233 terms

Nutrition Care Plan

Nutrition care plans are fundamental roles of a clinical dietitation. What are 5 important aspects?
- specific for each patient
- Nutrition assessment of patient
- specific goals for patient
- action plans to meet each goal
- evaluation measures should be indicated
What were the 3 original skills of a nutritional care plan?
- assessment skills
- planning implementation skills
- evaluation skills
What are the 4 phases of the ADA Nutrition care plan?
- Assessment
- Nutrition diagnosis
- nutrition intervention
- nutrition monitoring & evaluation
ADA - Nutrition Assessment
- obtain/collect timely and appropriate data
- analyze/interpret with evidence-based standards
- document
ADA - Nutrition Diagnosis
- identify and label problem
- determine cause/contributing risk factors
- cluster signs and symptoms/defining characteristics
- document
ADA - Nutrition Intervention
- plan nutrition intervention
- formulate goals and determine a plan of action
- implement nutrition intervention
- care is delivered and action is carried out
- Document
ADA - Nutrition Monitoring and Evaluation
- Monitor progress
- measure outcomes indicators
- evaluate outcomes
- document
Why assess nutrition status in hosptial?
- frequent cases of malnutrition in hospitalized patients
- nutrition status affects treatment and recovery from illness/surgery
- baseline health status allows us to determine changes while in care
Malnutrition in hospitalized patients - chronic disease
- associated with
- increased morbidity
- increased mortality
- extended hospital stays
- condition of being diseased
- proportion of disease to health in a community
frequency of death in a certain population or caused by a particular disease
rate of occurance - # of new cases of a disease during a certain period
where we are at right now - # of cases of a specific disease in existence in a given population at a certain time
Nutrition assessments need to be
ongoing as disease/condition/treatment change
Iatrogenic Malnutrition
- physician-induced malnutrition
- treatment, cure can have more of an effect on nutritional status than disease/condition itself
Causes of Hospitial Malnutrition
- failure to observe suboptimal intake
- withholding meals because of tests
- issues with dentition/depression
- delayed or inadequate nutrition support
How does disease affect nutritional requirements?
- metabolic rate (increase or decrease)
- fever (increase)
- catabolism
- medication effect
- food intake
- food/nutrient intolerance
- malabsorption - primary concern in GI pt
Losses - fluids, nutrients, electrolytes (input/output)
Consequences of Under/inadequate-nutrition
- loss of organ mass and function
- atrophy of GI tract allowing bacterial translocation
- reduced immunocompetence
- weight loss (esp. muscle)
- poor wound healing/decubitus ulcers
- increase LOS and cost to system
Decubitus ulcers
pressure sore from laying so long
Purpose of a Nutrition Assessment
1. identifies nutrition related problems
2. proviides justification for the nutrition care plan
3. forms the basis for evaluating teh nutrition care plan
Nutrition Assessment - Purpose - Identifies nutrition related problems
- assessment often preceded by screening for individuals with specific risk factors
- objective and subjective
Objective Measures
nutritional status
confirmed by professional
Subjective Information
provided by patient or caregivers
Nutrition Assessment - Purpose - Provides Justification for the nutrition care plan
- basis for the formulation of goals (made with patient/client, family, health care team)
- goals should be realistic and measurable (ongoing monitoring required, outcome based)
- specific action plans for each goal should be developed
Nutriition Assessment - Purpose - Forms the basis for evaluating nutrition care plans
- baseline measures to compare goals/outcomes to need to compare changes for individuals
Nutrition Assessment of Patients:
Medical and social history
Anthropometry & body composition
Biochemical Data
Clincial/physical examination
Diet History
Estimation of Requirements
Two Phases of Nutrition assessment of patients
- patient at nutritional risk
- high, mod, low risk

- 48 hrs, 72 hrs, re-access im 7d
Medical History
- diagnosis if known (primary and secondary)
- all diseases and conditions an individual has had over their lifetime
- all surgical procedures and individual has undergone over their lifetime
- all symptoms an indiviual is experiencing
- thorough medical history obtrained upon admission to hospital
Social History
- living arrangements
- cooking/shopping ability
- religion (food restrictions)
- socioeconomic status/food security
Method of diet history/assessment determined by
capabilities of pt
time constraints
information from secondary source
24 hr recall
- fast, random
- retrospective for previous 24 hrs
