ml/hr, plus
250 ml 20% lipids q day
Example1: Figure out total kcalories and
protein grams per day from this per
liter order:
500 ml 8.5% AA/L = 1 liter ‘admixture’
500 ml D50W/L
to be run@75ml/hr.
plus 500ml 10% lipid In this example, lipids
are hung separately
Protein Grams (per 500 mL):
Kcalories (per L):
Example 2:
Calculate total kcals and protein grams
provided in this per-day formula
960ml 8.5% AAs
960ml D50W
to run @ 80ml/hr (X 24h = 1920ml)
plus 250 ml 20% lipids q day
D50W:
8.5% AAs:
Lipids:
TPN Administration
A. Rate
1. Start slowly, especially w/dextrose. Allows
blood to adapt to increased glucose/osmolality
2. Infusion pump is used to ensure proper rate.
3. Example: Start at 40ml/hr x 24hr. Then
progress to 80ml/hr x 24h (equivalent to
increasing TPN by 1 liter per day), etc. until goal
rate has been reached or patient intolerance is
noted.
a. If rate is increased too quickly, hyperglycemia may result
b. Monitor tolerance: electrolytes, blood glucose,
triglycerides, ammonia, etc.
4. Introduce lipids gradually to avoid adverse reactions (fever,
chills, backache, chest pain, allergic reactions, palpitations,
rapid breathing, wheezing, cyanosis, nausea, and unpleasant
taste in the mouth)
5. When pt. is taken off TPN, rate must be tapered off
gradually to prevent hypoglycemia.
6. ( TPN by ½ X 2 hrs, then DC – usually sufficient to
prevent hypoglycemia)
7. PPN doesn’t need to be tapered off (uses more dilute
solution w/less dextrose)
B. Cyclic Infusion
1. TPN infused at a constant rate for only <24
hours/day (e.g. 12-14hr overnight)
2. Allows more freedom/normal daytime activity
3. Can be used to reverse fatty liver resulting from
continuous infusion
(Chronically high insulin levels may inhibit fat mobilization
 fatty liver)
4. Fewer kcals may be necessary to maintain N
balance (body fat better mobilized for energy)
5. Requires higher infusion rate: not all patients can
tolerate it.
Potential TPN Complications
A. Catheter or Care-Related Complications:
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Fluid in the chest (hydrothorax)
Air or gas in the chest (pneumothorax)
Blood in the chest (hemothorax)
Sepsis
Blood clot (thrombosis)
Infusion pump malfunctions
Myocardial or arterial puncture
B. Metabolic or Nutrition-related
Complications
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Hyperglycemia/Hypoglycemia
Dehydration/Fluid overload
Electrolyte imbalances
Hyperammonemia
Acid-base imbalance
Fatty liver
Bone demineralization
Transitional Feedings -- moving
from parenteral to enteral nutrition
A. Begin oral diet while tapering off TPN
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B. Tube feeding while tapering off TPN
1. Rate of TF gradually increases as TPN rate
decreases
2. Remember that long term TPN without enteral
nutrients  atrophy of intestinal villi
C. Discontinue TPN when oral/enteral intake
provides
1. Consider possible apprehension to begin oral
intake
2. Poor appetite possible at first
3. Team members should provide support and
reassurance