Hospital-Based Nutrition Flashcards
1
Q
Main considerations of when to begin feeding hospitalized patient
A
- Patient’s pre-existing nutritional status
- Patient’s level of illness
- Consequences to the patient of inadequate nutrition
2
Q
General rules of when to feed hospitalized patients
A
- Previously well-nourished adult with minimal acute medical illness:
- 10-14 days without food before nutritional deficiencies develop
- Previously undernourished adult with minimal medical illness OR previously well-nourished individual with serious acute medical illness:
- Might go 5-7 days without food before nutritional deficiencies develop
- Previously undernourished adults with serious medical illness:
- May develop nutritional deficiencies in 3-5 days if not fed
3
Q
Premorbid nutritional status assessment - types of patients to consider feeding sooner
A
- Patients who:
- are alcoholics
- are homeless
- are underweight
- have signs of muscle loss or cachexia
- have chronic diarrhea or other GI disturbances
- self-report poor dietary intake
- have chronic medical problems that increase energy expenditure
- have insensible losses of nutrients because of proteinuria, mucous production, bleeding
- Patients who have:
- Fever
- WBC < 1500
- Tachycardia
- Rapid respiratory rate
- Drainage from operative sites or sites of infection
- Healing wounds
- Substantial proteinuria
4
Q
Pros and cons of different feeding methods
A
- Key consideration is how they will be fed
- Enteral: nasogastric (NG)
- Benefit of being normal physiologic mechanism
- Need nutrition to help health of gut epithelium, needed for protective barrier function
- Drawback is danger of aspiration, trouble with placing food
- Parenteral
- Drawback is potential for infetion from central venous catheter
- Enteral: nasogastric (NG)
5
Q
Approaches to estimating nutrient needs
A
- Hospitalized patients typically have low levels of physical activity –> PAEE is low
- However, medical illness can increase resting energy expenditure
- TEE is about 22-25 kcal/kg/day for someone who is not that sick, increases to about 30-32 kcal/kg/day for someone who is very sick
- Multiply person’s weight in kg by number of kcal/day you think is appropriate based on patient’s history and status
- Enteral diets generally come in 1kcal/mL
- Number of kcal/day = number of ml/day to infuse
- Divide by 24 to calculate hourly infusion rate
- Dr. Bessessen’s Sick-o-Meter: sicker, larger people need more calories than smaller, healthier people
- Range: 22-35 kcal/kg/day
6
Q
Approach to writing order for nutritional support in hospitalized patient
A
- Guesstimate how many kcal/kg/day patient needs
- Multiply by patient’s weight in kg
- Subtract D5 calories
- Divide by 24 - hourly infusion rate
7
Q
Approach for determining if patient is receiving adequate nutritional support
A
- Be sure what has been ordered is also what is delivered
- Calculate total calories
8
Q
Effects of overfeeding
A
- Overfeeding causes hyperglycemia
- May occur 1-2 days after increase in nutrient administration because glycogen storage pool buffers
- May take several days to resolve because glycogen pool needs to deplete
9
Q
Effects of underfeeding
A
- Underfeeding causes negative nitrogen/protein balance
- Muscle brokendown to provide AAs for gluconeogenesis
- Protein breakdown can be measured by monitoring urinary nitrogen over 24 hours, if BUN is stable
- Urinary nitrogen (in grams) X 6.25 (protein to nitrogen ratio) = grams of catabolized protein
- Average protein requirement is 0.5-0.8 g/kg/day
- May be increased to 0.8-1.8 g/kg/day in illness
10
Q
Special issues in feeding patients with pulmonary/respiratory failure
A
- Overfeeding could lead to excess nutrient use, increased CO2 production –> increased ventilation
- Bad when the goal is to wean someone from ventilator
- Underfeeding can lead to weakness of respiratory muscles
- Hard to wean off ventilator
- More CO2 is produced / O2 with carbohydates as compared to fat
- More CO2 = increased work of breathing
- Some say high fat diet is better for ventilated patients - no great studies on this
- More CO2 = increased work of breathing
11
Q
Special issues in feeding patients with liver failure
A
- Pre-existing nutritional deficiency and insulin resistance common
- Hepatic encephalopathy in part from increased blood ammonia level
- May also have ascites due to salt/water retention –> may be good to limit salt, protein, water
- Must be balanced to avoid underfeeding
- Some end-stage complications may be due to false NTs resulting from high levels of aromatic AAs
- Can be reason to advocate for diet high in branched chain AAs to provide protein while limiting false NT production
12
Q
Special issues in feeding patients with renal failure
A
- If kidneys are not working, BUN goes up
- Protein catabolism is source of this nitrogen
- Some “renal diets” reduce protein for this reason
- Some say give normal protein, give dialysis for BUN
13
Q
Special issues in feeding patients with cardiac disease
A
- May be admitted due to CAD complications, acute MI, or CHF
- May be a good time to discuss diet and fat restriction
- For overweight patietns: may be important to restrict energy intake
- CHF patients need reduced 2g Na+ diet or “cardiac diet” (low fat, sodium, saturated fat, cholesterol)
14
Q
Special issues in feeding patients with diabetes
A
- Vital to coordinate insulin delivery with carbohydrate intake
- Also important to consider medication dosing based on patient diet as compared to what patient will be eating when they return home –> insulin dosage may not be correct
15
Q
Jevity
A
- Standard of tube feeding at Denver Health
- 1 kcal/mL
- Contains fat, carbs, protein, micro and macronutrients
