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Methods of Nutrition Support
KNH 411
Oral diets
“House” or regular diet
Therapeutic diets – soft or manipulated consistency to deal with mechanical or nutrient problems Maintain or restore health & nutritional statusAccommodate changes in digestion, absorption, or
organ functionProvide nutrition therapy through nutrient content
changes
Oral diets
Changes from the house dietCaloric levelConsistencySingle nutrient manipulationPreparationFood restrictionNumber, size, frequency of mealsAddition of supplements
Oral diets
Texture modifications (progresses from clear liquid, to full liquid, to soft diet)Soft dietsLiquid diets
Clear liquid Full liquid Consider osmolality
Preparation for a specific medical test
Oral Supplements
Goal: Increase nutrient density without increasing volumeSnacksLiquid meal replacement formulasModular productsCommercial supplements
Appetite Stimulants
Drugs that stimulate appetitePrednisoneMegestrol acetateDronabinol
Administration of nutrients with therapeutic intentEnteral- if the gut works, use it (should be primary
way of feeding)Parenteral- used if the gut is not working
Ethical considerations
Specialized Nutrition Support (SNS)
© 2007 Thomson - Wadsworth
Enteral Nutrition
Feeding through the GI tract via tube, catheter or stoma delivering nutrients distal to oral cavity
“Tube feeding”- feed by tube through nose to stomach/small intestine
Indicated for patients with functioning GI but unable to self-feed
Contraindications- if vomiting or diahhrea occur
Advantages- cost, improve wound healing, maintain GI function
Disadvantages- discomfort, infection, difficult to administer/placement complications
Enteral Nutrition
Decisions for the nutrition prescription GI access Formula Feeding technique Equipment needed
Enteral Nutrition
GI Access• Access route described by where it enters the
body and where the tip is located Nasogastric- nose (adv: patient can still talk) Orogastric- mouth Nasointestinal- nose to jejunum in small intestine
Typically used for short term Disadvantages- discomfort, tubes can clog
Enteral Nutrition
GI Access • – “Ostomy”
Gastrostomy Jejunostomy PEG- months, years, lifetime
• More permanent
© 2007 Thomson - Wadsworth
Enteral Nutrition
Formulas Based on substrates, nutrient density, osmolality,
viscosity Protein
Soy or casein 10-25% kcal Elemental or chemically defined- protein from
peptides Specialized amino acid profiles- renal formulas,
status-post for healing (in a stress state)
Enteral Nutrition
Formulas- when GI tract is compromised Carbohydrate
Monosaccharides, oligosaccarides, dextrins, maltodextrins
Lactose & sucrose free FOS- help with intestinal function Fiber- soluble, improved bowel function
May use insoluble- soy polysaccharides Constipation big concern
Enteral Nutrition
Formulas Lipid
Corn or soy oil Long- and medium-chain TG Omega-3 fatty acids- improve immune function Structured lipids- fish oils
Enteral Nutrition Formulas
Vitamins and minerals Meet DRI with 1500 cc Supplemental amounts
Fluid and nutrient density 1.0-2.0 kcal per mL Difference depends on water content Ensure adequate fluid - 80% water for 1 kcal per mL Osmolality- (enteral) number of osmoles attracting
molecules per water weight Osmolarity- number of milimole in liquid per liter of
solution
Enteral Nutrition Formulas
Other considerations Which type of formula works best for the
patient Considered medical food – not drug
No test for efficacy or benefit
Cost
© 2007 Thomson - Wadsworth
Enteral NutritionFeeding techniques/ delivery
methodsBolus feedings- 250-500cc,
3-6 times per day
Intermittent feedingsFeeding for 20-30 mins
X times per day
Continuous feedingsOnly for hospital bound or can’t
Tolerate other forms
© 2007 Thomson - Wadsworth
Enteral NutritionEquipment
Feeding tubes - french sizeCans or sealed containersPumps
Enteral Nutrition
Determining the nutrition prescription- clinical application- Steps for writing an enteral prescription
1. Dose weight
2. Calorie goal
3. Adjust for activity factor or injury
4. Calculate protein
5. State total calorie amount
6. Calculate calories from lipid
7. Calculate calories from carbohydrate
8. Electrolyte needs
9. Vitamin and mineral needs
10.Look at fluids
Enteral Nutrition
ComplicationsMechanical complications
Clogged or misplaced tubes
GI complications Diarrhea
Aspiration
Enteral Nutrition
Monitoring for complicationsDehydrationTube Feeding SyndromeElectrolyte ImbalancesUnderfeeding or OverfeedingHyperglycemiaRefeeding Syndrome
Monitor serum phosphorus, mg, potassium, monitor pre-albumin, phosphorus levels
Don’t overfeed client too quickly
Parenteral Nutrition
Administration by “vein” (peripheral vein)Short term solution, can only do for 7 days
a.k.a. – PN (parenteral nutrition), TPN (total parenteral nutrition), CVN (central vein nutrition), IVH (intravenous hemorrhage)
TPN vs. PPN
Indicated if unable to use oral diet or enteral nutrition
Certification of medical necessity
Parenteral Nutrition
Venous accessShort-term access
CVC inserted percutaneously Using subclavian, jugular, femoral veins PICC (peripherally inserted central catheter)
Long-term access (require surgery to insert) Tunneled catheters (on upper chest) Implantable ports (below the skin)
© 2007 Thomson - Wadsworth
Parenteral Nutrition
SolutionsCompounded by pharmacist using “clean room” Two-in-one
Dextrose & amino acids Lipids added separately (in separate line) Clear - easier to identify precipitates In quantities of 100cc, 250cc, or 500 cc
Three-in-one (quicker, easier, cheaper) Dextrose, amino acids & lipids Single administration (all three added in one line) Not concerned about calcium and phosphorus Used once patient is stable
Parenteral Nutrition
SolutionsProtein
4kacl/g of amino acid in solution Individual amino acids Modified products for renal, hepatic and stress Commercial amino acids 3.5-20% depending on patient .8- 1.8 g/kg depending on condition
.8 for normal patient 1.5-1.8 for burn, trauma, healing patients
Parenteral Nutrition
SolutionsCarbohydrates
Energy source – dextrose monohydrate 3.4 kcal/g of dextrose 1 mg/kg/min minimum 5%, 10%, 50%, 70% concentrations
10% most common More than 10% needs TPN or central line
Parenteral Nutrition
SolutionsLipids
Emulsion of soybean or safflower oil *Essential fatty acids (10% would fill this need) Source of energy Minimum of 10% kcal
10% = 1.1 calories per cc 20% = 2 calories per cc 30% = 3 calories per cc
1.2g/kg No more than 60% of calories from fat
Parenteral Nutrition
SolutionsElectrolytes
1-2 miliequivilants for sodium, potassium per kilo, Chloride or acetate based on levels, 5-7.5 miliequivilants per kilo, 4-10 magnesium per kilo, 20-40 phosphorus per kilo DRI standards used
Vitamins/Minerals (in a pre-made vile) (IV solution) A, C, D, E, K, and B vitamins
Trace minerals (5mL solution) Zinc, copper, chromium, iodide, molybtenum
Medications Can be added to line
© 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 based on lab values
Patient monitoring Intake vs. outputLaboratory monitoring
Parenteral Nutrition
ComplicationsGI complications
Cholestasis -condition in which the flow of bile from the liver is slowed or blocked.
Increased bacteria in GI
Infections May need to move line