Nutrition 3 - oral diet PDF

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CH 14(15 ON NOTES) Feeding Patients: Hospital Food and Enteral and Parenteral Nutrition ** Up to 40% of hospitalized patients are malnorished ● Hospital food may be refused because ● It is unfamiliar ● Tasteless (e.g., cooked without salt) ● Inappropriate in texture (e.g., pureed meat) ● Religiously or culturally unacceptable ● Served at times when the patient is unaccustomed to eating ● Meals may be withheld or missed. ● Inadequate liquid diets may not be advanced in a timely manner. ● Giving the right food to the patient is one thing; getting the patient to eat (most of it) is another. Oral Diet ● Easiest and most preferred method of providing nutrition ● Oral diets may be categorized as ● “Regular” ● Modified consistency ● Therapeutic ● Normal, regular, and house diets ○ Regular diets are used to achieve or maintain optimal nutritional status. ○ Regular diets are adjusted to meet age-specific needs throughout the life cycle. ○ Diet as tolerated (DAT) ○ ● Modified consistency diets ○ Modified consistency diets include ○ Clear liquid ○ Mechanically altered diets ○ Clear liquid diets may be used. ○ To maintain hydration during gastrointestinal illness ○ In preparation for bowel surgery or procedures ○ When oral intake resumes after a prolonged period ○ Most patients can tolerate a regular diet for their second postoperative meal. ● ○ Mechanically altered diets contain foods that are chopped, ground, pureed, or soft. ○ Diets prepared in a blender provide food in liquid form. ○ Dysphagia (Difficulty to swallow) diets are another variation of modified consistency diets. ● Therapeutic diets ○ Therapeutic diets differ from a regular diet. ○ Used for the purpose of preventing or treating disease or illness ● Nutritional supplements

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Some patients are unable or unwilling to eat enough food to meet their requirements Categories of supplements include ■ Clear liquid supplements ■ Milk-based drinks ■ Prepared liquid supplements ■ Specially prepared foods ○ Liquid Supplements are: ■ Easy to consume ■ Are generally well accepted ■ Tend to leave the stomach quickly ■ A good choice for between-meal snacks ■ Allow the patient to taste test several options available ■ Explain the rationale for adding supplements and closely monitor acceptance ■ Given on a rotation schedule ○ Modular Products ■ Less frequently used option for maximizing a patient’s oral intake ■ Generally composed of a single nutrient ■ Disadvantages ● Ineffective quality control (calculation errors) ● Bacterial contamination ● Higher costs than standard formulas Enteral Nutrition ● A way of providing nutrition for patients who are unable to consume an adequate oral intake but have at least a partially functional GI tract that is accessible and safe to use ● Enteral nutrition (EN) may augment an oral diet or may be the sole source of nutrition. Patients who: - Have problems chewing and swallowing - Have prolonged lack of appetite - Have an obstruction, fistula, or altered motility in the upper gastrointestinal tract - Are in a coma - Have very high nutrient requirements ● Contraindicated when the gastrointestinal tract is nonfunctional ● Patients who receive enteral nutrition experience less septic morbidity and fewer infections and complications than patients who receive parenteral nutrition. ● Significantly less costly than parenteral nutrition ● Has not been proven to reduce the length of the hospital stay and improve mortality ○ More high-quality trials are needed. ■ Factors that influence how and what is used to feed patients enterally include ■ The patient’s calorie and protein requirements

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■ Ability to digest nutrients ■ Feeding route ■ Characteristics of the formula ■ Equipment available ■ Method of delivery Feeding route ○ Depends on the patient’s medical status and the anticipated length of time the tube feeding will be used ○ Transnasal tubes ○ Nasogastric (NG) tube is the most common. ○ Generally used for tube feedings of relatively short duration ○ Ostomy feedings are preferred for permanent or long-term feedings. ○ Percutaneous endoscopic gastrostomy (PEG) tubes are placed with the aid of an endoscope Formula characteristics ○ Formulary of various enteral products available within major categories ○ Are designed to provide complete nutrition Protein ○ Enteral formulas are classified by the type of protein they contain. ○ Standard formulas ○ Made from whole proteins or protein isolates ○ Provide 34 to 43 g protein/L Variations - High in protein - High in calories - Fiber enriched - Disease-specific formulas designed for patients with diabetes, immune system dysfunction, renal failure, or respiratory insufficiency Hydrolyzed protein formulas ○ Completely hydrolyzed formulas contain only free amino acids as their source of protein. ○ Partially hydrolyzed formulas contain proteins that are broken down. ○ Intended for patients with impaired digestion or absorption ○ Disease-specific formulas are available for liver failure, HIV/AIDS, and immune system support. Calorie and nutrient density ○ Calorie density of a product determines the volume of formula needed. ○ Routine formulas provide 1.0 to 1.2 cal/mL. ○ High-calorie formulas provide 1.5 to 2.0 cal/mL. ○ Nutrient density ○ Varies among formulas ○ Ranges from 1000 to 1500 mL/day Water Content ○ Varies with the caloric concentration

