Transcript Specialized Nutritional Support

DNT 200
NUTRITION FOR HEALTH
SCIENCES
SPECIALIZED NUTRITION SUPPORT
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SPECIALIZED NUTRITIONAL SUPPORT
"Obstacles are those frightful things you see
when you take your eyes off your goal."
Henry Ford (1863-1947)
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SPECIALIZED NUTRITIONAL SUPPORT
Algorithm
Adequate Nutritional Status
Yes
Oral Diet; reassess
regularly; simple IV’s
If status changes
Functional GI tract?
Yes
Appetite/Physical
Ability to Eat?
Yes
Oral Diet;
Supplement PRN
No
Withhold elective therapy;
select feeding route
No
Long-Term Support
Anticipated; Severely
Malnourished?
No
Yes
Tube Feeding
TPN
No
PPN
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SPECIALIZED NUTRITIONAL SUPPORT
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SPECIALIZED NUTRITIONAL SUPPORT
• Supplemental nutrition
– When a person cannot get enough nutrition
from regular meals, the first step is to
supplement the diet with extra food between
meals
• Give snacks the person enjoys
• May find it easier to drink than to eat
– Liquids seem less filling
– Are easy for debilitated people to handle
– Examples
•
•
•
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Milk
Milk shakes
Proprietary foods
Adding powdered milk to these beverages makes
them higher in protein
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SPECIALIZED NUTRITIONAL SUPPORT
• Supplemental nutrition
– Palatability can be a problem with long term
use -- may need to add flavoring
– Serve liquid feedings attractively
• Served in a glass is more attractive than a can
• Serve it COLD
• Tube feedings
– Delivers a nutrient solution via tube into the
stomach or intestine
– Individual should have a functioning GI tract
(but may have an inability to ingest enough
nutrients to meet present needs)
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SPECIALIZED NUTRITIONAL SUPPORT
• Tube feedings (con’t)
– For people who cannot eat oral diets, tube
feedings are preferred to feedings by vein
wherever possible
• Enteral nutrition helps maintain normal gut
function
– When the gut is not used for a long time, villi shrink
and their enzyme activity slows
– When the gut is not used for a long time, intestinal
bacteria translocate to the portal vein and lymphatic
system and cause infection
• Enteral feedings are associated with fewer
infections
• Enteral feedings are less expensive
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SPECIALIZED NUTRITIONAL SUPPORT
• Tube feedings (con’t)
– Feeding tube placement
• Most commonly inserted through the nose and
passed into the stomach or intestine
• Can be surgically placed into openings in the
esophagus, stomach, or jejunum
– Feeding tubes come in a variety of diameters
and lengths -- smallest tube through which the
feeding will flow is best
– Complications
• Inadvertent placement of tube in the lungs
• Tube obstructions
• Can be serious and life threatening
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SPECIALIZED NUTRITIONAL SUPPORT
• Types of formula
– Intact formulas
• Are appropriate for people who are able to
digest and absorb nutrients without difficulty
• Can come as either protein isolate (HBV
protein that has been separated from a source
containing a variety of proteins [e.g. casein,
albumin] or blenderized formulas)
• Blenderized formulas can be either
blenderized or purchased commercially
– Hydrolyzed formulas -- are in a sense
“pre-digested” and require minimal
further digestion
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SPECIALIZED NUTRITIONAL SUPPORT
• Types of formula
– Types of commercial formulas available
• Ready-to-use liquid
• Liquid concentrate
• Powdered
– Concentration
• Standard = 1 kcalorie per cc
• 1.5 kcalorie per cc
• 2 kcalories per cc
– Modular formulas -- contain specific
nutrients for use as supplements
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SPECIALIZED NUTRITIONAL SUPPORT
• Types of formula (con’t)
– Formula osmolality
• Osmolality is the number of molecules and ionic
particles (measured in osmoles) per liter of water
in a solution
• The greater the number of particles in a solution,
the greater the osmolality
• Normal osmolality of blood serum is about 300
mOsm per liter
• Osmolality of formulas range from 250 to over
800 mOsm
• A formula that approximates the osmolality of the
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serum is referred to as an isotonic formula
SPECIALIZED NUTRITIONAL SUPPORT
