• For nurses providing holistic comprehensive
care for neuroscience patients, meeting
nutritional needs is a critical component in
the recovery process that requires an
appropriate knowledge base.
• Injury, physiological dysfunction and stress
often change the basic requirement and use
of nutrients and water for energy, cellular
function and repair of injured tissue.
• Additionally a patient with
neurological condition may have
deficits, such as an altered level of
consciousness or paralysis of the
muscles for chewing and swallowing
which further complicates ingestion
BASIC NUTRITIONAL REQUIREMENTS
• The RDA describes target intake levels
of essential nutrients for healthy people.
• Nutrient requirement includes
macronutrients and micronutrients.
• It is important to keep in mind that the
RDA cannot be relied onto precisely
calculate the need of patients who are
ill, especially if malabsorption is
• A nutritional assessment includes a
thorough history, physical examination
and laboratory studies.
• The RD assumes responsibility for
conducting the nutritional assessment ,
estimating nutritional requirement and
recommending a nutritional support plan
• The nurse implements
the nutritional plan of care
provide education to patients and
monitors both response to therapy and
implementation include safe
administration of nutrients by oral ,
enteral or o occasion , parenteral route.
COMPONENTS OF THREE
Recent weight loss
Anorexia , nausea , vomiting
This can be collected from medical
record, family member or the patient.
• Skin; turgor ,dryness, oedema, bruising
, scaling , dermatitis , seborrhoea
• Mucous membrane;
dryness, colour, bruising , especially
• Tongue; swelling , papillary atrophy
• Eyes; pale or dry conjunctiva , sunken
• Hair; dull looking hair or hair loss.
• Muscle; atrophy, wasting.
• Height and weight
• Anthropometric measurement such as
skin fold thickness and midarm
muscle circumference are not useful
in critically ill patients because of
frequent presence of fluid retention
and oedema. it is more useful in less
severely ill patients.
BLOOD AND URINE CHEMISTRIES
• Serum albumin ; index of nutritional
status , it has a long half life of
approximately 18 days and is a poor
marker of the effects of short term
feeding in hospitalized patients.
• Transferrin; half life of 8-10 days is
also frequently mentioned but is not
very helpful with critically ill patients.
• Nitrogen; represents the end product
of protein metabolism . nitrogen
balance studies such as 24 hrs urinary
urea nitrogen collection , compare
nitrogen intake with nitrogen
excretion to determine nitrogen
balance. A negative balance reflects
• The goal of nutritional support is a
positive nitrogen balance
TESTS OF THE IMMUNE SYSTEM
TOTAL CIRCULATNG LYMPHOCYTE
• Most circulating lymphocytes are T
cells . it’s a general indication for
• Infection and immunosuppressant
drug alter the number of circulating
lymphocytes and thus are not helpful
in critically ill patients.
Delayed cutaneous hypersensitivity
• This test is also not helpful in
critically ill, malnourished patients
because of decreased cellular
• When patient fails to react to any of
the several skin test antigens used
and are described as ‘anergic’.
FOLLOWING INJURY AND
• The key difference is that in critical
illness there is an increase in the
basal metabolic rate , glucose use and
• Starved stressed patients do not
readily mobilize stored fats.
Difference in early metabolic
responses to fasting and injury
Metabolic activity Simple starvation Starvation superimposed
on to injury or stress
Basal metabolic rate decreased BMR Decreased or normal BMR
Glucose levels Low High
Glucose utilizations Limited glucose use Increased glucose use
Gluconeogenesis increase Gluconeogenesis
initially ,Decrease after 5-7
Protein catabolism Low High
Fat catabolism High Low/ none
Ketone utilization Increased ketone use Decreased ketone use
Ketosis Present Absent
ketosuria Present Absent
• It is important because there are serious
adverse effects from both overfeeding and
• Overfeeding with high glucose infusion can
lead to hyperglycemias, hypokalemia,
oedema, a fatty liver degeneration and an
increased risk of nosocomial infection.
Overfeeding also increases the carbon
dioxide production which may lead to
difficulty weaning from ventilator.
