Transcript Nutritional support - Philadelphia University Jordan

Nutritional support
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
Philadelphia university
• Critically ill patients are often
unable to eat because of
1-Endotracheal intubation.
2-The need for mechanical ventilation.
3-Altered level of consciousness as a
result of severe trauma, major
surgery or acute medical condition.
lack of nutrients may:
1-Alter the structure and function
of the gut.
2-Increase the risk of entry and
spread of intestinal bacteria.
• Early
nutritional
support
for
critically ill patients has been
advocated to:
• 1-Promote the immune system
recovery
• 2-prevent as much as tissue
breakdown
• 3-nutritional deficit as possible
4-Improves patient outcomes.
5-Enhances recovery from illness.
Nutritional support means the
provision of patient's dietary
requirements
Nutritional support: includes:
the use of artificial feeding
methods such as tube feeding
(enteral feeding), totalparenteral
nutrition (TPN)and administration
of intravenous fluids
• Enteral
feeding
should
be
prescribed whenever oral intake
is inadequate for the patient who
has a functional gastrointestinal
tract.
• Enteral feeding has several
advantages over total parenteral
nutrition:
• 1-EN has been shown to be
easier, safer and cheaper than
PN.
• 2- EF maintains the structure and
functional integrity of the
gastrointestinal
tract
by
intraluminal delivery of nutrients
and preventing atrophic changes.
• 3-EF preserves the normal
sequence
of
intestinal
and
hepatic
metabolism,
fat
metabolism, lipoprotein synthesis
and prevents cholestasis by
stimulating bile flow.
4-Maintains normal insulin / glucagon
ratios.
5-Reduction in septic complications
with EF compared with PN.
6-EF improves systemic immunity and
lower infection risk.
7- Prevents translocation of bacteria
into the systemic circulation and
reduce the incidence of sepsis.
• On the other hand, intragastric EN
often is complicated by intolerance,
as indicated by elevated volumes of
aspirated gastric residual.
High
gastric residual is a return of at
least half of the hourly feeding rate.
It is commonly accepted that high
gastric residual volume enhances
regurgitation and increases the risk
for aspiration pneumonia.
• Gastric residual is the amount of
previous feeding remaining in the
stomach
• Gastric volume during intragastric
feeding is determined by the balance
between
• The amount of infused formula plus
• The endogenous secretions of saliva
• And gastric juice and
• The amount of fluid emptied from the
stomach.
• Fluids that commonly accumulate
•
•
•
•
in the gastrointestinal tract of a tube
fed patient include the
1-Feeding formula,
2-Swallowed saliva (> 0.8 L/ day),
3-Gastric secretion (1.5 L/ day),
4-Small bowel secretion regurgitated
into the stomach (2.7 – 3 L/ day).
• Critical care nurses play a crucial
role before initiating NS to
prevent high residual volume and
other complications.
• Critically ill patients with feeding
tubes are therefore at higher
risk for adverse outcomes than
are other patients with feeding
tubes
• Most
complications
can
be
prevented with close monitoring
and
timely
and
accurate
assessment
of
a
patient’s
tolerance to feeding.
• Nurses are responsible for
monitoring tolerance for the
duration of therapy.
A- Residuals should be checked for
color, consistency and amount of
last feeding still in the stomach,
also for tolerance of enteral
feeding .
B- Haemodynamic status should be
monitored during nasogastric
tube feeding.
• Patients
receiving
isotonic
formulas who are given too much
fluid may show signs of fluid
excess such as weight gain,
edema and may develop dilutional
hyponatremia.
• On the other hand, patients
receiving hypertonic, high-protein
feedings who do not ingest
enough fluid are at risk for lifethreatening
condition
called
tube-feeding
syndrome,
characterized by fluid-volume
deficit,
hypernatremia,
hyperchloremia and azotemia.
• So it is very important to monitor and
assess fluid intake and output such as
1- body weight,
2-edema and respiratory rate,
3-blood urea nitrogen and other
electrolytes.
