Nutrition Support Enteral & Parenteral Nutrition

Nutrition Support Nutrition Support Enteral & Parenteral Nutrition 7th edition • Revised August 2009 by Martha G. Acevedo, ms, rd 79506400 Jones Arl...
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Nutrition Support

Nutrition Support Enteral & Parenteral Nutrition 7th edition • Revised August 2009 by Martha G. Acevedo, ms, rd

79506400 Jones Arlington Branch Drive, 7th Floor, VAVA 22107 Blvd, FallsMcLean, Church, 22042 1-800-866-0919 • www.continuingeducation.com 1-888-781-5388 www.nutritiondimension.com

7950 Jones Branch Drive, 7th Floor, McLean, VA 22107 1-800-866-0919 (US & Canada) • 1-703-854-2531 (overseas) FAX:1-703-854-2531 • e-mail: [email protected]

Nutrition Support:

Enteral & Parenteral Nutrition 7th Edition • Revised August 2009 by Martha G. Acevedo,

ms, rd

Martha G. Acevedo, ms, rd, is Operations Manager for Guest Services at Tri City Medi-

cal Center in Oceanside, California. She participates in the nutritional care of pa- tients in the Intensive Care Unit and oversees all nutrition and nutrition support activities at this 377 bed medical center, including training and education for a staff of seven dieti- tians and technicians. She has maintained her certification as a Certified Nutrition Support Dietitian since 1990, and was recognized by the Calif. Dietetic Assn. for Excellence in Clinical Dietetics in 1998. Education: MS (Biology & Nutrition), University of Bridgeport (magna cum laude); BS (Home Economics & Dietetics), University of Tennessee (magna cum laude).

EXPIRATION DATE: Students of all professions must submit this course for credit no later than August 30, 2014. Credit will not be awarded for this course after that date.

Course Code: RD114 This course approved for: RD/DTR................ 12 CPEU CDM............12 Clock Hours DTR........................ 12 CPEU

Edited by: Dale Ames Kline, MS, RD, CNSC Copyediting/proofreading: Rich Kline, Gwen Hulbert Design: Knotwork Graphic Design & Typesetting © 1989-2009 Nutrition Dimension/Gannett Education, Inc. No part of this course may be reproduced, duplicated or copied in any way without the written permission of the copyright holder.

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How to Earn Continuing Education Credit 1. Read or watch the course material. Don’t forget to review the course objectives and take note of course tools available to you. The objectives provide specific learning goals and an overview of the course. Read the material in the order presented. If you need help with the material, please e-mail [email protected] with your specific question. We will forward your inquiry to the author, so allow adequate time for a reply. 2. CE credit will not be awarded for this course after August 30, 2014. 3. If you have an account on Nurse.com, TodayinPT.com, or TodayinOT.com, or NutritionDimension. com, please use that account username and password to sign in on ContinuingEduation.com. If you don’t already have one, please sign up for a user account. Click “sign up” or “login” in the upper right hand corner of any page on ContinuingEducation.com. If you have a CE Direct login ID and password (generally provided by your employer), please log in as you normally would at lms.nurse. com and search for this topic title. 4. Go to the “my courses” section of “my account.” Click on the title of the course you want to complete and then on “start course.” 5. Click “start test” to begin the exam. To earn contact hours, you must achieve a score of 75% on your multiple-choice exam for most courses. For webinar courses, you will need to achieve a score of 100%. You may retake the test as many times as necessary to pass. Clues are not provided on the exam. Certificates will be date/time stamped with the time and date of the day the user passes the test (Eastern Time, U.S.). 6. After successfully completing your exam click, “complete required survey.” In order to complete the test process and receive your certificate of completion, you must take a few moments to answer a brief survey about the course material. 7. After completing the survey, you will be taken to your transcript. Under Courses Completed, you can view, print, or e-mail your certificate. 8. Three months after you complete a course, you will receive an e-mail asking you to complete a followup survey. This is vital to our educational requirements so we can report our quality outcomes and effectiveness. We report course completions to National Commission for Health Education Credentialing (NCHEC) quarterly and The Association of Nutrition & Foodservice (ANFP, formerly DMA) monthly. Other professions should follow their certifying organization’s reporting instructions. We keep a record of course completions for 7 years. A Word About Copyrights:

We encourage health professionals to use material from this course in their practice. Please follow these guidelines: (1) Credit the author, Nutrition Dimension/Gannett Education and any referenced source. (2) Course material may not be sold, published, or made part of any program for which a fee is charged, without written permission from Nutrition Dimension/Gannett Education. (3) Inform Nutrition Dimension/Gannett Education by letter if you wish to make significant use of material from this course (e.g. if you wish to duplicate Appendix pages for a training session or patient handout).