ESTIMATING TOTAL DAILY
Factors necessary to calculate TDRs
• Calculation of basal metabolic rate (
• Energy expenditure during activity
• The thermogenic effect of food
• The following formula is useful
for calculation of TDR
DIRECT METHOD OF
• Harris- Benedict equation
• BMR(men) = 66 + ( 13.7 W ) + ( 5 H ) - (
6.8 A )
• BMR(women)= 665 + ( 9.6 W ) + ( 1.8 H )
- ( 4.7 A )
• W= weight in kilograms
• H= height in centimetres
• A= age in years
• The EEA provides a correction factor
based on the patients expenditure of
energy. Each 1 C increase in body
temperature increases the metabolic
rate by approximately 5-10%.
EEA correction factor on account to
Clinical condition Correction factor
Out of bed 1.3
Confined to bed 1.2
Fever 1+ 0.13 per degree ,C.
Multiple fractures 1.2- 1.4
Soft tissue trauma 1.14- 1.37
Sepsis 1.4- 1.8
Minor surgery 1.1.2
Starvation in adult 0.70
CALCULATING TER OF FOOD
• The increase in metabolic rate following
eating is about 5-10%of the daily energy
expenditure . the TER is difficult to
assess in the hospitalized patients.
Therefor using indirect calorimeter
during or shortly after feeding infusion
eliminates the need to estimate TER.
FORMULAS FOR ESTIMATING
REE IN HOSPITALIZD PATIENTS
• Equation has been developed for both the
ventilator dependent and spontaneously breathing
• After the REE has been calculated a correction
factor for activity is made.
• Hospitalized patients who are severly catabolic
or malnourished or those with high fever or sepsis
require an increases to the REE of 20% to 25%.
• Care should be taken to prevent overestimating
total energy needs to prevent overfeeding
• For ventilator dependent patients ,
• REE = 1925 - 10(A) +5(W) +281 (S)
+292 (T) +851(B)
• For spontaneously breathing patients
• REE= 629 – 11 ( A ) + 25 ( W ) - 605
• A= age
• W= body weight in kg
• S= sex (male = 1 , female = 2 )
• T = trauma ( present =1, absent = 0)
• B= burns ( present =1, absent = 0)
• O= obesity ( present =1, absent = 0)
INDIRECT METHOD OF
• Indirect calorimeter (metabolic cart)
• This method measures oxygen uptake
(Vo2 ) and carbon dioxide uptake
(Vco2 ) at the mouth .
• The equipment used include an open
circuit method with a set of one way
valves to direct expired air into a
• At the end of the collection time both the
volume and the composition of the expired air
are measured and the rate of the oxygen
consumption and the carbon dioxide
production is calculated by the difference
between the concentration of the inspired air
and the gas collected.
• The data from indirect calorimetry include
measurement of Vo2 and Vco2 for 15- 20 min .
• An estimate of REE and respiratory quotient
(RQ) can be calculated and extrapolated to 24
• RQ= Vco2/ Vo2
• RQ reflects whole body substrate utilization and
varies between 0.70 and 1.2 . an RQ grater than
1.0 is an indication of excessive carbohydrate
calories resulting in fat synthesis which leads to
high carbohydrate production , a situation to be
• Advantages are its accuracy and ability to be used
with ventilated patients .
• Disadvantages include the need for special
equipment , skilled personnel , increased cost,
inaccuracy when the inspired FiO2 is > 0.40 .
• Does the patient need nutritional support?
• If so , what are the energy and protein
requirement for this patient ?
• What route of administration should be
• If enteral feeding is used , where should
the tube be placed?
• When should the feeding begin ?
• What feeding should be given ?
• Those expected to receive nothing by
mouth for more than 7- 10 days .
• Those with hypermetabolic states ) sepis ,
• Those with pre-existing
• In neuroscience population – comatose,
multitrauma , septic patients
PROVIDING ADEQUATE ENERGY
AND PROTEIN REQUIREMENT
• BMR for more hospitalized patients is 2,100
k cal if the patient do not exceed 200 Ib
• Even with correction factors for fever and
sepsis ,patients total energy requirement are
usually less than 3000 k cal/day.
