Unit 9 - Supplemental Nutrition Flashcards
who benefits from vitamin supplements (4)
- those who fail to obtain recommended amts of vitamins & minerals from their diet (ex. chronic dieter, addictions, illness)
- vegetarians & vegans
- lactose intolerance or milk allergies
- those with special needs (pregnant, elderly)
see notes for longer list
what is the best way to receive nutritonal content
- best to try to make changes to diet to improve nutritional content
- only take supplements when needed
what are some cons to supplements (3)
- greater risk of toxicity
- may be expensive
- may give a false sense of security about the healthfulness of the diet
what can supplements interact w (3)
- meds
- foods
- and other supplements
what is an example of one food product that can intreract w many meds
- grapefruit
what are examples of natural health products (8)
- vitamins
- minerals
- herbal products
- homeopathic meds
- chinese traditional meds
- probiotics
- amino acids
- essential FA
what are the natural health product regulations
regulations regarding NHPs including:
- provisions on product licensing
- site licensing
- good manufacturing practices
- adverse rxn reporting
- clinical trials
- labeling
- premarket review
approved NHPs have on their bottle either a.. (2)
- Natural product number or
2. drug id number - homeopathic medicine (DIN-HM)
what does a NPN or DIN-HM let the consumer know
- that it has undergone & passed a review of its formulation, labelling, instructions for use
= safe product to choose
what in enteral nutrition
- involves giving nutrients thru the GI tract either orally or via tub feeding
what is parental nutrition
- involves giving nutrients intravenously
see figure 15-1 in the notes for a flow chart on selecting a feeding route
…
when might oral, nutrient fortified supplements be used
- if the individual is having difficulty maintaining adequate food intake
- but their GI tract is functional and are physically able to eat
list some examples of nutrient fortified oral supplements (3)
- BoostTM
- ensureTM
- and many more brands
what are some of the varieties of oral supplements (5)
- high protein
- extra calories
- reduced carbs
- high fibre
- etc.
what are some common flavours of oral supplements (3)
- vanilla
- chocolate
- strawberry
what are some forms that oral supplements are available in (3)
- shakes
- fortified pudding
- fortified fruit beverage
what are some ways to improve a pt’s intake of oral supplements (7)
- let the pt sample diff products & determine what they enjoy
- serve supplements attractively
- keep it cold so it is refreshing for the pt
- if a pt finds the smell unappeling, cover the top w plastic wrap or a lid, leaving just enough room for a straw
- if have small appeitite, offer it in small amts & frequently
- provide easy access
- suggest alternatives
when is tube feeding used
- if an individual is unable to meet their nutrient needs orally
- but the GI tract is still functioning
list indications for tube feeding (7)
- swallowing disorders
- impaired upper GI motility
- obstructions that can be bypassed by a feeding tube
- anorexia
- extremely high nutrient requirements (like burn victims who need high protein)
- mechanical ventilation
- CNS barriers
what are some contraindications for tube feeding (3)
- severe GI bleeds
- uncontrollable vomiting or diarrhea
- severe malabsorption
what is a transnasal feeding
- one that is inserted through the nose
list 4 types of transnasal feedings
- nasogastric
- nasointestinal
- nasoduodenal
- nasojejunal
what is orogastric feeding
- tube inserted into the stomach through the mouth
who is orogastric feeding often used in? why?
