nutrition support Flashcards
indications for PN
- bowel obstruction low in GI tract or ileus
- intractable diarrhea (GVHD) or n/v
- high output fistula & unable to feed distal
- extensive resection of small bowel
- severe necrotizing pancreatitis
bowel length needed for EN
100cm jejunum
150cm ileum with ileocecal valve
refeeding syndrome
- EN: start @ 25% of energy needs and increase over 3-5 days
- PN: start dextrose @ 25-50%
- monitor Ph, K, Mg
- fluid retention, cardiac dysfunction, respiratory failure
- high risk: chronic malnutrition, prolonged hypocaloric feeding, NPO>7d, chronic alcoholism, anorexia nervosa
high gastric residual volume
- consider prokinetics
- consider post-pyloric tube
- consider change to concentrated feeding at lower rate
aspiration/reflux
- elevate head of bead to 30-45 degrees
- use small bore feeding tube
- provide continuous infusion
- consider prokinetics
nausea, vomiting, abdominal distention, bloating
- continuous feed with low fat and/or isotonic formula
- consider prokinetics
- consider change to post-pyloric
- minimize narcotics, if able
- provide anti-emetics
- initiate feedings at low rate + advance slowly
diarrhea
- evaluate medications (sorbitol, magnesium-containing, laxatives, lactulose, etc)
- evaluate for usage of abx
- check stool for c.diff or infection
- provide anti-diarrheals if appropriate
- observe proper hang times, change tubing, use closed system (food safety)
- consider change in fiber content of formula
- consider change to elemental or semi-elemental formula
- adjust formula to lower fat or higher MCT content; consider panc enzymes
constipation
- increase free water/fluid intake
- consider change in fiber content of formula
- increase activity, if able
- minimize narcotics, if able
- add stool softeners +/- laxatives
- trial of prune juice
- evaluate and address underlying cause - may need to hold EN
dehydration
- increase free water
- monitor fluid losses; daily weights
- change to 1cal/ml formula
overhydration
- decrease free water flush
- change to concentrated formula
- monitor fluid status/intake; daily weights
hyperglycemia
- change to carb controlled or fiber containing formula
- recommend use of or adjust dose of insulin/hypoglycemic agents
hyponatremia
- change to concentrated formula, restrict fluids
- supplement with sodium
- restrict fluids/free water; diuresis
- may be due to SIADH, excess Na losses
hypokalemia
- may be due to refeeding
- decrease to 25% of goal rate + replete potassium
- may need to change formula
hyperphosphatemia
- consider change to low Ph formula or recommend phos binders
- recommend potential change to meds
- may be due to renal function, tumor lysis, phosphate containing antacids
hypophosphatemia
- may be due to refeeding
- decrease to 25% of goal rate + replete Ph
- discontinue phos binding antacids
avoid holding EN for gastric residuals less than
500ml
if <250ml - no action
if >250ml - consider prokinetics
if >500 - hold EN and perform physical assessment, evaluate glycemic control, consider prokinetic, minimize narcotics
metabolic complications of PN
- impaired glucose tolerance
- hepatobiliary complications (steatosis, cholestasis)
- renal dysfunction
- bone mineral disease
- potential toxicities/deficiencies
- catheter occlusion, venous thrombosis, catheter breakage
- infection: tunnel, catheter sepsis, catheter related bloodstream
PN in palliative care
- severe bowel obstruction, short bowel syndrome, malabsorption
- *if expected survival of several months or at least 6 wks or if malnutrition would cause death prior to disease progression; esp if receiving treatment
artificial hydration in palliative care
- may be appropriate, esp if patient is receiving treatment because it can decrease side effects and improve QoL, reduce ER visits
artificial hydration in hospice
- inappropriate, may decrease QoL
EN in palliative care
- may slow nutritional deficiency, prevent dehydration, improve QoL (in H/N)
- not generally recommended for terminal stage CA due to risk of complications
use of EN/PN in palliative care - cutoffs for PS scores
use not justified for:
Karnofsky score <50% or
ECOG score >2