• A general rule of thumb for caloric require
ment for seriously ill patient is 25-35
kcla/kg/day of ideal body weight and 1.5
g/kg/day for protein
ROUTE OF ADMINISTRATION
• Enteral feeding rather than parenteral nutrition
is clearly the prefferd route of administering
• Nutrients to the intestinal lumen protect the
iintefrity of the GI tract. They preserve optimal
gut function , maintain the gut barrier from
translocation of microorganism and support
gut associated immune system IgA secretion.
• Enteral nutrition is safer , more convenient and
less expensive than parenteral nutrition.
FEEDING TUBES AND SITE OF
• When there is an intact intestinal
tract 3 POSSIBILITIES EXIST FOR
delivering food into the alimentary
• Oral feeding is always the preferred method of
nutritional support . however in many
hospitalized neurological patients this is not
possible for a number of reasons , for coma ,
high risk for aspiration and multitrauma. In
that case temporary oral – gastric or
nasogastric tube into the stomach or naso
duodenal tube into the duodenum are
available. For neuroscience patients with a
basal skull fracture, facial fracture or leakage
of CSF-insertion of a tube nasally is
• Enteral feeding should not be delayed
to establish small bowel access.most
patients are able to tolerate some
gastric feeding early in the course of
illness. The need for prolonged tube
feeding is an indication for a simple
surgical procedure whereby a
gastrotomy or jejunostomy tube is
sutured into position on the
• Another enteral tube placement
option for long term feeding is
gastrostomy (PEG) it involves a
placement of a 16-18 gauge latex or
silicon catheter through the
abdominal wall directly into the
stomach using an endoscopic
• Early nutritional support within 12-
48 hours blunts the hypercatabolic
state and sepsis related to serious
• After insertion of a nasogastric or
nasoduodenal tube feedings are not
begun until an x-ray film of the
abdomen confirms appropriate GI
• Feeding should be started at 25-30 ml/hr
and increased by 10-25ml/hr every 1-4
hrs as tolerated until the caloric (25
kcal/kg/day)goal is achieved.
• Tolerance is evaluated by measurement of
gastric residuals (less than 200 ml) and
presence of abdominal distension,
vomiting, diarrhoea. If the gastric
residual is grater than 220ml , the feeding
is held for 2 hrs and then resumed.
• Feeding can be increased at a slower
rate ,but this is often not necessary
and delays achievement of the caloric
• The goal rate should be achieved by
the 3rd day of the therapy,if not
earlier. Feeding can be administered
intermittently a few times a day or
continuously with a food pump.
SELETION OF FEEDING FORMULA
description Brand names and
Standard Complete formulas that provide
macronutrients and micronutrients RDA.
Provide 1.0 1.2 kcal /ml
First choice for most patients.
High protein Have a higher protein /nitrogen and a ratio
of nonprotein calories to nitrogen of <130
:1, but >110:1
For those patients who are severely
catabolic and protein deficient , such as
severe trauma or patients with large or
poorly healing wounds .
Isocal HCN and
Similarto high protein , but with a lower
ratio of nonprotein calories to nitrogen of
Disease specific Intact protein designed specifically to
meet the protein , electrolyte and glucose
limitation of specific disease.
With fiber Thee formulas produce more fecal residue
that increases stool bulk .
For patients with constipation and
Elemental Calories aare supplied primarily as free
amino acids and oligosaccharides .
For patients with decreased ability to
digest and absorb standard formulas.
Caloric density >1.2kcal/ml
Useful when fluid overload is a problem
such as ascites, renal failure, congestive
Ensure plus, ensure
plus HN and
PROBLEMS ASSOCIATED WITH
The major problems are;
• related to starvation , depletion of protein
stores delayed wound healing high risk for
skin breakdown , high risk for nosocomial
infection , respiratory muscle weakness and
ventilator dependency, increased mortality and
• Causes are multifactorial and delay in
initiating feeding is common.
• Diarrhoea, vomiting, GI tract dysfunction and
electrolyte imbalance are problems which
interfere with adequate nutritional support in
patient receiving enteral feeding.