- likely not usual intake/not typical
Daily food records
- prospective for set time periods
- record or weigh food intake
- increase accuracy with increase time period
- can be used in the hospital
- typical days (1d, 3d, 7d)
Food Frequency Questionnaire
- food intake over a specific time period
- food lists
- consumption frequency
- can include portion size
- better for assessing groups
Direct Observations
- time and labour consuming
- can only be down in a controlled setting
- frequency used in hospital setting where there is concern about pts
Dietary Assessment Evaluation
- comparing intake to Canada's Food Guide recommended servings
- give an approximation of quality of intake (ex: missing a good group)
Nutrient Analysis
- food composition tables
- nutrient analysis software
- individual nutrients
- individual analysis must be compare to reference values
Daily Recommended intake
- all DRI values (RDA, EAR, AI, UL) are for healthy individuals/populations and are specific for age and gender
Recommended Daily Allowance
- amount that is adequate for 97-98% of healthy population
- goal is for optimum nutrition
- NOT used to assess diets of individuals or groups
Estimated Average Requirement
- would be used as reference values for nutrient analysis programs
- estimated requirement adequate in 50% of the population
- MAY be used to assess diets of individuals and groups
Adequate intake
- used when RDA and EAR exists due to lack of scientific evidence
- MAY be used to assess diets of individuals and groups
- used as REFERENCE VALUES for nutrient analysis programs when no EAR exists
Tolerable Upper Intake
- maximum nutrient intake NOT associated with adverse side effects (folate, Ca, iron)
Diet History/Assessment: In hospital
- a combo of many methods
- needs to determine any changes to diet with disease/symptom onset
Clinical/Physical Assessment
- examine the patient for clinical signs and symptoms reflecting malnutrition
- physical signs do not usually appear until deficiency level is severe
- physical signs are often not specific
Dietitians generally examine for
Protein, Energy Deficiencies
if concerned about __________________ lab tests are done
Protein, Energy Deficiencies are apparent in Hair, Face, Skin, and musculoskeletel by
Hair: dry, dull, alopecia
Face: drawn in
Skin: delayed wound healing, skin breakdown, decubitus ulcers
musculoskeletel: wasting, decreased strength
- may be a sign of protein deficiency
- may be a sign of very low activity level/immobilization
- may indicate poor renal function (chronic or acute)
- can contribute to skin breakdown
Antropometry - used to determine body size and proportions
- height
- weight
- circumferences
Antropometry - Height
- used for energy requirement calculations
- used for BMI
- used for height/weight tables
- measure if possible
- can be used by other members of health care team to determine drug dosages
Supine Measurement
- used if pt is to ill to stand
- should be lying flat/straight
- measure both sides
Antropometry: Frame Size
- Wrist circumference
- elbow breadth
Wrist Circumference
- smallest point distal to ulna/radius styloid process
- r = height(cm) / wrist cir (cm)
- compared to reference values
Elbow Breadth
- distance between epicondyles or humerous
- compared to reference values
Antropometry: Body Weight
- most important
- requires measurement (standing, chair, bed scales available)
- take amputations into account
- fluid status
- needs to be measured on an ongoing basis
Fluid Status
- edema can affect weight (wet weight)
- attempt to determine dry weight
- evaluates weight independent of height
- interpretations
- different values at age 65
- evaluation of obesity
- association with health risks
BMI Pros
- easy to use
- correlates with body fat measures
- not influenced by height
- high correlation with specific diseases
- permits comparison between groups
BMI Cons
- not as useful (children, elderly >65, atheletes, pregnancy)
- doesn't take body composition into consideration
Ideal Body Weight (IBW)
- calculation (Hamwii Method)
- not all acct for age, race, frame size
- healthy weight range (USDA)
- reference populations
- use desireable BMI ranges for specific age groups
= current wt/IBW x 100
Usual Body Wt (UBW)
- used to determine weight changes
- rapid or unintentional change in UBW
Rapid or unintentional change in UBW
- may indiciate nutritional risk
- used for some differential diagnoses
- can be a nutrition screening tool
- can indicate
- decreased energy intake
- increased energy requirement
= current wt/UBW x 100
% weight change
= (UBW - current wt) / UBW x 100
Most important weight assessments
% Wt Change
Body Shapes
android - apple (more at risk)
gynoid (in butt)
Unplanned weight loss indicating risk of malnutrition
> 5% of UBW over one month
> 10% of UBW over 6 month
What does a weight gain of more than 1 kg/week likely indicate?
