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Melanie Horbal Shuster, PhD, ACNS-BC, CRNP, CNSC
To prepare the CNS to confidently prescribe enteral and parenteral nutrition ◦ Increase knowledge of nutritional requirements of
hospitalized adult patients
◦ Increase knowledge of Enteral Nutrition and Parenteral Nutrition access devices
◦ Increase knowledge of enteral feeding products
◦ Increase knowledge of PN orders
Patients who are able to sustain oral intake ◦ Oral diets ◦ Fortification of diet with energy and protein ◦ Commercially available oral supplements Complete Fat free
Invasive therapy ◦ Enteral ◦ Parenteral
Enteral
What is the enteral access needed? ◦ Temporary ◦ Semi-permanent ◦ Permanent
Parenteral
What vascular access is needed? ◦ Central ◦ Peripheral
Why is nutritional support needed?
How long is the patient expected to need nutritional augmentation?
Defining the endpoint can contribute to success.
Medical Decision
◦ Cannot eat
◦ Should not eat
◦ Will not eat Ethical
Legal
Moral
Types of access ◦ Gastric feeding Nasogastric Bedside placement Guidance Radiologic Endoscopic
◦ Jejunal feeding Endoscopic Radiologic
Distal tip location
Method of administration
◦ Bolus
◦ Continuous
◦ Nocturnal cyclic
◦ Intermittent
Medication administration
Enteral access patency
◦ Flushing
◦ Fluid balance
Monitoring ◦ Metabolic Laboratory values
CBC CMP
Markers of inflammation CRP
Nutritional Pre-albumin Albumin Iron studies 25 OH Vitamin D B12 PT INR
◦ Functional status ◦ Weight
Nursing Responsibilities
◦ Insert the tube (NG) (ND-NJ)
◦ Secure the tube Nasal Abdominal wall
◦ Verify position X-ray interpretation Document external
length ◦ Maintain the position
tube Repeat verification by
external measurement If in doubt re-image
Nursing Responsibilities ◦ Maintain tube position
Secure the tube
Verify position
x-ray
Maintain the tube position
Measure external length
Nursing Responsibilities ◦ Maintain function Flushing
◦ Monitor for tolerance Nausea Vomiting Diarrhea
◦ Monitor for complications Electrolyte abnormalities Glycemic control Skin integrity
◦ Monitor for desired effect Weight gain Improvement in nutrition marker Improvement in laboratory tests Functional improvement
Vascular access ◦ Central access
Peripherally inserted central catheter
◦ Peripheral access
Midline
Length of therapy ◦ Temporary
◦ Permanent
Tunneled
Implanted
Nursing Responsibilities ◦ Vascular access Patency Infection Appearance of insertion site Extremity
◦ Monitor for metabolic complications Electrolyte abnormalities Glycemic control
◦ Monitor for desired effect Weight gain Improvement in nutrition marker Improvement in laboratory tests Functional improvement
Determine patients nutritional needs ◦ Energy
◦ Protein
◦ Hydration
◦ RD assessment
Indirect calorimetry
Height & Weight
Equations ◦ Harris Benedict
◦ 140 equations
Kcalories/Kg/day
Protein grams/kg/day
Hydration
http://fnic.nal.usda.gov/interactiveDRI/
http://www.globalrph.com/estimated_energy_requirement.cgi
Determine patients nutritional needs
Select an enteral feeding product ◦Diagnosis ◦ Fluid balance ◦ Enteral access
Caloric density
Protein content
Fiber
Disease specific ◦ Renal failure
◦ Immune modulating
◦ Respiratory failure
◦ Diabetic
Physical state ◦ Intact
◦ Peptide based
◦ Pre-digested or elemental
Product Ingredients
Complete ◦ Requires digestion
◦ Fiber
Water
Caloric density ◦ 1 Kcalorie/mL
◦ 2 Kcalories/mL
Protein content ◦ 40 – 50 grams/L
Corn syrup Maltodextrins FOS Safflower oil Canola oil MCT oil Caseinates Soy protein Vitamins Minerals
Determine the administration schedule ◦ Type of enteral
access
◦ Anatomic location of the distal tip of the enteral access device Gastric
Jejunal
Options ◦ Continuous--20
