Nutritional Supplements Chapter 55 Nutritional Supplements Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Copyright © 2014 by Mosby, an imprint 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 Fat formulations Protein formulations Altered amino acid formulations Impaired glucose tolerance Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Enteral Formulation Group: Elemental Peptamen, Vital HN, Vivonex Plus, Vivonex TEN Minimal digestion needed; residual is minimal Used for malabsorption, partial bowel obstruction, irritable bowel disease, other conditions Hyperosmolarity of formulas may cause GI problems Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Enteral Formulation Group: Polymeric Complete, Ensure, Ensure Plus, Isocal, Osmolite, Portagen, Jevity, Sustacal 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Enteral Formulation Group: Modular Three types Carbohydrate: Moducal, Polycose Fat: MCT Oil, Microlipid Protein: Casec, ProMod, Propac, Stresstein Single nutrient formulas Intended for use with monomeric or polymeric formulations Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient who has a history of type 1 diabetes mellitus is in need of enteral nutrition. Which enteral formulation does the nurse anticipate administering to this patient? Ensure Glucerna Polycose Jevity Correct answer: B Rationale: Glucerna is appropriate for use in patients with impaired glucose tolerance (e.g., diabetic patients). Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint 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) Copyright © 2014 by Mosby, an imprint 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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse is administering tube feeding to a patient taking multiple medications. The nurse is most concerned about absorption of which medication when administered with tube feedings? digoxin penicillin phenytoin furosemide Correct answer: C Rationale: Tube feedings can reduce the absorption of phenytoin, which may result in seizures. It is recommended that tube feedings be held for at least 2 hours before and after the administration of phenytoin. This can be problematic, because the patient may not receive adequate nutrition due to withholding of feedings. This issue is somewhat controversial, and some suggest that the interaction is more theoretical than actual. Thus, some institutions have decided to ignore this possible interaction and to monitor phenytoin levels and patient status, rather than holding the tube feedings, whereas others continue to hold the tube feedings. Often the patient requires intravenous phenytoin when continuous tube feedings are necessary. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Enteral Nutrition: Adverse Effects Gastrointestinal intolerance Dumping syndrome Aspiration pneumonia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse identifies which condition as the most common adverse effect of nutritional supplements? Infection Phlebitis Diarrhea Hyperglycemia Correct answer: C Rationale: The most common adverse effect of nutritional supplements is gastrointestinal intolerance, manifesting as diarrhea. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Hyperalimentation Total parenteral nutrition (TPN) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Parenteral Nutrition (cont’d) Formulations vary according to individual patient nutritional needs Amino acids Carbohydrates Lipids Trace elements Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Amino Acids Protein synthesis, or anabolism Types of amino acids Essential Nonessential Semiessential Amino acid crystalline solutions (Aminosyn 3%, 5%, and 10%, and FreAmine III 8.5% and 10%) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Carbohydrates Carbohydrates are usually supplied to patients through dextrose Peripheral parenteral nutrition (PPN) dextrose concentrations are usually kept below 10% to decrease the possibility of phlebitis Central TPN dextrose concentrations can range from 10% to 50%, but they are commonly 25% to 35% Supplemental insulin may be given simultaneously in nutritional supplements Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Fats Intravenous fat emulsions serve two functions Supply essential fatty acids Source of energy or calories Essential fatty acid deficiency Lipid emulsions, Intralipid and Liposyn, are available as 10%, 20%, or 30% emulsions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Varying Amounts of Energy from 1 g of Dextrose, Fat, or Protein Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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% Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question When caring for a patient receiving PPN, it is most important for the nurse to assess for the development of which adverse effect? Hypertension Anemia Renal failure Phlebitis Correct answer: D Rationale: The most devastating adverse effect of PPN is phlebitis, which is vein irritation or inflammation of a vein. If phlebitis is severe and is not treated appropriately, it can lead to the loss of a limb, although this is rare. Another potential adverse effect is fluid overload. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Peripheral TPN: Adverse Effects Phlebitis is the most devastating adverse effect Can lead to loss of a limb Fluid overload Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Central TPN Delivered through a large central vein Subclavian Internal jugular Long-term use (more than 7 to 10 days) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 7 to 10 days Patients who are unable to tolerate large fluid loads Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Trace Elements Chromium Copper Iodine Manganese Molybdenum Selenium Zinc Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Assess baseline laboratory studies, such as total protein, albumin, BUN, RBC, WBC, cholesterol Collect anthropometric data Assess for allergies to components of enteral nutritional supplements (such as whey, egg whites) Assess for lactose intolerance Copyright © 2014 by Mosby, an imprint 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 volumes before administering a feeding Follow procedures for flushing tubing to prevent clogging the feeding tube with formula Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient is receiving peripheral parenteral nutrition (PPN). When the current bag is empty, the nurse discovers that the next ordered bag is not yet ready from the pharmacy. What will the nurse do? Convert the IV to an IV lock until the next bag is ready. Hang a bag of 10% dextrose. Hang a bag of 20% dextrose. Notify the physician that the bag is not ready. Correct answer: B Rationale: PPN infusions should have no more than 10% concentrations of dextrose fluids because higher concentrations could cause sclerosing of the vein. If the new bag is not ready, it is important to hang the 10% dextrose solution to prevent a sudden drop in serum glucose levels. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint 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 according to facility policy Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse is assessing a patient admitted to the unit following major bowel surgery. The nurse anticipates administering which type of nutrition for this patient? Enteral feedings through a percutaneous endoscopic gastrostomy (PEG) tube Peripheral parenteral nutrition Total parenteral nutrition A high-residue diet Correct answer: C Rationale: Patients who have had major bowel surgery will not be able to take feedings via the gastrointestinal tract. Total parenteral nutrition is indicated for long-term nutritional support when oral feeding is not possible. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.