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Andalosia nutrition
1.
2. Content outline
• Overview
• Physiological principles
• Patient at risk to develop malnutrition
• Nutritional assessment
• Nutritional requirements
• Determining nutritional requirement
• Methods of nutritional support
3. • Recognition of the importance of the
gastro-intestinal tract and its potential
role in the development of multiple
organ failure has been increasing over
the last 10 years.
4. Physiological principles
• Protein-Energy Malnutrition (PEM)
A pathologic state resulting from a relative or
absolute deficiency of protein and energy
• The Hypermetabolic State
An increase in energy demands that
accompanies any significant physiologic
and/or psychological insult
5. Physiological principles
• Protein-Energy Malnutrition (PEM)
A pathologic state resulting from a
relative or absolute deficiency of
protein and energy
• The Hypermetabolic State
An increase in energy demands that
accompanies any significant
physiologic and/or psychological insult
6. • The Catabolic State
A progressive loss of lean body mass in
response to any significant
insult, physiological or psychological
• Body Composition: The Importance of
Lean Body Mass and Fat Mass
• Total Body Weight = Lean Body Mass*
+ Fat Mass
7. Fat Mass (25%)
Adipose Tissue
Lipid
Metabolically Inactive
Contracts If Energy
Demand Exceeds
Intake
Expands If Energy
Intake in Excess
Stored kcal: 150,000
Lean Body Mass (75%)
70% Water, 20% Protein, 10%
Minerals
Metabolically Active
Compartment Size Highly
Regulated
Essential for Survival
Potential kcal: 40,000
Contains All Skeletal and
Smooth Muscles
Tissue and Skin
Visceral Protein
Collagen
Enzymes, Antibodies
Growth Factors
10. Components of nutrition assessment for
malnutrition
–Dietary history
–Physical
examination
–Laboratory
examination
–Weight loss
–Anthropometric
measurements
–Immunological
studies.
–Nitrogen balance
studies.
–Determinants of
nutritional
requirement.
–Indirect Calorimetry
11. 1 ) History:
• wt changes over past 6 months
• appetite
• recent vs. usual food intake
• alcohol
• dietary/herbal supplements
• food intolerances
• GI complaints (especially if >2 wk)
• changes in functional status
Components of nutrition assessment for
malnutrition
12. Physical Findings associated with Malnutrition:
• Cachexia & Muscle wasting
• Signs of dehydration
• Ascites, edema
• Poor hair quality, skin ulcers or rashes, nonhealing
wounds
• Pallor or redness of
gums, stomatitis, glossitis, obesity.
• Unintentional weight loss of >10% within 6 month
or >5% within 1 month
Components of nutrition assessment for
malnutrition
13. Weight and height
BMI = weight / height2
Triceps or subscapular thickness of skin fold
Mid-arm muscle circumference and mid-arm
muscle area
Body Composition Parameter
14. Anthropometric Measurements
• Anthropometry is the
measurement of body size
, weight , and proportions
• Anthropometry measures
can be used to evaluate
nutritional status .
• Anthropometry also is
considered the method of
choice for estimation body
composition in a clinical
setting .
15. Height
• Procedure
• The client
stands erect
with feet flat
on the floor
and slightly
apart, legs
and back.
16. Weight
• Procedure
• On the same scale
each time.
• At the same time of
day, preferably before
breakfast.
• With the same
amount of clothing on
each time and
without shoes.
Record the weight
immediately
22. Interpretation
• Compare measurements to previous MAC to
identify any change.
• Measurements less than 90% of reference
standard may indicate the need for nutritional
support.
23. Triceps Skinfold (TSF)
• Measures subcutaneous fat
stores and is therefore an
index of total body
fat, because more than half
the total body fat
tissubcutaneous.
33. Estimate of Weight Loss
Usual weight - present weight x 100 =
percent of weight change
Estimate of PEM
Mild Moderate Severe
% Wt loss 10% 15%-25% > 25%
34. Mid-arm muscle circumference
(MAMC):
• MAMC (cm) = MAC (cm) − *3.14 ×
TSF (cm)]
Arm muscle area (AMA)
• AMA (cm2) for females = {[MAC- ( x
TSF)] 2 / 4} – 6.5.
• AMA (cm2) for males = {[MAC- ( x
TSF)] 2 / 4} – 10.
35. Laboratory data
• Evaluation of protein level
• There are 2 types of protein
1- Somatic protein which found is
skeletal muscle .
2- Visceral protein found in viscera of
body (liver , kidney , pancreas , heart)
red blood cell & white blood cell.
