Lec 10: Advanced Nutrition

nutrition def

science of optimal cellular metabolism and its impact on health and disease

list the main categories of nutrients

• carbohydrates

• proteins

• fats

• water

• minerals

• vitamins

what are some examples of primary and secondary prevention with nutrition

• p=health eating, canada food guide, physical activity

• s= screening (lipid, BG, BMI, waist circumference, obesity staging)

what are some examples of tertiary prevention with nutrition

• dietary interventions=dietician, speech language pathology

• enteral nutrition

• parenteral nutrition

• surgical intervention

• pharmacology

what can we assess with nutrition

• health history

• BMI, calorie count

• physical examination (including LOC, pain, nutrition)

• safety - allergies

• activity levels and ability to complete ADLs

waist circumference normal parameters

• women = <31.5 in

• men = <37 in

BMI ranges

• underweight = <18.5

• normal = 18.5-24.9

• overweight = 25-29.9

• obese = 30-34.9

what labs should we test for and their ranges

• pre-albumin= 19-38 mg/dL or 190-380 mg/L

• lipase (0-160 U/L)

• amylase (23-85 U/L)

• BG and hemoglobin A1C

• lipid profile

• electrolytes

• hemoglobin and hematocrit

what are some pharmalogical interventions (supplements)

• protein and nutrient supplements = ensure, nutrition bars

• vitamin supplements = multivitamins, vit B, vit C, folic acid

• mineral supplements = iron, calcium, magnesium, zinc

• herbal and naturopathic remedies = omega 3 fish oil, glucosamine, ginseng, echinacea, st johns wort, garlic, etc

• statins = atorvastatin, simvastatin

• insulin or oral diabetic agents

Who needs advanced nutrition?

pts who are malnourished or are at risk for developing nutrition complications due to:

• impaired oral intake (ex decreased LOC)

• impaired digestion/absorption (ex gastric surgery)

• increased metabolic demand (ex trauma and burns)

• altered organ fx (ex end stage liver disease)

Screening process (what do we assess)

• changes in weight

• changes in oral food and fluid intake

• past medical/surgical history

• food allergies or following a special diet

• diseases and conditions (short bowel syndrome, bowel obstruction, critically ill pts, and severe acute pancreatitis)

what are the major goals with nutrition tx

• attaining an optimal level of nutrition

• preventing infection

• maintaining skin integrity

• enhancing coping skills

• adjusting to changes in body image

• acquiring knowledge of and skill in self-care

• preventing complications.

variations

pts unable to take in their total daily calories and protein in a typical oral form => they are at risk of being or are undernourished

who is enteral nutrition used for and def

pts with a functional GI tract that can be accessed

• nutrition taken through a tube that goes directly to the stomach or small intestine

who is parenteral nutrition used for and def

malnourished pts that arent candidates for EN

• a method of getting nutrition into the body through veins (through peripheral IV or central line)

enteral feeding def

meets nutritional requirements when oral intake is inadequate or not possible, but GI tract is functioning

• feed formulas discarded after 24 hours

enteral feed pro’s

• safe and cost-effective

• preserves GI integrity

• preserves the normal sequence of intestinal and hepatic metabolism

• maintains fat metabolism and lipoprotein synthesis

• maintains normal insulin and glucagon ratios

what forms of tubes are there with EN

• nasogastric tube

• percutaneous endoscopic gastrostomy (PEG) tube

what methods of EN are there

• intermittent bolus feedings

• intermittent gravity drip

• continuous infusion

• cyclic feeding

what do we need to monitor with EN

hydration

• free water flushes every 4 to 6 hours

The Care of the Patient Receiving an Enteral Feeding, what to keep in mind

• nutritional status and nutritional assessment

• factors or illnesses that increase metabolic needs

• hydration and fluid needs

• digestive tract fx

• renal fx and electrolyte status

• medications that affect nutrition intake and function of the GI tract

• compare the dietary prescription to the patient’s needs

Enteral Feeding Complications

• fluid/electrolytes=dumping syndrome, refeeding syndrome

• glucose regulation

• infection/inflammation/tissue integrity

• gas exchange (on placement of NG tube, aspiration)

• perfusion (hemorrhage)

• pain with bloating/distension

• elimination = N&V diarrhea, constipation

• psychosocial (comfort, functional ability)

parenteral nutrition def

method to provide nutrients to the body by an IV route

how long should PN be done for once initiated

at least 7-14 days

who are the types of pts who cant be fed enterally or have intestinal failure but parentally

• extended bowel rest

• sepsis

• head injury

• burns

• perioperative bowel rest

what are the diff methods for PN

• total parenteral nutrition (TPN) - through a central IV line

• peripheral parenteral nutrition (PPN) - through a peripheral IV line

PN characteristics

• short term or long term

• provides total or supplemental nutrition intravenously

• caution needs to be used for critical ill, pediatric, and neonatal pts

Nurse’s role and responsibilities

• nutrition/hydration status

• electrolytes

• S&S of hypoglycemia or hyperglycemia, monitor BG levels

• assess for potential complications

• VS including temp q4h or by protocol

• measure weight

• I&O

Parenteral Nutrition Complications

• infection= culture and sensitivity of drainage at site or of infected IV catheter tip

• gas exchange - air embolism, pneumothorax, hypercapnia

  • pt positioning for air embolism, chest tube for pneumothorax, ask for help

• perfusion - catheter occlusion or dislodgement

• glucose management = give D10W if pt disconnected from PN

• acid base or electrolyte imbalance = consult doctor

• fluid overload, azotemia = check BUN, urea, creatinine; meds for fluid overload, adjust admin rate

what are the key lab values for monitoring liver fx and their ranges

• total bilirubin = <20 u/mol

• albumin = 35-50 g/l

• alanine aminotransferase (ALT) = <50 u/l

• aspartate aminotransferase (AST) = 0-40 u/l

TOTAL BILIRUBIN [<20 UMOL/L] def

• combo of unconjugated & conjugated

• derived from the breakdown of RBCs

• small amount is absorbed back into the blood then excreted by the kidneys and responsible for the yellow color of urine

• elevated with obstruction to the flow of bile

ALBUMIN [35-50 G/L] def

• protein produced by the liver and helps maintains the oncotic pressure in the vascular system

• binds to substances (drugs, lipids, hormones, toxins) and converted to a water-soluble form by the liver

• lack of this protein allows fluid to leak into the interstitial spaces

ASPARTATE AMINOTRANSFERASE (AST) [0-40 U/L] def

• highest concentration within the liver and used to detect liver necrosis

• comparison of the ratio of AST to ALT helps evaluate liver disease

• with alcoholic cirrhosis, the AST is usually twice that of ALT

• non-alcoholic fatty liver disease, the ALT is higher than AST

• both enzymes rise before there are any signs of jaundice

what lab values are used to monitor renal fx and their ranges

• blood urea nitrogen (BUN) = 2.5-8 mmol or 7-20 mg/dl

• creatinine = 50-105 umol/l

BLOOD UREA NITROGEN (BUN) [2.5-8 MMOL/L OR 7 TO 20 MG/DL] def

• waste product of protein metabolism and excreted by the kidneys

• elevation can be an indication of renal failure or dehydration

• over hydration and liver failure invalidate it as a test for renal failure

CREATININE [50-105 UMOL/L] def

• end product of muscle metabolism

• only condition where you see an elevation is damage to a large number of nephrons in the kidney

• only increased when 1/4 of the nephrons are non-functioning

• 3 types of acute renal failure= pre, intra, post

Interrelated Concepts pic