• Types of formula (con’t)
• A hypertonic formula has a higher
osmolality than serum
– Can cause water to be drawn from in and
around the body cells into the intestine
– Not a problem if the body has time to
adopt to the hypertonic solution
– Can otherwise cause diarrhea, vomiting,
cramps or nausea
– It is preferable to use a formula that is as
nearly isotonic as possible
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SPECIALIZED NUTRITIONAL SUPPORT
• Residue and fiber
– Fiber is the portion of the intestinal contents
that remain in the colon because people don’t
have the enzymes to digest it, e.g. cellulose
– Residue is the total amount of material in the
colon; includes dietary fiber and also
undigested foods, intestinal secretions, bacterial
cell bodies, and cells shed from the intestinal
mucosa
– High fiber diets benefit people who can tolerate
them because they maintain gut integrity
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SPECIALIZED NUTRITIONAL SUPPORT
• Other characteristics of formulas
– Can be made from many different
ingredients
• May or may not contain lactose
• May or may not include a higher biologic
value protein
– Cost can vary widely
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SPECIALIZED NUTRITIONAL SUPPORT
• Formula selection
– No formula is perfect
– Rule of thumb -- the formula that meets the
client’s nutrient needs with the least risk of
complication at the lowest cost is the one of
choice
– A formula given orally needs good taste -- the
more hydrolyzed and lower its fat content, the
less tasty it will be
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SPECIALIZED NUTRITIONAL SUPPORT
• Formula selection (con’t)
– Additional factors
• The client’s digestive and absorptive
function
– If the GI tract does not function, the client is
not a candidate for oral or tube feeding
– People with minimal GI function may benefit
from hydrolyzed formulas
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SPECIALIZED NUTRITIONAL SUPPORT
• Formula selection (con’t)
– Additional factors
• The placement of the
feeding tube (stomach vs.
intestine)
– Feedings delivered directly
into the intestine must be
easily digested -- however if
the GI tract is functional they
need not be hydrolyzed
– Isotonic feedings are
preferred for intestinal
feedings
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SPECIALIZED NUTRITIONAL SUPPORT
• Formula selection
(con’t)
– Additional factors
• Nutrient requirements -should be based on
careful assessment
• Individual preferences
and tolerances (food
allergies and sensitivities)
-- consider lactose
intolerance
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings
– Prepare formula in a clean environment with
clean equipment and clean hands
– Store opened or mixed formulas in refrigerator
– Discard unlabeled or improperly labeled
containers and all opened containers of
formulas not used within 24 hours
– Deliver formula in a fresh container daily -never add fresh formula to formula still in the
container
– Before adding formula to a feeding bag or
bottle, rinse the feeding container, the tubing
attached to it, and the feeding tube itself with 19
water
SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Change the feeding bag or bottle and tubing
attached to it (except the feeding tube itself)
every 12 to 24 hours
– Formulas sometimes come pre-packaged in
containers that can be used to dispense formula
without being added to another feeding bag -greatly reduces the risk of bacterial
contamination
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Rate of administration and concentration
• People with severe stress or those who have not
eaten for several weeks may not be able to
tolerate large volumes of highly concentrated
formulas
• Rule of thumb -- people who have low albumin
levels (less than 3.5 grams per 100ml) are more
likely to have problems tolerating concentrated
formulas
• Formulas may have to be diluted to 1/2or 1/3
strength and given slowly (30 to 50 ml per hour)
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Rate of administration and concentration
• Increase as tolerated, 25 ml per hour every 8-12
hours
• Once the desired flow rate is reached, increase the
concentration
• If intolerance develops, back up and give the
client more time to adapt
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Water is important
• Supplemental water is often needed to meet
client’s daily fluid requirements
• Guideline -- adults need 1,500 to 2,000 ml of
water daily
• Indicators