change in fluid status
Body Composition
- body circumferances and areas
- skin-fold measurements
- bio-electrical impedance
Body Circumferences/Areas
- used to estimate skeletal muscle mass (somatic protein stores and body fat stores)
- Waist Circumference
- Waist-to-hip ratio
- mid-upper-arm curcumference
Waist Circumference
- correlates with visceral fat stores
- increase risk for CVD and Type 2 Diabetes
males > 40in/102cm
females >35in/88cm
Waist-to-hip ratio
- estimates distribution of subcutaneous and intra-abdominal adipose and muscle tissue
- possible increased risk for morbidity and mortality with ratios
men >1.0
women >0.8
Mid-upper-arm circumference
- measure skeletal muscle within the arm
- sequential measure can be used to monitor nutrition intervention
Skinfold Thickness
- measurement of subcutaneous adipose tissue stores
- measured with calipers
- adipose stores vary with age, sex, race
- need to be done by trained individuals (measured in triplicate
Four Measurements of Skinfold thickness
- Triceps Skinfold (TSF)
- Subscapular skinfold (triangle on back)
- Biceps skinfold
- Supraillac skinfold (3 fingers below waist)
measure in triplicate
Bioelectrical Impedance Analysis (BIA)
- estimates body composition
- total body water
- fat-free mass and fat mass
- body cell mass
- Low level electrical current passes through the body
- fat free mass = electrical conductor
- fat mass = insulator
Dual-energy X-Ray Absorptiometry (DEXA)
- estimates body composition
- fat tissue
- lean tissue
- bone mass
- low levels x-ray passes through the body
- Accuracy - accurate and reproducible
Biochemical Analysis
- can detect sub-clinical deficiencies
- usually measured by blood or urine samples
- Pt result compared to reference values
Common Specimens of Biochemical Analysis
- whole blood
- serum or plasma
- blood cells (erythro (RBC)), leucko (WBC))
- blood spots
- Urine
- Feces
- Other tisses (scraping of biopsy)
Difference between serum and plasma
Serum - without coaggulating factor
Plasma - with coaggulating factor
Serum Total Protein
- composed of mostly albumin and 4 types of globulin (half life 20 days)
- not always representative of protein status
- low sensitivity, low specificity
- affected by: protein intake, protein metabolism/synthesis, hydration, medications, activity level
Serum Alb (Albumin)
- half life ~ 20 days
- may show longer term protein status
- decrease significanty when overhydrated and with acute illness
- most useful for pts being followed long term and without acute illness
Serum Albumin (g/L)
Level of Visceral Protein Depletion
Thyroxin Binding Protein (Prealbumin, Pre Alb)
- Half life 2 day
- may show short term changes in protein status
- sensitive to acute nutritional changes
- decreased significantly with acute illness
- Most useful for patients being followed in hospital and once pt is recovering
C-Reactive Protein (CRP)
- serum marker of acute inflammation
- increased signficantly by acute phase inflammation and acute illness
- most useful for pts with surgery and pts with acute trauma
- not protein specific
Urine Analysis
- Nitrogen Balance
- Creatinine Excretion
Nitrogen Balance
- reflects fetal protein mass (urea excreted)
- gives a measurement of protein breakdown
- requires 24hr urine collection
Creatinine Excretion
- reflects muscle mass
- increased muscle wasting - bedridden pts
- lost faster in males
3Types of Iron
- Essential (RBC, myoglobin, enzymes)
- Transferrin
- Ferritin
Essential Iron
- myoglobin