mL/hr
◦ Bolus--1 can QID
◦ Intermittent Nocturnal--100 mL/hr x 12 hours
Upper GI Series Naso enteric feeding tube
Type of tube Method of access
Gastrostomy tubes
Jejunostomy tubes ◦ Location of distal tip
Type of tube
Material
Manufacturer
Brand name
Size
Operator
◦ Surgeon
◦ Radiologist
◦ Gastroenterologist Technique of guidance
◦ Endoscopic
◦ Radiologic
◦ Surgical Method of placement
◦ Percutaneous
◦ Open
◦ Laparoscopic
https://www.youtube.com/watch?v=fS1ao7pHNmM&feature=player_detailpage
Medication administration
GI intolerance Liquids ◦ Osmolality
Do not crush list ◦ Only crush pills that
can be crushed ◦ No extended release
enteric coated through tubes
Obstruction ◦ Forgetting to flush
Leaking ◦ Malposition ◦ Migration ◦ GI dysfunction
Granulation tissue Proud flesh
Feeding tubes should not leak ◦ Displacement
◦ Constipation
◦ Gastroparesis
Leaking requires further investigation ◦ Insertion site
◦ Inability to rotate
◦ Painful
◦ Cannot move to & fro
Tip of
Feeding
Catheter
Stomach
Insertion site
Site of Obstruction
Problem
Prevention
Medication administration ◦ Tube occlusion
Nausea
Vomiting
Diarrhea ◦ Loose ◦ Watery stools ◦ Quantify
Flush before, in
between and after medication administration
Medications ◦ Hyperosmolar
Incontinence ◦ Fiber ◦ Anti-diarrheals
PROUD FLESH
Proud Flesh
Observe for redness ◦ Fungal infection
◦ Cellulitis
http://www.childrens.com/Assets/Documents/specialties/AsthmaManagementProgram/Care-child-g-tube.pdf
Leakage
Proud flesh ◦ Granulation tissue
http://www.childrens.com/Assets/Documents/specialties/AsthmaManagementProgram/Care-child-g-tube.pdf
Observe for leakage
Acute Buried Bumper Syndrome. Qasim Khalil, MD, Rizwan Kibria, MD, Salma Akram, MD, FACG
Disclosures South Med J. 2010;103(12):1256-1258. http://www.medscape.com/viewarticle/733885_2
Creation of a
Janeway Stoma http://hungzollinger.blogspot.com/2011/08/gastrostomy_27.html
Patient Care System
Tube is in the right place
Tube is functioning properly
Right product is administered at the right time and rate
Metabolic parameters are within normal limits
Desired effect is achieved
Standardized approach to enteral feeding ◦ Appropriate candidates ◦ Appropriate tube
Standardized equipment
Policy and procedures Planned follow-up and
on going care Discontinuing enteral
feeding
Unable to use the GI tract ◦ Short gut syndrome
◦ Fistulae
◦ Obstruction
◦ Ileus
Oral intake not adequate ◦ Patient refuses feeding tube placement
◦ PPN
Vascular access ◦ Central access
Peripherally inserted central catheter
◦ Peripheral access
Midline
Length of therapy ◦ Temporary
◦ Permanent
Tunneled
Implanted
Superior vena cava
Right atrium
Caval atrial junction
Short term
Long term ◦ Weekly labs
◦ Monthly labs
Vascular access function
Baseline data Monitoring
Baseline data ◦ C - reactive protein (CRP)
◦ Pre-albumin
◦ Liver function tests
◦ CMP
◦ Magnesium
◦ Phosphorus
◦ Ionized calcium
◦ HA1c
Monitor POC glucoses every 6 hours
Serum triglycerides the morning after to first dose of TPN with lipid emulsion
Monitor daily laboratory results
Monitor weekly weights
41
Monitor daily oral intake Monitor daily intake and output
Determine weight8 ◦ Ideal
◦ Actual
◦ Adjusted
Determine energy needs ◦ Example 30 kcal/day X 70kg= 2100 Kcal/day
Determine hydration needs: ◦ Example: 30 ml/kg X 70 kg= 2100 ml/day
Determine protein needs ◦ Example 1.5 grams/Kg/day = 105 grams/day
42
Estimated needs Orders
70 kg patient Total calorie @
30/Kg/day = 2100 kcal
Water needs @ 30 ml/Kg/day =2100 ml
Protein @ 1.5 grams/Kg/day = 105 grams
2100 Kcalories 2.1L/day
105 grams of Protein
43
Energy = 2100 Kcalories Protein = 105 grams/day
Protein = 4 Kcalories/gram
Dextrose = 4 Kcalories/gram
Fat emulsion ◦ Soybean oil
◦ Egg phospolipid