○ Formulas that provide 1.0 cal/mL provide 850 mL of water per liter. ○ High-calorie formulas are lower at 690 to 720 mL/L. ○ Adults generally need 30 to 40 mL/kg/day. ○ Need additional free water ● Other Nutrients ○ High-fat formulas are available for patients with respiratory disease. ○ Modified-fat formulas are designed for patients with malabsorption. ○ Diabetic formulas are available. ○ Electrolyte-modified formulas for renal disease ● Fiber and residue content ○ Terms fiber and residue are frequently used interchangeably. ○ Fiber ■ Stimulates peristalsis, increases stool bulk, and is degraded by gastrointestinal bacteria ■ Combines with undigested food, intestinal secretions, and other cells to make residue ● Osmolarity ○ Osmolality ○ Determined by the concentration of sugars, amino acids, and electrolytes ○ Isotonic formulas have approximately the same osmolality as blood. ○ Some patients develop diarrhea when a hypertonic formula is infused. ● Intermittent feeding ○ Administered throughout the day ○ Generally used for noncritical patients, home tube feedings, and patients in rehabilitation ○ More closely resemble a normal intake ○ Allow the client freedom between feedings ■ Bolus feedings ● Variation of intermittent feedings ● Large volume of formula delivered relatively quickly ● Often cause dumping syndrome ● Continuous drip method ○ Given at a constant rate over a 12- to 24-hour period ○ Recommended for feeding of critically ill clients ○ Continuous feedings should be interrupted every 4 hours. ● Cyclic feedings ○ Variation of continuous drip feedings ○ Cyclic feedings are usually well tolerated. Initiating and advancing the feeding—(cont.) ○ Commonly recommended maximum flow rate for gastric feedings is 125 mL/hour. ○ Using a standard feeding progression schedule helps to ensure timely progression of feedings to the goal rate. ○ Tolerance may be a problem for patients who are malnourished, who are under severe stress, or who have not eaten in a long time.

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Tube Feeding Complications ○ GI, metabolic, and respiratory complications are possible. ○ Aspiration is the most serious potential complication. ○ More common than large-volume aspirations is a series of clinically silent small aspirations. ○ Increases the risk of aspiration-related pneumonia Giving medications by tube ○ Should never be given while a feeding is being infused ○ Some drugs become ineffective if added directly to the enteral formula. ○ Ensure the tube is flushed with 15 to 30 mL of water before and after the drug is given. Transition to an oral diet ○ Goal of diet intervention is to ensure an adequate nutritional intake while promoting an oral diet. ○ Gradually increase meal frequency until six small oral feedings is accepted.

Paternal Nutrition ● ● ●

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Developed in the 1960s Infusion of a nutritionally complete, hypertonic formula Life-saving therapy in patients who have a nonfunctional GI tract ○ Also used for other clinical conditions such as critical illness, acute pancreatitis, liver transplantation, AIDS, and in patients with cancer receiving bone marrow transplants Overfeeding can cause a life-threatening complication known as the refeeding syndrome. PN is expensive, requires constant monitoring, and has potential infectious, metabolic, and mechanical complications. Used only when an enteral intake is inadequate or contraindicated and when prolonged nutritional support is needed Should be initiated when oral intake has been or is expected to be inadequate over a 7- to 14-day period

Composition of PN ● Provide protein, carbohydrate, fat, electrolytes, vitamins, and trace elements in sterile water. ● “Compounded” or mixed in the hospital pharmacy ● Two-in-one formula (dextrose and amino acids) ● Used by most hospitals ● Lipids given separately ● Three-in-one formula (dextrose, amino acids, and lipids) Protein

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Provided as a solution of crystalline essential and nonessential amino acids Amino acid formulations are available with and without electrolytes. Providing adequate protein is a primary concern when formulating PN. Nitrogen balance study can be used to determine adequacy of protein intake.

Carbohydrates ● ● ● ●

Carbohydrate used in parenteral solutions in the United States is dextrose monohydrate. Minimal amount of carbohydrate needed to spare protein is generally accepted as 1 mg/kg/min. Hyperglycemia is associated with immune function impairments and increased risk of infectious complications. High carbohydrate load may also lead to excessive carbon dioxide production.

