1. Nutritional Supplements
Chapter 55
Nutritional Supplements
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2. Nutrition Supplements
Dietary products used to provide nutritional support
Can be given in a variety of ways
Vary in amounts and complexity of carbohydrates, protein, and fat content
Electrolytes, vitamins, minerals, and osmolality may also vary
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3. Nutrition Supplements (cont’d)
Malnutrition
The body’s nutritional needs are not met by nutrient intake
Enteral nutrition
Provision of food or nutrients through the GI tract
Parenteral nutrition
Delivery of nutrients directly into the circulation by means of an intravenous solution
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Enteral Nutrition
Provision of food or nutrients through the GI tract
Oral consumption is the most common and least invasive route
Feeding tubes through various routes can be used for enteral nutrition
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6. Enteral Nutrition (cont’d)
Feeding tubes are used for those with:
Abnormal esophageal or stomach peristalsis
Altered anatomy secondary to surgery
Depressed consciousness
Impaired digestive capacity
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7. Enteral Formulation Groups
Provide basic building blocks for anabolism
Supply complete dietary needs through the GI tract by oral route or by feeding tube
Elemental
Polymeric
Modular
Carbohydrate formulations
Fat formulations
Protein formulations
Altered amino acid formulations
Impaired glucose tolerance
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8. Enteral Formulation Group: Elemental
Peptamen, Vital HN, Vivonex Plus, Vivonex TEN
Minimal digestion needed; residual is minimal
Used for malabsorption, partial bowel obstruction, irritable bowel disease, other conditions
Hyperosmolarity of formulas may cause GI problems
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9. Enteral Formulation Group: Polymeric
Complete, Ensure, Ensure Plus, Isocal, Osmolite, Portagen, Jevity, Sustacal
Preferred over elemental formulations for patients with fully functional GI tracts and few specialized nutrient requirements; cause fewer GI problems
Most closely resemble normal dietary intake
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10. Enteral Formulation Group: Modular
Three types
Carbohydrate: Moducal, Polycose
Fat: MCT Oil, Microlipid
Protein: Casec, ProMod, Propac, Stresstein
Single nutrient formulas
Intended for use with monomeric or polymeric formulations
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11. Enteral Formulation Group: Altered Amino Acid
Amin-Aid, Hepatic-Aid, Travasorb Renal, Traum-Aid HBC
Contain varying amounts of specific amino acids
Used for patients with diseases associated with altered metabolism capabilities
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12. Classroom Response Question
A patient who has a history of type 1 diabetes mellitus is in need of enteral nutrition. Which enteral formulation does the nurse anticipate administering to this patient?
Ensure
Glucerna
Polycose
Jevity
Correct answer: B
Rationale: Glucerna is appropriate for use in patients with impaired glucose tolerance (e.g., diabetic patients).
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13. Enteral Formulation Group: Impaired Glucose Tolerance
Glucerna
Contains proteins, carbohydrates, fat, sodium, potassium
Used in patients with impaired glucose tolerance (e.g., diabetic patients)
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14. Enteral Nutrition: Interactions
Various nutrients can interact with drugs to produce significant food-drug interactions
Enteral nutrition can delay absorption of some medications
Enteral nutrition may inactivate some medications (e.g., tetracycline and nutrient formulations that contain calcium)
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15. Classroom Response Question
The nurse is administering tube feeding to a patient taking multiple medications. The nurse is most concerned about absorption of which medication when administered with tube feedings?
digoxin
penicillin
phenytoin
furosemide
Correct answer: C
Rationale: Tube feedings can reduce the absorption of phenytoin, which may result in seizures. It is recommended that tube feedings be held for at least 2 hours before and after the administration of phenytoin. This can be problematic, because the patient may not receive adequate nutrition due to withholding of feedings. This issue is somewhat controversial, and some suggest that the interaction is more theoretical than actual. Thus, some institutions have decided to ignore this possible interaction and to monitor phenytoin levels and patient status, rather than holding the tube feedings, whereas others continue to hold the tube feedings. Often the patient requires intravenous phenytoin when continuous tube feedings are necessary.
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16. Enteral Nutrition: Adverse Effects
Gastrointestinal intolerance
Dumping syndrome
Aspiration pneumonia
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17. Classroom Response Question
The nurse identifies which condition as the most common adverse effect of nutritional supplements?
Infection
Phlebitis
Diarrhea
Hyperglycemia
Correct answer: C
Rationale: The most common adverse effect of nutritional supplements is gastrointestinal intolerance, manifesting as diarrhea.
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Parenteral Nutrition
Totally digested nutrients are given intravenously, directly into the circulatory system
The entire GI system is bypassed, eliminating the need for absorption, metabolism, or bowel elimination
Hyperalimentation
Total parenteral nutrition (TPN)
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19. Parenteral Nutrition (cont’d)
Formulations vary according to individual patient nutritional needs
Amino acids
Carbohydrates
Lipids
Trace elements
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Amino Acids
Protein synthesis, or anabolism
Types of amino acids
Essential
Nonessential
Semiessential
Amino acid crystalline solutions (Aminosyn 3%, 5%, and 10%, and FreAmine III 8.5% and 10%)
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Carbohydrates
Carbohydrates are usually supplied to patients through dextrose
Peripheral parenteral nutrition (PPN) dextrose concentrations are usually kept below 10% to decrease the possibility of phlebitis
Central TPN dextrose concentrations can range from 10% to 50%, but they are commonly 25% to 35%
Supplemental insulin may be given simultaneously in nutritional supplements
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Fats
Intravenous fat emulsions serve two functions
Supply essential fatty acids
Source of energy or calories
Essential fatty acid deficiency
Lipid emulsions, Intralipid and Liposyn, are available as 10%, 20%, or 30% emulsions
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23. Varying Amounts of Energy from 1 g of Dextrose, Fat, or Protein
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24. Parenteral Nutrition (cont’d)
Peripheral total parenteral nutrition
Temporary, short term (less than 2 weeks)
Dextrose concentration generally less than 10%
Central total parenteral nutrition
Long-term use (over 2 weeks)
Dextrose concentrations may be 10% to 50%, but are commonly 25% to 35%
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Peripheral TPN
Used to provide nutrients to patients who need more nutrients than present oral intake can provide
Indicated for:
Procedures that restrict oral feedings
Anorexia caused by chemotherapy or radiation treatments
GI illnesses that prevent oral food intake
Postsurgical patients
When nutrition deficits are minimal, but oral nutrition will not be started for more than 5 days
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26. Classroom Response Question
When caring for a patient receiving PPN, it is most important for the nurse to assess for the development of which adverse effect?