The practice that is very important
during feeding is measuring the
gastric residual volumes: to help the
nurse to confirm the placement of the
tube,
determine the nutritional tolerance
and occurrence of gastric delay and
if a high gastric residual volume can be
detected early, it may be possible to
prevent complications.
COMPLICATIONS OF EF •
• Mechanical complication
• Gastrointestinal complications
• Metabolic complications
Mechanical complication
• Aspiration
• Tube obstruction
• Tube displacement
• Aspiration is the most dangerous
mechanical complication associated
with EF. Pulmonary aspiration of EF
with subsequent pneumonia is a
frequent and serious complication of
enteral nutrition in critically ill adults
despite the presence of cuffed and
properly inflated endotracheal tubes.
• Aspiration pneumonia develops in 43%
of patients on nasogastric tube
feeding and in 56% of patients with a
gastrostomy
• CAUSES OF ASPIRATION
A-When gastric motility is moderately
or seriously impaired, feedings
accumulate in the stomach along with
gastric secretions and predispose to
reflux and aspiration. Therefore, if a
high gastric residual volume can be
detected early, it may be possible to
prevent aspiration.
• Nosocomial pneumonia accounts for
13% to 18% of nosocomial infections
and is the leading cause of death.
Rates of nosocomial pneumonia and
associated mortality are high in
patients
receiving
mechanical
ventilation and aspiration is the
primary route by which bacteria
enter the lung.
B-Other common causes of aspiration is
tube placed in the trachea and
regurgitation, this can be prevented
by several techniques such as:
1-Checking the tube position before
feeding
2-Elevating head of bed 30-60 degree
during feeding and for one hour
afterwards and if feeding is given by
bolus.
3-No more than 330 ml should be given
at one feeding to prevent excessive
distension of stomach.
4-Also checking the gastric residual
before each feed and if more than
150 ml, feeding should be held to
prevent gastric distension.
• NURSING ROLE
• Critical care nurses play a vital role in
early detection of aspiration of
gastric content into the pulmonary
bed through the following methods:
• food coloring method
• Checking Ph
• glucose strips
• Using the food coloring method, by
adding blue food coloring to feeding
formulas to achieve a visible blue
color,
then
suctioning
tracheal
secretions into transparent suction
trap and examining the specimen for
blue discoloration against a white
background under full room lighting.
• Checking pH is another method for
detecting aspiration of gastric fluid
into the lungs, because pulmonary
fluid has a pH of approximately 7.6
while
gastric
pH
is
less
than 4.
• Moreover glucose strips can help to
identify the fluid aspirated from the
nasogastric tube as follows: a positive
glucose reading is defined as a
tracheal secretion specimen having a
glucose concentration of ≥20 mg /dl
measured using an automated glucose
meter.
• Presumptive aspiration is defined
as having occurred when tracheal
secretions showed either a positive
glucose reading or observable blue
discoloration.
• On the other hand, measuring the
glucose level is considered a more
labored intensive technique because
nurses should be trained and
certified to use the bedside glucose
testing equipment, in addition to the
costs associated with the glucose
strips.
• Clinically, significant aspiration is
defined as the occurrence of
objective aspiration combined with
one or more signs of systemic
inflammation (temperature ≥ 37.8oC;
heart rate ≥ 100 beats/min; leukocyte
count ≥ 10.000 /cu mm)
• and one or more signs of respiratory
deterioration (respirations ≥ 20/min
Pao2 < 60mmHg with Fio2 > 0.50) in
addition to X ray
• So it is very important to observe and
measure the vital signs to determine
the occurrence of aspiration and any
alterations in the haemodynamic
status that can lead to increasing the
days remaining in the hospital and on
nasogastric tube feeding
Gastrointestinal complications
•
•
•
•
•
Nausea and vomiting,
Constipation
Delayed gastric emptying
Distension
Diarrhea
• Nausea and vomiting associated with
EF can be caused by the following:
1-Tube migration into the esophagus,
2-Decreased absorption that lead to
increase the gastric residual volume
and
hyperosmolar
formula
and
excessive infusion of air.