- for infants bc a nasogastric tube may hinder the infant’s breathing
what is an enterostomy
- an opening into the GI tract thru the abdominal wall
what are 2 types of enterostostomy
- gastrostomy
- jejunostomy
what is a nasogastric tube
- tube place into the stomach via the nose
what is a nasointestinal tube
- tube place into the GI tract via the nose
- includes nasoduodenal & nasojejunal feeding routes
what is a nasoduodenal tube
- tube is placed into the duodenal via the nose
what is a nasojejunal tube
- tube is placed into the jejunum via the nose
what is a gastrostomy
- an opening into the stomach thru which a feeding tube can be passed
what is a PEG
percutaneous endoscopic gastrostomy
- a nonsurgical technique for creating a gastrostomy under local anathesia
what is a jejunostomy
- an opening into the jejenum thru which a feeding tube can be passed
what is a PEJ
percutaneous endoscopic jejunostomy
- nonsurgical technique for creating a jejunostomy
what is the duration of transnasal feeding tubes
- short term
- <4 weeks
what is an advantage of transnasal tubes (2)
- does not require surgery or incisions
- can be placed by a nurse
what are 2 disadvantages to transnasal feeding
- may cause nasal, throat, or esophageal irritation
- easy to remove by disorientated pts
what is the most common enteral route for pts with normal GI function
- nasogastric
what are 3 benefits to nasogastric tubes
- easy to insert & maintain
- feedings can be given intermittently without an infusion pump
- least expensive
what are 2 disadvantages to nasogastric feedings (2)
- risk of tube migration to the small intestine
- highest risk of aspiration in compromised pts
what are advantages to nasoduodenal & nasojejunal tubes (3)
- allows enteral feedings for pts who have obstruction, fistulas, gastric motility problems , or minimal stomach volume due to prior gastric surgery
- allow for earlier tube feedings than gastric placement
- lower risk of aspiration in compromised pts
what are 3 disadvantages of nasoduodenal and nasojejunal tube feedings
- more difficult to insert & maintain than nasogastric
- risk of tube migration to the stomach
- infusion pump required for formula administration
describe the duration of tube enterostomies
- long term access
- >4 weeks duration
what are the advantages to tube enterostomies (3)
- more comfortable than transnasal
- site is not visible under clothing
- allow the lower esophageal sphincter to remain closed = lowered risk of aspiration
what are the disadvantages to tube enterostomies
- must be placed by a physician or surgeon
- placement may require general anathesia
- risk of complications or infection from the insertion procedure
what is the most common mthod for long term tube feedings
- gastrostomy
what are the advantages of gastrostomy (2)
- easier insertion than jejunostomy
- feedings can be given intermittently without an infusion pump
what are the disadvantages of gastrostomy
- feedings are witheld 12-24 hrs before and 48-72 hrs after the procedure (for surgically placed tubes)
- moderate risk of aspiration in high-risk patients
what are the advantages to a jejunostomy (3)
- allows enteral feedings for pts who cannot undergo gastric feedings due to obstruction, gastric motility, minimal stomach volume
- earlier tube feedings then gastrostomy after placement
- lowest risk of aspiration
what are disadvantages to a jejunostomy
- most difficult insertion procedure
- infusion pump required for formula admin
- most costly
what are the 4 main types of enteral formulas available
- standard
- elemental
- specialized
- modular
what plays a role in formula selection (4)
- the pts medical condition
- digestive/absorptive capabilities
- nutrient status
- individual tolerance
what is another name for standard formula
- polymeric formula
who are standard formulas used for
- for people who can digest & absorb nutrients equally
what do standard formulas contain
- proteins from milk or soybeans
- carbs sources such as hydrolyzed corn starch and sugars
- contain whole proteins, complex carbohydrates, and long chain triglycerides = meaning the nutrients are intact and have not been broken down, which requires additional work by the digestive system
= must have full digestive & absorptive function
what are blenderized standard formulas produced from
whole foods such as
- chicken
- veggies
- fruits
- oils
- and added vitamins & minerals
who are elemental formulas used for
- for compromised digestive tracts
what do elemental formulas contain
- nutritionally complete
- but carbs & proteins which have been partially broken down to fragments which require little to no digestion
who are specialized formulas used for
- disease specific
ex. liver, kidney, & pulmonary failure, severe wounds
what are modular formulas
- created from individual marconutrient preparations
- can be combined to meet very specific needs
see figure 15-3 in the notes on selecting a formula
…
list 4 ways formulas differ in
- macronutrient composition
- energy density
- fibre content
- varying osmolality
who are high nutrient density formulas used for
- people w low fluid tolerance
- bc it offers the greatest quanitity of nutrition for least amt of fluid
list 5 factors that influence formula selection
- GI function
- nutrient & energy needs
- fluid reqiurements
- need for fibre modification
- individual tolerances (ex. allergies & sensitivities)
what kind of formula is used for people w functional GI tract? functional but impaired GI tract?