Hypertension
Anemia
Renal failure
Phlebitis
Correct answer: D
Rationale: The most devastating adverse effect of PPN is phlebitis, which is vein irritation or inflammation of a vein. If phlebitis is severe and is not treated appropriately, it can lead to the loss of a limb, although this is rare. Another potential adverse effect is fluid overload.
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27. Peripheral TPN: Adverse Effects
Phlebitis is the most devastating adverse effect
Can lead to loss of a limb
Fluid overload
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Central TPN
Delivered through a large central vein
Subclavian
Internal jugular
Long-term use (more than 7 to 10 days)
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Central TPN (cont’d)
Disadvantages are the risks associated with central line insertion, use, and maintenance
Higher risk for infection, catheter-induced trauma, metabolic alterations
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Central TPN (cont’d)
Delivers total dietary nutrients to patients who require nutritional supplementation
Patients with large nutritional requirements (metabolic stress or hypermetabolism)
Patients who need nutritional support for more than 7 to 10 days
Patients who are unable to tolerate large fluid loads
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31. Central TPN: Adverse Effects
Most common are those surrounding the use of the central line for the delivery of TPN
Infection
Catheter-induced trauma
Greater chance for hyperglycemia because of the larger and more concentrated volumes given
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Trace Elements
Chromium
Copper
Iodine
Manganese
Molybdenum
Selenium
Zinc
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Nursing Implications
Ensure that a complete nutritional assessment is taken, including a dietary history, weekly and daily food intakes, and weight and height measurements
Consult with a registered dietitian
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34. Nursing Implications (cont’d)
Assess baseline laboratory studies, such as total protein, albumin, BUN, RBC, WBC, cholesterol
Collect anthropometric data
Assess for allergies to components of enteral nutritional supplements (such as whey, egg whites)
Assess for lactose intolerance
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35. Nursing Implications (cont’d)
If administering enteral nutrition by tube feedings, follow facility policy for ensuring proper tube placement and for checking residual volumes before administering a feeding
Follow procedures for flushing tubing to prevent clogging the feeding tube with formula
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36. Nursing Implications (cont’d)
Carefully monitor how the patient is tolerating enteral feedings
Keep in mind that most enteral feedings are started slowly, and the rate is increased gradually
Monitor for signs of lactose intolerance
Cramping
Diarrhea
Abdominal bloating
Flatulence
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37. Nursing Implications (cont’d)
Follow facility policies and procedures for care and maintenance of TPN IV lines, including tubing and dressing changes
Monitor patient’s temperature; report any increase immediately
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38. Nursing Implications (cont’d)
Monitor blood glucose levels with a glucometer
Monitor for hyperglycemia
Headache, dehydration, weakness
Monitor for hypoglycemia
Cold, clammy skin, dizziness, tachycardia, tingling of the extremities
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39. Classroom Response Question
A patient is receiving peripheral parenteral nutrition (PPN). When the current bag is empty, the nurse discovers that the next ordered bag is not yet ready from the pharmacy. What will the nurse do?
Convert the IV to an IV lock until the next bag is ready.
Hang a bag of 10% dextrose.
Hang a bag of 20% dextrose.
Notify the physician that the bag is not ready.
Correct answer: B
Rationale: PPN infusions should have no more than 10% concentrations of dextrose fluids because higher concentrations could cause sclerosing of the vein. If the new bag is not ready, it is important to hang the 10% dextrose solution to prevent a sudden drop in serum glucose levels.
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40. Nursing Implications (cont’d)
While on TPN, the pancreas provides increased amounts of insulin to cover the increased glucose levels
If TPN is discontinued abruptly, rebound hypoglycemia may occur until the pancreas has time to adjust to changing glucose levels
If TPN must be discontinued abruptly, then infuse 5% to 10% glucose to prevent hypoglycemia according to facility policy
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41. Nursing Implications (cont’d)
Monitor for fluid overload while on TPN
Weak pulse
Hypertension
Tachycardia
Confusion
Decreased urine output
Pitting edema
Monitor daily weights and intake and output volumes
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42. Nursing Implications (cont’d)
Monitor for therapeutic responses to nutritional supplementation
Improved well-being, energy, strength, and performance of activities of daily living
Increased weight
Laboratory studies that reflect a more positive nutritional status
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43. Classroom Response Question
The nurse is assessing a patient admitted to the unit following major bowel surgery. The nurse anticipates administering which type of nutrition for this patient?
Enteral feedings through a percutaneous endoscopic gastrostomy (PEG) tube
Peripheral parenteral nutrition
Total parenteral nutrition
A high-residue diet
Correct answer: C
Rationale: Patients who have had major bowel surgery will not be able to take feedings via the gastrointestinal tract. Total parenteral nutrition is indicated for long-term nutritional support when oral feeding is not possible.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.