Methods of Nutrition Support KNH 411

Oral diets “House” or regular diet Therapeutic diets Maintain or restore health & nutritional status Accommodate changes in digestion, absorption, or organ function Provide nutrition therapy through nutrient content changes

Oral diets Changes from the house diet Caloric level Consistency Single nutrient manipulation Preparation Food restriction Number, size, frequency of meals Addition of supplements

Oral diets Texture modifications Soft diets Liquid diets Clear liquid Full liquid Consider osmolality Preparation for a specific medical test

Oral Supplements Goal: Increase nutrient density without increasing volume Snacks Liquid meal replacement formulas Modular products Commercial supplements

Appetite Stimulants Drugs that stimulate appetite Prednisone Megestrol acetate Dronabinol

Administration of nutrients with therapeutic intent Enteral Parenteral 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” Indicated for patients with functioning GI but unable to self-feed Contraindications Advantages / Disadvantages?

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 Orogastric Nasointestinal Typically used for short term Disadvantages?

Enteral Nutrition GI Access – “Ostomy” Gastrostomy Jejunostomy PEG 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 Specialized amino acid profiles

Enteral Nutrition Formulas Lipid Corn or soy oil Long- and medium-chain TG Omega-3 fatty acids Structured lipids

Enteral Nutrition Formulas Vitamins and minerals Meet DRI Supplemental amounts Fluid and nutrient density kcal per mL Difference depends on water content Ensure adequate fluid - 80% water for 1 kcal per mL Osmolality and osmolarity

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

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Enteral Nutrition Feeding techniques/ delivery methods Bolus feedings Intermittent feedings Continuous feedings © 2007 Thomson - Wadsworth

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

Enteral Nutrition Determining the nutrition prescription - clinical application

Enteral Nutrition Complications Mechanical complications Clogged or misplaced tubes GI complications Diarrhea Aspiration

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” a.k.a. – PN, TPN, CVN, IVH 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 Using subclavian, jugular, femoral veins PICC Long-term access Tunneled catheters Implantable ports

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Parenteral Nutrition Solutions Compounded by pharmacist using “clean room” Two-in-one Dextrose & amino acids Lipids added separately Clear - easier to identify precipitates Three-in-one Dextrose, amino acids & lipids Single administration

Parenteral Nutrition Solutions Protein Individual amino acids Modified products for renal, hepatic and stress Commercial amino acids % g/kg depending on condition

Parenteral Nutrition Solutions Carbohydrates Energy source – dextrose monohydrate 3.4 kcal/g 1 mg/kg/min minimum 5%, 10%, 50%, 70% concentrations

Parenteral Nutrition Solutions Lipids Emulsion of soybean or safflower oil Essential fatty acids Source of energy Minimum of 10% kcal

Parenteral Nutrition Solutions Electrolytes DRI standards used Vitamins/Minerals Trace minerals Medications

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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 Patient monitoring Intake vs. output Laboratory monitoring

Parenteral Nutrition Complications GI complications Infections