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Chapter Topic

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Contents

Page

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Nutrition Assessment Anthropometrics • Biochemical Review Energy Requirements • Protein Requirements Subjective Global Assessment

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Enteral Nutrition Normal Digestion • Enteral Nutrition Support Benefits of Enteral Feedings • Access • Formulas Methods of Feeding • Complications

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Parenteral Nutrition Criteria for Use • Access • Formula Preparation Energy Sources, Protein, Vitamins and Minerals Formulas • Monitoring and Complications

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Gastrointestinal Disorders GI Tract Problems • Malabsorption Short Bowel Syndrome • Pancreas

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Stress and Sepsis Stress Response • Nutrition Requirements • Energy Fat, Carbohydrate, Protein • Arginine and Glutamine Vitamins and Minerals • Nutritional Repletion

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Obesity and Diabetes Mellitus Determining Nutrient Needs • Nutritional Assessment Long-term Care • Diabetes

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Respiratory Failure 79 Energy Requirements • Assessing Nutrient Needs Treatment Modalities • Formulas • ARDS Assessment and Monitoring

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Renal Disease Nutritional Assessment • Chronic Renal Failure Enteral Feedings • TPN • Acute Renal Failure • Protein

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Liver Disease Metabolism of Protein, Fat, Carbohydrates, Micronutrients Nutritional Assessment • Micronutrients Nutrition Support

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101

10 Cancer Patients Surgery, Radiation, Chemotherapy Nutrient Needs

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11 AIDS and HIV-Positive Patients Effects of AIDS on Immune System Nutrition Assessment • Nutrition Support

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12 Transition to Home Care Guidelines for Home Nutrition Support Complications of Long-term TPN

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Appendices 131 Review Question Answers • Physical Changes of Malnutrition • Height & Weight Tables Creatinine • Height Index • Anthropometric Measurement Standards • Tricep Skinfold/ Arm Muscle Circumference • Non-nutritional Factors • Nutrient Absorption • TPN Monitoring Form Recommended • Dietary Allowances • Standard TPN Admixtures • Determining TPN Values • Metabolic Complications of TPN Exam

147

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Learning Objectives After completing this course, the student will be able to: 1. Describe the pros and cons of using anthropometric measurements for the nutrition assessment of the critically ill patient. 2. Analyze the usefulness of serum albumin, prealbumin and transferrin in assessing the nutritional status of a critically ill patient. 3. Determine the caloric needs of patients with the following types of diseases: severe sepsis, obesity, liver disease, renal disease and pulmonary disease. 4. Determine the type, amount, route and method of enteral feedings for hospitalized patients with the diseases listed in objective #3. 5. List five causes of diarrhea in hospitalized patients. 6. Discuss four complications of enteral feedings and the cause of each complication. 7. Analyze enteral formulas and discuss the pros and cons of the type and amount of protein, carbohydrate and fat found in each one. 8. Determine if a hospitalized patient is a candidate for total parenteral nutrition (TPN). 9. Calculate the total calories, nonprotein calories, total protein, calorie to nitrogen ratio and amount of fat in TPN solutions. 10. Identify metabolic complications that occur with TPN, the cause of the complications and a plan of action if the complications occur in a patient. 11. Design a nutrition care plan for a patient who has had his jejunum and ileum re- moved, beginning post-op and continuing until the patient is discharged. 12. Discuss how liver, renal and pulmonary disease impact the following nutritional needs of hospitalized patients: calories, protein, fat, carbohydrate, electrolytes and vitamins and minerals. 13. Explain how AIDS and ARC impact the nutrition needs for calories, protein, fat, carbohydrate, electrolytes and vitamins and minerals.

