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Clinical Nutrition > Nutrition Support Lectures > Flashcards

Nutrition Support Lectures Flashcards

0
Q

DAT Diet

-regular or full-

A
  • safely tolerate oral feedings
  • can feed themselves
  • pt has no disease or illness that requires a modified diet
  • no modifications to diet
  • ideal
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1
Q

Intervention

-3 types-

A

Oral intake

  • Regular DAT (diet as tolerated)
  • modified (therapeutic diets, energy increase

Enteral feeds

Parenteral Nutrition
- IV Nutrition

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2
Q

Therapeutic Diets

-Nutrition Support-

A
  • modification of the normal diet to treat the disease, illness or physical symptoms
  • texture modification for swallowing
  • nutritional or electrolyte composition differences
  • lactose intolerance
  • allergies
  • gluten free
  • kosher is a modified DAT but it is NOT therapeutic
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3
Q

Modified Diets

-Purpose-

A
  • maintain or restore nutritional status
  • rest an affected organ
  • adjust ability to digest, metabolize, or excrete
  • improve tolerance of food intake
  • adjust for mechanical difficulties (broken jaw)
  • increase or decrease body weight
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4
Q

Diet Modifications

-5 catagories-

A
  1. consistency - fluid, solid, fluid thickness
  2. texture - puree, minced
  3. energy - high or low kcals
  4. nutrients - high or low specific nutrients (low Na, high protein ~ renal or liver probms)
  5. Seasoning - bland diet (doesn’t really exist anymore)
    diet prescription - specific therapeutic diet is ordered
    - states what modifications to the regular diet are
    - can be more than one modification
    - macronutrient – add supplement with a DET
    - micronutrients - not a DET, separate diet
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5
Q

Diet Modifications

Consistency - clear fluids

A
  • clear = minimal or no residue in GI tract
  • foods that are liquid at body temperature
  • short term use, supplements can be included = change to full diet
    indications:
  • bowel prep
  • transition diet following IV feeding or >5 days NPO
  • acute GI disturbances with or without n/v
  • post operative diet
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6
Q

Diet Modification

Consistency - full fluids

A
  • liquid at body temperature
  • easily digestible
  • can be nutritionally adequate ~ vit/min? supplements are provided
  • can be bland

Indications: dysphagia, esophageal problems, transition diets, severe chewing problms, decreased appetite (chemothereapy)

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7
Q

Diet Modifications

-texture-

A
  • pureed, minced, diced (soft to chew)
  • consistency will be the same when it reaches the stomach
  • nothing containing raw eggs, no nuts or seeds, nothing really dry or sticky, raw, membranous,

indications

  • chewing or swallowing difficulty
  • due to mechanical (teeth, surgery, cancer) or neurological
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8
Q

Diet Modification

-energy-

A
  • can be a specific kcal level ~ weight gain, weight loss, diabetes
  • can be high/increased calorie/energy diet ~ weight maintenance, weight gain
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9
Q

Diet Modification

-nutrients-

A
  • can be a specific nutrient (adding protein will often add calories)
  • specific levels
  • high/low
  • often met with supplements
  • a diet may incorporate several
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10
Q

Diet Modification

-bland/light-

A
  • based on tradition
  • foods are mildly seasoned , low in fibre, low in fat
  • often transition diet to regular
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11
Q

terminology

A

JPEN - journal of parenteral and enteral nutrition
ASPEN - am. society for parental and enteral nutrition
RD CNSD - certified nutrition support dietitian
PEG - percutaneous Endoscopic Gastrostomy
ORS - oral rehydration solution

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12
Q

Enteral Feedings

-when to introduce-

A
  • swallowing problems
  • nerve disease
  • trauma
  • pt is unconscious
  • stroke
  • severe burns (hypermetabolic, high stress factor)
  • eating food is still considered enteral bc you are using the GI tract
  • dysphagia
  • severe dehydration (just for fluid needs)
  • if GI tract is not used it gets leaky and more prone to infections
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13
Q

Dumping Syndrome

A
  • GI disorder
  • large amounts of partially digested food reach the small intestine (hyperosmolar syndrome)
  • may need a tube fed past the stomach and as a pre-digested formula
  • nausea, weakness, sweating, palpations, diarrhea, syncope
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14
Q