- enzymes
- iron transport protein
- Transferrin saturation (T-SAT) - higher value
- Total iron binding capacity (TIBC) - lower value
- storage form of iron
- can reflect a deficiency, excess, or normal iron status
(liver, bone marrow, spleen)
- RBC synthesis
- B12
- Folate
- Iron
- Pt anemic - all 3 levels should be checked
- iron deficiency anemia = clinical deficiency ( once all storage and transport iron used up)
Single Nutrient in Serum
- nearly all vitamins and minerals can be measured in serum
- may increase/decrease with certain diseases/conditions
Nutrient Deficiency in Nutrition Assessment: Diet History
Primary Lack or Secondary Cause
- decrease intake
- decreased absorption
- increased need
Nutritent Deficiency in Nutrition Assessment: Biochemical Measures
Declining Stores

Abnormal Functions inside the body
Nutrient Deficiency in Nutrition Assessment: Clinical Exam/Anthropometrics
Clincial signs and symptoms
Subjective Global Assessment
- nutritional assessment based on pts medical hx and physical exam
- high correlation to objective measures
What assessment is useful for the critically ill?
Subjective Global Assessment
What assessment method predicts post op infection better than objective measures
Subjective Global Assessment
What are the HISTORY features of SGA?
- weight changes
- dietary intake
- GI symptoms
- functional ability
- metabolic demands
What are the PHYSICAL EXAM features of SGA?
- loss of subcut. fat
- muscle wasting
- edema
- ascites
SGA features are based on
information collected
SGA features subjectively catergorize pts
A= well nourished
B= moderate or suspected malnutrition
C= severe malnutrition
SGA: Pros
- less time required
- can be taught to a variety of health professionals
- all pts in facility rated by some system
SGA: Cons
- less detail
- harder to establish baselines for individual parameters
Estimation of Requirements
- Energy (Kcal)
- Protein
- Fluid
Requirement Assessment: Energy: Factors
- nutritional status
- activity
- severity of illness
- wounds, trauma, ventilation, infection, fever (can increase or decrease requirement)
- malabsorption
- medications
- age, gender, height/weight, body composition
Energy Estimation Equations
- Basal Energy Expenditure (BEE)
- Harris-Benedict Equation (HBE)
- FAO/WHO Equations
Basal Energy Expenditure
- maintaining body function
- 65% energy needed for functioning
Harris-Benedict Equation
- may overestimate BEE
- most commonly used
- considers ht, wt, gender, age
- still used because of data to compare
considers wt, gender, age
Activity Factor (AF)
- physical activity from bed-bound to strenuous activity
- BEE is multipled by AF
Stress Factor (SF)
- stress from various clinical states
- may change over clinical course
Critical Illness & Severe Malnutrition
Ireton-Jones Equation
Ireton-Jones Equation
- different for ventilated & spontaneously breathing pts
- spontaneously breathing - includes for increased obesity
- ventilated - includes for increase for burns/trauma
Obesity and BEE
- different opinions of what wt to used for HBE
- ideal IBW, actual, average of ideal and actual
Adjusted Wt (ABW >125% of IBW)
- IBW + actual IBW x 0.25
Kilocalories/kilogram body wt
- total energy requirement
- 25-35 Kcal/g
- 21 Kcal/g for obese pt
- quick to calulate w/o formulas
Indirect Calorimetry
- actual measurement rather than estimated by calculation
- measures O2 consumed, CO2 produced
- assumes 1L O2 = 3.9 & 1L CO2 = 1.1
What does indirect calorimetry calculate?
