Methods of Nutrition Support

KNH 411

Oral diets

“House” or regular diet

Therapeutic diets – soft or manipulated consistency to deal with mechanical or nutrient problems Maintain or restore health & nutritional statusAccommodate changes in digestion, absorption, or

organ functionProvide nutrition therapy through nutrient content

changes

Oral diets

Changes from the house dietCaloric levelConsistencySingle nutrient manipulationPreparationFood restrictionNumber, size, frequency of mealsAddition of supplements

Oral diets

Texture modifications (progresses from clear liquid, to full liquid, to soft diet)Soft dietsLiquid diets

Clear liquid Full liquid Consider osmolality

Preparation for a specific medical test

Oral Supplements

Goal: Increase nutrient density without increasing volumeSnacksLiquid meal replacement formulasModular productsCommercial supplements

Appetite Stimulants

Drugs that stimulate appetitePrednisoneMegestrol acetateDronabinol

Administration of nutrients with therapeutic intentEnteral- if the gut works, use it (should be primary

way of feeding)Parenteral- used if the gut is not working

Ethical considerations

Specialized Nutrition Support (SNS)

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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”

Gastrostomy Jejunostomy PEG- months, years, lifetime

• More permanent

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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 Formulas

Other considerations Which type of formula works best for the

patient Considered medical food – not drug

No test for efficacy or benefit

Cost

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Enteral NutritionFeeding techniques/ delivery

methodsBolus feedings- 250-500cc,

3-6 times per day

Intermittent feedingsFeeding for 20-30 mins

X times per day

Continuous feedingsOnly for hospital bound or can’t

Tolerate other forms

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Enteral NutritionEquipment

Feeding tubes - french sizeCans or sealed containersPumps

Enteral Nutrition

Determining the nutrition prescription- clinical application- Steps for writing an enteral prescription

1. Dose weight

2. Calorie goal

3. Adjust for activity factor or injury

4. Calculate protein

5. State total calorie amount

6. Calculate calories from lipid

7. Calculate calories from carbohydrate

8. Electrolyte needs

9. Vitamin and mineral needs

10.Look at fluids

Enteral Nutrition

ComplicationsMechanical complications

Clogged or misplaced tubes

GI complications Diarrhea

Aspiration

Enteral Nutrition

Monitoring for complicationsDehydrationTube Feeding SyndromeElectrolyte ImbalancesUnderfeeding or OverfeedingHyperglycemiaRefeeding 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 accessShort-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)

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Parenteral Nutrition

SolutionsCompounded 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

Parenteral Nutrition

SolutionsProtein

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

SolutionsCarbohydrates

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

Parenteral Nutrition

SolutionsLipids

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

SolutionsElectrolytes

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

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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 based on lab values

Patient monitoring Intake vs. outputLaboratory monitoring

Parenteral Nutrition

ComplicationsGI complications

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