Enteral Formulas

-6 characteristics they differ in-

A
  • osmolality
  • digestibility
  • energy density
  • lactose content
  • viscosity
  • fat content
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15
Q

Osmolality

A
  • can influence fluid balance - fluid imbalance can lead to diarrhea, nausea, GI distress
  • water moves from a dilute solution (low osmolality) to a concentrated solution (high osmolality)
  • important to start with an isotonic solution
  • high osmolality slows down gastric emptying due to more fat and carbs
  • energy density will often increase with more osmolality
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16
Q

Osmolality

-of fluids-

A

~ 300 mOsm/kg
whole milk - 275
orange juice - 935
sherbet - 1225

  • the greater the number of particles in solution = increased osmolality
  • for a given concentration, the smaller the particle size = increased osmolality
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17
Q

Osmolality

-nutrient effect-

A

CARBOHYDRATES
- high molecular weight = large particles (starch) –> low osmolality
- low molecular weight = small particles (sugar) –> high osmolality
PROTEINS
- large particles = minimal effect
- small particles (amino acids) = high osmolality
FATS
- no not form solution in water = minimal effect
ELECTROLYTES
- small particles = high osmolality
highest effect => simple sugars, amino acids and electrolytes

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18
Q

Feeding Routes

-Non surgical and surgical-

A

non-surgical

  • for short term use (less than 12 weeks)
  • possibility of esophageal or tracheal damage
  • naso-gastric, naso-duodenal, naso-jejunal

Surgical

  • for longer term use
  • minimal discomfort
  • minimal altered body image
  • infants fed after 2 days, adults if no more than 25% is being eaten after a few weeks
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19
Q

Feeding Routes

-non surgical-

A

nasogastric - placed by gastric fluids, medium risk of aspiration, low dumping risk, easy removal, fair tolerance
nasoduodenal - placed by x-ray, low aspiration risk, medium dumping risk, easy removal and fair tolerance
nasojejunal - placedby x-ray, low aspiration risk, high dumping risk, easy removal and fair tolerance
- less than 12 weeks

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20
Q

Feeding Routes

-surgical, more permanent-

A

esophagostomy (rare)
- high aspiration risk, low dumping risk, difficult removal, good tolerance, indicated by maxillofacial injury
gastrostomy
- low-med risk of aspiration, low dumping risk, difficult removal, good tolerance, indicated by esophageal obstruction (stroke, dysphagia)
jejunostomy
- low aspiration risk, high dumping risk, difficult removal, good tolerance, indicated by gastric cancer, nausea, ulcer

  • all placed by endoscopic or radiological placement; longer term feedings also gastro-duodenal, and gastro-jejunal tubes *
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21
Q

Enteral Nutrition

-benefits-

A
  • physiologic
  • immunological
  • safety
  • cost
22
Q

indications for enteral feeding

A
  • oral supplementations when decreased appetite due to illness or treatment
  • usually supportive therapy
  • can be used as a primary therapy such as in Crohn’s disease
23
Q

indications of Enteral Feeds

-adulthood-

A
  • renal disease
  • HIV
  • short bowel syndrome
  • Crohn’s disease
  • intestinal pseudoobstruction
  • anorexia nervosa
  • muscular dystrophy
  • liver disease
24
Q

Contraindications to Enteral Support

A
  • severe coagulopathy (won’t clot) where risk of GI bleeding is high
  • severe portal hypertension
  • abdominal wall infection
  • massive ascites
  • expected needs <5-10 days for adults or 1-2 days for children
  • severe acute pancreatitis; may feed below Ligament of Trietz (jejunal)
  • high-output proximal fistula
  • diarrhea or vomitting
  • complete bowel obstruction
25
Q

Enteral Feeding Regimens

A
  • supplemental vs total support
  • bolus vs intermitten bolus vs continuous feeds
  • bolus feed: over 15 minutes - 30 minutes
  • intermittent bolus: 1-2 hours
  • continuous feeds >2 hours
  • vegas nerve is bypassed when fed directly to the stomach, alters stomach’s contractility and emptying and why a small amount over a longer time can only be tolerated
26
Q

Bolus Feeds

A
  • short time
  • easy
  • inexpensive (no pump required)
  • potential intolerance
  • must be sitting up
27
Q