3-An excessive accumulation of EF and
gastric secretions increases the
potential for regurgitation and
vomiting.
• Nursing interventions to reduce this
complication include :
1-Checking residuals and holding feeding for
one hour and rechecking if high gastric
residual is found.
2-The head of the bed should be kept
elevated.
3-When giving a bolus feeding, tubing should
be pinched off when refilling syringe with
formula and when giving continuous
feeding, checking that the bag does not
empty before closing off tubing is
importance.
• Also
when
patients
experience
nausea, it is important to empty the
stomach by aspirating the gastric
residual volumes through the gastric
tube.
4- Other interventions to reduce nausea and
vomiting include changing the formula to
low- fat formula.
5-Administering
prokinetic
agent
(metoclopramide, cisapride) to stimulate
gastrointestinal motility.
6-Positioning the patients on the right side
to facilitate the passage of gastric
contents through the pylorus.
7-Maintaining the patients head of bed
elevated at 30-45 degree angle during
feeding and for 30-60 minutes after
feeding.
Delayed gastric emptying: is also considered
among the problems associated with EF.
To determine the presence of delayed
gastric
emptying,
measuring
gastric
residual volumes should be done.
Residual volume greater than the hourly rate
indicates impairment in gastric emptying.
• Delayed gastric emptying can be
caused by several causes such as
critical illness, high density and high
lipid content and effect of medication
such as narcotic
• Distension is another gastrointestinal
complication associated with tube
feeding, causes of distension may
include:
1-Poor gastric emptying that lead to
increase gastric residual volume.
2-Rapid infusion of feeding and
constipation or diarrhea.
• Air in the tube
• Cold formula and bolus feeding rapidly
administered.
• Nursing measures to reduce distension
include:
1-Reducing the rate of infusion and giving
gastric motility agents.
2-If possible encourage mobility and treat
constipation or diarrhea.
3-Check the rate and temperature of the
formula before administration.
4-Eliminate all air from the delivery system
before attaching it to the feeding tube and
always keep tube clamped between
intermittent feedings.
• Diarrhea: There are several causes leading
to diarrhea namely:
• Drug therapy
• Hypoalbuminemia or high osmolarity of the
formula,
• The rapid infusion, bolus feeding,
• Bacterial-contaminated: feeding which is
considered a significant cause of diarrhea.
Potential contamination during checking
residual volumes can occur, since this is not a
sterile procedure.
•
• In addition to the formula which can
become contaminated at any point in
the preparation and delivery process
• as well as temperature of the formula .
However, the cause of diarrhea is often
multifactorial, particularly in critically ill
patients.
• When
patients
have
moderate
deficits in serum albumin levels
indicating malnutrition, possibly this
malnutrition leads to less efficient
intestinal
absorption
which
predisposes the patient to diarrhea.
Also pulmonary patients who are
critically ill and require mechanical
ventilation may be in catabolic phase
of metabolism which may decrease
the ability of the gut to absorb.
• The treatment of diarrhea is based
on the cause and is aimed at replacing
fluid and electrolytes and decreasing
the number, volume and frequency of
stools.
• Nursing management include
the
following:
1-Evaluating the drug regimen for
possible
cause
of
drug-induced
diarrhea
such
as
antibiotic,
magnesium-containing antacids
2-Checking the serum albumin levels,
3-Administering formula requiring less
digestion and by a slow rate,
4-Administering lactose-free formula,
5-Replacing the bag and tubing using
aseptic techniques and careful hand
washing
before
formula
administration,
6-Changing to high fiber formula.
7-Assessing fluid balance, electrolyte
levels
8-As well as
checking formula
temperature. .
Metabolic complications
• Consist of fluid and electrolytes
imbalance namely;
• Hypernatremia,
• Hhyponatremia,
• Hhyperkalemia,
• Hhypokalemia,
• Overhydration,
• Dehydration,
• Hyperglycemia and hypoglycemia.