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Introduction

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utrition support is complex nutrition care provided to those patients who are, or have been, critically ill. It also applies to care provided to those patients with disease states that affect their nutritional status and/or ability to utilize particular nutrients. It has evolved from simple tube feedings into a highly complex system which meets the nutrition needs of patients who would not otherwise have survived medical crises. Nutrition support patients can vary from an elderly patient with dementia who requires enteral (gastric or duodenal tube) feedings, to a patient who has had significant gastrointestinal surgery and requires parenteral (intravenous) feedings, to a patient who has acute renal failure and septic shock and cannot digest and utilize nutrients except through intravenous feedings. Nutrition support is, therefore, a varied and highly specialized field, requiring an increased level of knowledge by the nutrition care practitioner. This knowledge base can only come with experience and the continual study of appropriate literature, as new ideas and research are promulgated and new feeding formulas developed. No doubt the field will continue to grow and change, making some practices now in use obsolete. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is an excellent resource for the person interested or involved in nutrition support. ASPEN produces a bimonthly journal, Journal of Parenteral and Enteral Nutrition (JPEN), that provides state-of-the-art information on research and trends in nutrition care, and has devised standards of care for various areas of nutrition support and standards of practice for the different disciplines providing care. Also published by ASPEN is a bimonthly publication Nutrition in Clinical Practice, a more hands-on resource which can be invaluable in your practice and several excellent reference books. ASPEN has a certification process for its members. Currently, nutrition support certification is attainable for qualified dietitians, nurses, physicians, and pharmacists; the designation is CNSC (Certified Nutrition Support Clinician).

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Dietitians in Nutrition Support, a practice group of the American Dietetic Association, is also an excellent resource for dietitians, dietetic technicians and students interested in nutrition support. This practice group publishes an informative bimonthly newsletter, Support Line, and conducts workshops across the country. This course will provide practical guidelines and references for the nutrition care practitioner, focusing on the clinical practitioner’s role. Methods of nutrition assessment, an overview of enteral and parenteral regimens, and guidelines for the nutrition support of patients with specific diseases and conditions are included. As in all areas of nutrition, research has changed accepted clinical practice and calculations. This course reflects the latest thinking in clinical practice, and will be updated periodically throughout its publication period as information emerges. Throughout the course, I refer to specific brand-name feeding formulas. I wish to emphasize that these are included because they are in general use in hospitals everywhere. No mention of a brand name should be construed as an endorsement, except where I have pointed out that one product meets specific criteria. There are no commercial objectives to any such mention, and neither I nor Nutrition Dimension, Inc., has received any incentives or consideration for mentioning a specific brand name or company. Rather, I have attempted to use my own experience and that of the sources cited in this course in the most practical way: by making specific points in terms the average practitioner can understand and use in his or her daily work. Because of the complex nature of the topic and the fact that only an objective postexamination is available, I have included review questions at the end of each chapter, and provided answers and discussion as an appendix. I strongly advise that the student attempt to complete these questions before reading the answers. They are not “extra.” Rather, they are an integral part of the course, and will serve to illuminate the textual material and facilitate completion of the post-exam. The case studies I’ve designed simulate typical problems and situations that occur in hospital care — many of them, in fact, are drawn from actual cases. Since nothing is ever totally “by the book,” these will help the student see how a case can change, and how seemingly minor variations in lab values can be important. Again, I urge the student to follow these discussions closely. In the 20 years since the first edition of this course was published, numerous dietitians have responded with cogent observations and thoughtful advice for making it better. Throughout the period, these recommendations have enabled me to make minor corrections and clarifications in the text, which the publisher was able to incorporate in subsequent printings. It is impossible to name all the dietitians who took the time to write or call with advice, but their input and concern is greatly appreciated, as is that of the reviewers for certification, who also made many excellent suggestions.

