1. Methods of Nutrition Support KNH 411

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

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

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

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

11. 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 Specialized Nutrition Support (SNS)

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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” Gastrostomy Jejunostomy PEG- months, years, lifetime More permanent

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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 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

25. 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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27. Enteral Nutrition Feeding techniques/ delivery methods Bolus feedings- 250-500cc, 3-6 times per day Intermittent feedings Feeding for 20-30 mins X times per day Continuous feedings Only for hospital bound or can’t Tolerate other forms © 2007 Thomson - Wadsworth

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 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

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” a.k.a. – PN, TPN, CVN, IVH 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- most common can be placed at bedside Using subclavian, jugular, femoral veins PICC- per. Inserted central catheter Long-term access- requires surgery- cannot be done at bedside Tunneled catheters Implantable ports

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38. Parenteral Nutrition Solutions- hand in hand with the pharmacy Compounded by pharmacist using “clean room” Two-in-one Dextrose & amino acids- hung, clear solution Lipids added separately- 100 cc, 250 cc, or 500 cc Clear - easier to identify precipitates Can make sure none of the minerals fall out of solution Three-in-one Dextrose, amino acids, & lipids Single administration Cloudy solution- minerals can fall out, not concerned about calcium and phosphorus No other line- less opportunity for infection Cost, easy to use, used for someone that is stable

41. Parenteral Nutrition Solutions Protein- 3 (PPN) -20 (CONSENTRATED 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-??? For normal 1.5-1.8- after surgery,burns trauma 4 calories/gram of amino acid Restrict with renal- look at BUN, creatinin

42. Parenteral Nutrition Solutions Carbohydrates Energy source – dextrose monohydrate 3.4 kcal/g 1 mg/kg/min minimum Use in ICU setting 5%, 10 (normal) %, 50%, 70 (small volumes of PN) % concentrations Grater than 10% need TPN

43. Parenteral Nutrition Solutions Lipids Emulsion of soybean or safflower oil Essential fatty acids Should be 1-1.2 grams per kilo- no more than 60% grater than coming from FA Source of energy Minimum of 10% kcal (have 1.1 calorie per cc of solution) 20% has 2 calories per cc of solution 30% has 3 calories per cc of solution (rare) EFA need to be present after a month or so, a few weeks is not a huge deal

44. Parenteral Nutrition Solutions Electrolytes- not premade vila 1-2 ME per kilo, Na & K Cl or acetate- pH balance to determine 5-7.5 ME per kilo, Ca 4-10 ME per kilo, Mg 20-40 ME per kilo, P DRI standards used Vitamins/Minerals- premade vial- standard A,C,D,E,K,Bvit complex Trace minerals- Zn, Cu, Cr, I, Mb Medications- could add insulin, albumin, could have drug nut interactions

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47. Parenteral Nutrition Determining the nutrition prescription – clinical application - sample form

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

50. Parenteral Nutrition Complications GI complications- long term GI complications- lack of GI use- billirubin increasing- increased bacteria- get them back on oral feels ASAP Infections- can occur at the site (must replace line in a different area) Cycle the TPN