◦ Glycerol
◦ 10% = 1.1 Kcalories/ml
◦ 20% = 2 Kcalories/ml
◦ 30% = 3 Kcalories/ml
Calculate the energy from protein ◦ 105 x 4 = 420 Kcalories
◦ Subtract protein calories from total calories 2100-420 = 1680
1680 Kcalories provided as carbohydrate and fats
◦ 60% as dextrose =1008/4 = 252 grams
◦ 40% as Fat =672/1.1 = 610 mL of 10%
◦ 305 mL of 20%
44
45
Parenteral nutrition Nutrients Day 1 TPN
CHO 150 grams 510 calories
FE 25 grams 250 calories
AA 100 grams 400 calories
Total Calories 1160
Na Acetate: 150
KCl 50
Mg SO4 16
Ca Gluconate 10
KPO4 30
TE 1
MVI 10
Thiamine 100 mg
50% or less of estimated goals
Electrolytes based on chemistries, acid base balance and fluid balance
TV=2000 mL based on weight, renal function, edema and fluid balance
Sodium- 1-2 meq/kg/d (For the example 70-140 meq/day)
Potasium-1-2 meq/kg/day (For example 70-140 meq/day)
Magnesium-16 meq/day
Calcium Gluconate-9.3 meq/day
Phosphorous- 30 mmol/day (as Na phosphate or K phosphate)
46
Multivitamins- 10 ml/day
Trace elements- 1 ml/day
Insulin
◦ Start with an initial dose of 0.1 to 0.2 unit/gram of dextrose
Thiamine-100 mg /day for 3 days if the patient has been without eating for > 1 week and or if vomiting.
Famotidine-20-40 mg/day
47
48
Nutrients Day 1 Day 2 Day 3
CHO 150 grams 510 calories
200 grams 680 calories
250 grams 850 calories
FE 25 grams 250 calories
50 grams 500 calories
50 grams 500 calories
AA 100 grams 400 calories
100 grams 400 calories
100 grams 400 calories
Total Calories 1160 1580 1750
Na Acetate: 150 mEqs 150 150
KCl 50 mEqs 50 50
Mg SO4 16 mEqs 16 16
Ca Gluconate 10 mEqs 10 10
KPO4 30 mM 30 30
TE 1 mL 1 1
MVI 10 mL 10 10
Thiamine 100 mg 100 mg 100 mg
Daily
Monitor daily oral intake
Monitor daily intake and output
Monitor daily labs ◦ BMP
◦ Magnesium
◦ Phosphorus
◦ Ionized calcium
49
Nutrients Day 4
CHO 300 grams
1020 calories
FE 50 grams
500 calories
AA 100 grams
400 calories
Total Calories 1920
Na Acetate: 150 mEqs
KCl 0
Mg SO4 16 mEqs
Ca Gluconate 10 mEqs
KPO4 30 mM
TE 1 mL
MVI 10 mL
Weekly monitoring
◦ C - reactive protein
(CRP)
◦ Pre-albumin
◦ Liver function tests
◦ CMP
50
Nutrients Day 5 Weaning
CHO 300 grams
1020 calories
150 grams
510 calories
FE 50 grams
500 calories
25 grams
250 calories
AA 100 grams
400 calories
60 grams
240 calories
Total Calories 1920 1000
Na Acetate: 150 150
KCl 0 50
Mg SO4 16 8
Ca Gluconate 10 10
KPO4 30 0
TE 1 1
MVI 10 10
Thiamine 100 mg D/C
Patient Care System
Vascular access device is in the right place
Catheter functioning properly
The metabolic parameters are within normal limits
Desired effect is achieved
Vascular access device is in the right place
Catheter functioning properly
The metabolic parameters are within normal limits
Desired effect is achieved
“You see only what you look for; you recognise only what you know“ ◦ Dr. Merrill Sosman
◦ http://emedsa.org.au/Students/AntiMaxims.html
"More is missed from not looking than not knowing“ ◦ Thomas McCrae (1870–1935) was Professor of Medicine at Jefferson Medical College,
and student and later colleague of Sir William Osler
◦ http://en.wikipedia.org/wiki/Thomas_McCrae_(physician)
53
Summary • Nutrition support enteral and/or parenteral
interventions may improve clinical outcomes
• Nutrition interventions improved nutrition status
nutrient intake physical function quality of life
• Nutrition intervention reduced readmissions
reduced post-op complications in the severely malnourished population
Monitor
54
Summary Recognize
malnutrition
Use evidence
based practice
Provide
nutritional
support
Establish goals
of care Monitor
Nutrition plan
for transition
of care
Discontinue
nutritional
therapy
Clinical Nurse Specialist
The problem with communication is the illusion that it has occurred.