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Chapter One: Nutrition Assessment

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utrition assessment is a valuable tool in the early identification of malnutrition and/or undernutrition. Malnutrition and/or undernutrition has been estimated to occur in at least one in five hospitalized patients. The incidence increases to almost 50 percent in patients with a longer length of stay (Hill, 1992). Often a patient’s nutritional status will deteriorate during a hospital stay. Reasons for this decline in nutritional status may include anorexia with resultant decreased intake, surgery, infection, medication interactions, chemotherapy and radiation therapy. Malnutrition may increase the incidence of sepsis, cause poor wound healing and poor respiratory effort, and decrease absorption of nutrients (Cerra, 1984). The patient with malnutrition is at increased risk for infection because of compromised lymphocyte function and growth. Antibodies, phagocytes and macrophages all have diminished function and/or effectiveness (Kline, 1999). Morbidity associated with malnutrition has been estimated at 25 percent, while mortality due to malnutrition alone occurs in about 5 percent of cases. Protein stores are depleted by as much as 75 gm/day during the initial stages of malnutrition (Cahill, 1988). Early nutrition therapy may decrease a patient’s propensity to develop malnutrition and delay or prevent the onset of these complications. The first step in providing appropriate nutrition therapy is nutrition assessment. In performing a nutrition assessment, the practitioner must review all aspects of the patient’s history, appropriate current factors, and clinical and biochemical parameters. Initially, something as simple as a nutrition screening should be carried out (see chart on the following page). The information obtained in the screening can be used as a reference point for comparison later in the hospital course and can assist in identifying the patient at increased risk for nutrition problems during the hospital stay.

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Nutritional Screening Height and weight Diet history Weight change history Appetite

Chewing/swallowing problems Diagnosis & chewing Laboratory data Bowel habits

After the initial screening has identified a patient as high risk, further evaluation should include examination for any overt clinical signs of malnutrition. Obvious calorie/protein malnutrition may be manifested by muscle wasting, edema or ascites, and changes in hair and skin condition. Symptoms of vitamin and mineral deficiencies may include changes in the condition of the skin, eyes, mouth and gums. Neurological changes such as ataxia, convulsions and encephalopathy may occur with malnutrition. A more complete listing of physical changes associated with malnutrition can be found in Appendix #1. Another course in this series, Nutrition Assessment: Tools and Techniques also outlines the complexities of assessment in more detail. Clearly, one of the most important components of assessment is height and weight. These give an indication of current nutritional status, as well as of chronic changes in nutritional status. Height helps in determining ideal body weight (IBW). This figure can be determined by using the Metropolitan Life Insurance Height/ Weight Tables (Appendix #2) or the Hammwi method: Males: 106 lb, plus 6 lb per inch over 5 feet +/– 10 percent Females: 100 lb, plus 5 lb per inch over 5 feet +/– 10 percent A comparison of actual weight to IBW should be made to determine the existence of underweight or obesity, as shown on the next page. Factors such as edema, ascites, and fluid overload should be taken into account in the assessment of weight for height data.

Ideal Body Weight Comparison > 200 percent = Morbidly obese > 150 percent = Obese > 120 percent = Overweight 80 to 90 percent = Mild caloric depletion 70 to 80 percent = Moderate caloric depletion < 69 percent = Severe caloric depletion Hopkins B: Assessment of nutritional status. In Nutrition Support Dietetics. ed. by Shronts EP, ASPEN, Silver Spring MD, pp 15-60, 1989.

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Another comparison — actual weight to usual weight — can be made to determine the relevance of changes in body weight. This comparison may be more important than other assessments in the clinical setting as an indicator of malnutrition. An unintentional and/ or unexplained weight loss or gain of more than 10 percent of body weight within 6 months or 7.5 percent within 3 months has been associated with increased surgical mortality, and should alert the clinical practitioner to the possibility of complications affecting nutritional status. Body mass index (BMI) compares weight to height and is sometimes utilized to determine the incidence of obesity and/or malnutrition.

BMI BMI = 19-25 21-27 >27.5 27.5-30 30-40 >40

weight (kg) Height2 (m2) (height squared (meters squared))

appropriate weight (19-34 yr) appropriate weight (>35 yr) obesity mild obesity moderate obesity severe or morbid obesity

17-18.5 mild malnutrition 16-17 moderate malnutrition 80% = mild depletion 60 – 80% = moderate depletion

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