• Related to complication such as
hyperglycemia, azotemia, hypertonic
dehydration, electrolyte imbalance,
edema, metabolic acidosis, hypercapnia,
hyperlipidemia , hepatic stenosis ,
refeeding syndrome and an increased
risk of nosocomial infection
• Causes are overestimating daily caloric
• The potential problems are diarrhoea,
vomiting, gastric distension,
imbalance, other disease related
intolerance, migrating feeding tube,
refeeding syndrome, catheter
• The size and location of feeding tube
, as well as the specific drug must be
• The diameter of the tube is important
. the smaller the diameter tube the
more likely is to become clogged .
Drug administration guidelines
• Use liquid preparation of a drug, if available.
Crushing or dissolving of tablets is
discouraged, if absolutely necessary , dissolve
in at least 10 – 15 ml of water.
• Hard gelatinous casule should be oened and
dissolved in at least 10 – 15 ml of water
• Drugs irritating to the gi tract should be
dissolved in large amount of water before
• Do not add drugs to the enteral feeding
• Stop the feeding before administering the
• Flush the feeding tube with water to remove
residual formula before administering the
• Flush the feeding tube with 10-30 ml of water
after administering the drug.
• For patients on an intermittent gastric feeding
schedule , adjust the timing of medication of
the feeding schedule according to the need for
drug delivery on a full or empty stomach.
Drug with special administration
requirements with enteral feeding
• Patients receiving phenytoin and receiving
continuous feeding require increased doses of
phenytoin to maintain therapeutic level
because it binds to protein resulting in
decreased absorption of the drug.
• carbamazepine suspension is another
commonly prescribed anticonvulsant drug
.dilute the suspensions so that it will not
adhere to the walls of the feeding tube .
• Flush well after the administration.
Monitoring patients receiving
• Renal function
• Liver function
• Other chemistries; glucose
• Other laboratory data; calcium,
phosphorus , magnesium, albumin,
prealbumin triglycerides , cholesterol
baseline and as indicated .
• The nurses role ; meeting the
nutritional needs of a patients;
• The nurse begins with conducting a
nutritional assessment to establish a
baseline and plan of care.
• Based on a nutritional assessment, various
collaborative problems and nursing diagnosis can
• Because of the complexity of neurological illness
that impacts on the nutritional goal, several
potential collaborative problems must be kept in
mind, they include starvation, paralytic ileus,
hypoglycaemia, hyperglycemias, negative
nitrogen balance, electrolyte imbalance, sepsis ,
aspiration I pneumonia,.
• Other problems may be added, such as renal or
hepatic failure based on complication that occur
as a result of neurological insult.
The following nursing diagnosis are
often identified for the patient with
problems related to nutritional needs
• impaired nutrition more than body
• impaired nutrition less than body requirement
• risk for deficit fluid volume
• risk for excess fluid volume
• impaired swallowing
• risk for aspiration
• The nurse can monitor the patients nutritional
status with the following parameters
• Once stabilized , weigh the patients twice a
week on designated days and note trends in
stability of weight.
• Observe skin turgor, the condition of the
tongue and mucous membranes, muscle tone
and muscle bulk daily for evidence of
• Record and monitor intake and output
and daily balance .
• Maintain a calorie count with the help of
the clinical dietician.
• Monitor tolerance to oral or enteral
feeding , use as base for process of
feeding to caloric goal.
• Monitor appropriate laboratory data ,
electrolyte , glucose, prealbumin,
• Enteral feeding may be administered in one of
two ways; continuously with the use of a food
um or intermittently with the use of a gavage
• Check the position of the tube to be sure it has
• If the patient has a tracheotomy tube in lace
deflate the cough; keep it deflated for one hr
after completion of the feeding. The purpose of
this action is to prevent aspiration
• Addition of a few drops of blue food
colouring into the feeding is often
recommended as a way to assess
pulmonary aspiration of enteral
formula in incubated patients .
• Follow hospital recommendation.
• If used, observe the tracheal
secretion to note blue discolouration
a an indication of aspiration .
• New studies have been undertaken to fill
the multiple gaping knowledge and to
clarify areas of controversy. For nurses
providing holistic comprehensive care for
neuroscience patients, meeting nutritional
needs is a critical component in the
recovery process that requires an
appropriate knowledge base.