Transcript Methods of Nutrition Support - KNH 411 Medical Nutrition

Methods of Nutrition Support
KNH 411
Oral diets
 “House” or regular diet
 In hospital for testing before any diagnoses have been
made
 Therapeutic diets
 Soft/manipulating texture or nutrients
 Maintain or restore health & nutritional status
 Accommodate changes in digestion, absorption, or organ
function
 Provide nutrition therapy through nutrient content changes
Oral diets
 Changes from the house diet
 *Caloric level (most important!)
 Mifflin Equation
 Consistency
 From a regular diet-to a soft diet
 Single nutrient manipulation
 Fat, CHO, Pro
 Ex: low-fat diet with a patient who has a high lipid content
 Preparation
 Low Na? High K? How will be manipulate foods?
 Food restriction
 Standard serving sizes/amounts needed to lose weight once they leave the
hospital
 Number, size, frequency of meals
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Multiple feedings, high calorie, high energy, nutrient-dense—cancer patients!
 Addition of supplements
Oral diets
 Texture modifications
 Soft diets
 Liquid diets
 Clear liquid
 Low osmolarity
 Full liquid
 More consistency & higher osmolarity
 Adds back in milk products/lactose
 Consider osmolality
 Soft diet
 Preparation for a specific medical test
Oral Supplements
 Goal: Increase nutrient density without increasing
volume
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Snacks
Liquid meal replacement formulas
Modular products
Commercial supplements
Ex: status post bariatric surgery
Appetite Stimulants
 Drugs that stimulate appetite
 Post-op
 Cancer Patients
 Prednisone
 Megestrol acetate
 Dronabinol
 Derivative of marijuana (“munchies”)
Specialized Nutrition Support (SNS)
 Administration of nutrients with therapeutic intent
 Enteral
 If gut works, use it!
 First line of defense
 Adequate feeding via gut
 Parenteral
 Gut isn’t working
 Peripherally or centrally using the veins for feeding
 Second line of defense
 PPN: if GI tract can’t tolderate feeds, can do this for 7 days
 If longer, a central line will be surgically planced via a central line
 Ethical considerations
© 2007 Thomson - Wadsworth
Enteral Nutrition
 Feeding through the GI tract via tube, catheter or stoma delivering nutrients
distal to oral cavity
 “Tube feeding” (nasogastric? Orogastric?)
 Indicated for patients with functioning GI but unable to self-feed
 Alterened mental status
 Swallowing dysfunction
 Contraindications
 Concerns with inflammatory response (nausea, vomiting)
 Advantages / Disadvantages?
 Quick, cost effective, decreased rate of infection, improved wound healing,
need to maintain GI function
 Difficult to administer (nose to stomach or SI), poor tolerance (patient may
pull out tube), constantly checking for correct placement, vomiting/diarrhea
Enteral Nutrition
Decisions for the nutrition prescription
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GI access
Formula
Feeding technique
Equipment needed
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Pump?
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Bolus feeds?
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
Orogastric
Nasointestinal (nose to duodenum or jejunum)
Typically used for short term
Disadvantages?
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Discomfort with NG tube
Tubes may get clogged if smaller (constant flushing)
Enteral Nutrition
GI Access
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– “Ostomy”
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Gastrostomy
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Jejunostomy
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PEG
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Endoscope to go into stomach to place tube to put the
formula in
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Long-term solution
More permanent
© 2007 Thomson - Wadsworth
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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Protein from peptides (completely broken down)
Specialized amino acid profiles
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Increase protein product for dialysis patient
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Decrease protein product for pre-renal
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S/P surgery or in a stressed state: increased protein
Enteral
Nutrition
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Formulas
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Carbohydrate
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Monosaccharides, oligosaccarides, dextrins, maltodextrins
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Lactose & sucrose free (most individuals with GI
complications don’t want to complicate that GI sytsem
further with lactase)
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FOS
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Fermented into short chains
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Compromised GI tracts (helps maintain GI integrity)
Fiber ?
