Methods of Nutrition Support

KNH 411

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

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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

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

Oral Supplements

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

Appetite Stimulants

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

Specialized Nutrition Support (SNS)

 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

© 2007 Thomson - Wadsworth

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

Enteral Nutrition

  Decisions for the nutrition prescription GI access  Formula  Feeding technique  Equipment needed   Pump?

Bolus feeds?

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)

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

© 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 (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

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

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

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

Enteral Nutrition

  Formulas

Other considerations

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Considered medical food – not drug

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No test for efficacy or benefit Cost

© 2007 Thomson - Wadsworth

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

Enteral Nutrition

 Equipment  Feeding tubes - french size  Cans or sealed containers  Pumps

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?)

Enteral Nutrition

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

Enteral Nutrition

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

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

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

© 2007 Thomson - Wadsworth

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

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

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

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.

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

© 2007 Thomson - Wadsworth

Parenteral Nutrition

 Determining the nutrition prescription – clinical application - sample form

Parenteral Nutrition

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

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