Continuous Feeds

A
  • potentially increase GI tolerance
  • decreased risk of aspiration or gastric residual
  • disadvantage is costly (requires pump)
  • less freedom
  • smaller amount over a longer period of time
28
Q

Complications of Tube Feeding

-detailed-

A

nausea, vomiting; large gastric residual, improper tube location, rapid infusion rate, hyperosmolar formula
large gastric residuals ; hyperosmolar formula, high fat content of formula, formula too cold
diarrhea; medication, lactose intolerance, nutrient malabsorption, bacterial overgrowth, inadequate fibre, rapid infusion rate, hyperosmolar formula, hyperalbuminemia
constipation; dehydration, obstruction, not enough fibre, medications, intestinal dysmotility
dehydration; fever, infection, not enough fluid, weight loss, drug therapy
increased serum electrolytes; high in formula, excess fluid losses, low intake, renal failure, drug therapy
decreased electrolytes; drug therapy, excess fluid intake, water retention, wrong formula amount
hyperglycemia; probably just cause vomiting in rapid feeding, metabolic stress, diabetes, excess, drug intake
hypokalemia/hypophosphatemia; refeeding syndrome medications, excessive losses

29
Q

Metablic Complications of Tube feeding

-list of 10-

A
  • nausea, vomitting
  • large gastruc residuals
  • diarrhea
  • constipation
  • dehydration
  • increased serum electrolytes
  • decreased serum electrolytes
  • hyperglycemia
  • hypokalemia
  • hypophosphatemia
30
Q

Mechanical Complications of Tube Feeding

A

clogged tube - excess residue in formula, inappropriate mixing of meds
nasal irritation/erosion - improper taping of tube, prolonged use of ng tube
tube displacememnt - migration of tube into esophagus or duodenal junction
skin infections - skin too moist, leakage around tube, mechanical irritations

31
Q

Types of Enteral Formulas

A

polymeric (intact protein)
semi-elemental and elemental (predigest and broken down protein and lipid)
- protein either smaller peptides or aa, fat may contain MCT
- for delayed gastric emptying or malabsorption issues
- short bowel, severe GI inflammation, liver disease
specialized formula: hypermetabolism, disease specific, immune enhancing
- energy density from 1-2 kcal/ml
-higher energy density typically for fluid restricted patients with hypermetabolism (higher osmolality)
- protein concentration from 0.04 - 0.08 g/ml

32
Q

Oral Rehydration Solutions

  • WHO and Pedialyte have bicarbonate as a base (citrate/acetate)
  • gatorade has highest amount of carbs and lowest amount of electrolytes
A

.

33
Q

Rate of feeding Ranges

A

start = 25-50 ml/hr (1200 ml)
advance = 50-75 (1800 ml)
Upper limit = 75-150 (3600 ml)

increase rate every 4 - 6 hours until requirements are met

34
Q

Case Studies

- protein and fluid requirements

A

protein: at least 1g/kg or possibly higher - at least 67 g/d
fluid: 35 ml/kg (always use actual weight or dry weight to calculate)
- increase any feeds 10-30 ml/hr if unable to reach goal in 24 houra
- add extra water if needed by flushes
- over 200 ml/hr can be too hard to tolerate

35
Q

Aims for PN

A
  • maintenance in adults, infants and children
  • growth in infants and children
  • enteral is the preferred form of nutrition when possible because using the gut will stimulate its functioning, less risk of infections, less time for nursing staff and is less expensive, associated with less metabolic complications
36
Q

Why is TPN necessary?

A

fasting –> catabolism –> negative N balance -> reduction in resistance to infection, optimal wound healing, and low growth and neuro-development in children

37
Q

Indications for TPN use

A
  • significant bowel dysfunction resulting in inability to receive adequate enteral nutrition for >7-10 days for adults and >4-5 days for children or 2-3 days for infants
  • hypermetabolism (from trauma or burns)
  • moderate to severe pancreatitis requiring bowel rest >7 days
  • bowel dysfunction
38
Q

Reasons for Bowel dysfunction

A
  • paralytic ileus (when the gut is not moving correctly)
  • major gut resection leading to diarrhea or malabsorption
  • small bowel obstruction
  • radiation enteritis
  • GI fistula; except when enteral access can be placed distal to the fistula
  • hemodynamic instability where high risk for mesenteric ischemia
  • severe dysmotility leading to non functioning GI
39
Q