- BEE (awake, fasted, supine)
- REE (after 30 min rest, 4 hrs after a meal
- RQ = VCO2/VO2
RQ values
CHO - 1
Fat - 0.7
Pro - 0.82
Alcohol - 0.67
Indirect Calorimetry: Pros
- accurate measurement of calorie requirements
- information on substrate utilization
- can see acute changes
- can be used on ventilated pts
Indirect Calorimetry: Cons
- expensive
- trained professional
- exact testing criteria
Requirement Assessment: Protein Estimation: Healthy Adult
FAO/WHO = 0.75g/kg body wt
Canada = 0.86g/kg body wt
DRI (RDA >19 yr) = 0.8g/kg body wt
Protein Estimation: In Hospital
- moderately stressed: 1.0-1.5g/kg body wt
- severely stressed: 1.5-2.0g/kg body wt
DRI Macrpnutrient Distribution Ranges: Adult
CHO: 45-65%
PRO: 10-35%
Fat: 20-35%
DRI Macrpnutrient Distribution Ranges: Young Children
CHO: 45-65%
PRO: 5-20%
Fat: 30-40%
DRI Macrpnutrient Distribution Ranges: Older Children
CHO: 45-65%
PRO: 10-30%
Fat: 25-35%
Conditions that may change protein requirement
- renal disease - increase in dialysis
- liver disease - increase or decrease
- pregnancy/lactation
- trauma
Requirement Assessment: Fluid/Hydration Estimation
- total body water = 55-65% of body wt
Hydration status affects other areas of nutrition
- biochemical measurements
- physical exam
- anthroprometrics
Fluid Inputs
- food and drink
- IV fluids
- irrigation
Fluid Outputs
- urine and stool
- insensible losses
- sweating/fever
- wound output
- vomitting
- diarrhea
- medications (diuretics)
Fluid Calculation based on
- Wt
- Age & Wt
Weight fluid calculaton
1st 10 kg = 100ml/kg
next 10 kg = 50ml/kg
>20 kg = 20ml/kg
Age and Weight fluid calculation
16-30 active = 40ml/kg/d
20-55 = 35ml/kg/d
66-75 = 30ml/kg/d
>75 = 25ml/kg/d
Energy Fluid calulation
1ml per kcal
fluid balance
urine output + 500 ml
Nutrition Diagnosis (Dx)
- nutritional problem that the dietitian is responsible for treating
- identifies and describes the problem
PES Statement
- Problem, Etiology, Signs/Symptoms
- writting for a Nutrition diagnosis using standardized language
Nutrition Intervention
= nutrition plan + implement
- purposely planned actions designed with the intent of changing a nutrition-related behaviour, risk factor, environmental condition, or aspect of health status for an individual, a target group, or population at large
Nutrition intervention should be targeted at the
= formulate and determine a plan of action
- prioritize the nutrition Dx (most current issue first)
- select specific strategies
- define intervention plan
- determine expected outcomes
- define time and frequency of care
- identify resources
= action phase of the nutrition care plan
how do you carry out (implement) the plan?
- communicate with pts and other health professional team
- continue data collection & modify the plan of care as needed
- follow-up and verify that implementation occurs
- evaluate food-drug interactions: counsel accordingly
- educate pts
Nutrition Care Process/Plan
Nutrition Dx - articulated as etiology
Nutrition Intervention - Addresses etiology or signs/symptoms
Nutrition Monitoring & evalution
Planning Nutrition Support: How will we provide the requirements?
- Diet/Nutrition prescription: type, amt, frequency, route of feeding
- P.O. intake = regular/general diet or modified
- enternal nutrition (EN) - tube feeding
- parenteral nutrition (PN) - iv feeding
Diet Classifications
- pt can safely tolerate oral feeding
- can feed themselves
- pt has not disease or illness that require modification of diet
- Regular/Full
- diet provided with no modifications
What is a therapeutic diet?
- modification of the normal diet to treat the disease, illness or physical symptoms
Why might someone need a therapeutic diet?
- swallowing problem
- lactose problem
- diabetes
- religion
- vegan
- recoverying from surgery
What is the purpose of a modified diet?
- maintain and restore nutritional status
- rest an affected organ
- adjust ability to digest, metabolize or excrete
- improve tolerance of food intake
- adjust for mechanical difficulties
- increase or decrease body wt
- eliminate specific foods
What is a diet prescription?
