study of metabolomics
concentration of small molecules that are the result of metabolic processes. Create metabolic profiles to id molecular level differences - who will benefit from losing weight.
dietary needs of COPD pts
Protein is most important bc they need to pdc RBCs so that there's something for O to attach to. Unfortunately, they have little appetite.
breakdown of biochemical substances into simpler substances. Worst environment for pts who are sick -- leads to imbalances in body -- incr difficulty in healing
catabolism and injury
malabsorption (missing Es); Obstruction (peristalsis stopped, no nutrients); Liver/pancreas disease; Diminished perfusion (gut mesentery); Immobility (muscle wasting, bone resorption); Gastroparesis (paralyzed stomach); Inflammatory processes (infxn, autoimmune); Critical illness/injury
GI mucousal integrity
Inner-most endoth layer, responsible for GI secretions and sensitivity to chemicals and mechanical stimuli. Different areas have columnar epith cells. These cells, along with mucous, make mucosa impermeable to HCl
Increased energy needed for healing
Normal: Post-op; +10-30: Multiple fractures; +30-50: Severe infection; +50-110: 3rd degree burns
Mucosal lining b/down leads to translocation of B into bloodstream and the beginning of overwhelming infxn - immune response - organ failure - death from sepsis. Normally E. Coli. Needs to protect GI lining
Outcome of Gut Translocation
Bowel is resevoir of B, normal flora. If enter portal of systemic circulation, initiate sepsis or perpetuate on-going process
EBP w/ gut translocation
Early and continued enteral feeding promotes mucosal integrity, minimizing gut breakdown. Limit IV feeding! Switch to enteral or normal food ASAP.
Nurse's role with nutrition
Positive comments about trays, intake flow sheets, consult RD for diet instructions, poor appetite, suspected malnutrition, alternate nutritional support
Factors for diet selection
Diagnosis, age, diet order, albumin levels, pressure ulcers, food/drug interactions, length of stay. High risk - consult RD.
anorexia in in-patients
ill pts often have poor appetite. ketosis (linked to starvation) suppresses appetite, diagnostic tests and NPO can disrupt meal times. Watch that folks don't miss meals
Signs of malnutrition
pressure ulcers, pitting edema, dry skin, thinning/dry hair, temporal muscle wasting, ascites, hepatomegaly, excess/deficient subq fat, muscle wasting, bone pain
High-Risk for Malnutrition
Surgery, NPO, diagnosis, vent support >24hr, Albumin <3, Prealbumin <18, Braden <14, Wt loss >5 lbs/mo, diarrhea >24h, poor eating, inappropriate diet orders (prolonged clear liquids)
Albumin vs. prealbumin
Albumin - nutritional status over last 3 mos; Prealbumin - previous week (for nutritional status)
Carrier protein (zinc, Ca, etc) - necessary for maintaining oncotic pressure. Low - malnutrition, increased risk for morbidity, chronic rather than acute depletion
Limitations of Albumin
Long half-life (20d) so insensitive to acute, large body pool, affected by fluid status, not definition measure
Carrier protein for retinol-binding protein and transport protein for thyroxine. Sensitive indicator of visceral protein status. Acute
Advantage of prealbumin
Half-life of 2-3 d so sensitive for acute, better indicator of dietary change, not affected by fluid status
Limitations of prealbumin
Ltd. use in situations where there is a sudden demand for protein synthesis. More expensive
How to prevent malnutrition
Deliver meals hot, Help with tray set-up, oral care before/after, help them sit-up in chair, help with calorie count, consistently record height/weight on chart
Tube vs. IV
Tube - gut functioning but can't eat. ST: NG, ND. LT: gastrostomy or jejunostomy tube. IV - gut not functioning. TPN/hyperalimentation
For longer-term feeding. Weight at end drops through stomach to duodenum. Stays for months. Inserted by nurse. 2 tubes. Top - sucks out juices to prevent vomiting. Bottom - allows to feed past motility problems. Push to stomach, then peristalsis pulls further. Can't use until xray confirms.
Advantages of enteral nutrition
Physiologic and easier, preserves immune fxn, preserves gut barrier fxn, cheaper than TPN, fewer complications
gastric-residual volume. how much fluid we put in and how well body is tolerating it. estimates for liquid amts aren't EB. should be <200 but be really concerned if >400
Preventing infxn with enteral feeding
Clean top of formula can with alcohol wipe before opening, switch bedside container every 24 hrs, replace formula every 4 hrs
TPN Contents per day
Yellow. Liquid: (30-40 mL/kg); Energy: (30-60 kcal/kg); AAs (1-2 g/kg, depending on catabolism); essential fatty acids, vitamins, minerals. Rely on lab values!
Milky. Provide supplemental kilocalories and prevent essential fatty acid deficiencies. Normally separate bc don't mix well. Select line based on tonicity -- higher tonicity reqs central line.
Central vs peripheral veins for TPN
<10% dextrose - peripheral in combo with AAs and lipids. >10% central vein
Start slow and incr if they tolerate. 40-60 mL/hr. Too quick - osmotic diuresis/dehydration
TPN and causes of death
Gall stones bc too much pdxn of bile in relation to diet. Or, immune cells in liver become too fatty and don't work.
Complications of TPN (1-4)
Things that we can control: 1) Pneumothorax, 2) Air embolism; 3) Catheter occlusion; 4) Catheter sepsis