Contraindications of PN

A
  • use the gut if it works
  • previously well nourished adults where GI tract is expected to work in 7-10 days
  • when the prognosis does not warrant aggressive nutrition support ~ not for palliation in adults
  • vascular access is severely compromised (save the veins for medication)
40
Q

Conditions Warranting Cautious use of PN

A
  • severe hyperglycemia (glucose goes directly into veins)
  • severe renal failure
  • multi-organ system failure
  • severe metabolic acidosis or alkalosis
  • hyperosmolality
  • severe electrolyte disturbances
41
Q

Complications of PN

A
  • typically due to over feeding and lack of GI stimulation
  • cholestatic liver disease
  • liver steatosis
  • PN associated cholelithiasis (due to low secretion of CCK)
  • infection (pay attention to central line)
42
Q

PN induced liver Disease

A
  • severe disease common in infants and children whose nutrition provisions are based on PN
  • risk factors include prematurity, duration of PN, infection, lack of GI stimulation, bacterial overgrowth, overfeeding of fat and carbohydrates
43
Q

EN or PN?
38 year old woman POD#6 spinal surgery. NPO. On high doses of pain meds. Abdomen distended, NG to suction with high output, no BMs.

A
  • PN
  • NG to suction is not a tube feed, distention is a sign of GI dysfunction as well as high output, check for frequency and amount for bowel movements, NPO for 6 days
44
Q

EN or PN?
78 year old man POD#6 back surgery. Minimal oral intake x 5 days, Nausea and dislike for hospital food, no vomiting and has an IV for hydration and meds

A
  • EN
  • no indication that GI tract is not working
  • anytime there is high gastric output, likely do not put on enteral feeds
45
Q

EN or PN?
16 year old girl with history of cerebral palsy, fed by G-J tube, admitted with a small bowel obstruction, surgery planned in 4 days

A
  • PN
  • she is young (less complications)
  • if obstruction is lower than where the G-J tube is placed this might compromise absorption
  • significant bowel obstruction is indicative of PN
46
Q

Routes of Administration for PN

A
  • IVs can be central or peripheral line
  • IV in chest are usually central line
  • IV that go into smaller veins are known as peripheral IV lines, only a small amount of nutrition 510kcal/day
  • more concentrated nutrition is delivered through central lines (bigger veins)
47
Q

Peripheral lines for PN

A
  • usually lasts for 5-7 days
  • meant for short term
  • can only handle hypotonic or isoosmolar solutions
  • higher concentrations could cause the line to blow and damage the vein
  • if inserted at midline, IV could last up to 2 weeks
  • inserted at arm, feet or head (can be elsewhere)
48
Q

Central Lines for PN

A
  • may last for months or years
  • can handle hypertonic solutions
  • multiple types
  • usually inserted into chest, arm or let (femoral vein)
  • ex. port-a-catheters, hickman, broviacs, PICC line which goes in at the arm and all the way to the chest
49
Q

Device Related Complications for PN

A 
Infectious 
- need to use asceptic techniques 
- endogenous skin flora
- contamination of catheter site
- seeding deevice from distant site (feces)
- contamination of infusate (PN)
Non-infectious (mechanical)
- catheter occlusions
- thrombosis
- breakage
- phlebitis
50
Q

Peripheral Lines

A
  • PN is needed less than 2 weeks
  • patient not fluid restricted (you are already limited in the amount you can give the pt)
  • nutrient needs can be met and central PN is not feasible
51
Q

Central Line

A
  • PN is needed for more than 2 weeks
  • patient is fluid restricted
    0 peripheral access is limited
  • nutrient needs cannot be met by peripheral PN
52
Q

Components of PN solutions

A
  • fluid
  • carb - dextrose
  • protein - amino acids
  • lipid - intralipid
  • vitamins and minerals
  • trace elements and electrolytes
53
Q

Forms of TPN

A

2 in 1 solutions (amino acid and dextrose in one bag and lipids in another)
- pt if unstable will require special PN often made as 2in1
3 in 1 soltuions (all macronutrients are mixed together) = TNA total nutrient admixtures
- standardized bags or specialized
- less expensive and preferred method
- less lines used
- it matters bc it impacts ability to deliver nutrients and medication interactions

Clinical Nutrition (14 decks)

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