- specific type of therapeutic diet ordered
- states what modifications to the regular diet will be used
5 Diet Modifications
- Consistency
- Texture
- Energy
- Nutrients
- Seasoning
Consistency Diet Modifications
- Clear fluids
- Full Fluids
Clear Fluids
- clear
- minimal or no residue in GI tract
- foods that are liquid at room temp (consumee, ginger ale, jello)
- used in transition diet following IV feeding
- intended for short use 24-48 hrs
- supplements can be included
Full Fluids
- liquid at body temp
- easily digested foods (cream soup, ice cream, pudding, cooked cereals)
- used in pts with
- swallowing difficulties, esophgeal problems
- transition from CF to full diet
- severe chewing problems
- decreased appetite / severe vomitting
- nutritionally adequate
- can be monotonous/bland
Texture Diet Modifications
- pureed -> minced -> diced (soft to chew)
- progressive consistency
Used for
- chewing difficulties
- mechanical (teeth, ENT surgery)
- neurological (stroke, brain injury)
Energy Diet Modifications
- can be specific kcal lever
- weight loss, weight gain, diabetes
- Cen be high/increased calorie/energy diet
- wt maintenance, weight gain
Nutrient Diet Modification
- can be specific nutrient
- specific level
- high/low
- often met with supplements
- a diet may incorporate/restrict several
Bland/Light Nutrient modification
- based on tradition
- foods are mildly seasoned, low in fiber, low in fat
- often transition diet to regular
Nutrition Monitoring and Evaluation Components
monitor progress, measure outcomes, evaluate outcomes
Monitor Progress
- check pts's understanding and adherance
- determine if intervention is being implemented as planned
- determine if pt's status is or is not changing
- identify other positive or negative outcomes
- gather information indicating reasons for any lack of progress
Measure Outcomes
- select outcome indicators that re relevant to signs or symptoms, nutrition goals, medical diagnosis and outcomes or quality management goals
Evaluate Outcomes
- compare current findings with previous status, intervention goals, and or reference standards
Enteral Nutrition - Definition
- provision of supplemental or total nutrition by feeding directly into the GI Tract
- Oral feeding cannot be tolerated
what are some occasions where oral feeding cannot be tolerated
- swallowing problem
- nerve damage
- trauma
- Pt is unconscious
- stroke
- severe burn
Indications for enteral feeding
- insufficient to meet estimated need by oral food intake
> 5 days an PEM
< 50% requirements 5-10 days
- GI tract is functional
What are the benefits of enteral feeding
- maintenance of GI integrity, decreasing atrophy
- decrease gastric ulceration
- enhance nutrient utlilization
- safe a less costly
Contraindications for enteral support
- non-functional GI
- bowel obstruction (physical or paralytic ileus)
- extended bowel rest
Enteral Feeding Route - non-surgical (<6 weeks)
- Nasogastric (NG)
- Nasoduodenal (ND)
- Nasojejunal (NJ)
Enteral Feeding Route- NS - Aspiration Risk
NG - med
ND - low
NJ - low
Enteral Feeding Route- NS - Dumping Risk
NG - low
ND - med
NJ - high
Enteral Feeding Route - NS - Ease of Removal
NG, ND, NJ - easy
Enteral Feeding Route - NS - long term tolerance
NG, ND, NJ - fair
How can you tell when non-surgical Enteral feeding tubes are in the correct place?
NG - gastric juices
ND - x-ray
NJ - x-ray
Enteral Feeding - surgical (>6 weeks)
- esophagostomy
- gastrostomy
- jejunostomy
percutaneous endoscopic gastrostomy
Enteral Feeding Route- S - Aspiration Risk
- esophagostomy - high
- gastrostomy - low
- jejunostomy - low
Enteral Feeding Route- S - Dumping Risk
- esophagostomy - low
- gastrostomy - low
- jejunostomy - high
Enteral Feeding Route - S - Ease of Removal
- esophagostomy - diff
- gastrostomy - diff
- jejunostomy - diff
Enteral Feeding Route - S - long term tolerance
- esophagostomy - good
- gastrostomy - good
- jejunostomy - good
Selection of Enteral Formula
- osmolarity
- digestability
- energy density
- lactose content
- fat content
- viscosity
Enteral Formula - osmolality
- fluid imbalance can lead to diarrhea, nausea, GI distress
- H20 moves from a dilute sol to a conc. solution
Enteral formula differs in
osmolality - by wt, # of osmoloes solute/kg solution
osmolarity - by vol, # of osmoles solute/L solution
Osmolality of body fluid
~ 300 mOsm/kg
The great the # of ____________, the smaller the _____
the greater the # of PARTICLES IN SOLUTION, the smaller the PARTICLE SIZE.
