Lec 1: Nutrition Support Flashcards
Hospital Food Service and Nutrition Support & Menu Planning
LEC 1:
Some key hospital terminology:
Inpatient:
Outpatient:
[What you recommend/do is very different between these populations]
Rounds:
In: on site, in hospital - you can control what they do, eat and can check in with other staff on progress and ins/outs monitoring
Out: outside the location - AKA at home - you cannot control their intakes, activities, lifestyle - you can only ask them
Rounds: When the health care team gets together to talk collectively about patients
[5 in Course pack]
Hospital Food Service Basics
-> Important for RDs & clinical dietetics because:
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-> b/c you learn what kinds of food resources are avaiable anto you and your patients
- different diet orders ( Diabetes, CVD, Swallowing difficulty, kidney disease)
- Food safety is key - many patients are immunocompromised
- Computer programs to keep track of diet orders & guide planning/food purchasing
- Tray Delivery
- Rotating Hospital Menus - length depends on typical length of stay
- Different kitchen models
Types of Hospital Kitchens
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- AKA
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1 Conventional Kitchen
- AKA: Cook and Serve
- some premade/ mainly from stratch
- more expensive yet easier to individualize menus
2 Cook Chill and Cook-Freeze Systems
- food is cooked then froze until time to serve
- can be lower cost as food may be prepared elsewhere and delivered to hospital
- quality of nutrs can be high
- easier to provide choice / however not all foods freeze well
3 Assembly and Serve Systems
- buy product premade - assemble and serve
- can be difficult to accommodate dietary needs / create waste
Hospital Menu Planning
-> Rotating menu:
-> Start with a…
[should be tasty and appealing / avoid repetition]
DM order = CHO spread thru day
CVD = low sodium & Sat Fat
Renal order = low Na, Phos, K & maybe PRO
[Designed to meet avg caloric needs of patient population]
-> Hospitals should provide foods:
-> Should take into account:
NEW directions in hospital menu planning:
- local / traditional foods / healthy foods in vending machines / improving client food service experience / fitting the dietary patterns of CAN - vegan etc.
-> 3,5,7 day / 2,3,4wk
-> a… regular diet menu then for other diet orders such as gluten-free, switch out foods accordingly
-> Foods that are acceptable and familiar - cultural foods, vegetarian, halal, kosher etc.
-> : cost, availability, equip, staff training
NUTRITION SUPPORT (aka Nutr Therapy)
Oral and Enteral Nutrition
** [Slide 16] - visual guiding which feeding to do **
Oral Nutrition Support:
-> Refers to:
used in patients with:
[Liquid supplements avail in 1.0/1.5/2.0 kcal/mL]
-> Nutritionally balanced…
Meal replacements have higher levels of micros (Boost)
Intended to supplement not replace meals
-> Sometimes administered as part of a ‘med-pass’:
WHAT type of patients might need oral nutrition support?
Problem -
refers to: liquid or solid supplements take orally -
: used in patients with functional GI tracts and who have anorexia, reduced dietary intake, difficulty chewing and/or need to gain weight
-> … ie. 55-60% CHO / 10-15% PRO / 25-30% fat with added micros
-> : 60mL of a 2.0kcal/mL formula 4-5 times daily with meds
? cancer patients, wound healing, children with disease or texture problem, older adults who lose appetite/dementia, taking meds that suppress appetite
P - Fiber content
Enteral Nutrition =
Indications (of use):
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others: inability to gain access to GI (obesity/ previous srugery, altered anatomy)
- short bowel syndrome / GI inflammation
= Feeding using a tube, directly into the GI tract, distal to the oral cavity
Indications:
- FUNCTIONAL GI tract but whose energy/nutrient intake is insufficient to meet needs
ie. coma, dysphagia (difficulty swallowing), transition phase of TPN
Contraindications:
- Distal GI obstruction (lower GI blocked)
- Diffuse peritonitis (inflamm of the peritoneal membrane)
- IIeus (gut stops moving)
- GI ischemia (lack of 02 in the gut)
- Intractable vomitting - it won’t stop
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- Formula selection, rate and method of feeding
- Also,
- calculating patients energy/nutrients needs
- assess tolerance and side effects, monitor patient condition
- sanitary practices (done with nursing)
- Manage transitional feeding
Gastrointestinal Access Sites for Enteral Nutrition
[GI access described according to where tube enters body and where tip of tube is located]
> Determined by physician
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What is Aspiration:
1 Nasoenteric: access to GI tract through NOSE - tubes can be nasogastric (most common), nasoduodenal, nasojejunal
[Fast, easy, short term]
2 Oroenteric: access to GI tract through MOUTH - tubes can be orogastric, oroduodenal, orojejunal
3 Enterostomy: access to GI tract through ABDOMEN - typically gastrostomy or jejunostomy
[Long-term]
{if surgically placed = called G or J tube}
{if endoscopically placed = called PEG (percutaneous endoscopic gastrostomy) & PEJ)}
: foreign particles (food) in the lungs
Equipment:
Tubes, Poles, Bags, Pumps (or gravity drip)
[French size - smaller = more narrow / must be compatible with formula viscosity]
- PEG tubes are not weighted
Closed VS Open system:
C =
O =
C = formula from a sealed container (common in ICU/LTC)
Adv = sterility/ Dis = cost
- many a day
O = formula poured from cans into a feeding bag or container
Adv = lower cost / Dis = increased risk of microbial contamination
- change ~ 1 a day
Formula Selection for Enteral Nutrition
-> Composition selected based on…
[most institutions have an established formulary]
-> Formulas should be delivered at…
-> Rule of thumb…
-> on… food needs, sensitivities, thickness, diseases, GI access, fluid restriction etc.
