Methods of Nutrition Support KNH 411

Reasons why people are not getting enough

Oral diets “House” or regular diet Therapeutic diets – soft or manipulated consistency to deal with mechanical or nutrient problems Maintain or restore health & nutritional status Accommodate changes in digestion, absorption, or organ function Provide nutrition therapy through nutrient content changes

Oral diets Changes from the house diet Caloric level Consistency Single nutrient manipulation Preparation Food restriction Number, size, frequency of meals Addition of supplements Mifflin St Jorg calculation used to determine how much each individual needs

Oral diets Texture modifications (progresses from clear liquid, to full liquid, to soft diet) Soft diets Liquid diets Clear liquid Full liquid Consider osmolality Preparation for a specific medical test

Clear liquid diet is not to last longer than two days, 500 calories

High osmolality can cause gastric problems- diarrhea, dumping syndrome Blood has an osmolality of 300- aim for liquids around this number

Oral Supplements Goal: Increase nutrient density without increasing volume Snacks Liquid meal replacement formulas Modular products Commercial supplements Other ways to increase calorie and macronutrient intake

Appetite Stimulants Drugs that stimulate appetite Prednisone Megestrol acetate Dronabinol

Specialized Nutrition Support (SNS) Administration of nutrients with therapeutic intent Enteral- if the gut works, use it (should be primary way of feeding) Parenteral- used if the gut is not working Ethical considerations

TPN by central vein after 7 days © 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” More permanent Gastrostomy Jejunostomy PEG- months, years, lifetime More permanent For when patient is going home and still needs to tube feed

© 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 Other considerations 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 Nutrition Feeding techniques/ delivery methods Bolus feedings- 250-500cc, 3-6 times per day Intermittent feedings Feeding for 20-30 mins X times per day Continuous feedings Only for hospital bound or can’t Tolerate other forms © 2007 Thomson - Wadsworth

Enteral Nutrition Equipment Feeding tubes - french size Cans or sealed containers Pumps

Enteral Nutrition Determining the nutrition prescription clinical application Steps for writing an enteral prescription Dose weight Calorie goal Adjust for activity factor or injury Calculate protein State total calorie amount Calculate calories from lipid Calculate calories from carbohydrate Electrolyte needs Vitamin and mineral needs Look at fluids

Enteral Nutrition Complications Mechanical complications Clogged or misplaced tubes GI complications Diarrhea Aspiration

Enteral Nutrition Monitoring for complications Dehydration Tube Feeding Syndrome Electrolyte Imbalances Underfeeding or Overfeeding Hyperglycemia Refeeding 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 access Short-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)

Left subclavian most used Infections major concern © 2007 Thomson - Wadsworth

Parenteral Nutrition Solutions Compounded 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

Write a prescription for dextrose, amino acids, and electrolytes depending on lab values Standard amount of multivitamins

Parenteral Nutrition Solutions Protein 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 Solutions Carbohydrates 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 Too much can lead to hyperglycemia

Parenteral Nutrition Solutions Lipids 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 Solutions Electrolytes 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 Patient monitoring Initiate 1 L first day; increase to goal volume on day 2 based on lab values Patient monitoring Intake vs. output Laboratory monitoring

Parenteral Nutrition Complications GI complications Infections 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