KNH 411

Oral diets
 “House” or regular diet
 Therapeutic diets
 Maintain or restore health & nutritional status
 Accommodate changes in digestion, absorption, or organ function
 Provide nutrition therapy through nutrient content changes

Oral diets
 Changes from the house diet
 Caloric level
 Consistency
 Single nutrient manipulation
 Preparation
 Food restriction
 Number, size, frequency of meals
 Addition of supplements

Oral diets
 Texture modifications
 Soft diets
 Liquid diets
 Clear liquid
 Full liquid
 Consider osmolality
 Preparation for a specific medical test

Oral Supplements
 Goal: Increase nutrient density without increasing volume
 Snacks
 Liquid meal replacement formulas
 Modular products
 Commercial supplements

Appetite Stimulants
 Drugs that stimulate appetite
 Prednisone
 Megestrol acetate
 Dronabinol
 Marijauna may help as well
 For cancer patients

 Administration of nutrients with therapeutic intent
 Enteral
 Being first method
 If the gut works use it!
 Parenteral
 Ethical considerations

© 2007 Thomson - Wadsworth

Enteral Nutrition
 Feeding through the GI tract via tube, catheter or stoma delivering nutrients distal to oral cavity
 “Tube feeding”
 Indicated for patients with functioning GI but unable to self-feed
 Contraindications
 Advantages / Disadvantages?

Enteral Nutrition
 Decisions for the nutrition prescription
 GI access
 Formula
 Feeding technique
 Equipment needed

Enteral Nutrition
 GI Access
• Access route described by where it enters the body and where the tip is located
 Nasogastric: patient can talk
 Orogastric
 Nasointestinal: basically going for the nose to the duodenum to the jejunum
 Typically used for short term
 Disadvantages?

Enteral Nutrition
 GI Access
• – “Ostomy”
 Gastrostomy
 Jejunostomy
 PEG
• More permanent

© 2007 Thomson - Wadsworth

Enteral Nutrition
 Formulas
 Based on substrates, nutrient density, osmolality, viscosity
 Protein
 Soy or casein 10-25% kcal
 Elemental or chemically defined
 Specialized amino acid profiles

Enteral Nutrition
 Formulas
 Carbohydrate
 Monosaccharides, oligosaccarides, dextrins, maltodextrins
 Lactose & sucrose free
 FOS
 Fiber ?

Enteral Nutrition
 Formulas
 Lipid
 Corn or soy oil
 Long- and medium-chain TG
 Omega-3 fatty acids
 Structured lipids

Enteral Nutrition
 Formulas
 Vitamins and minerals
 Meet DRI
 Supplemental amounts
 Fluid and nutrient density
 1.0-2.0 kcal per mL
 Difference depends on water content
 Ensure adequate fluid - 80% water for 1 kcal per mL
 Osmolality and osmolarity

Enteral Nutrition
 Formulas

 Considered medical food – not drug

 Cost

© 2007 Thomson - Wadsworth

Enteral Nutrition
 Feeding techniques/ delivery methods
 Bolus feedings
 Intermittent feedings
 Continuous feedings
© 2007 Thomson - Wadsworth

Enteral Nutrition
 Equipment
 Feeding tubes - french size
 Cans or sealed containers
 Pumps

Enteral Nutrition
 Determining the nutrition prescription
- clinical application

Enteral Nutrition
 Complications
 Mechanical complications
 Clogged or misplaced tubes
 GI complications
 Diarrhea
 Aspiration
 Refluxing some of the formula

Enteral Nutrition
 Monitoring for complications
 Dehydration
 Tube Feeding Syndrome
 Loosing of ccs of fluid via dehydratio
 Electrolyte Imbalances
 Underfeeding or Overfeeding
 Hyperglycemia
 Increase glucose increased triglycerides increased LFTS
 Refeeding Syndrome
 Monitor serum phosphorus, mg, potassium

Parenteral Nutrition
 Administration by “vein”
 a.k.a. – PN, TPN, CVN, IVH
 TPN vs. PPN
 Indicated if unable to use oral diet or enteral nutrition
 Certification of medical necessity

Parenteral Nutrition
 Venous access
 Short-term access
 CVC inserted percutaneously
 Most common and can be placed at bedside with local anesthia
 Using subclavian, jugular, femoral veins
 PICC
 Long-term access—requires surgery and can not be done at bedside
 Tunneled catheters
 Lie completely below the skin
 Implantable ports

© 2007 Thomson - Wadsworth

Parenteral Nutrition
 Solutions
 Compounded by pharmacist using “clean room”
 Two-in-one
 Dextrose & amino acids
 Lipids added separately- piggy back seperately
 Clear - easier to identify precipitates
 Three-in-one
 Dextrose, amino acids & lipids
 Single administration

Parenteral Nutrition
 Solutions
 Protein
 Individual amino acids
 Modified products for renal, hepatic and stress
 Commercial amino acids 3.5-20%
 .8- 1.8 g/kg depending on condition

Parenteral Nutrition
 Solutions
 Carbohydrates
 Energy source – dextrose monohydrate
 3.4 kcal/g
 1 mg/kg/min minimum
 5%, 10%, 50%, 70% concentrations

Parenteral Nutrition
 Solutions
 Lipids
 Emulsion of soybean or safflower oil
 Essential fatty acids
 Source of energy
 Minimum of 10% kcal

Parenteral Nutrition
 Solutions
 Electrolytes
 DRI standards used
 Vitamins/Minerals
 Trace minerals
 Medications

© 2007 Thomson - Wadsworth

Parenteral Nutrition
 Determining the nutrition prescription
– clinical application
- sample form

Parenteral Nutrition
 Administration techniques
 Initiate 1 L first day; increase to goal volume on day 2
 Patient monitoring
 Intake vs. output
 Laboratory monitoring

Parenteral Nutrition
 Complications
 GI complications
 Infections