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Needed for those with Inflamed GI tract
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Thickening formulas helping with improved bowel
functions—soluble fibers
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Insoluble fibers: soy, polysaccharides
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Long-term feeding patients have concerns with
constipation
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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Maintains immune function
Structured lipids
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Newer products made from fish oils that help with CV
health
Enteral Nutrition
Formulas
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Vitamins and minerals
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Meet DRI
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Supplemental amounts
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Most formulas with 1500 cc’s will contain the needed vitamin amount
Fluid and nutrient density
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1.0-2.0 kcal per mL (per cc)
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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 vs.** osmolarity
*: # water attracting particles per water weight
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Enteral feedings/how many calories per cc
**: # miilimoles of solid or liquid in liter solution
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Parenteral nutrition (feeding via VI) and how dense/hypertonic
particles are in fluid solution going through a vein
Enteral Nutrition
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Formulas
 Other considerations
 Considered medical food – not drug
 No test for efficacy or benefit
 Cost
© 2007 Thomson - Wadsworth
Enteral Nutrition
 Feeding techniques/ delivery
methods
 Bolus feedings
 250-500 cc’s spread out
throughout the day (3-6 times
per day)
 Intermittent feedings
 Several times per day over 20-30
minutes
 Continuous feedings
 Reserved for hospital/bed bound
clients
© 2007 Thomson - Wadsworth
Enteral Nutrition
 Equipment
 Feeding tubes - french size
 Cans or sealed containers
 Pumps
Enteral Nutrition
 Determining the nutrition prescription
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clinical application
Determine dose weight
Determine calorie goal
Adjust for activity or injury (that would increase needs)
Calculate protein goal
Identify overall calories
ID appropriate amount calories from lipids, then CHO, then
consider electrolyte needs, with consider vitamin/mineral
needs
- Look at fluids (fluid restricted or can they receive the
normal 1 calorie per cc?)
Enteral Nutrition
 Complications
 Mechanical complications
 Clogged or misplaced tubes
 GI complications
 Diarrhea
 Aspiration (formula reflux)
 ^All signs they may need perenteral nutrition
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”
 Gut doesn’t work
 Nutrition via IV for 7-14 days
 Dextrose levels <10
 a.k.a. – PN, TPN (total parenteral nutrition), CVN (central
vein nutrition), IVH (intravenous hyperalimentation)
 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
 Most common
 Can be placed at bedside
 Using subclavian, jugular, femoral veins
 PICC
 Long-term access
 Tunneled catheters
 Concerned with infection—needs to be done using surgery
 Implantable ports lye completely below the skin—surgery
© 2007 Thomson - Wadsworth
Parenteral Nutrition
 Solutions
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Work hand-in-hand with pharmacist
Compounded by pharmacist using “clean room”
300, 400, or 500 cc’s are common
Two-in-one
 Dextrose & amino acids
 Lipids added separately
 Benefit: clear - easier to identify precipitates
 Three-in-one
 Dextrose, amino acids & lipids
 Quick/easy access
 Cost saving
 Single administration
 Less opportunities for infection
Parenteral Nutrition
 Solutions
 Protein
 3% (PN patient) -20% (individual who is needing a concentrated
solution)
 4 cals/g of amino acid put into solution
 Individual amino acids
 Modified products for renal, hepatic and stress
 Commercial amino acids 3.5-20%
 .8- 1.8 g/kg depending on condition
 .8-.8: regular patient in hospital
 1.5-1.8: Burn patient, trauam, staus post-surgery
Parenteral Nutrition
 Solutions
 Carbohydrates
 Energy source – dextrose monohydrate
 3.4 kcal/g
 1 mg/kg/min minimum
 5%, 10%, 50%, 70% concentrations (large range)
 Greater than 10%= will need TPN
 Too much CHO being used: hypoglycemia, fatty liver
infiltration, excessive CO2
Parenteral Nutrition
 Solutions
 Lipids
 Emulsion of soybean or safflower oil
 Essential fatty acids
 Source of energy
 1-1.2 g/kilo is ideal
 Not go above 60% calories from lipids
 Minimum of 10% kcal solution has 1.1 calorie per cc of solution
(100 calories)
 20% has 2 calories per cc of solution (200 calories)
 30% is rare, and is 3 calories per cc (300 calories)
 Essential fatty acids need to be present!
 Ex: premature infants, short-gut syndrome, etc.
Parenteral Nutrition
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Solutions
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Electrolytes
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1-2 milliequivalents/kilo for potassium and sodium
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Chloride/acetate: need to look at pH balance
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5-7.5 mEq/kilo for Ca
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4-10 mEq/kilo for Mg
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20-40 mEq/kilo for Phosphorus
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DRI standards used
Vitamins/Minerals
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Looking at pre-made multi-vitamins
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Trace minerals
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Standard has: A,C,D,E,K and B vitamins
Zinc, copper, chromium, iodide, mellyb??
Medications
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Insulin
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Albumin
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Heparin
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Be aware of drug-nutrient interaction that may occur with TPN
© 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
 Bile accumulation in gall bladder due to lack of GI use
 Increased bacteria can be produced in the gut causing GI
atrophy
 Want to get them on oral/tube feedings right away
 Infections
 At the site of delivery of TPN