• The
loss
of
gastrointestinal
secretions by vomiting, diarrhea or
nasogastric suctioning may cause
sodium, potassium and chloride loss,
excessive gastric residual can be
reinjected to prevent electrolyte
abnormalities and nutrients loss.
• The basal oral potassium requirement
is 5 –6 m mol / kg body weight per
day, however, in depleted and
catabolic patients this may increase
to a maximum of 9 m mol / kg body
weight over 24 hours.
• Intravenous potassium chloride is
usually given for correcting potassium
deficit and maintaining potassium
balance.
• Hyperkalemia (↑ 5.0 m Eq/L) may be
caused by: extrarenal causes such as
metabolic acidosis, decreased insulin
availability/hyperglycemia that is
enhancing
the
delayed
gastric
emptying and may increase the
gastric residual volume, exercise,
tissue
catabolism,
excessive
intravenous
infusions
or
oral
administration of potassium, blood
for transfusion that is two weeks old
or more and digitalis overdose.
• Renal causes include renal failure,
renal insufficiency, decreased urine
output after surgery, decreased
effective arterial blood volume miner
alocorticoid deficiency that may
result from either the production of
aldosterone or the diminished effect
of the hormone on the kidney.
• The nursing management include
reducing potassium intake, closely
monitoring of serum potassium level,
in addition to the flow rate of
intravenous fluid with potassium
• Hypokalemia (↓3.5mEq/L) may be due
to
extrarenal
causes
such
as
gastrointestinal
losses
namely;
vomiting,
diarrhea,
nasogastric
suctioning that lead to decrease the
gastric residual volumes, excessive tap
water enemas,
• medications such as potassium-wasting
diuretics, insulin which moves glucose
and potassium back into cells, steroids
and beta-adrenergics promot potassium
loss and alkalosis which causes
potassium to shift into cells in exchange
for the hydrogen ion.
• Renal
causes
such
as
mineralocorticoid excess,
nonreabsorbable anions and diuretic
phase of acute renal failure .
• Nursing management: the nurse should
• Monitor serum potassium daily,
• Assess patients for signs and symptoms of
decreased cardiac output and the
development of congestive heart failure
because, in hypokalemia, the contractility
of the cardiac muscle is impaired,
• The ECG should be observed for changes
indicative of hypokalemia,
• The emergency resuscitation equipment
should be kept readily available,
• Nurses should provide appropriate
support and assistance as necessary
because muscle weakness is a common
manifestation of hypokalemia and the
patients may not have the strength to
perform activities.
• Hypernatremia (↑ NA 145 m Eq/L) may
be caused by
A-hypovolemic hypernatremia such as
renal losses (osmotic diuresis, severe
hyperglycemia) or extrarenal losses
(decreased thirst, diarrhea occurring
with inadequate volume replacement or
fluid replacement with hyperosmolar
solutions)
B-Hypervolemic hypernatremia such as
the administration of concentrated
saline solutions, hypertonic feedings,
commercially prepared soups and
canned vegetables.
C-Euvolemic hypernatremia
such as
excess fluid losses from the skin and
lungs, hypodipsia in the elderly and
infants.
• To decrease the total body sodium
and replace fluid loss, either a hypoosmolar electrolyte solution (NaCL) or
D5 W is administered.
• Nursing
management
for
hypernatremia include: Assess the
patients for the following:
1-Signs and symptoms of dehydration
namely daily body weight, skin turgor,
oral mucous membrane, blood urea
nitrogen, central venous pressure,
tachycardia and hypotension,
2-Assessment for drugs that contain
sodium such as cough medication and
corticosteroids,
3-The diet should also be assessed
for sodium consumption
4-And the serum sodium level should
be checked.
• Hyponatremia (↓ NA 135 m Eq/L), is
usually associated with fluid volume
status.
• Hyponatremia may occur when the
total body water is decreased
• Also may result from the kidney's
inability to excrete sufficiently
diluted urine.
•
• Hyponatremia may be caused by:
A-Hypovolemic hyponatremia such as:
• Renal loss of sodium from diuretic use,
diabetic glycosuria, intrinsic renal
disease.