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Lipid emulsions ○ Made from soybean oil or safflower plus soybean oil with egg phospholipid as an emulsifier ○ Isotonic ○ Available in 10%, 20%, and 30% concentrations ○ Significant source of calories ○ Necessary to correct or prevent fatty acid deficiency Electrolytes, vitamins, and trace elements ● Quantity of electrolytes provided is based on the patient’s blood chemistry values and physical assessment findings. ● Parenteral multivitamin preparations usually contain 12 to 13 essential vitamins. ● Most adult formulations now contain a small amount of vitamin K. ● Trace element preparations contain between four and seven trace elements. Medications ● ● ●

Patients receiving PN may have insulin ordered if glucose levels are above 150 to 200 mg/dL. Heparin may be added to reduce fibrin buildup on the catheter tip. Medications should not be added to PN solutions because of the potential incompatibilities of the medication and nutrients in the solution.

Administration ● Administered according to facility protocol ● Continuous drip by pump infusion is needed to maintain a slow, constant flow rate. ● Rapid changes in the infusion rate can cause ○ Severe hyperglycemia or hypoglycemia ○ Potential for coma, convulsions, or death ● After the patient is stable, PN may be infused cyclically.

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Cyclic PN allows serum glucose and insulin levels to drop during the periods when PN is not infused. To give the pancreas time to adjust to the decreasing glucose load, the infusion rate is tapered near the end of each cycle. During the last hour of infusion, the rate may be reduced by one-half to prevent rebound hypoglycemia. When the patient is able to begin consuming food orally, the amount of PN is gradually reduced to prevent ○ Metabolic complications ○ Nutritional inadequacies

CH16- nutrition for patients w/ Metabolic or respiratory nutrition ● The body’s attempt to promote healing and resolve inflammation when homeostasis is disrupted ● Intensity of the stress response depends to some extent on the cause and/or severity of the initial injury. ● Metabolic stress ○ Changes in metabolic rate ○ Heart rate ○ Blood pressure ○ Nutrient metabolism ● Hormonal response to stress ● Ebb phase ● Immediate postinjury phase ● Typically lasts 12 to 24 hours ● Characterized by ○ Shock with hypovolemia and diminished tissue oxygenation ○ Cardiac output, oxygen consumption, urinary output, and body temperature fall ○ Glucagon and catecholamine levels rise ● Hormonal response to stress—(cont.) ○ Treatment goals ● Restore blood flow to organs ● Maintain adequate oxygenation to all tissues ● Stop bleeding ● Ebb phase ends when the patient is hemodynamically stable. ■ Flow phase ■ Metabolic response to stress ■ Counterregulatory hormones ● Makes energy available to carry on essential bodily functions ■ State of hypercatabolism and hypermetabolism created ○ Oxygen consumption, cardiac output, carbon dioxide production, and body temperature increase. ○ Length of phase depends on ■ Severity of injury or infection

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■ Development of complications ○ Glycogen is depleted within the first 24 hours after the injury. Inflammatory response ○ Acute-phase response ○ Body’s attempt to destroy infectious agents and prevent further tissue damage ○ Characterized by a change of at least 25% in the plasma concentration of certain proteins known as acute-phase proteins ■ C-reactive protein is positive protein. ■ Negative acute-phase proteins decrease in response to inflammation; albumin is one example. Acute-phase response—(cont.) ○ Cytokines and other immune system molecules ○ Regulate acute-phase proteins ○ Produce changes in other cells that cause systemic symptoms of inflammation ■ Anorexia ■ Fever ■ Lethargy ■ Weight loss Systemic inflammatory response syndrome (SIRS) ○ Life-threatening condition ○ May occur when severe inflammation lasts longer than a few days ○ Heart rate, respiratory rate, white blood cell count, and/or body temperature become critically elevated. ○ If caused by infection, sepsis may occur. Systemic inflammatory response syndrome (SIRS)—(cont.) ○ SIRS and sepsis cause ○ Excessive fluid accumulation ○ Low blood pressure ○ Impaired blood flow ○ Inadequate oxygenation of tissues can lead to septic shock, multiple organ failure, and death. ○ Patient’s prior nutritional status is an important predictor of morbidity and mortality.

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Nutritional needs/support ○ Considered after the patient is hemodynamically stable ○ Overwhelming nutritional concern during metabolic stress is protein catabolism. ■ Can lead to impaired immune system functioning, increased risk of infection, impaired or delayed wound healing, and increased mortality ○ Primary goal of nutrition therapy is to protect lean body mass and prevent or alleviate malnutrition.

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Calories ○ Indirect calorimetry is rarely used.