increasing OSM
Osm and CHO, PRO, Fat, Electrolytes
CHO - if high Mol wt: large particles (low osm effect)
- is low Mol wt: smaller particles (high osm effect(
PRO - large particle: minimal osm
- small particle: high osm
Fat - do not form solution in water
- very minimal osmotic effect
Electrolytes - small particles (K+, Na+): high osm effect
Types of tube feeding formula
- blended
- elemental (monomeric)
- non-elemental (polymeric)
- specific nutrient modular
- disease-specific formula
Blended tube feeding
- blended regular foods
- sometimes baby food
- rarely used
- tubes may plug
Elemental Diet tube feeding
- low residue (peptides, glucose, EFA)
- lactose free
- unpalatable for oral use
- basic nutrients "ready to absorb"
AA & short peptiides
glucose, dextrose
no fat, or minimal MCT
- more H20 soluble than most fats
- require less bile salts
diffuse more rapidly
are not re-esterified in the enterocyte
- transported as fatty acid bound to albumin through portal circulation
- portal blood flow = much greater than the lymphatic system
Non-elemental diets
- low residue or with fibre
- low osmolality
- may contain lactose
- oral or enteral feeding
- intact macro-nutrients
eg) prot - soy, Na or Ca casinate
CHO - corn syrup, glucose polymer, corn starch
Fat - veg oil
Nutrient Modules (single nutrient)
- supply single nutrients
- good for diet manipulations
eg) PRO - whey, albumin
CHO - glucose polymers
Fat - TG with MCT or LCFA
Special Formula Tube Feeding
- pts have normal GI function but have a metabolic or oral esophageal problem
Special Formula tube feeding products
- Glucerna (Diabetes)
- 50% fat-high MUFA
- 33% CHO - corn starch, fructose
- Amin-Aid (Renal Disease)
- 4% pro
- NPE:N 800:1
- Pulmocare - Pulmonary Disease (COPD) :RQ
- 55% fat
- 28% CHO
- Impact - improve immune function
- RNA - increase host immune responsiveness & survival
- Arg - increase celluar immune function
- Omega 3 fat: alter PG synthetic pathway
Methods of formula administration
- continuous drip feeding
- intermittent drip feeding
- bolus feeding (all at once)
- cyclic drip feeding
Continuous Drip Feeding
- preferred methods
- slow and steady
- low complications
- 16-24 hrs
- pump
Intermittent Drip
- not ideal - used in special situations
- q4-6 (over 30-60 min)
- gravity drip or pump
- miminc meal time
Bolus Feeding
- rapid feeding syringe or feeding bag
- q4-6 (in 15 min)
- feed only to stomach
- complications: aspiration, digestion
Cyclic Drip Feeding
- night feeding only
- 8-16 h
- pump
- used as transition feedings
- allow greater mobility
- good for home nutrition support
Isotonic solutions
- can be started at full strength
Hypertonic Solutions
- very slow delivery rate to begin with
Rate of Feeding
Start - 25-50ml/h --- max 1200 ml/d
Advance - 50-75ml/h --- max 1800 ml/d
Upper Limit - 75-150ml/h --- max 3600 ml/d
Dumping Syndrome
- a complex physiological response to the rapid emptying of hypertonic contents/undigested foods into the duodenum and jejunum (hyperosmolar syndrome)
Dumping Syndrome Symptoms
- n/v, weakness, fatigue, sweating, palpitation, diarrhea, syncope
- progresses to weakness, sweating, dizziness
Dumping Syndrome Causes
- stomach surgery (gastrectomy, gastric bypass surgery)
- EN feeding to the jejunum
Dumping syndrome
Parenteral Nutrition Definition
Provision of nutritents directly into the bloodstream intravenously without using the GI tract
Indications of PN support
- unavailable functioning GI, Bowel rest