37. Nitrogen Balance Studies
• It is a very important parameter of protein
synthesis & metabolism.
• Nitrogen balance = [protein intake (in
grams)] / 6.25 – [24-hour (in grams) urinary
urea nitrogen (UUN) + 4]
• If it equals zero nitrogen balance is present.
• If it equals a + ve number protein synthesis is
occurring
• If it equals a –ve number protein catabolism.
39. Other tests
• Hemoglobin level iron — contain
pigment in red blood cell.
• Hematocric packed red cell volume.
• W.B.C&R.B. C.
• Fluids & electrolytes level in body .
40. Determining nutritional requirement
• The BMR is the amount of energy
expended at complete rest, shortly after
awakening and in a fasting state for 12 to
18 hours. The BMR depends on
age, sex, and body size and correlates
roughly with body surface area. It is
proportional to lean body mass, not to fat.
The metabolic rate increases 20% after
elective surgery and 110% after a severe
burn.
41. Resting energy expenditure REE, which is
often used synonymously with
BMR, represents the amount of energy
expended 2 hours after a meal under
conditions of rest and thermal
neutrality. It is generally 10% higher
than the BMR.
42. • The energy requirements can be
calculated as:
• Total energy expenditure = BMR x
stress factor x activity factor.
• Estimation of energy requirements at
rest (basal energy expenditure, BEE) is
most often using the equation of Haris.
43. Basal energy expenditure
BEE : Men
66.47 + (13.75 weight in kg) + (5.0
height in cm) – (6.76 age in yr.)
BEE: Women
655.10 + (9.56 x weight in kg) + (1.7 x
height in cm) – (4.68 age in yr.)
46. Indirect Calorimetry
• Indirect calorimetry is a technique that
measures oxygen consumption and
carbon dioxide production to calculate
resting energy expenditure and
respiratory quotient (RQ). One liter of
oxygen consumed generates 3.9 kcal
(16.32 kJ); 1 L of carbon dioxide
produced generates 1.1 kcal (4.60 kJ).
47. • Indirect calorimetry allows the precise
measurement of the daily caloric
expenditure.
• Use of a stress factor to account for
injury is not necessary because the
measured energy expenditure accounts
for the effects of disease
state, stress, and trauma.
48. • Because the measurement occurs at
rest, it is necessary to multiply by an
“activity” factor of 1.0 to
1.3, depending on whether the patient
is intubated, at bed rest, or ambulatory.
• In addition, indirect calorimetric data
provide, via the RQ (RQ = carbon
dioxide production / oxygen
consumption).
49. • The RQ can be useful in altering a
patient’s nutritional support regimen.
Normal RQ ranges from 0.7 to 1.0.
• An RQ of greater than 1.0 most often
indicates overfeeding
• whereas an RQ less than 0.82 is often
associated with underfeeding .
52. Why
• do we feed MV patients?
When
• should we start to feed them?
Who
• are the patients we should feed?
Which
• route should we feed by?
How w
• can we estimate the amount of feeding we should give?
What
• should the feed contain?
53. Why feed?
• To provide sufficient energy to spare protein
• To prevent patient moving from an early stage
of malnourishment to a severe stage.
• To optimize management from the nutritional
point to aim for the best outcome
• To prevent PEM, and micronutrients
deficiencies
54. Why • do we feed mechanically ventilated pts?
MalnutritionPatients on admission
Catabolism of illness
Poor outcomes
Wasting of lean body mass
55. What should we feed critically ill
patients?
• Exactly what we should be feeding for
optimum recovery remains less clear.
• Enteral nutrition with supplemental
arginine, glutamine and omega-3 fatty acid
instead of standard enteral diet improved
immunological, metabolic and clinical
outcomes
• Micronutrients (vitamins & minerals) should
be considered
56. What route?
Enteral nutrition is the route of choice
Promote immunocompetence of the gut
Overgrowth of gut bacteria
Translocation of gut bacteria
57. • Early feeding usually defined as starting within
the first 48 hours of admission
When • should we start to feed them?
58. Timing of feeding
• Within 48h in mild to moderate PEM
• In severe PEM gradual restoration to avoid
refeeding syndrome
• The aims of early feeding are:
- Preservation of function
- Survive particular episode of illness
- Reduction of complications
59. Early feeding
Starting of feeding within the first 24 hours of
admission “ ACCEPT”
Algorithms for Critical Care Enteral and Parenteral Therapy
60. • All malnourished patients
• All patients who are unlikely to regain normal
oral intake within either 2 or 5-7 days
depending on your view
Who
• are the patients we should feed?
