Melanie Horbal Shuster, PhD, ACNS-BC, CRNP, CNSC

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









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

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

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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

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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%

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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)

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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

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48

Nutrients Day 1 Day 2 Day 3

CHO 150 grams 510 calories

200 grams 680 calories


FE 25 grams 250 calories



AA 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


Vascular access device is in the right place

Catheter functioning properly

The metabolic parameters are within normal limits


“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)

http://emedsa.org.au/Students/AntiMaxims.html

http://en.wikipedia.org/wiki/Thomas_McCrae_(physician)



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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.

57

58

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.

Nutritional and metabolic assessment of the hospitalized patient. JPEN.

1977;1(1):11-22.

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.

Perioperative Nutrition in Abdominal Surgery: Recommendations and Reality.

Gastroenterology Research and Practice. 2011;2011:739347.

doi:10.1155/2011/739347.

59

References

17. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional

supplements for disease-related malnutrition in adults. Cochrane Database of

Systematic Reviews 2011;9. Art. No.: CD002008. DOI:

10.1002/14651858.CD002008.pub4.

18. Burden S, Todd C, Hill J, Lal S. Pre-operative Nutrition Support in Patients Undergoing Gastrointestinal Surgery. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD008879. DOI: 10.1002/14651858.CD008879.pub2.

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

21. Robinson, JD., Lupkiewicz, SM., Palenik, L., Lopez, LM., Ariet, M. Determination of ideal body weight for drug dosage calculations. Am J Hosp Pharm. 1983 40(6):1016-9.

22. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&ncdver=1&bc=AAAAQAAAAAAA&

23. http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitati

ons.pdf