Chapter 6 Nutritional Therapy Copyright 2017 Elsevier Inc

Chapter 6 Nutritional Therapy Copyright © 2017 Elsevier Inc. All rights reserved.

Introduction All critically ill patients are assumed to be at nutritional risk Nutritional support is an important part of overall care plan Copyright © 2017 Elsevier Inc. All rights reserved. 2

Anatomy and Physiology Review GI System Copyright © 2017 Elsevier Inc. All rights reserved. 3

Utilization of Nutrients Cells require: Carbohydrates Ø Proteins Ø Fats Ø Water Ø Electrolytes Ø Vitamins Ø Trace elements Ø Copyright © 2017 Elsevier Inc. All rights reserved. 4

Utilization of Nutrients (Cont. ) Nutrients are ingested orally Mouth first breaks down food with saliva Stomach stores and mixes food with gastric secretions Secretes intrinsic factor for vitamin B 12 absorption Ø Secretes fluids high in Na+ and K+ Ø Copyright © 2017 Elsevier Inc. All rights reserved. 5

Utilization of Nutrients (Cont. ) Duodenum Pancreas and liver empty here Ø Absorbs minerals Ø Jejunum Ø Glucose and water-soluble vitamins absorbed Ileum Protein broken down and absorbed Ø Absorbs fat-soluble vitamins Ø Copyright © 2017 Elsevier Inc. All rights reserved. 6

Utilization of Nutrients (Cont. ) Colon Vitamin K formed Ø Absorbs Na+ and K+ Ø Water reabsorbed Ø Absorption of short-chain fatty acids Ø Copyright © 2017 Elsevier Inc. All rights reserved. 7

Utilization of Nutrients (Cont. ) Pancreas Ø Liver Ø Secretes digestive enzymes Multiple functions Gallbladder Ø Assists in emulsifying fats Copyright © 2017 Elsevier Inc. All rights reserved. 8

Nutritional Assessment Provides baseline subjective and objective data regarding nutritional status Determines nutritional risk factors Identifies nutritional deficits Establishes nutritional needs Identifies medical, psychosocial, and socioeconomic factors Copyright © 2017 Elsevier Inc. All rights reserved. 9

Nutritional Assessment Objective and Subjective Data Patient’s medical history Ø Malabsorption syndrome Ø Laboratory values • What is important? • Review laboratory alert Ø Input and output Ø Daily weight Ø Gag reflex Ø Dysphagia Ø Adequate dentition Ø Oral mucosa Ø Hydration status Ø Copyright © 2017 Elsevier Inc. All rights reserved. 10

Critical Thinking Challenge Which team members would the nurse consult to assist with the nutritional support of critically ill patients? Copyright © 2017 Elsevier Inc. All rights reserved. 11

Nutrition Care Plan Determine: Patient’s calorie, protein, and fluid needs Ø Intake targets Ø Route of administration Ø Set measurable short- and long-term goals Weight gain Ø Stable laboratory values Ø Copyright © 2017 Elsevier Inc. All rights reserved. 12

Quick Quiz! Patients who are not able to meet their nutritional needs orally should be started on enteral nutrition within what time frame? A. 6 -12 hours B. 12 -24 hours C. 24 -48 hours D. 5 days Copyright © 2017 Elsevier Inc. All rights reserved. 13

Enteral Nutrition Any patients who cannot meet their nutritional needs orally should be started on enteral nutrition in the first 24 to 48 hours. Copyright © 2017 Elsevier Inc. All rights reserved. 14

Enteral Nutrition (Cont. ) Delivery of nutrients to GI tract Preferred method Lower risk of infection Ø Less expensive Ø Short-term nutrition: Small- versus large-bore nasogastric tubes for delivery Gastric versus small bowel feeding Long-term nutrition: PEG or jejunostomy Copyright © 2017 Elsevier Inc. All rights reserved. 15

Guidelines for Enteral Feeding Short-term enteral feeding Nasogastric route Ø Nasoduodenal route Ø Nasojejunal Ø Long-term enteral feeding Gastrostomy tube Ø Jejunostomy tube Ø Copyright © 2017 Elsevier Inc. All rights reserved. 16

Enteral Formulas Standard 1 calorie/m. L Ø Contain protein, fats, carbohydrates, vitamins, and trace elements Specialized formula examples Elemental Ø High protein Ø Fiber enriched Ø Wound healing Ø Immune-enhancing formulas Copyright © 2017 Elsevier Inc. All rights reserved. 17

