-
• refers to a comprehensive nutritional
assessment based on identified client needs
upon which therapeutic treatment of disease
processes can be based.
• It is provided by a dietician in conjunction with
collaborative management by health care
providers.
MEDICAL NUTRITION THERAPY
-
It is used to:
o Correct & replace nutrient deficiencies
o Provide adequate nutrition for clients
with defined health problems
MEDICAL NUTRITION THERAPY
-
It is important to include nutrition as a part of a
sound foundation on which to base identified
needs, expected outcomes, and response to
treatments.
FIRST-LINE TREATMENT
-
IMPORTANCE OF NUTRITION IN THE OVERALL
MANAGEMENT
- • Dietary factors greatly influence disease risk and
- progression.
- • A stable weight pattern within range of IBW is
- associated with a decreased risk of disease
- progression.
- • Clients feel better when they eat better and are
- in an acceptable weight range pattern (per BMI).
-
Indications for nutritional support:
- • Client physical conditions
- • Therapeutic bowel rest
- • Severe PCM/PEM
-
4 TYPES OF NUTRITIONAL SUPPORT METHOD
- Oral Supplement
- Tube Feedings
- Tube Enterostomy
- Parenteral Nutrition
-
• provides calories & nutrients
• In liquid or powdered form & are usually
packaged in ready-to-use formulations.
• Is categorized into 4 types according to formula
types.
oral supplements
-
4 categories of oral supplements:
- modular supplements
- polymeric ( intact protein )
- elemental ( predigested/hydrolyzed )
- disease-specific
-
type of oral supplement:
One nutrient source
Not nutritionally complete by
themselves
Considered to be nutrient
dense without increasing
volume
modular supplements
-
type of oral supplement:
Essential nutrient in a specific
volume based on a specified
formulation
Contains intact proteins of
high biologic value, complex
CHOs, fats, vitamins,
minerals, & trace elements
polymeric ( intact protein )
-
type of oral supplement:
Provides nutrients in
predigested form, making
their transport & absorption
easier in the body
elemental ( predigested/hydrolyzed )
-
type of oral supplement:
Provides formulation specific
to metabolic requirements
disease-specific
-
Clinical Indications for Tube Feedings:
- • Condition that prevents food intake (e.g.,
- swallowing & chewing problems, mouth
- infections)
- • Disease state that prevents/limits food
- absorption (e.g., intestinal disease,
- malabsorptive states)
- • Increase metabolic needs when oral intake
- cannot meet needed nutrient requirements
- (e.g., malnutrition, burns, & trauma)
-
Site Selections for Tube Feedings
- • NG – nasogastric tube
- • ND – nasoduodenal tube
- • NJ – nasojejunal tube
-
Involves placement of tubes through a surgical
opening to provide nutrient/fluid intake
Tube Enterostomy
-
Indications for Tube Enterostomy:
- Specific malabsorptive problems
- requiring long-term therapy
-
Site Selections for Tube Enterostomy:
- PEG tube - percutaneous endoscopic
- PEJ tube - percutaneous endoscopic jejunostomy
-
Nutrients/fluids are delivered through the parenteral route to maintain adequate metabolic balance.
Parenteral Nutrition
-
Site Selections for parenteral nutrition:
- PPN - peripheral parenteral nutrition
- TPN - total parenteral nutrition
-
Nutritional requirements for clients with supportive
methods
- • Macronutrients
- • Micronutrients
- • Water
-
refers to a method of feeding clients who have
a functioning GI tract but are unable to take a
diet orally or whose diet is inadequate.
ENTERAL NUTRITION
-
Indications for Enteral Nutrition:
- o Short-term – via nasogastric tubes or
- oral route
- o Long-term – via enterostomy place
- surgically or percutaneously
-
clinical indications of enteral nutrition:
- o Condition that prevents food intake
- (e.g., swallowing & chewing problems,
- mouth infections)
- o Disease state that prevents/limits food
- absorption (e.g., intestinal disease,
- malabsorptive states)
- o Increase metabolic needs when oral
- intake cannot meet needed nutrient
- requirements (e.g., malnutrition, burns,
- & trauma)
-
3 types of feeding in enteral nutrition
Continuous, discontinuous ( cyclic, intermittent, bolus )
- cyclic - feeding pump for <24h/day
- intermittent - 20-60 min q4-6h w/wo feeding pump
- bolus - over short period of specified interval via gravity drip or syringe
-
nursing interventions in enteral nutrition
- • Inspect the formula to be used.
- • Check placement of tube prior to any feeding,
- flush, or medications administration.
- • Aspiration of gastric contents
- • Introduction of air with auscultation
- • X-ray
- • Position the client to semi-fowlers to highfowler’s position.
- • Flush the tube before and after feedings (30-
- 50ml).
- • Irrigate tubes every 6-8 H.
- • Include the amounts of flush or irrigation used in
- the client’s I & O.
- • Medications must be of liquid form. Crush tabletform medications (refer to pharmacist). Flush
- with 20cc of water.
- • Do not mix together multiple medications
- simultaneously unless compatibility is known.
- • Do not hang more than the documented amount
- of formula.
- • Change solution/tubing per hospital protocol.
- • Monitor pertinent labs and document daily
- weights.
- • Work with the health care team members in
- order maintain nutritional balance and skin
- integrity.
- • Incorporate the concepts of altered nutritional
- status & body image in developing plan of care.
- • Be aware that the placement of feeding tubes
- may be long-term in nature given the client’s
- underlying medical condition.
