© 2007 Thomson - Wadsworth Methods of Nutrition Support Chapter 7

© 2007 Thomson - Wadsworth Malnutrition 30 – 50% of hospitalized patients 95% of nursing home patients Resulting in reduced quality of life & increased health care costs May be remedied by providing nutrition support Oral diets Supplemental foods Enteral and parenteral nutrition

© 2007 Thomson - Wadsworth

Oral diets “House” or regular diet Therapeutic diets Maintain or restore health & nutritional status Accommodate changes in digestion, absorption, or organ function Provide nutrition therapy through nutrient content changes

© 2007 Thomson - Wadsworth Oral diets Changes from the house diet Caloric level Consistency Single nutrient manipulation Preparation Food restriction Number, size, frequency of meals Addition of supplements

© 2007 Thomson - Wadsworth Oral diets Texture modifications Soft diets Liquid diets Clear liquid Full liquid Consider osmolality Table 7.1 Preparation for a specific medical test

© 2007 Thomson - Wadsworth

Oral Supplements Goal: Increase nutrient density without increasing volume Snacks Liquid meal replacement formulas Modular products Commercial supplements

© 2007 Thomson - Wadsworth

Appetite Stimulants Drugs that stimulate appetite Prednisone Megestrol acetate Dronabinol

© 2007 Thomson - Wadsworth Specialized Nutrition Support (SNS) Administration of nutrients with therapeutic intent Enteral Parenteral Ethical considerations

© 2007 Thomson - Wadsworth

Enteral Nutrition Feeding through the GI tract via tube, catheter or stoma delivering nutrients distal to oral cavity “Tube feeding” Indicated for patients with functioning GI but unable to self-feed Contraindications Advantages / Disadvantages?

© 2007 Thomson - Wadsworth Enteral Nutrition Decisions for the nutrition prescription GI access Formula Feeding technique Equipment needed

© 2007 Thomson - Wadsworth Enteral Nutrition GI Access Access route described by where it enters the body and where the tip is located Nasogastric Orogastric Nasointestinal Typically used for short term Figure 7.3 Disadvantages?

© 2007 Thomson - Wadsworth

Enteral Nutrition GI Access – “Ostomy” Gastrostomy Jejunostomy PEG More permanent Table 7.4

© 2007 Thomson - Wadsworth

Enteral Nutrition Formulas Based on substrates, nutrient density, osmolality, viscosity Protein Soy or casein 10-25% kcal Elemental or chemically defined Specialized amino acid profiles

© 2007 Thomson - Wadsworth Enteral Nutrition Formulas Carbohydrate Monosaccharides, oligosaccarides, dextrins, maltodextrins Lactose & sucrose free FOS Fiber ?

© 2007 Thomson - Wadsworth Enteral Nutrition Formulas Lipid Corn or soy oil Long- and medium-chain TG Omega-3 fatty acids Structured lipids

© 2007 Thomson - Wadsworth Enteral Nutrition Formulas Vitamins and minerals Meet DRI Supplemental amounts Fluid and nutrient density kcal per mL Difference depends on water content Ensure adequate fluid - 80% water for 1 kcal per mL Osmolality and osmolarity

© 2007 Thomson - Wadsworth Enteral Nutrition Formulas Other considerations Considered medical food – not drug –No test for efficacy or benefit Cost

© 2007 Thomson - Wadsworth

Enteral Nutrition Feeding techniques/ delivery methods Bolus feedings Intermittent feedings Continuous feedings

© 2007 Thomson - Wadsworth Enteral Nutrition Equipment Feeding tubes - french size Cans or sealed containers Pumps

© 2007 Thomson - Wadsworth Enteral Nutrition Determining the nutrition prescription Box 7.4 – clinical application

© 2007 Thomson - Wadsworth Enteral Nutrition Complications Mechanical complications Clogged or misplaced tubes GI complications Diarrhea Aspiration

© 2007 Thomson - Wadsworth Enteral Nutrition Monitoring for complications Dehydration Tube Feeding Syndrome Electrolyte Imbalances Underfeeding or Overfeeding Hyperglycemia Refeeding Syndrome Monitor serum phosphorus, mg, potassium

© 2007 Thomson - Wadsworth

Parenteral Nutrition Administration by “vein” a.k.a. – PN, TPN, CVN, IVH TPN vs. PPN Indicated if unable to use oral diet or enteral nutrition Certification of medical necessity

© 2007 Thomson - Wadsworth Parenteral Nutrition Venous access Figure 7.7 Short-term access CVC inserted percutaneously Using subclavian, jugular, femoral veins PICC Long-term access Tunneled catheters Implantable ports

© 2007 Thomson - Wadsworth

Parenteral Nutrition Solutions Compounded by pharmacist using “clean room” Two-in-one Dextrose & amino acids Lipids added separately Clear - easier to identify precipitates Three-in-one Dextrose, amino acids & lipids Single administration

© 2007 Thomson - Wadsworth

Parenteral Nutrition Solutions Protein Individual amino acids Modified products for renal, hepatic and stress Commercial amino acids % g/kg depending on condition

© 2007 Thomson - Wadsworth Parenteral Nutrition Solutions Carbohydrates Energy source – dextrose monohydrate 3.4 kcal/g 1 mg/kg/min minimum 5%, 10%, 50%, 70% concentrations

© 2007 Thomson - Wadsworth Parenteral Nutrition Solutions Lipids Emulsion of soybean or safflower oil Essential fatty acids Source of energy Minimum of 10% kcal

© 2007 Thomson - Wadsworth Parenteral Nutrition Solutions Electrolytes DRI standards used Table 7.7 Vitamins/Minerals Table 7.8 Trace minerals Medications

© 2007 Thomson - Wadsworth

Parenteral Nutrition Determining the nutrition prescription Box 7.5 – clinical application Figure sample form

© 2007 Thomson - Wadsworth

Parenteral Nutrition Administration techniques Initiate 1 L first day; increase to goal volume on day 2 Patient monitoring Intake vs. output Laboratory monitoring

© 2007 Thomson - Wadsworth Parenteral Nutrition Complications GI complications Infections