61. • All hospitalized patients should be screened
for risk or presence of malnutrition within 24
hr of admission.
Which • patients should we feed?
62. Patient at risk to develop malnutrition
• Chronic disease
• Severe catabolism
• Inability to use GIT
• I.V support for more than 5 days
63. – Trauma, Burns
– Sepsis, organ failure
– Bowel obstruction
– Severe digestive or absorptive disorders
– Severe pancreatitis
– Prolonged NPO or clear liquids
– Poor oral health, Dysphagia
– Poor functional capacity, elderly.
Conditions associated with Malnutrition Risk
64. Nutritional Support
• The general goals of nutritional therapy are:
• To provide adequate nutrients for anabolism
• Maintain fluid balance
• Prevent infection and complications
associated with nutritional therapy.
• Provide information & emotional support
65. • Water and electrolytes
• Micronutrients
• Carbohydrate
• lipid
• Nitrogen
• Intact proteins
• Crystalline amino acid solutions
What • should the feed contain?
66. • Carbohydrates:
• Purpose:
– To provide energy.
– To spare body proteins.
• I.V source:
• Dextrose is the I.V source of
carbohydrates calories. Carbohydrates calories
can also be provided by glycerol, sorbitol, or
fructose.
• Dextrose 5% 500 ml provides 100 calories, as
each 100 ml contains 5 gm of glucose and each
gram provides 4 calories.
• 1 gm CHO=4 K cal.
67. Proteins:
• Purpose:
• To promote tissue growth repair & replacement of body
cells.
• I.V source:
• Amionsteril which provides 30 gm of amino
acids /500 ml.
•
• Daily requirement:
• The protein requirement of an adult is 0.8 gm
/kgm /day, in disease states this should be increased to 1-
3 gm / kgm/day.
•
1 gm of protein provides 4 kilocalories
68. Protein requirement
• In many critically ill
patients, 1.2 - 1.3 g
protein/kg of non-
edematous weight
• 1.0 g/kg of current
edematous weight)
suffices to minimize
net loss of body
protein.
69. Fats:
• Purpose:
• To provide energy and calories.
• To help in absorption of fat soluble vitamins.
• To help the patient to gain weight.
• I.V source:
• Fat emulsion (Intralipids) provide
from 1000 cal / one liter.
• 1 gm of fat =9 kilocalories.
70. Micronutrients:
Electrolytes:
– potassium
• Purposes:
• To transport glucose and amino acid
across the cell membrane.
•
• Daily requirement:
• Approximately 30 to 40 mEq of potassium is
necessary for each 1000 calories provided through
parentral route.
71. Micronutrients:
– Magnesium, soudium, chloride and phosphorus.
• Salvical which provide electrolytes and
energy.
• Vitamins:
• Water soluble and fat-soluble vitamins are added.
• E.g. solu vit and cobalamin (B_12).
74. How w
• can we estimate the amount of feeding we should give?
75. REE (kcal/d) = 8 x body weight + 14 x height + 32 x
minute ventilation + 94 x body temperature - 4834
REE can be measured by indirect calorimetery using
metabolic monitor
Harris-Benedict was designed to estimate BEE
in healthy, unstressed adults, but more closely
estimates REE
76. ICU patients rarely have much physical activity.
Chemical neuromuscular paralysis & Heavy
sedation decreases energy expenditure by as much
as 30%.
Total energy expenditure “TEE”
= REE x Stress Factor x Activity Factor
78. • Protein → 10-35% of total caloric intake
• Carbohydrate → 45-65% of total caloric intake
• Fat → 20-35% of total caloric intake
Caloric requirement
81. Enteral Nutrition
• Tube Feeding
• Definition:
• Tube feeding is the delivery of a liquid feeding
formula directly to the stomach using a feeding
tube that is made of silicon, rubber or
polyurethane.
• It has a small diameter, and more flexible, so
decrease oropharyngeal irritation, distal
esophageal irritation, and discomfort from
swallowing.
82. • Purposes:
The nurse initiates enteral tube feedings to:
1. Administer nutrients to achieve calculated
nutri-tional requirements.
2. Administer nutrients to achieve the
recommended daily allowance (RDA) of
vitamins and minerals.
