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NFSC 470 Seminar MNT Review of Clinical Nutrition. What are some signs/symptoms of dysphagia? What labs might be affected?. If dysphagia doesn’t resolve and you must recommend a tube feeding, where would you recommend it be placed and why?.

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slide3
If dysphagia doesn’t resolve and you must recommend a tube feeding, where would you recommend it be placed and why?
slide7

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?

slide8
What are the most common causes of gastric ulcers? What recommendations would you give to your patients with ulcers?
slide9
The post-gastrectomy diet is designed to decrease risk for dumping syndrome. What are the primary tenets of this diet?
slide10

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

for someone with acute pancreatitis who requires a tube feeding where should it be placed and why
For someone with acute pancreatitis who requires a tube feeding, where should it be placed and why?
slide27
What pair of lab values may indicate dehydration? (Tell me which way they’d be off, either elevated or depressed).
slide32
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

list the desirable or optimal values
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 ___________
slide39
What type of dietary fiber helps reduce serum cholesterol? How does it do it? What are some good food sources?
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

What are the main tenets for the TLC diet? (Therapeutic Lifestyle Changes)
enteral nutrition
Enteral Nutrition
  • Indications
    • Patient must have a functioning GI tract
    • Malnourished patient expected to be unable to eat >
    • Normally nourished patient expected to be unable to eat >
    • (anorexia, comotose, head/neck surgery, hypermetabolic, adaptive phase of SBS, upper GI obstruction if TF can be placed beyond it)
slide43
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
slide44
Types of formulas
    • Intact (Standard)
    • Hydrolyzed (Elemental)
    • Modular
  • Kcals:
    • Standard
    • Concentrated
  • Osmolality
enteral calculations
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)

parenteral nutrition
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
slide49
Indications for TPN
  • NPO for extended period (>10 days)
  • Enteral nutrition support projected to be inadequate for >14 days
  • Extensive small bowel resections
  • Radiation enteritis
  • Intractable diarrhea/vomiting
  • GI tract obstruction
  • Severe acute pancreatitis
  • Fistula
slide50
B. Contraindications

1. Patients for whom EN would meet requirements

2. Terminally ill patients.

routes for parenteral nutrition central venous access52
Routes for Parenteral NutritionCentral Venous Access
  • PICC Line
    • Peripherally inserted central catheter
      • Easier to insert than central line
peripheral parenteral nutrition ppn
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
slide55
Contraindications:
  • Weak peripheral veins
  • Fluid restrictions (i.e. kidney disease, congestive heart failure, etc.)

Limitations

Peripheral site more prone to inflammation/infection

Fewer kcals administered

Remember: PPN solution needs to have:

  • <10% [dextrose] to avoid phlebitis
  • lipids q day to protect the vein
slide57
Intravenous Solutions

Abbreviations:

D: dextrose

W: water

NS: normal saline (0.9% sodium chloride solution)

D5W:

D10W:

D50W:

D70W:

slide58
  Calculations
  • Dextrose =
  • AA =
  • Lipid
    • 10% lipid provides
    • 20% lipid provides
    • Lipid can be infused separately or with dextrose and amino acid (admixture)
slide59
TPN Orders – Several ways they can be written. Examples:
    • Per liter
      • Example: 500 ml 70% dextrose, 500 ml 15% AA @ 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
slide60
Example1: Figure out total kcalories and protein gramsper day from this per liter order:

500 ml 8.5% AA/L

500 ml D50W/L

to be run@75ml/hr.

plus 500ml 10% lipid

= 1 liter ‘admixture’

In this example, lipids are hung separately

slide61
Protein Grams (per 500 mL):

Kcalories (per L):

slide63
Example 2:

Calculate total kcals and protein grams provided in this per-day formula

960ml 8.5% AAs

960ml D50W

to run @ 80ml/hr (X 24h = 1920ml)

plus 250 ml 20% lipids q day

slide64
D50W:

8.5% AAs:

Lipids:

tpn administration
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.
slide66
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 doesn’t need to be tapered off (uses more dilute solution w/less dextrose)

slide67
Cyclic Infusion
    • TPN infused at a constant rate for only <24 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.
potential tpn complications
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
slide69
B. Metabolic or Nutrition-related Complications
  • Hyperglycemia/Hypoglycemia
  • Dehydration/Fluid overload
  • Electrolyte imbalances
  • Hyperammonemia
  • Acid-base imbalance
  • Fatty liver
  • Bone demineralization
transitional feedings moving from parenteral to enteral nutrition
Transitional Feedings -- moving from parenteral to enteral nutrition
  • Begin oral diet while tapering off TPN
slide71
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