NFSC 470 Seminar MNT Review of Clinical Nutrition

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NFSC 470Seminar MNT Review of Clinical Nutrition
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What are some signs/symptoms of dysphagia? What
labs might be affected?

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If dysphagia doesnt resolve and you must
recommend a tube feeding, where would you
recommend it be placed and why?

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What are your diet and lifestyle recommendations
for someone who has GERD?
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So for GERD

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What are the nutrition implications of chronic
gastritis? In other words, the absorption of
what vitamin might be affected, and this would
lead to what condition?

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What are the most common causes of gastric
ulcers? What recommendations would you give to
your patients with ulcers?

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The post-gastrectomy diet is designed to decrease
risk for dumping syndrome. What are the primary
tenets of this diet? 

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What are the signs of fat malabsorption? What
are the nutritional implications? What are your
dietary recommendations for someone with fat
malabsorption, in general??

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What are your recommendations for someone with
lactose intolerance?
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What is IBD? Name two forms.

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What are the nutritional recommendations for IBD?

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What are the dietary recommendations for
diverticulosis? Diverticulitis?

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Describe the nutrition recommendations for
someone with a colostomy or ileostomy.
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What are some causes of hepatic steatosis? What
are your nutrition recommendations?
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What are the biochemical indicators for hepatic
steatosis?
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Ascites is associated with what disease state?
What are the nutritional recommendations?
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Cirrhosis may cause steatorrhea. Why? Whats
the MNT?
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Would you expect a change in lab values for
someone with cirrhosis?
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What are the hallmark lab indicators of acute
pancreatitis? Hallmark symptoms?
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Why would pancreatitis cause steatorrhea?
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Whats the MNT for acute pancreatitis?
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For someone with acute pancreatitis who requires
a tube feeding, where should it be placed and
why?
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Tell me what could cause elevated blood glucose
levels.  
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Whats albumin and why do we look at it when
assessing nutritional status?
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What pair of lab values may indicate dehydration?
(Tell me which way theyd be off, either
elevated or depressed).
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What might cause low electrolyte values?
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What does it mean, in general, if someone has a
low Hgb and Hct?
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What does a high MCV mean, and what dietary
factors could cause it? 
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What are the two labs that (in general) together
indicate kidney disease?
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In renal failure, how would you expect the
following labs to change? (Indicate up, down, or
n/c for no change)

• ___BUN ___creatinine
• ___uric acid ___K (potassium)
• ___ PO4 (Phosphorus)
• ___ Hgb/Hct __albumin

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What is Hgb A1c and what does it indicate?
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What are the LDL goals for people with diabetes,
and why?
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What does GFR indicate?
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What are the dietary restrictions associated with
kidney failure? (pre-dialysis)
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Which one of these changes once dialysis is
initiated?
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List the desirable or optimal values

• Total cholesterol (for people age 30)
  ____________
• LDL cholesterol __________
• HDL cholesterol __________
• TG (triglycerides) __________
• Blood pressure ______________
• Fasting blood glucose (range) ____________
• Serum albumin ___________

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What type of dietary fiber helps reduce serum
cholesterol? How does it do it? What are some
good food sources?
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What is the DASH diet? For whom is it
appropriate? What are the main tenets of this
diet?
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What are the main tenets for the TLC diet?
(Therapeutic Lifestyle Changes)

• Nutrient
• Saturated fat
• Polyunsaturated fat
• Monounsaturated fat
• Total fat
• Carbohydrate
• Fiber
• Protein
• Cholesterol

• Recommended Intake

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Enteral Nutrition

• Indications
• Patient must have a functioning GI tract
• Malnourished patient expected to be unable to eat
  gt
• Normally nourished patient expected to be unable
  to eat gt
• (anorexia, comotose, head/neck surgery,
  hypermetabolic, adaptive phase of SBS, upper GI
  obstruction if TF can be placed beyond it)

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• Contraindications
• Intractable vomiting and/or diarrhea
• Intestinal obstruction, ileus, or bleed
• Early SBS
• Fistula
• Early short-bowel syndrome
• Pt. intolerance
• No enteral access/pt. refusal
• Pt. expected to eat within reasonable timeframe
• Aggressive therapy not warranted

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• Types of formulas
• Intact (Standard)
• Hydrolyzed (Elemental)
• Modular
• Kcals
• Standard
• Concentrated
• Osmolality

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• Routes of Administration
• NG
• ND
• NJ
• PEG
• PEJ

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Enteral Calculations

• Volume
• rate (ml/hr) x 24 hours ml total volume/day
• Kcals
• volume x kcal/ml kcals
• Protein
• g_ x volume (L) g prot/day
• L
• Water
• volume x free water (plus flushes) ml/day
• (Review Homework Problems)

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Parenteral Nutrition

• TPN Total Parenteral Nutrition
• Provision of nutrients intravenously
• Central
• Peripheral (PPN)
• For patients who are already malnourished or have
  the potential for developing malnutrition and who
  are not candidates for enteral nutrition

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• Indications for TPN
• NPO for extended period (gt10 days)
• Enteral nutrition support projected to be
  inadequate for gt14 days
• Extensive small bowel resections
• Radiation enteritis
• Intractable diarrhea/vomiting
• GI tract obstruction
• Severe acute pancreatitis
• Fistula

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• B. Contraindications
• 1. Patients for whom EN would meet
  requirements
• 2. Terminally ill patients.