*bowel obstruction, fistulas, short bowel syndrome, ileus
- inadeuquate enteral nutrition >5-7 to 10 d
*variable upon institute
- severe malnutrition/preoperative nutrition rehabiliation
*anorexia, wt loss >= 10-15%: nutritional repletion
Contraindications for PN support (reasons to not use)
- functional GI or recover GI function in 7-10 d
- nutrition support is anticipated for < 7 d
- ricks of PN exceed potential benefits
- inability to obtain venous access
- aggressive nutrition support contraindicated
PN access
Central PN access
- Total Parenteral Nutrition (TPN)
- catheter into vena cava
- can infuse concentrated (hyperosmolar) formula
- less pressure incurred
- decreased phlebitis
Peripheral PN access
- Peripheral Parenteral Nutrition (PPN)
- catheter into vein in arm
- cannot provide concentrated nutrients & electrolytes
- easy to put in
- use less < 7 day
Central (TPN) Pros
- long term use > 14 day
- hypertonic solutions
- meets nutrition requirements
Central (TPN) Cons
- ++ risk of infection
- invasive
- + nursing care time
Peripheral (PPN) Pros
- non-invasive/short term 7-14 day
- peripheral vein - risk of infection
Peripheral (PPN) Cons
- amts limited by Osm
- duration of line placement (less)
TPN Components: Fat
- lipid emulsions
- essential FA included
- calorie density: 20% lipid, 1g = 10 kcal
- max dose 1-1.5 g/kg/day
- soybean oil based (intralipid)
- olive oil based (ClinOliec)
- glycerine used to make emulsion isotonic
TPN Components: Vitamins
- STD vitamin solution -- 9 water soluble and 3 fat soluble vitamins
- provides maintenance amt of vitamin
- daily requirement: 10 mL of multi-12
- extra vitamins can be added
Water Soluble vitamins
Vit C
pantothenic Acid
Fat soluble vitamins
Vitamin A, D, E
TPN Components: Minerals (TES)
STD trace element solution
I, Zn, Cu, Cr, Mn, Se
- provides maintenance amt of minerals: 2ml of trace
Why is Fe rarely used in TPN
doesn't mix well with nutrients
anaphalatic rxn can occur
- extra nutrients can be added
TPN Components: Electrolytes
Na, K, PO4, Ca, Mg
- individualized and adjusted daily based on serum levels
TPN and insulin, ranitidine, heparin
Insulin - hypoglycemia can occur - so not usually used
Ranitidine - histamine
Heparin - added to help protect the vein
Total Nutrient Admixture
- mix all components of TPN into one bag
- the AA solution and dextrose are mixed in one bag
- lipid is administered in a seperate bag
Completing PN Requistion
Pts requirement
1) determine protein (g) to provide
2) determine glucose (g) to provide
3) make up the remainder of Kcal with lipid
4) determine the amt of electrolytes (based on daily IV requirements, serum levels and renal function)
5) include multi vit, TES and any other additives
PN infusion rate
- variable -- continuous vs. cyclic infusion
- pt dependent
- volume dependent
- to discontinue
- gradual decrease in infusion rate until transition to oral or EN meets minimal nutrient needs
- catheter often remains for medications
PN Complications: Metabolic related
- hyper/hypoglycemia
- hypertriglyceridemia
- EFA deficiency
- Fluid Overload/dehydration
- Prerenal azotemia
- hyper/hypo electrolytes
- abnormal liver function tests
- metabolic acid/base balance
- hyperammonemia
- iron deficiency
Essential fatty acids
linolenic, linoleic acid
PN Complications
- placement and positioning of catheter
- infection - catheter, site, solution
- Phiebitis - irriation of vessel wall by catheter or hyperosmolar solutions
- thrombosis
- Perforation
- Pneumothorax
- occlusion