• Extrarenal loss of sodium from
vomiting, diarrhea, increased sweating
and burns.
B-Hypervolemic hyponatremia such as:
edematous disorders resulting in sodium
deficits namely congestive heart failure,
acute and chronic renal failure.
C-Euvolemic hyponatremia such as
sodium deficit.
Inappropriate
secretion
of
antidiuretic
hormone
or
the
continuous secretion of antidiuretic
hormone due to pain.
Discarding gastric residual volume can
lead to a decrease in the sodium level
because of gastrointestinal secretion
losses mainly sodium.
• Nursing management, the nurse should be:
• Obtain a history of the cause of
hyponatremia such as vomiting, diarrhea
and decrease intake of sodium.
• Check serum sodium levels and estimating
the serum osmolality.
• Assess urine output as well as recent
fluctuation in body weight.
• Observe
signs
and
symptoms
of
hyponatremia (headache, mental status
changes, nausea, vomiting and abdominal
cramping ).
• Hyperglycemia,
a
metabolic
complication that can be caused by
high carbohydrate formula and
Hyperosmolar
feeding
of
fluid
overload.
• Hyperglycemia can be prevented by:
1-Monitoring for fluid balance, urine
and blood for glucose.
2-Administering insulin on a sliding
scale if necessary
3-Changing the formula to lower calorie
content
and
observing
for
hypercapnea.
• hypoglycemia, caused by:
• Sudden cessation of feeding can be
prevented by frequent monitoring of
blood sugar if feeding is interrupted.
• Dehydration caused by:
1-High osmolality formula.
2-Diarrhea and excessive protein
intake with inadequate fluid intake.
3-Large amount of fluid that can be
lost during prolonged uncorrected
vomiting
and
diarrhea
without
adequate replacement of fluid and
electrolytes.
4-Also it may result if gastric and
intestinal suctioning occur without
the proper monitoring of intake and
output to ensure that fluid and
electrolytes losses are adequately
replaced.
Management of dehydration include:
1-Management of the diarrhea,
2-Decreasing the protein content of
the formula
3-The provision of additional water and
changing the formula if
high
osmolality formula is used
4-Also reporting signs and symptoms of
dehydration.
• Overhydration, can be caused by:
1-Fluid overload,
2-When the metabolic demands are
high and the organ function is
impaired namely cardiac, renal or
hepatic.
Management of Overhydration include:
1-Restricting free water intake
2-Changing to concentrated formula
3-Administering diuretics
4-Decrease the delivery rate.
• Body weight alteration,
• body weight is the most important single
indicator of the overall nutritional status in
adults. Reasons for weight loss include:
• Reduced oral intake, patients dislike of the
food offered,
• The wrong timing of meals
• Medications affecting patient's appetite
• In addition to the environment.
• Moreover defective gastrointestinal
function can cause poor absorption of
nutrients
• the catabolic effects of disease can
accelerate weight loss.
• On the other hand, rapid excessive
weight gain can be caused by:
• Excess calories,
• Excess
fluid
and
electrolytes
imbalance.
• Most patients can be weighed on
scales, but sometimes it is difficult
or impossible to obtain a patient’s
weight, because of the patient’s
medical
conditions,
equipment
attached to the patient (for example,
life
support
devices,
traction
equipment.) or lack of a suitable bed
or wheelchair scale.
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FEMALES
Age
Equation
19-59
(KH X1.01)+(MAC X 2.81)-66.04
60-80
(KH X 1.09)+(MAC X 2.68)-65.51
MALES
19-59
(KH X 1.19)+(MAC X 3.21)-86.82
60-80
(KH X 1.10)+(MAC X 3.07)-75.81
KH knee height
MAC mid-arm circumference
mechanical complications
• Tube obstruction
• Tube displacement
• Aspiration
• Tube obstruction, a mechanical
complication associated with NGF can
be related to
1-The increased frequency of checking
residual volume.
