1. Methods of Nutrition Support
KNH 411

2. Reasons why people are not getting enough

3. Oral diets “House” or regular diet
Therapeutic diets – soft or manipulated consistency to deal with mechanical or nutrient problems
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 Consistency
Single nutrient manipulation
Preparation
Food restriction
Number, size, frequency of meals
Addition of supplements
Mifflin St Jorg calculation used to determine how much each individual needs

5. Oral diets
Texture modifications (progresses from clear liquid, to full liquid, to soft diet)
Soft diets
Liquid diets
Clear liquid
Full liquid
Consider osmolality
Preparation for a specific medical test

6. Clear liquid diet is not to last longer than two days, 500 calories

7. High osmolality can cause gastric problems- diarrhea, dumping syndrome
Blood has an osmolality of 300- aim for liquids around this number

8. Oral Supplements
Goal: Increase nutrient density without increasing volume
Snacks
Liquid meal replacement formulas
Modular products
Commercial supplements
Other ways to increase calorie and macronutrient intake

10. Appetite Stimulants Drugs that stimulate appetite Prednisone
Megestrol acetate
Dronabinol

11. Specialized Nutrition Support (SNS)
Administration of nutrients with therapeutic intent
Enteral- if the gut works, use it (should be primary way of feeding)
Parenteral- used if the gut is not working
Ethical considerations

12. TPN by central vein after 7 days
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13. 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

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

15. 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

17. Enteral Nutrition GI Access – “Ostomy” More permanent Gastrostomy
Jejunostomy
PEG- months, years, lifetime
More permanent
For when patient is going home and still needs to tube feed

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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
Specialized amino acid profiles- renal formulas, status- post for healing (in a stress state)

22. 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

23. Enteral Nutrition Formulas Lipid Corn or soy oil
Long- and medium-chain TG
Omega-3 fatty acids- improve immune function
Structured lipids- fish oils

24. Enteral Nutrition Formulas Vitamins and minerals
Meet DRI with 1500 cc
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- (enteral) number of osmoles attracting molecules per water weight
Osmolarity- number of milimole in liquid per liter of solution

25. Enteral Nutrition Other considerations
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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27. Enteral Nutrition Feeding techniques/ delivery methods
Bolus feedings cc,
3-6 times per day
Intermittent feedings
Feeding for mins
X times per day
Continuous feedings
Only for hospital bound or can’t
Tolerate other forms
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28. Enteral Nutrition Equipment Feeding tubes - french size
Cans or sealed containers
Pumps

29. Enteral Nutrition Determining the nutrition prescription
clinical application
Steps for writing an enteral prescription
Dose weight
Calorie goal
Adjust for activity factor or injury
Calculate protein
State total calorie amount
Calculate calories from lipid
Calculate calories from carbohydrate
Electrolyte needs
Vitamin and mineral needs
Look at fluids

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

31. Enteral Nutrition Monitoring for complications Dehydration
Tube Feeding Syndrome
Electrolyte Imbalances
Underfeeding or Overfeeding
Hyperglycemia
Refeeding Syndrome
Monitor serum phosphorus, mg, potassium, monitor pre- albumin, phosphorus levels
Don’t overfeed client too quickly

35. 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

36. Parenteral Nutrition Venous access Short-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)

37. Left subclavian most used
Infections major concern
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38. Parenteral Nutrition Solutions
Compounded 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

39. Write a prescription for dextrose, amino acids, and electrolytes depending on lab values
Standard amount of multivitamins

41. Parenteral Nutrition Solutions Protein
4kacl/g of amino acid in solution
Individual amino acids
Modified products for renal, hepatic and stress
Commercial amino acids % depending on patient
g/kg depending on condition
.8 for normal patient
for burn, trauma, healing patients

42. Parenteral Nutrition Solutions Carbohydrates
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
Too much can lead to hyperglycemia

43. Parenteral Nutrition Solutions Lipids
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

44. Parenteral Nutrition Solutions Electrolytes
1-2 miliequivilants for sodium, potassium per kilo, Chloride or acetate based on levels, miliequivilants per kilo, magnesium per kilo, 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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47. Parenteral Nutrition Determining the nutrition prescription
– clinical application
- sample form

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

50. Parenteral Nutrition Complications GI complications Infections
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