Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 54 Nutritional Supplements

2 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

3 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

5 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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

7 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Carbohydrate formulations Fat formulations Fat formulations Protein formulations Protein formulations  Altered amino acid formulations  Impaired glucose tolerance

8 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Elemental  Vivonex Plus, Peptamen, Vital HN  Minimal digestion needed; residual is minimal  Used for pancreatitis, partial bowel obstruction, irritable bowel disease, other conditions  Hyperosmolarity of formulas may cause GI problems

9 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Polymeric  Ensure, Ensure-Plus, Isocal, Osmolite, Sustacal, Jevity, others  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

10 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Modular  Three types  Carbohydrate: Moducal, Polycose  Fat: MCT oil, Microlipid  Protein: Casec, ProMod  Single nutrient formulas  Intended for use with monomeric or polymeric formulations

11 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

12 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Impaired Glucose Tolerance  Glucerna  Contains proteins, carbohydrates, fat, sodium, potassium  Used in patients with impaired glucose tolerance (e.g., diabetic patients)

13 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

14 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

15 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition (cont’d)  Also known as total parenteral nutrition (TPN) or hyperalimentation  Formulations vary according to individual patient nutritional needs  Amino acids  Carbohydrates  Lipids  Trace elements

16 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition (cont’d)  Amino acids  Nonessential amino acids  Essential amino acids  Semi-essential amino acids  Trace elements  Chromium  Iodine  Copper  Manganese

17 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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19 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%

20 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

21 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Peripheral TPN: Adverse Effects  Phlebitis is the most devastating adverse effect  Can lead to loss of a limb  Fluid overload

22 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Central TPN  Delivered through a large central vein  Subclavian  Internal jugular  Long-term use (more than 2 weeks)

23 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

24 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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 2 weeks  Patients who are unable to tolerate large fluid loads

25 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

26 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

27 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Assess baseline laboratory studies, such as total protein, albumin, BUN, RBC, WBC, cholesterol, and so on  Collect anthropometric data  Assess for allergies to components of enteral nutritional supplements (such as whey, egg whites)  Assess for lactose intolerance

28 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  If administering enteral nutrition by tube feedings, follow facility policy for ensuring proper tube placement and for checking residual before giving a feeding  Follow procedures for flushing tubing to prevent clogging the feeding tube with formula

29 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

30 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

31 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

32 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

33 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

34 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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