– Thirst in alert adults
– Body weight changes
– High serum electrolytes, hematocrit and blood
pressure
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Water is important
• Water should be used to flush the feeding
tube before and after a feeding
– Prevents the line from being clogged
– Hydrates the patient
– Give water orally if the person can drink it
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings
(con’t)
– Delivery of feedings
• Bolus feeding
– Administered 4 to 6 times per day
– Patient can move about freely between
feedings
• Continuous drip
– Delivered slowly over 16 to 24 hour period
– Benefits people intolerant of larger feeding
volumes
– Infusion pumps may be used to assure
accurate and constant flow rates
• Prevention of complications -- monitor
to ensure early detection of problems
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Delivery of feedings
• Feeding tubes used to administer drugs
– Tube feedings widely used for people who are
seriously ill -- these people also need many
medications
– Crushing tablets and mixing them with water is a
common practice but should be avoided
» May clog tube
» Some types of tablets should not be crushed -designed to be released more slowly
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SPECIALIZED NUTRITIONAL SUPPORT
• Administration of tube feedings (con’t)
– Delivery of feedings
• Psychological implications of tube feedings
– Feeding becomes merely nourishment, not an
expression of personal preference, social
pressure, or cultural tradition
– Many feel self conscious about how the tube
looks and may feel tied down by the feeding
equipment
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition
– Terms
• Intravenous means through
a vein
• Parenteral nutrition is the
delivery of nutrients
through a vein, bypassing
the intestine
• Dextrose is a form of
glucose that is especially
soluble in water and used
in IV solutions
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition
– Parenteral IV solutions may consist of
some or all of the essential nutrients:
• Water
• Amino Acids
• Dextrose
• Lipids
• Electrolytes (minerals)
• Vitamins
• Trace elements
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition
– Simple IV solutions generally
provide
• Water
• Dextrose
• Electrolytes
• Three liters provide about 510
kcalories per day
*****
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition
– IV fat emulsions and peripheral total
parenteral nutrition
• Peripheral veins are the smaller diameter
veins that bring blood to the
extremities(arms and legs)
• Simple glucose solutions containing only
amino acids fall short of meeting total
nutrient needs
• IV fat emulsions make it possible to deliver
needed nutrients by peripheral vein
– Provides a concentrated source of kcalories
– IV fat is isotonic -- does not irritate veins
– Provides essential fatty acids
****
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous
nutrition (con’t)
– Peripheral TPN
cannot deliver quite
enough nutrients for
people with very
high energy needs - is suitable for
short term (7-14
days) nutritional
support
***
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition (con’t)
– TPN by central vein
• Abbreviated TPN
• IV catheter surgically placed in a large
diameter central vein
• Enables quick dilution of concentrated
solutions -- by the time these solutions
reach the peripheral veins, they are not so
irritating
• Advantage -- concentrated solutions of
nutrients can be delivered to people who
cannot or should not be fed through the GI
**
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tract
SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition (con’t)
• Actual concentrations of formula determined
by each person’s unique nutritional needs
• Electrolytes, trace elements, and fat can be
added
• Other possible additions
– Albumin
– Heparin -- prevents clots from forming on the
catheter that might obstruct the flow of formula
– Insulin -- to help regulate blood glucose levels
• Like a tube feeding, TPN should be started
slowly to give the client time to adjust to the
high glucose concentrations and the
osmolality of the TPN
*
formula
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SPECIALIZED NUTRITIONAL SUPPORT
• Intravenous nutrition
(con’t)
• Possible indications for TPN
– Major small bowel resections
– Severe diarrhea
– Inflammatory bowel diseases
– Moderate to severe
pancreatitis
– Severe malnutrition when the
GI tract is non-functional
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