Quick Quiz! The nurse would suggest oral or enteral feedings for which patient? A. A patient with a GI obstruction B. A patient who is severely malnourished C. A patient who has been NPO for 36 hours D. A patient experiencing intractable vomiting Copyright © 2017 Elsevier Inc. All rights reserved. 18

Nutritional Therapy Goal is nutritional support consistent with metabolic needs and disease process while avoiding complications. Interdisciplinary team Copyright © 2017 Elsevier Inc. All rights reserved. 19

Practice Guidelines for Enteral Feeding (Cont. ) Feeding schedule Intermittent: gastric Ø Continuous: small bowel feedings Ø Assess gastric residuals How? How often? Ø What is significant? Ø Differences between gastric and small bowel locations Ø Copyright © 2017 Elsevier Inc. All rights reserved. 20

Quick Quiz! When flushing a feeding tube, the nurse knows to use how many m. L of water? A. 15 m. L B. 30 m. L C. 50 m. L D. 100 m. L Copyright © 2017 Elsevier Inc. All rights reserved. 21

Tolerance of Enteral Nutrition Presence of bowel sounds in four quadrants, as determined by auscultation Presence of bowel motility or bowel movements Palpation of a soft abdomen Percussion of the abdomen revealing tympanic findings Copyright © 2017 Elsevier Inc. All rights reserved. 22

Signs of Intolerance Nausea or vomiting Absent bowel sounds Abdominal distension Cramping Diarrhea Copyright © 2017 Elsevier Inc. All rights reserved. 23

Preventing Complications Enteral tube obstruction Aspiration and improper tube placement Diarrhea Ø Consider Clostridium difficile Dumping syndrome Hyperglycemia Electrolyte imbalances Copyright © 2017 Elsevier Inc. All rights reserved. 24

Guidelines for Parenteral Nutrition Feeding delivered into bloodstream Central line (TPN)—hypertonic Ø Peripheral line (PPN)—isotonic Ø Copyright © 2017 Elsevier Inc. All rights reserved. 25

Guidelines for Parenteral Nutrition (Cont. ) Used for patients who are unable to tolerate enteral feeding GI obstruction Ø Intractable vomiting Ø Intractable diarrhea Ø NPO for an extended period of time (>1 week) Ø Patients who are admitted very malnourished Ø Start immediately, if unable to tolerate enteral feeding Unable to meet nutritional demands with EN Copyright © 2017 Elsevier Inc. All rights reserved. 26

Guidelines for Parenteral Nutrition (Cont. ) Monitor for complications Infection (sepsis) Ø Electrolyte imbalances Ø Fluid imbalances Ø Hyperglycemia Ø Copyright © 2017 Elsevier Inc. All rights reserved. 27

Quick Quiz! A patient with a feeding tube is prescribed an oral medication. What would be the best action for the nurse to take? A. Crush the medication and administer with the tube feeding. B. Contact the pharmacist to check the medication and obtain it in liquid form. C. Melt the medication in 30 m. L of water and administer through the feeding tube. D. Turn off the feeding for 30 minutes and have the patient swallow the medication with a glass of water. Copyright © 2017 Elsevier Inc. All rights reserved. 28

Drug-Nutrient Interactions Check medications for compatibility with enteral feeding Flush before and after administration of medication via enteral route Give preference to liquid formulations Ø Consult pharmacist Copyright © 2017 Elsevier Inc. All rights reserved. 29

Nursing Care Assess patient’s ability to obtain or use nutrients If infection, look for malnutrition as cause Be alert for food-nutrient-drug interactions Assess for recent changes in health status Weigh daily Assess protein-energy malnutrition in the elderly Interpret laboratory findings cautiously Copyright © 2017 Elsevier Inc. All rights reserved. 30

Monitoring Complications Risk of refeeding syndrome Risk for diabetes or glucose intolerance Monitor liver function for parenteral support Copyright © 2017 Elsevier Inc. All rights reserved. 31

Monitoring and Evaluating Assess progress in meeting objectives Begin at the initiation of therapy Ø Stable patient assessed every week Ø Critically ill patient assessed more often Ø Documentation Review changes in medications Copyright © 2017 Elsevier Inc. All rights reserved. 32