Start with something regular/ basic
-> At room temp to decrease GI side effects such as cramping
-> from polymeric (intact protein) -> semi elemental (peptides) -> elemental (AA) - the more elemental the worse it tastes
[NOTE- elemental are usually fed right into the gut - so taste isn’t an issue]
Types of formulas
- Blenderized
- Polymeric (most common)
- Hydrolyzed / partially-hydrolyzed
- Modular
- Disease specific
B - blenderized whole foods (eg. meat/beg)
P -protein intact / more GF / polysacc & glucose - most lactose free / triglycerides of vegetable origin / fibre / micros in adequate amounts
(1.0-2.0 kcal/mL) (300-790 mOsm/kg)
H - for when feeding beyond the stomach (intestine) and need things more broken down
AKA semi-elemental
- useful in clients with impaired disgestion/absorption / free AA / mono&disacc/ low in fat often / no fibre / micros adequate / 1.0kcal/mL / 400-650 mOsm/kg / some flavoured or unflavoured
M - 1 type of nutrient (have to flush tubes) - ex protein or fat is more common, used to enhance a standard formula or multiple nutrients that can be combined to produce a nutritionally complete macronutrient formula
D-S - mostly complete nutritional solutions with specific nutrients either added or removed to meet specific requirements
Osmolality of Enteral Formulae
-> Physiological mOsm =
-> Most enteral formulae =
Isotonic or iso-osmolar formula =
Hypertonic formula =
CHOICE DEPENDS ON:
= a measure of osmotic pressure exerted by a solution; number of water-attracting particles per weight of water in kilograms
P = ~300 mOsm/kg (ie. body fluids like serum)
Formulae = ~300-600 mOsm/kg - determined by # and size of electrolytes, minerals and CHO (>/= 1.5kcal/mL - higher mOsm)
Iso = osmolality matches physiological osmotic pressure - promotes best tolerance in ill patients - preferred if feeding directly into sm intestine
H = osmolality is higher than physiological osmotic pressure - may induce shift of free water into intestinal space and cause diarrhea if fed directly into sm intestine
* the stomach can usually handle a hypertonic formula b/c the pylorus prevents the passage of lg volume of formula into duodenum and b/c gastric secretions have dilutional effect
: on where the tube ends
Osmolality is not the concern it once was: particularly if tip of feeding tube ends in:
However if feeding into the:
Delivery of Enteral Nutrition
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: in the stomach
: into the jejunum - osmolality must be considered (intestines don’t have this shift in fluid that the stomach has)
1 Continuous - controlled over 8-24 hours done by a pump
- sm intestine will take this not Bolus - as small intestine is more sensitive to lg volumes and sudden rate changes
- tolerance is maximized (used for new enteral and acute)
- appropriate for gastric/duodenal/jejunal feedings
- can restrict mobility
2 Intermittent - formula administered several times daily over 2-3- minutes, by gravity drip or pump
- generally used for non-critically ill, home enteral
- best used for gastric feedings - not duo/jej b/c of rapid administration
3 Bolus - more like a meal - stomach can take because of sphincter controlling speed
- (grey line btw intermittent and bolus)
- rapid administration o =f 250-500mL formula several times a day, using syringe (sometimes gravity drip)
- duo/jej shouldn’t use
- may increase risk of aspiration, nausea, vomiting, diarrhea - use with caution
The Enteral Nutrition Prescription: Putting it all together:
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Re: Free water:
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** CALCULATIONS PRACTICE **
1 - Determine energy, macronutrient (typically PRO) and fluid requirements of patient
2 Determine most appropriate formula - consider patient diagnosis, nutritional needs, digestive and absorptive capabilities (start with basic formula and see if needs are met)
3 Determine how much formula needed to met energy requirements (HOW? divide total daily energy need by energy density of the formula (kcal/mL)
4 Determine whether macros and free water in volume are appropriate for patient
(only usually need to consider micros in special circumstances)
: esp important in unconscious patients / need to be controlled in some conditions
5 Determine rate of delivery of enteral formula
(usually start with continuous)
Protocol for starting & maintaining enteral nutrition
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1 Begin with continuous feeding at slow rate to assess tolerance
2 If tolerated, increase after 4 hours by increments of 10-75mL/h then to target after another 4 hours (Target is usually 75-80mL/h for continuous) start @ 50% of target
3 Monitor hang time
4 Flush tubing - every few hrs (nurses do/ RD orders how/when/often/ how much)
5 Switch to intermittent/bolus if long term is anticipated - when patient is stable