- functional = standard
- impaired = elemental
list 3 situations where individuals may have different nutrient & energy needs
- diabetes = need to control carbs
- critical care = high protein & energy requirements
- chronic kidney disease = limit intakes of proteins & several minerals
describe consideration when choosing a formula for someone with fluids restrictions
- formulas should ahve adequate nutrient & energy densities to provide the required nutrients in the volume prescribed
which individuals might beneficial from enteral formulas with fibre
can help manage problems like
- diarrhea
- constipation
- hyperglycemia
which individuals might need to avoid fibre (2)
if they have
- increased risk of bowel obstruction
- or other complications
nearly all formulas are…
- lactose-free and gluten-free
what is important to check before tube feeding begins (2)
- make sure it is correctly placed
- securely attached
what are 3 ways of administering enteral formulas
- continuous
- bolus
- intermittent
what is a pro to intermittent feedings
- offers freedom between meals
what are 2 cons to intermittent feedings
- may be difficult to tolerate bc are given in high volume doses
- increased risk of aspiration
what is bolus feeding
- feeding that uses a syringe and is very rapid
what are 2 pros to bolus feeding
- allow greater independence
- fast to administer
what are 4 cons to bolus feeding
- abdominal discomfort
- nausea
- cramping
- greatest risk of aspiration
who are bolus feedings used with
- only in pts who are not critically ill
what is 1 pro to continuous feeding
- easiest to tolerate
who are continuous feedings recommended for? (2)
- critically ill pts
- preferred for intestinal feedings
what is a con to continuous feedings
- pt must be attached at all times
how can complications of tube feeding be prevented (4)
- choosing the appropriate feeding route
- approp formula
- & delivery method
- considering their medical condition & meds
what should be monitored throughout the tube feeding process to detect/prevent complications & pt tolerance (3)
- body weight
- hydration status
- lab test results
list 6 complications that can occur during tube feeding
- aspiration
- clogged feeding tube
- constipation
- diarrhea
- fluid & electrolytes imbalances
- NV, cramps
list 3 causes of aspiration of enteral formula
- inappropriate tube placement
- delayed gastric emptying
- excessive sedation
list 5 ways to prevent/correct aspiration of formula
- ensure correct placeemnt
- elevate head during & after feeding
- decrease formula delivery rate is gastric residual volume is excessive
- consider using intestinal feedings if high-risk
- minimize use of meds that cause sedation
list 2 causes of clogged feeding tube
- excessive formula viscosity
- improper admin of meds
list ways to prevent a clogged feeding tube (6)
- ensure tube size is appropriate
- flush tubing w water before and after giving formula
- use oral, liquid, or injectable meds whenever possible
- avoid mixing meds w formula
- dilute thick or sticky liquid meds
- crush tablets to a fine powder & mix w water
list 1 way to correct a clogged feeding tube
- flush w warm water or solutions w pancreatic enzymes & sodium bicarb
list 4 causes constipation w enteral feeding
- inadequate dietary fiber
- dehydration
- lack of exercise
- med side effect
describe how to prevent constipation w enteral tube feedings (4)
- use a formula w approp fibre content
- provide additional fluids
- encourage physical activities
- constul physician about minimizing or replacing meds that cause constipation
what are 4 causes of diarrhea during enteral feeding
- med intol
- infection in GI tract
- formula contamination
- excessively rapid formula admin
what are 3 ways to prevent diarrhea during enteral feeding
- dilute hypertonic meds
- avoid using poorly tolerated meds
- decrease formula delivery rate or use continuous feedings
what are 4 causes of fluid & electrolyte abnormalities during tube feedings
- diarrhea
- inappropriate fluid intake or excessive losses
- inappropriate insulin, diuretic, or other therapy
- inappropriate nutrieny intake
list 7 ways to prevent fluid & electrolyte imbalanced during tube feedings
- follow ways to reduce diarrhea
- monitor daily weight & I+O
- monitor electrolyte lvls
- monitor for signs of dehydration or overhydration
- ensure water & formula intake is approp
- ensure med doses are approp
- use a formula w approp nutrient content
list 4 causes of NV, and cramps during tube feeding
- delayed stomach emptying
- formula intol
- med intol
- response to disease or diseasze treatment
list 7 ways to prevent NV, and cramps during tube feeding
- decrease formula delivery rate or use continuous feedings
- halt feeding is gastric residual volume is excessive
- evaluate for obstruction
- consider use of med to improve emptying
- ensure formula is at room temp
- approp delivery rate
- consider using meds that control NV
what is parental nutrition
- nutrients given intravenously
when is parental nutrition used
- if GI function is impaired
list indications for parental nutrition (theres lots lol but 8)
- conditions that require bowel rest
- severe GI bleeding
- intractable vomiting or diarrhea
- paralytic ileus
- short bowel syndrome
- severe malnutrition (due to refeeding syndrome) & intolerance to enteral nutrition
- people who cannot digest or absorb nutrients
- bone marrow trans plants
list contraindications to parental nutrition
- GI tract is functioning or accessible
- only short term treatment anticipated (less than 7 days)
- risks outweight benefits
- palliative care/terminal
- pt not stable
- inability to obtain venous access
what is 2 ways parental nutrition can be administered
- thru peripheral veins
2. central veins
how long is peripheral nutrition used?
