1. Methods of Nutrition Support KNH 411

3. Oral diets “House” or regular diet In hospital for testing before any diagnoses have been made Therapeutic diets Soft/manipulating texture or nutrients Maintain or restore health & nutritional status Accommodate changes in digestion, absorption, or organ function Provide nutrition therapy through nutrient content changes

4. Oral diets Changes from the house diet *Caloric level (most important!) Mifflin Equation Consistency From a regular diet-to a soft diet Single nutrient manipulation Fat, CHO, Pro Ex: low-fat diet with a patient who has a high lipid content Preparation Low Na? High K? How will be manipulate foods? Food restriction Standard serving sizes/amounts needed to lose weight once they leave the hospital Number, size, frequency of meals Multiple feedings, high calorie, high energy, nutrient-dense—cancer patients! Addition of supplements

5. Oral diets Texture modifications Soft diets Liquid diets Clear liquid Low osmolarity Full liquid More consistency & higher osmolarity Adds back in milk products/lactose Consider osmolality Soft diet Preparation for a specific medical test

8. Oral Supplements Goal: Increase nutrient density without increasing volume Snacks Liquid meal replacement formulas Modular products Commercial supplements Ex: status post bariatric surgery

10. Appetite Stimulants Drugs that stimulate appetite Post-op Cancer Patients Prednisone Megestrol acetate Dronabinol Derivative of marijuana (“munchies”)

11. Administration of nutrients with therapeutic intent Enteral If gut works, use it! First line of defense Adequate feeding via gut Parenteral Gut isn’t working Peripherally or centrally using the veins for feeding Second line of defense PPN: if GI tract can’t tolderate feeds, can do this for 7 days If longer, a central line will be surgically planced via a central line Ethical considerations Specialized Nutrition Support (SNS)

12. © 2007 Thomson - Wadsworth

13. Enteral Nutrition Feeding through the GI tract via tube, catheter or stoma delivering nutrients distal to oral cavity “Tube feeding” (nasogastric? Orogastric?) Indicated for patients with functioning GI but unable to self-feed Alterened mental status Swallowing dysfunction Contraindications Concerns with inflammatory response (nausea, vomiting) Advantages / Disadvantages? Quick, cost effective, decreased rate of infection, improved wound healing, need to maintain GI function Difficult to administer (nose to stomach or SI), poor tolerance (patient may pull out tube), constantly checking for correct placement, vomiting/diarrhea

14. Enteral Nutrition Decisions for the nutrition prescription GI access Formula Feeding technique Equipment needed Pump? Bolus feeds?

15. Enteral Nutrition GI Access Access route described by where it enters the body and where the tip is located Nasogastric Orogastric Nasointestinal (nose to duodenum or jejunum) Typically used for short term Disadvantages? Discomfort with NG tube Tubes may get clogged if smaller (constant flushing)

17. Enteral Nutrition GI Access – “Ostomy” Gastrostomy Jejunostomy PEG Endoscope to go into stomach to place tube to put the formula in Long-term solution More permanent

19. © 2007 Thomson - Wadsworth

21. Enteral Nutrition Formulas Based on substrates, nutrient density, osmolality, viscosity Protein Soy or casein 10-25% kcal Elemental or chemically defined Protein from peptides (completely broken down) Specialized amino acid profiles Increase protein product for dialysis patient Decrease protein product for pre-renal S/P surgery or in a stressed state: increased protein

22. Enteral Nutrition Formulas Carbohydrate Monosaccharides, oligosaccarides, dextrins, maltodextrins Lactose & sucrose free (most individuals with GI complications don’t want to complicate that GI sytsem further with lactase) FOS Fermented into short chains Compromised GI tracts (helps maintain GI integrity) Fiber ? Needed for those with Inflamed GI tract Thickening formulas helping with improved bowel functions—soluble fibers Insoluble fibers: soy, polysaccharides Long-term feeding patients have concerns with constipation

23. Enteral Nutrition Formulas Lipid Corn or soy oil Long- and medium-chain TG Omega-3 fatty acids Maintains immune function Structured lipids Newer products made from fish oils that help with CV health

24. Enteral Nutrition Formulas Vitamins and minerals Meet DRI Supplemental amounts Most formulas with 1500 cc’s will contain the needed vitamin amount Fluid and nutrient density 1.0-2.0 kcal per mL (per cc) Difference depends on water content Ensure adequate fluid - 80% water for 1 kcal per mL *Osmolality vs.** osmolarity *: # water attracting particles per water weight Enteral feedings/how many calories per cc **: # miilimoles of solid or liquid in liter solution Parenteral nutrition (feeding via VI) and how dense/hypertonic particles are in fluid solution going through a vein