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Harris- Benedict equation is not for the critically ill Basal enegrey expenditure (BEE) Multiply the patient’s weight in kilograms by a specified calorie level Adjusted upward or downward based on the patient’s response

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Underfeeding ○ Excessive calorie intake increases metabolism, oxygen consumption, and carbon dioxide production. ○ Increases the burden already placed on the heart and lungs to regulate blood gases ○ Refeeding syndrome ○ Feeding critically ill patients at 100% of calculated need is associated with worse, not better, clinical outcomes. ○ Underfeeding during critical illness (80% calories) is associated with shorter ICU and hospital stays. ○ Modest calorie intake is also associated with a higher chance of achieving ventilator independence before leaving the ICU. ○ Hypocaloric intake is maintained for 3 to 5 days.

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Protein ○ Recommendations for protein are not universally agreed on. ○ Range from 1.0 to 2.0 g/kg depending on BMI ○ Patients with severe burns may need 2.0 to 2.5 g/kg. ○ Specific types of amino acids given may influence the stress response and recovery. ○ Arginine and glutamine, two nonessential amino acids, may become conditionally essential during periods of stress. Carbohydrates and fat ○ Should provide 50% to 60% of total calorie needs ○ Fat may provide up to 40% of total calories.

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Fluid ○ ○ ○

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Highly individualized requirements according to losses that occur through exudates, hemorrhage, emesis, diuresis, diarrhea, and fever Avoid overhydration Decreased renal output is a frequent complication of metabolic stress.

Micronutrients ○ Vitamin and mineral requirements during stress are unclear. ○ Trauma and burn patients have been documented to have high urinary and tissue losses of the trace elements selenium, zinc, and copper. ○ When replaced, ○ Patients experienced significantly fewer infections. ○ Wound healing also improved.

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Method of feeding Enteral nutrition (EN) is recommended over parenteral nutrition (PN) in critically ill patients who are hemodynamically stable and have a functional GI tract. Common complication in critically ill patients is gastroparesis. Parenteral nutrition is required when the GI tract is nonfunctional. Associated with increased rate of hyperglycemia Oral diets are provided as soon as possible. Nutrition support—either complete or supplemental tube feedings—is necessary when calorie needs are not met through an oral intake.

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Burns ○ Extensive burns are the most severe form of metabolic stress. ○ Fluid and electrolyte replacement to maintain adequate blood volume and blood pressure is the priority of the initial postburn period. ○ Degree of hypermetabolism and hypercatabolism in the metabolic response phase correlates to the extent of burn.

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Nutrition therapy ○ Priority is to meet calorie and protein needs. ○ Protein needs are typically 2.0 to 2.5 g/kg. ○ Especially if burns cover more than 10% of total body surface area ○ Calorie and protein needs increase if complications develop. ○ Vitamin C, vitamin A, and zinc plus a multivitamin are recommended by the Shriners Burn Hospital.

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Respiratory Stress ○ Occurs when gas exchange between the air and blood is impaired ○ May cause hypermetabolism ○ When nutritional needs are not met, fewer nutrients are available to maintain respiratory muscle function. ○ Chronic or acute respiratory stress can lead to ■ Respiratory failure ■ Multiple organ failure ■ Death ○ Chronic obstructive pulmonary disease ■ As many as 60%of patients with chronic obstructive pulmonary diease (COPD) have malnutrition, which is associated w/poor outcomes ■ Many patients w/ COPD are hypermatabolic ■ Chronic inflammation ■ Anorexia may occur’ ■ Early satiety - Nutrition therap;y - Correcting or preventing malnutrition is the priority - High-calorie, high-protein diet is used - Some patients may be overweight from steriod use

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For patients hospitalized w/exacerbation of COPD, calorie needs may be 140% above BEE - Protein may be 1.2 g/kg body weight Ventilator Dependency and Carbohydrate Restriction ○ Patients on ventilator support may benefit from a restricted carbohydrate intake. ○ Carbohydrates produce more carbon dioxide when they are metabolized than do either proteins or fats. ○ This creates a greater burden on the lungs. ○ Work with client and family to solicit food preferences. ○ Young children may regress in their eating behaviors. ○ Adults may prefer foods they associate with recovery as children (e.g., chicken soup).

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Promoting Maximum Intake in Patients Whose Needs Are High and Appetite Is Low— (cont.) ○ Encourage the family to bring food from home. ○ Discourage intake of empty-calorie food and beverages. ○ Provide nutrient-dense liquid supplements between meals. ○ Provide emotional support and allow the patient to verbalize feelings. ○ CH17- Nutrition for Patie...