- shorter term (7-14 days)
who uses peripheral nutrition
- people who do not have high nutritional needs or fluid restrictions
describe the solutions for peripheral parental nutrition
- must be less concentrated to prevent damage (phlebitis) to the peripheral vein
= higher volumes of solution are needed to provide nutritional needs
what is central parental nutrition
- referred to as total parental nutrition (TPN)
- bc a person’s entire nutrient needs can reliably be provided via this route
when is TPN used
- when parental nutrition is required longer term
describe the solutions for TPN
- can be more concentrated
= volume needed is lower
typically, how do central catheters for parental nutrition enter the circulation
- at right subclavian vein & are threaded into the superior vena cava with the tiip of the catheter lying close to the heart
what are 3 other ways for a catheter to enter the superior vena cava
from the:
- left subclavian vein
- internal jugular vein
- external jugular vein
how are peripherally inserted catheters typically inserted
- thru the basilic or cephalic vein
- and are guided up toward the heart so that the catheter tip rests in the SVC
who plays a role in deciding the appropriate parental solution used (4)
- doctors
- nurses
- pharmacists
- dieticians
parental solutions are either..
- 2 in 1
- 3 in 1
what is a 2-in-1 solution
- contains dextrose & amino acids
- and the lipid emulsion would be administered separately
why is the lipid emulsion administered seperately in a 2-in-1 solution
- can reduce the stability of the solution & form lipid droplets which obstruct capillaries
what is a 3-in-1 solutions?
- aka TNA = total nutrient admixture
- contains dextrose, amino acids, and lipids
how can parental nutrition be administered
- continuously
- cyclic
what is meant by continuously administered parental nutrition
- over a 24 hr period
what is meant by cyclic administered
- over an 8-16 hr time period
how are dextrose concentrations written
- by the ltter D followed by its conc in water or NS
what does D5W mean
- dextrose 5% in water
what is the purpose of lipid emulsions in parental solution
- supply essential fatty acids
what are lipid emulsions made from
- soybean or olive oil
- with an egg phospholipid emulsifier & glycerol to make the solution isotonic
what 5 nutrients are added to parental solutions
- Na
- K
- Ca
- Mg
- phosphate
what other 2 things are added to parental solutions
- multivitamin
- trace mineral preparations
what is typically excluded from parental solutions? why?
- iron
- bc it can destabilize lipid emulsification & cause allergies
what is refeeding syndrome
- occurs when a severely malnourished individual get food reintroduced
what are symptoms of refeeding syndrome
- fluid & electrlyte imbalances
- hyperglycemia
describe the administration of parental nutrition
- start at slow rate & increase over a 2-3 day period or a smaller conc amt given
who is continuous infusion of parental nutrition often given to
- acutely ill pts
long term recipients of parental nutrition receive infusions for how long?