25. Enteral Nutrition Formulas Other considerations Considered medical food – not drug No test for efficacy or benefit Cost

26. © 2007 Thomson - Wadsworth

27. Enteral Nutrition Feeding techniques/ delivery methods Bolus feedings 250-500 cc’s spread out throughout the day (3-6 times per day) Intermittent feedings Several times per day over 20-30 minutes Continuous feedings Reserved for hospital/bed bound clients © 2007 Thomson - Wadsworth

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

29. Enteral Nutrition Determining the nutrition prescription -clinical application -Determine dose weight -Determine calorie goal -Adjust for activity or injury (that would increase needs) -Calculate protein goal -Identify overall calories -ID appropriate amount calories from lipids, then CHO, then consider electrolyte needs, with consider vitamin/mineral needs -Look at fluids (fluid restricted or can they receive the normal 1 calorie per cc?)

30. Enteral Nutrition Complications Mechanical complications Clogged or misplaced tubes GI complications Diarrhea Aspiration (formula reflux) ^All signs they may need perenteral nutrition

31. Enteral Nutrition Monitoring for complications Dehydration Tube Feeding Syndrome Electrolyte Imbalances Underfeeding or Overfeeding Hyperglycemia Refeeding Syndrome Monitor serum phosphorus, mg, potassium

35. Parenteral Nutrition Administration by “vein” Gut doesn’t work Nutrition via IV for 7-14 days Dextrose levels <10 a.k.a. – PN, TPN (total parenteral nutrition), CVN (central vein nutrition), IVH (intravenous hyperalimentation) TPN vs. PPN Indicated if unable to use oral diet or enteral nutrition Certification of medical necessity

36. Parenteral Nutrition Venous access Short-term access CVC inserted percutaneously Most common Can be placed at bedside Using subclavian, jugular, femoral veins PICC Long-term access Tunneled catheters Concerned with infection—needs to be done using surgery Implantable ports lye completely below the skin—surgery

37. © 2007 Thomson - Wadsworth

38. Parenteral Nutrition Solutions Work hand-in-hand with pharmacist Compounded by pharmacist using “clean room” 300, 400, or 500 cc’s are common Two-in-one Dextrose & amino acids Lipids added separately Benefit: clear - easier to identify precipitates Three-in-one Dextrose, amino acids & lipids Quick/easy access Cost saving Single administration Less opportunities for infection

41. Parenteral Nutrition Solutions Protein 3% (PN patient) -20% (individual who is needing a concentrated solution) 4 cals/g of amino acid put into solution Individual amino acids Modified products for renal, hepatic and stress Commercial amino acids 3.5-20%.8- 1.8 g/kg depending on condition.8-.8: regular patient in hospital 1.5-1.8: Burn patient, trauam, staus post-surgery

42. Parenteral Nutrition Solutions Carbohydrates Energy source – dextrose monohydrate 3.4 kcal/g 1 mg/kg/min minimum 5%, 10%, 50%, 70% concentrations (large range) Greater than 10%= will need TPN Too much CHO being used: hypoglycemia, fatty liver infiltration, excessive CO2

43. Parenteral Nutrition Solutions Lipids Emulsion of soybean or safflower oil Essential fatty acids Source of energy 1-1.2 g/kilo is ideal Not go above 60% calories from lipids Minimum of 10% kcal solution has 1.1 calorie per cc of solution (100 calories) 20% has 2 calories per cc of solution (200 calories) 30% is rare, and is 3 calories per cc (300 calories) Essential fatty acids need to be present! Ex: premature infants, short-gut syndrome, etc.

44. Parenteral Nutrition Solutions Electrolytes 1-2 milliequivalents/kilo for potassium and sodium Chloride/acetate: need to look at pH balance 5-7.5 mEq/kilo for Ca 4-10 mEq/kilo for Mg 20-40 mEq/kilo for Phosphorus DRI standards used Vitamins/Minerals Looking at pre-made multi-vitamins Standard has: A,C,D,E,K and B vitamins Trace minerals Zinc, copper, chromium, iodide, mellyb?? Medications Insulin Albumin Heparin Be aware of drug-nutrient interaction that may occur with TPN

46. © 2007 Thomson - Wadsworth

47. Parenteral Nutrition Determining the nutrition prescription – clinical application - sample form

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

50. Parenteral Nutrition Complications GI complications Bile accumulation in gall bladder due to lack of GI use Increased bacteria can be produced in the gut causing GI atrophy Want to get them on oral/tube feedings right away Infections At the site of delivery of TPN