2-The use of dense formula or
insufficiently crushed medicines
Nursing interventions to prevent or
decrease tube obstruction:
1-Obtaining liquid medications when
possible
2-Flushing feeding tube before and
after medication administration
3-And diluting feeding with water if it
is dense and straining if necessary.
• Whenever
different
types
of
medications are administered, each
type should be given separately using
the bolus method that is compatible
with its preparation and the tube
should be flushed with 15 to 30 ml of
water after each dose.
• Tube
displacement,
another
mechanical complication of NGF, can
be detected through aspirating
gastric residual volume.
• Failure to aspirate recognizable
gastric contents is an indication that
the tube is not in the stomach.
• However others believe that inability
to aspirate fluid through the syringe
may merely reflect collapse of the
walls of the small-bore feeding tubes.
• Tube displacement may be caused by
excessive coughing, vomiting, tracheal
suctioning, air way intubation and this
can be managed by checking tube
placement
before
administering
feeding.
Parenteral Nutrition
• A variety of locations can serve as
sites for catheter insertion including:
• subclavian,
• internal jugular,
• external iliac,
• and cephalic veins
• Solutions containing 10% or less
dextrose (final concentration) plus
amino acids (750-900 mOsm/L).
• This practice is associated with a
high risk of phlebitis and is therefore
reserved for short-term therapy in
individuals with robust veins
• Initiating Parenteral Nutrition (PN)
• 1. Formula Determination
• Determine
energy
requirement
Determine protein requirements.
• Determine fluid requirements .
• Determine the proportion of calories
to be provided as intravenous fat
Complications of Parenteral Nutrition
• Technical
• Septic
• Metabolic complications
• Technical complications associated
with PN include:
• Air embolism
• Subclavi
anartery
puncture/hemotoma/laceration
• Pneumothorax, hemothorax
• Carotid artery injury
•
•
•
•
•
Thromboembolism
Catheter embolism
Catheter malposition
brachial plexus injury
and phrenic nerve paralysis
• Septic complications associated with
PN include:
• Catheter infection,
• Catheter tunnel infection, and sepsis.
Metabolic complications
Complication
Dehydration
Possible Cause
Inadequate
fluid
support;
unaccounted
fluid
loss
(e.g.
diarrhea, fistulae, persistent high
fever
Overhydration
Excess
fluid
administration;
compromised renal or cardiac
function
Alkalosis
Acidosis
Inadequate K to compensate for
cellular uptake during glucose
transport; excessive GI or renal
K losses. Inadequate Cl in
patients undergoing gastric
decompression.
Excessive renal or Gl losses of
base; excessive Cl in PN
Hypocalcemia
Excessive PO4salts, low
serum albumin. Inadequate Ca
in PN
Hypercalcemia Excessive Ca in PN or
administration of vitamin A in
patients with renal failure.
Hypomagnese
mia
Inadequate Mg in PN;
excessive Mg losses; cellular
uptake with induction of
anabolism
Hypophosphate
mia
Excess losses (urinary PO4; in
alkalosis, diabetes mellitus, steroid
and diuretic therapy); cellular uptake
with induction of anabolism
Hyperglycemic,
hyperosmolar
nonketonic coma
Sustained
untreated
glucose
intolerance. Easily prevented by
frequent glucose monitoring. 40%
mortality rate.
Hyperglycemia
Stress response. Occurs in
approximately 25% of cases.
Hypoglycemia
Sudden
withdrawal
concentrated glucose.
common in children.
of
More
Hypercarbia
Excessive calorie or
carbohydrate load
Essential fatty
acid
Inadequate provision of linoleic acid in
PN; release of linoleic deficiency acid from
adipose stores prevented by continuous
dextrose
infusion
and
associated
hyperinsulinemia.
Hepatic tissue
damage and fat
infiltration
Unclear etiology. Maybe be
related to excessive glucose or
energy administration;
Cholestasis
Lack of GI stimulation. Sludge present
in 50% of patients on PN for 406
weeks; resolves with resumption of
enteral feeding.