26 July 1856 – 2 November 1950
1 National CNS Competency Task Force. 2010. Clinical nurse specialist core competencies. Executive Summary 2006-2008.
2 DeLegge, M., et al. (2010). A.S.P.E.N. The state of nutrition support teams and update on current models for providing nutrition support therapy to patients. Nutrition in Clinical Practice, 25(1). 76-84.
3 Transitional Care Model. Retrieved from www.transitionalcare.info
4 No author. 2013. NHS watchdog to tackle malnutrition in hospitals. The Gauardian. Retrieved from: http://www.theguardian.com/society/2013/mar/03/nhs-watchdog-malnutrition-hospitals?CMP=share_btn_link
5 Barrocas, A., et al. (2010). A.S.P.E.N. ethics position paper. Nutrition in Clinical Practice, 25(6). 672-679.
56
6. Aspen Practice Management Task Force (2010). The state of nutrition support teams and
update on current models for providing nutrition support therapy for patients. Nutrition in Clinical Support, 25(1), 76-84.
7. Guenter, P. et al., (2015). Addressing disease related malnutrition in hospitalized adults: A call for a national goal. The Joint Commission Journal on Quality and Patient Safety, 41(10), 469-473.
8. Tappenden, K., et al. (2013). Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
9. Green, S.M. & James, E.P. (2013). Barriers and facilitators to undertaking nutritional screening of patients: A systematic review. Journal of Human Nutrition and Dietetics, 26. 211-221.
10. Mueller, C, Compher, C, Druyan, ME. A.S.P.E.N. clinical guidelines: Nutrition screening,
assessment and interventions in adults. JPEN. 2011;35(1):16-24.
11. Ferguson, M., Capra, S., Bauer, J., Banks, M. Development of a valid and reliable
malnutrition screening tool for adult acute hospital patients. Nutrition. 1999; 15 (6): 458-64.
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References
12. Joint Commission on Accreditation of Healthcare Organizations.
Comprehensive Accreditation Manual for Hospitals. Chicago, IL: Joint
Commission on Accreditation of Healthcare Organizations; 2007.
13. Blackburn, GL., Bistrian, BR., Maini, BS., Schlamm, HT., Smith, MF.
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14. Seres DS, Valcarcel M, Guillaume A. Advantages of enteral nutrition over
parenteral nutrition. Therapeutic Advances in Gastroenterology.
2013;6(2):157-167. doi:10.1177/1756283X12467564.
15. Stroud, M., Duncan, H., Nightingale, J. Guidelines for enteral feeding in
adult hospital patients. GUT. 2003;52(supplement VII):vii1-vii12.
16. Cerantola Y, Grass F, Cristaudi A, Demartines N, Schäfer M, Hübner M.
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Gastroenterology Research and Practice. 2011;2011:739347.
doi:10.1155/2011/739347.
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References
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supplements for disease-related malnutrition in adults. Cochrane Database of
Systematic Reviews 2011;9. Art. No.: CD002008. DOI:
10.1002/14651858.CD002008.pub4.
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19. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative Total Parenteral Nutrition in Surgical Patients (1991). New England Journal of Medicine, 325(8), 525-532.
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References 20. White, JV., Guenter,, P., Jensen, G., Malone, A., Schofield, M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). et al. Journal of the Academy of Nutrition and Dietetics , Volume 112 , Issue 5 , 730 - 738
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23. http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitati
ons.pdf
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