1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 55 Nutrition Supplements

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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  Nutrients are delivered directly into the circulation by means of an intravenous solution

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 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

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Groups  Provide the basic building blocks for anabolism  Supply complete dietary needs through the GI tract by oral route or by feeding tube  Elemental  Polymeric  Modular  Altered amino acid  Impaired glucose tolerance

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Elemental  Vivonex Plus, Peptamen, Vital HN  Minimum digestion needed; residual is minimal  Used for malabsorption, partial bowel obstruction, irritable bowel disease, other conditions  Hyperosmolarity of formulas may cause GI problems

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Polymeric  Complete, Ensure, Ensure-Plus, Isocal, Osmolite, Sustacal, others  Preferred over elemental formulations for patients with fully functional GI tracts and few specialized nutrient requirements; cause fewer GI problems

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Modular  Three types  Carbohydrate: Moducal, Polycose  Fat: MCT oil, Microlipid  Protein: Casec, ProMod, Stresstein  Single nutrient formulas  Can be added to other formulas if needed

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Enteral Formulation Group: Altered Amino Acid  Amin-Aid, Hepatic-Aid, Lonalac, Stresstein, Travasorb Renal  Contain varying amounts of specific amino acids  Used for patients with diseases associated with altered metabolism capabilities

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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)

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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 (i.e., tetracycline and nutrient formulations that contain calcium)

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition (cont’d)  Amino acids  Nonessential amino acids  Essential amino acids  Semiessential amino acids  Trace elements  Chromium  Iodine  Copper  Manganese

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition (cont'd)  Also known as total parenteral nutrition (TPN) or hyperalimentation  Formulations will vary according to individual patient nutritional needs  Amino acids  Carbohydrates  Lipids  Trace elements

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

19. Parenteral Nutrition (cont’d)  Peripheral administration  Temporary, short term (less than 2 weeks)  Dextrose concentration generally less than 10%  Central administration  Long-term use (over 2 weeks)  Dextrose concentrations may be 10% to 50%

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Peripheral TPN  Used to provide nutrients to patients who need more nutrients than present oral intake can provide  Procedures that restrict oral feedings  Anorexia caused by chemotherapy or radiation treatments  GI illnesses that prevent oral food intake  After surgery  When nutrition deficits are minimal, but oral nutrition will not be started for more than 5 days

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Peripheral TPN: Adverse Effects  PHLEBITIS is the most devastating adverse effect  Can lead to loss of a limb  Fluid overload

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Central TPN  Delivered through a large central vein  Subclavian  Internal jugular  Long-term use (more than 2 weeks)

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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 2 weeks  Patients who are unable to tolerate large fluid loads

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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 due to the larger and more concentrated volumes given

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Assess baseline laboratory studies, such as total protein, albumin, BUN, RBC, WBC, cholesterol, etc.  Collect anthropometric data  Assess for allergies to components of enteral nutritional supplements (such as whey, egg whites)  Assess for lactose intolerance

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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 before giving a feeding  Follow procedures for flushing tubing to prevent clogging the feeding tube with formula

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor how the patient is tolerating enteral feedings carefully  Most enteral feedings are started slowly and the rate is increased gradually  Monitor for signs of lactose intolerance  Cramping, diarrhea, abdominal bloating, flatulence

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

31. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  While on TPN, the pancreas is providing 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

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate 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