- 8-14 hours only (cyclic)
what type of technique is used for catheter insertion during parental nutrition
- aseptic
- to avoid infection
describe monitoring during parental nutrition
- catheter site monitored for infection
list catheter-related complications of parental nutrition (7)
- air embolism
- blood clotting at catheter tip
- dislodgment of catheter
- improper placement
- infection, sepsis
- phlebitis
- tissue injury
list metabolic complications of parental nutrition (8)
- electrolyte imbalances
- gallbladder disease
- hyper & hypoglycemia
- hypertriglyceridemia
- liver disease
- metabolic bone disease
- nutrient deficiencies
- refeeding syndrome
what might slow formula flow during parental administration indicate (2)
- clogged catheter
- blood clot
describe how to manage hyperglycemia during parental nutrition (4)
- provide insulin w parental feeds
- avoid overfeeding
- keep feed rates slow
- restrict quantity of dextrose in solution
what can cause hypertriglyceridemia during parental nutrition (2)
- dextrose overfeeding
- overly rapid lipid infusions
what can cause refeeding syndrome during parental nutrition
- dextrose increases the circulation of insulin
= promotes anabolic processes which quickly remove phosphate, K+, and Mg from the blood = fluid retention
what can refeeding syndrome cause (4)
- edema
- cardiac arrythmias
- muscle weakness
- fatigue
how can we prevent refeeding syndrome
- only provide half of the body’s energy requirement at first
how can we prevent gallstones during parental nutrition
- give meds to stimulate gallbladder contraction to prevent buildup & conc of contents
- surgically remove
how can we prevent metabolic bone disease during parental nutrition
- adjust supplemental nutrients
- increase weight bearing activity
what is dyaphagia
- difficulty in swallowing
what does dyaphagia effect
- food & beverage intake
- mouth care
- meds
who is included on the multidisciplinary team for management of dysphagi
- speech language pathologists
- dieticians
- occupational therapists
- pharmacists
- dental specialists
- medical doctors
what are symptoms of dysphagia
- drooling
- choking or coughing during or after meals
- pocketing food
- absent gag reflex
- inability to suck from a straw
- chronic upper resp infections
- weight loss/anorexia
- gurgly voice quality
what are some complications of dysphagia (5)
- aspiration
- dehydration
- loss of enjoyment for eating
- weight loss
- malnutrition
see table 17-2 for causes of oropharyngeal & esophageal dysphagia (too long for cards)
…
what is the goal of nutrition interventions for dysphagia
- ensure the diet remains nutritionally adequate & palatable in a consistency safely tolerated by the pt
what are 2 common management strategies for dysphagia
- altering food texture
- altering the viscosity
what is a “soft” texture modification
standard diet, modified w
- soft to chew foods
what is a soft/minced diet
- soft diet
- with the inclusion of some plain minced meats when the soft textured meat is not suitable
- may be modified to provide minced meat, veggies, and pureed fruit as required
what is a minced diet
standard diet modified w
- minced meat, poultry, fish
- soft casseroles made w minced meat/poultry
- minced, whipped, or mashed fruits & veggies
- soft breads & baked products
- sandwiches w minced consistency fillings & cheese
- cream/stock soups w soft/minced meat & soft veggies without skin/seeds
what is a total minced diet
standard diet modified w:
- minced entrees
- minced/whipped or mashed cooked veggies & fruits
- excludes whole breads & baked products, cheese portions, cold cereals
- cream/stock soups w minced meat & veggies without skins/seeds
what is a pureed diet
standard diet modified w
- only liquid or pureed foods of a smooth homogenous texture
what is a blenderized diet
pureed diet, modified w
- foods blenderized to a liquid form
what is a thick fluid-nectar diet
standard diet modified with
- replacement of thin liquid w thick liquids of nectar consistency
who is a thick fluid-nectar diet recommended for
- individuals with dysphagia
describe the consistency of a thick fluid-nectar diet
- thinner than honey
what is a thick fluid-honey diet
standard diet, modified w
- replacement of thin liquids w thick fluids of honey consistency
who is a thick fluid-honey diet recommended for
- individuals w dysphagia
what is a “no fluids combined w solids” diet
standard diet, modified w
- exclusion of liquids combined w solids (ex. cold cereal w milk)
- thin liquids as the standard
why is the texture of foods modified
- to make them easier to swallow
what types of foods are easier to swallow than dry foods
- foods that are naturally soft & form a cohesive bolus
ex. macaroni casseroles, egg dishes, meat loaf
what can make foods easier to swallow
- adding sauces & gravies to foods
- also adds additional calories
what kind of foods are difficult to manage ? how is this prevented?
- mixed texture foods
ex. cereal w milk - often blended to a single consistency
what happens once the texture of foods is modified
- the food becomes less appealing
list some ways to improve the acceptance of mechanically altered food (7)
- help stimulate the appetite by preping fav foods & foods w pleasant smells
- substitute white veggies for colored
- place contrasting colors side by side
- shaped pureed & ground foods so they resemble traditional foods
- laying ingredients so they resemble a casserole
- use attractive plates & silverware
- use colorful garnishes
why are thickened fluids preferred over thin (2)
- thin fluids require the most coordination & control to consume
= easily aspirated into the lungs - thickened fluids easier to swallow
what is a concern w thickened fluids
- hydration
can nectar think fluids be sipped thru a straw? honey thick?
- nectar = yes
- honey = no
what is an example of nectar thick fluid? honey thick?
- nectar thick = tomato juice
- honey = tomato sauce
what is another alternative for pts w dysphagia (4)
learning alternative feeding techniques like
- exercises to strengthen the tongue
- new methods of swallowing
- change positioning
- seeing a speech language pathologist or OT