-
parameters to monitor
- • Tube placement
- • Urine glucose q shift
- • Gastric residuals q 4H
- • BM and consistency
- • Tolerance to feedings
- • Record daily weight and I&O
- • Record weekly:
- o Serum e- and blood counts
- o Chemistry profile
- o Nitrogen balance
-
complications in enteral nutrition
- Mechanical
- • Clogged tube
- • Tube dislodgment
- • Defected infusion pump
- Metabolic
- • DHN
- • E- imbalances
- • Altered blood glucose levels
- Formula-related
- • Diarrhea
- • Cramps
- • Abdominal distention
- • Constipation
- • Nausea
- • Vomiting
- Dermatologic
- • Skin irritation
- • infection
-
It is the administration of nutrients by a route
other than the GI tract, usually intravenously.
What is parenteral nutrition?
-
2 types of parenteral nutrition:
- a. Total Parenteral Nutrition (TPN)
- b. Peripheral Parenteral Nutrition (PPN)
-
type of parenteral nutrition:
osmolality >10%
GIT not functional
IV sites: superior vena cava, subclavian vein
access: central line/PICC ( peripherally inserted central catheter)
indications for use: long term
Total Parenteral Nutrition
-
type of parenteral nutrition:
osmolality: isotonic solns, <10% dextrose, <5% amino acids
GIT functional
IV sites: peripheral vein
access: peripheral line
indications for use: short term
peripheral parenteral nutrition
-
list of nutrients to be given in parenteral nutrition and are calculated by RNDs
- • Dextrose (Carbohydrate source)
- • Amino acids (protein source)
- • Lipids (fat source)
- • Water
- • Electrolytes
- • Micronutrients
- • Vitamins
- • Additives
-
aka 3-in-1 mixture
Lipid emulsions are added to dextrose and amino acid mixtures
advantage: allows infusion over 24 hours
Total nutrient admixture (TNA), sometimes referred to as 3-in-1, is the combination of all macronutrients (dextrose, amino acids, and intravenous fat emulsion [IVFE]) with electrolytes, vitamins, minerals, trace elements, and sterile water for injection in 1 intravenous (IV) solution. ( source: net )
Total Nutrient Admixture ( but sa tiktok kay TPN )
-
TNA 2 in 1 vs 3 in 1
In 2in1, all nutrients are mixed in the same IV bag, except for lipids, whereas in 3 in 1 all nutrients are mixed in the same IV bag to form a lipid emulsion
-
Nursing Interventions for TPN
- • Verify TPN prescription with 2 RNs using 5/10
- Rights of Medication principles.
- • Run TPN through a dedicated line.
- • Change TPN solutions & tubing per protocol q 24
- hours.
- • Ensure that a pharmacist mixes all TPN solutions.
- • Inspect TPN products prior to hanging for
- “cracking” (lipid separation). Do not hang if it is
- present. Return it to the pharmacy.
- • Infuse TPN using an infusion pump per protocol.
- • Continuously assess for complications.
- • When client is progressing and TPN therapy is to
- be stopped, follow protocol for discontinuing
- therapy. DO NO STOP TPN ABRUPTLY – It can
- cause rebound hypoglycemia.
- • As TPN is stopped, enteral feeding routes are
- increased to a greater percentage of the total
- intake. When enteral feedings are being
- tolerated by the patient (60% of caloric intake),
- the client is ready to be taken off from TPN.
- • Collaborate with RND & AP in the assessment
- and evaluation of client response.
- • Provide education and support to patient and
- SOs.
- • Document pertinent findings relative to TPN
- therapy.
-
Nursing Interventions for PPN
- NURSING INTERVENTIONS (PPN)
- • Inspect IV site for S/Sxs of potential irritation &
- infection.
- • Use a dedicated line for infusion. Always use an
- infusion pump with filter.
- • Change solutions bag q 24H per agency protocol
- –decrease risk of infection.
- o 2 RNs must verify solution prior to
- hanging:
- o Prescription of Tx
- • Contents of bag with original order
- • Communicate with the entire health care team.
- • Continuously assess for complications
-
PARAMETERS TO MONITOR
Every 8 H
• VS
• Urine fractionals
Daily
• Wt
• I&O
• Serum e-, glucose, crea, BUN until stable; then
twice weekly
Weekly
• Serum Mg, Ca, Ph, Albumin
• Liver function Tests
• CBC
• Review of actual, oral, enteral, and TPN intake
Fluid Disorders
• Urine Na or fractional Na excretion
• Serum osmolality
• Urine specific gravity
Protein Status
• Nitrogen balance, serum prealbumin
Lipid Disorders
• Serum triglycerides
• Respiratory quotient
• Essential fatty acids
Hepatic Encephalopathy
• Plasma amino acids
Gastrointestinal Losses
• Serum trace elements
• Stool e
Baseline Assessment
• Weight, height, BMI
• Chemistry profile, CBC, coagulation profile, FE,
Total Fe-binding capacity and Mg
• Lipid profile
• Liver function tests
• Measures of protein status
• (Albumin, prealbumin, & transferrin)
On-going Assessments
• Q shift – VS & I&O
• Daily weights & 24H I&O
• Pertinent labs
• Client’s progress towards resumption of normal
feeding route
• Response to Tx
aab
-
complications in mnt:
catheter related
- • Occlusion due to thrombosis
- • Development of air embolism
- • Incorrect placement
-
complications in mnt:
metabolic related
- • Acid-base imbalances
- • E- imbalances
- • Nutrient deficiencies
- • DHN
- • Fluid retention
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