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Routes for Parenteral NutritionCentral Venous
Access
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Routes for Parenteral NutritionCentral Venous
Access

• PICC Line
• Peripherally inserted central catheter
• Easier to insert than central line

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Peripheral Parenteral Nutrition (PPN)

• Utilization of peripheral veins for the
  administration of nutrients
• Indications for use
• Short term PN
• No access to central vein
• Malnourished pts with frequent NPO for
  procedures/tests

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• Contraindications
• Weak peripheral veins
• Fluid restrictions (i.e. kidney disease,
  congestive heart failure, etc.)
• Limitations
• Peripheral site more prone to inflammation/infecti
  on
• Fewer kcals administered
• Remember PPN solution needs to have
• lt10 dextrose to avoid phlebitis
• lipids q day to protect the vein

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Review of PN Solutions and Calculations
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• Intravenous Solutions
• Abbreviations
• D dextrose
• W water
• NS normal saline (0.9 sodium chloride
  solution)
• D5W
• D10W
• D50W
• D70W

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•   Calculations
• Dextrose
• AA
• Lipid
• 10 lipid provides
• 20 lipid provides
• Lipid can be infused separately or with dextrose
  and amino acid (admixture)

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• TPN Orders Several ways they can be written.
  Examples
• Per liter
• Example 500 ml 70 dextrose, 500 ml 15 AA _at_ 50
  ml per hour, plus 250 ml 20 lipid/d
• Final concentration
• Example 20 dextrose, 6 AA at 85 ml/hr plus
• 500 ml 10 lipid/d
• Per Day
• 960ml 8.5 Aas, 960ml D50W at 80ml/hr, plus
  250 ml 20 lipids q day

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• Example1 Figure out total kcalories and protein
  grams per day from this per liter order
• 500 ml 8.5 AA/L
• 500 ml D50W/L
• to be run_at_75ml/hr.
• plus 500ml 10 lipid

1 liter admixture
In this example, lipids are hung separately
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• Protein Grams (per 500 mL)
• Kcalories (per L)

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• Example 2
• Calculate total kcals and protein grams provided
  in this per-day formula
•  
• 960ml 8.5 AAs
• 960ml D50W
• to run _at_ 80ml/hr (X 24h 1920ml)
• plus 250 ml 20 lipids q day

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• D50W
•  
• 8.5 AAs
•  
• Lipids

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TPN Administration

• Rate
• Start slowly, especially w/dextrose. Allows
  blood to adapt to increased glucose/osmolality
• Infusion pump is used to ensure proper rate.
• Example Start at 40ml/hr x 24hr. Then progress
  to 80ml/hr x 24h (equivalent to increasing TPN by
  1 liter per day), etc. until goal rate has been
  reached or patient intolerance is noted.

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• a. If rate is increased too quickly,
  hyperglycemia may result
• b. Monitor tolerance electrolytes, blood
  glucose, triglycerides, ammonia, etc.
• 4. Introduce lipids gradually to avoid adverse
  reactions (fever, chills, backache, chest pain,
  allergic reactions, palpitations, rapid
  breathing, wheezing, cyanosis, nausea, and
  unpleasant taste in the mouth)
• 5. When pt. is taken off TPN, rate must be
  tapered off gradually to prevent hypoglycemia.
• 6. (? TPN by ½ X 2 hrs, then DC usually
  sufficient to prevent hypoglycemia)
• 7. PPN doesnt need to be tapered off (uses more
  dilute solution w/less dextrose)

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• Cyclic Infusion
• TPN infused at a constant rate for only lt24
  hours/day  (e.g. 12-14hr overnight)
• Allows more freedom/normal daytime activity
• Can be used to reverse fatty liver resulting from
  continuous infusion
• (Chronically high insulin levels may inhibit fat
  mobilization ? fatty liver)
• Fewer kcals may be necessary to maintain N
  balance (body fat better mobilized for energy)
• Requires higher infusion rate not all patients
  can tolerate it.

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Potential TPN Complications

• Catheter or Care-Related Complications
• Fluid in the chest (hydrothorax)
• Air or gas in the chest (pneumothorax)
• Blood in the chest (hemothorax)
• Sepsis
• Blood clot (thrombosis)
• Infusion pump malfunctions
• Myocardial or arterial puncture

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• B. Metabolic or Nutrition-related Complications
• Hyperglycemia/Hypoglycemia
• Dehydration/Fluid overload
• Electrolyte imbalances
• Hyperammonemia
• Acid-base imbalance
• Fatty liver
• Bone demineralization

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Transitional Feedings -- moving from parenteral
to enteral nutrition

• Begin oral diet while tapering off TPN

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• B. Tube feeding while tapering off TPN
• Rate of TF gradually increases as TPN rate
  decreases
• Remember that long term TPN without enteral
  nutrients ? atrophy of intestinal villi
• C. Discontinue TPN when oral/enteral intake
  provides
• Consider possible apprehension to begin oral
  intake
• Poor appetite possible at first
• Team members should provide support and
  reassurance