3. Administer tree water for fluid balance
83. Indications:
• 1-Inability to ingest adequate nutrients
orally
• 2-Inability to maintain adequate caloric
needs
• 3-For patients with a disturbed level of
consciousness
84. Contraindications to enteral nutrition
• Absolute contraindications:
• Diffuse peritonitis
• Intestinal obstruction that prohibits use of the bowel
• Intestinal perforation
• Paralytic ileus
• Severe diarrhea that makes metabolic management
difficult
• Relative contraindications:
• Severe pancreatitis
• Enterocutaneous fistula
• Gastrointestinal ischemeia
• Severe malabsorption
85. Methods of delivering formula through feeding
tube
Bolus feedings
• Bolus feedings are given by a large syringe in
volume as high as 400ml over 5-10 minutes, 5-6
times a day.
• The stomach is the preferred site for
administration.
• It allow patient mobility between feedings
because his freedom from mechanical devices.
• Bolus feedings are not well tolerated as a result
of high residuals, so
nausea, vomiting, cramping, diarrhea, or
aspiration are often accompanied.
86. • Intermittent feedings
• Intermittent feedings are administered as 300-
400 ml by a slow gravity drip 4-6 times a day
over a period of 30-60 minutes.
• The preferable site is the stomach.
• Intermittent feedings are associated with
decrease the risk for osmotic diarrhea.
87. Continuous feedings
• Continuous feedings are used when the tip of the
tube in the duodenum ,or jejunum ,and are
administered over 24 hrs with the aid of a feeding
pump to ensure a constant flow rate.
• Continuous pump feedings are the preferred
method for intestinal feeding because too rapid
delivery may lead to (dumping syndrome) which
is characterized by characterized by osmotic
diarrhea, abdominal
distention, cramp, hyperperstalesis, lightheadnes
s, diaphoresis, and palpitations.
• Continuous feedings can decrease the risk of
aspiration , and allow more time for nutrients to
be absorbed.
88. • Cyclic feedings
• Cyclic feedings are continuous feedings that
deliver the total daily nutritional requirements
in a shorter time frame over 8-12 hrs to allow
patient freedom from 24 hrs continuous
feedings.
• Cyclic feeding of high density & high volume
are given at night to allow hunger to develop
during the day.
89. Route Advantages Disadvantages
Nasogastric
Short term (less than
6 weeks) with
functional GIT
Stomach is normal
reservoir for food.
Presence of
hydrochloric acid in
stomach helps
destroy
microorganism
possibly reduce
infection.
Intermittent feeding
into stomach are
better tolerated than
those into small
intestine.
Not as appropriate
for patients on long
term tube feeding.
Contraindicated for
patients with history
of aspiration
pneumonia and
those at high risk for
aspiration.
Some tubing
materials are
uncomfortable.
90. Route Advantages Disadvantages
Naso duodenal
Short term with
functional GIT may
be used post
operatively following
gastric surgery.
May carry less risk for
aspiration.
May allow feeding
after gastric
surgery
Not desirable for long
term tube feeding.
Contraindicated for
Patients with history
of aspiration
pneumonia and
those at risk for
aspiration.
Difficult to place and
maintain in the small
intestine.
Some tubing
materials are
uncomfortable.
91. Route Advantages Disadvantages
Gastrostomy
For long-term tube
feeding into the
stomach for patient
with alterations in
swallowing
secondary to
neurologic disease or
brain injury.
Same as nasogastric
but more
comfortable.
Can not be misplaced
into trachea.
Easier to confirm
tube placement.
Usually inserted
under anesthesia.
Percutaneous endoscopic
gastrostomy (PEG) is
contraindicated for
patient’s with peritonitis,
ascites, esophageal
obstruction or severe
gastroesophageal reflux.
General anesthesia may
be contraindicated.
Possible aspiration risk
for patient’s with gastric
reflux or those who are
weak and debilitated.
Risk of skin break down
around tube if the site is
not properly cared for.
Tube dislodgment before
tract is mature may lead
to peritonitis.
92. How to give Medication via N.G.T correctly?
Medications are a frequent cause of tube blockage.
To minimize the problem, follow these guidelines:-
• Administer the drug’s liquid formulation when ever
possible.
• Dilute the drug adequately before giving it. Viscous solution
increases the risk for clogging.
• If the drug is available only as a tablet or capsule, ask the
pharmacist whether if it can be rushed or can be opened.
Never crush or open enteric coated medications.
• Flush the tube with warm not hot water before and after
giving the medication.
• If you are giving more than one medication, do not mix
them together flush the tube with 5 - l0 ml of water
between medications.
• Do not mix the medication with the formula.
94. Continue Mechanical complications (related
to the tube size).
