Nutrient Delivery To determine Kcal and protein needs, along with appropriate diet medical nutrition therapy is needed SCREEN is a series of nutrition related questions that determine risk factors ASSESSMENT is the use of anthropometric, biochemical, clinical data to determine nutrition status INTERVENTION is the plan of care instituted to address nutrition problems identified in assessment MONITORING is the tracking of nutritional markers for efficacy of treatment course

Nutrient Delivery Diet manuals are institutional set meal plans or formularies determined to address a variety of nutritional needs Currently a diet is A PHYSICIAN ORDER, with medical implications for patient safety Diet modifications are often needed for chronic illness and food textures, including clear, soft, full, purée, mechanical, and regular Often diets must be held for procedures, such as CT, MRI, and cath lab, but NOT for surgery until <2hrs before Pts NPO greater than >4 days are considered at risk and will require a nutrition consult

Nutrient Delivery Nutrition support can be given enterally or parenterally depending on clinical status Oral intake is ALWAYS preferred and can be encouraged with assistance, food quality, bed positioning, and supplements Supplements can be given orally or enterally and are SPECIFIC for disease states, in concentrated amounts Modular formulas provide single nutrients while element formulas have isolated peptides and FAs For GI patients, ideally trials of standard formula is preferred and then as tolerated elemental formulas made be needed

Nutrient Delivery For patients with a functional gut but are unable to take PO, consider enteral nutrition For patients requiring nutrition support FOR <2 WEEKS, a NGT, NJT, OGT is appropriate For patients needing long term EN a PEG, PEJ is appropriate if the patient is a surgical candidate Tube feeding can begin 2-4 hours after PEG in the adult patient, or after x-ray confirmation of NGT, OGT

Nutrient Delivery Tube feeding should be >45 degrees to prevent aspiration, and should advanced to GOAL as directed Bolus feeding is typically for patients who have functional lives and can tolerate larger volumes Continuos feeds are for bed bound patients or risk for aspiration which require low volume Gastric Residual Volume (GRV) should be checked q 4hrs with a HOLD of EN only when >500ml

Nutrient Delivery Always wear gloves, clean the top of cans, label the bag, discard in 24hrs, can hang for 8hrs Never add free water or medications to EN formulas, give with separate flushes Take strict I/Os of total volume, fluids, urine output, GRV, and bowl movements Consideration for bowel regimen, diuretics, steroids, sedation, and prokenetics

Nutrient Delivery Parenteral Nutrition, indicated for NPO >7 days, GI surgery, pancreatitis, emesis, esophageal varices PPN via arterial line, TPN via central line or PICC depending on access and concentration Composed of AA, CHO, and separate Lipids, with micronutrients and vitamins PPN is for short term support with mOsol <900, typically not providing 100% of kcal needs

Nutrient Delivery PO > EN > TPN, if the gut works use it, always consider clinical status TPN risk of infection, hyperglycemia, liver damage, hyperlipemia, renal damage, gut ischemia Cost is >1000$/day and must be ordered <24hrs for compounding by pharmacy Pt can be discharged on TPN in extreme cases, with some cases of >20 years