• Tube obstruction
• Depressed cough
• Otatis media
• Impaired gas exchange ( if aspiration
occurs).
• Parotitis (an inflammation of one or
both parotid glands, the major salivary
glands located on either side of the face)
95. II- GIT complications (10 %-20%)
• Diarrhea
• Mal-absorption
• High gastric residuals (return of at least
half the amount given over an hour)
• Distension
• Nausea & vomiting
• Abdominal cramp
96. III- Metabolic
• Hyper or hypoglycemia
• or fat & albumin
• or mineral or vitamin
• Pre renal azotemia
• Fluid & electrolyte alteration
• Essential fatty acids deficiency
• Hyperosmolar
• coma
97. Parenteral nutrition
1- Peripheral parenteral nutrition
• Is the administration of macro-& micro-
nutrients necessary to maintain health
in the form of liquid solution suitable for
direct intravenous administration.
98. Purposes
• To improve the patient's nutritional
status, provide calories, replaces essential
vitamins, electrolytes and minerals.
• To restore nitrogen balance.
• To meet the patient's energy requirements.
• To improve wound healing promotes tissue
synthesis.
• To promote weight gain.
• To promote anabolism.
• To allow bowel rest and healing.
• To improve tolerance to surgery.
99. Indications:
• A 10% deficit in body weight in short period of time
(3-6 months).
– Excessive vomiting.
– Anorexia nervosa.
– Malabsorption.
• Inability to take oral feeding or fluid within 7 days
post operative.
• Gastrointestinal problem: as intestinal obstruction
& pancreatitis.
• Ulcerative colitis.
100. Hyper-catabolic state.
• Trauma.
• Sever burns.
• Immunocompromised states as: bone marrow
depression &Aids.
• Cancer.
• Major infection with fever.
101. Parenteral nutrition medication additives
• Insulin is considered to be chemically stable in
nutrition; insulin is responsible for adequate
metabolism of carbohydrates. As hyperglycemia is
the most common complication of TPN which is
due to high concentration of glucose.
• Heparin doses of 100 to300 unit / liter have been
routinely used to decrease the incidence of
subclavian vein thrombosis.
• Cimetedine can be added to the TPN solution as
prophylactic measure against development of
stress ulcer.
102. Methods of TPN administration
Peripheral parenteral nutrition:
• Indications:
• Patients in whom central venous access is
either impossible or contraindicated.
• Patients with fluid restrictions.
• Patients expected to resume enteral
feeding within 7 to 10 days.
103. Types of solutions administered
• Dextrose 5% and 10%.
• Crystalline amino acids
• Electrolyte, trace elements and vitamins.
• Fat emulsions
104. Advantages
• Avoids insertion and maintenance of central
catheter.
• Delivers less hypertonic solution than venous
TPN.
• Reduces the chance of metabolic complication
than central venous TPN
105. Disadvantages
• Can't be used in nutritionally depleted
patients.
• Does not generally increase a patient's weight.
• May cause phlebitis due to osmolarity of
solutions
106. Central parenteral nutrition
Indications:
• Large volume of fluids.
• High concentration and hyperosmolarity solutions.
Advantages:
• Useful for long term therapy (usually longer than 3
weeks).
• Useful for patients with large caloric &nutrient needs.
• Decrease the incidence of phlebitis.
• Examples:
• 8.5-10% amino acids.
• 50-70%dextrose
107.
108. Disadvantages:
• Requires a minor surgical to insert central line.
• May cause metabolic complication as glucose
intolerance, electrolyte imbalance and
essential fatty acid deficiency.
113. 3- Serious cavity problems
• Hydrothorax
• Cardiac tamponade
4- Metabolic
• As enteral feeding
• Respiratory distress (carbohydrate produces
carbon dioxide & water. In patients with
respiratory disease, the increase in Co2
production from the metabolism of the hypertonic
glucose solutions in TPN may not tolerated
115. Nursing considerations:
• Assess for sharp chest pain or decreased
breath sounds
• Assess the LOC, presence of
paralysis, seizures and tremors.
• Check for increased or decreased blood
pressure, decreased urinary
output, presence of fever, distended neck
veins, wheezes, edema, nausea or
vomiting, and diarrhea.
116. • Full aseptic precautions should be used
during any manipulation of any lumen of the
catheter, in line care, and in dressing
changes and solution preparation.
• Inspect insertion site q shift for potential
phlebitis.
• Inspect oral mucosa at least once daily for
signs of potential painful oral
mucosa, gingivitis and/or xerostomia
