NUTRITION

FOOD SOURCES OF CARBOHYDRATES = 4 cal/g

CELLULOSE FRUCTOSE GLUCOSE LACTOSE STARCH SUCROSE
Apples Fruits Carrots Milk Barley Apricots
Beans Honey Corn Beets, Granulated
carrots and table sugar
peas
Bran Dates Corn Honeydew &
cantaloupe
Cabbage Grapes Oats Molasses
Oranges Potatoes Peaches
Pasta Peas and corn
Rye Plums
Wheat

FOOD SOURCES OF FATS = 9 cal/g

CHOLESTEROL MONOUNSATURATED POLYUNSATURATED SATURATED
FATS FATS FATS
Animal Products Ducks and goose Corn oil Beef
Egg yolks Eggs Safflower oil Butter
Liver and organ Olive and peanut oils Sunflower oil Hard yellow
meats cheeses
Luncheon
meats

FOOD SOURCES OF PROTEIN = 4 cal/g

Bread and cereal products
Dairy products
Dried beans
Meat

FOOD SOURCES OF VITAMINS

WATER SOLUBLE
FOLIC NIACIN Vitamin B1 Vitamin B2 Vitamin B6 Vitamin Vitamin
ACID (Thiamine) (Riboflavin) (Pyridoxine) B12 C
(Cobalami (Ascorbic
n) Acid)
Green Meats Pork and Milk Yeast Meat Citrus
leafy nuts fruits
vegetables
Liver Poultry Whole Lean meats Corn Liver Tomatoes
grain
cereals
Beef Fish Legumes Fish Meat Broccoli
Fish Beans Grains Poultry Cabbage
Legumes Peanuts Fish
Grapefruit Grains
Oranges

 Not stored in the body; excreted in the urine

 Vit. C – production of collagen = wound healing

1
 FOOD SOURCES OF VITAMINS
FAT SOLUBLE
Vitamin A Vitamin D Vitamin E Vitamin K
Liver Fortified milk Vegetable oils Green leafy
vegetables
Egg yolk Fish oils Green leafy Cauliflower
vegetables
Whole milk Cereals Cereals Cabbage
Green or orange Apricots
vegetables
fruits Apples
Peaches

 Stored in the body, excess leads to toxicity

 Vit. K – catalyst for blood clotting factors (Prothrombin)
 Vit. A – eyesight and epithelial linings.

FOOD SOURCES OF MINERALS

CALCIUM CHLORIDE MAGNESIUM PHOSPHORUS
Broccoli Salt Avocado Fish
Carrots Canned White tuna Nuts
Cheese Cauliflower Organ meats
Collard greens Cooked rolled oats Pork, beef, chicken
Green Beans Green leafy veggies Whole grain bread and
cereals
Milk Low-fat yogurt
Rhubarb Milk
Spinach Peanut butter
Tofu Peas
Yogurt Pork, beef, chicken
Potatoes
Raisins

POTASSIUM SODIUM IRON ZINC

Avocado American cheese Bread and cereals Egg
Bananas Bacon Dark green veggies Leafy veggies
Cantaloupe Butter Egg yolk Meats
Carrots Canned Food Liver Protein-rich foods
Fish Cottage cheese Meats
Mushrooms Cured pork
Oranges Frankfurters
Pork, beef, veal Ketchup
Potatoes Lunch Meat
Raisins Milk
Spinach Mustard
Strawberries Processed food
Tomatoes Snack food
Soy Sauce
Table Salt
White and whole wheat
bread

 Catalyst for chemical reaction and enhances cell function.

FOOD GUIDE PYRAMID

2
 Peak
Fats, Oils
& Sweets
Use Sparingly

3. Milk, Yogurt, 3. Meat, Poultry, Fish

& Cheese Dry Beans, Eggs,
Group & Nuts Group
2-3 servings 2-3 servings

2. Vegetable 2. Fruit
Group Group
3-5 servings 2-4 servings

1. Bread, Cereal, Rice & Pasta Group

6-11 servings

 Six broad families of food foods

THERAPEUTIC DIETS

1. CLEAR LIQUID
Indications Nsg Consideration
Primary fx: provide F & E to prevent Not use more than 1-2 days
dehydration
Initial feeding after complete bowel rest Transparent to light and liquid at room or
body temp.
Initially to feed malnourished or Dairy products are not allowed
not had any oral intake for some time
Use for bowel prep for surgery or test
Post-op diet
Diarrhea
water carbonated beverages lemonade regular or decaf coffee
bouillon gelatin popsicles tea
clear broth hard candy

2. FULL LIQUID
Indications Nsg Consideration
2nd diet after clear liquid ff. a surgery Clear and opaque liquid foods
Unable to chew or swallow Liquefy at body temp
plain ice cream breakfast drinks pudding soups that are strained
sherbet milk custard strained veggie juices

3. SOFT DIET
Indications Nsg Consideration

3
Dental problems, poor fitting dentures W/ mouth sores serve at cooler temp.
Difficulty chewing and swallowing Reduced flow of saliva encourage to suck
sour candy
Ulceration of mouth or gums Provide plenty of fluids
Oral surgery, broken jaw Use straw
Plastic surgery of head or neck Liquid, chopped and pureed foods are best
tolerated
Dysphasia, stroke
Impaired digestion and absorption
= ulcerative colitis and Crohn’s dse.
Avoid foods:
with nuts or seeds raw fruits and veggies fried foods whole grains

4. BLAND DIET
Indications Nsg Consideration
Gastritis Less likely to form gas
Ulcers Eliminate foods that stimulate gastric acid
secretions & irritating to gastric mucosa
Reflux esophagitis
GI disorders
CHF
MI
Avoid:
alcohol cola tea pepper
caffeine cocoa fried foods spicy foods

5. LOW-RESIDUE/ LOW-FIBER DIET

Indications Nsg Consideration
Narrowed, inflammed, scarred GI tract dairy products limited to 2 servings/ day
Slow GI motility
Inflammatory bowel dse
Partial obstruction of GI tract
Enteritis
Diarrhea
GI disorders
CHO residue:
white bread cereals pasta
Avoid:
raw fruits except veggies seeds plant fiber whole grains
banana

6. HIGH-RESIDUE/ HIGH -FIBER DIET

Indications Nsg Consideration
Constipation Provides 20-25 g of dietary fiber daily
Irritable bowel syndrome: alternating consti Speeds mov’t of undigested materials thru
& diarrhea and asymptomatic diverticular dse intestine
DM: regulate blood glucose Adds volume and weight to stool
Heart dse: control blood cholesterol
fruits vegetables whole grain
7. FAT-CONTROLLED DIET
Indications Nsg Consideration

4
Atherosclerosis Limit total amount of fats:
DM mono, poly and saturated fats
Hyperlipidemia cholesterol
HPN and MI
Nephrotic syndrome and renal failure
Reduce risk of heart dse

8. HIGH-CALORIE DIET
Indications Nsg Consideration
Severe stress CHON – to build or maintain lean body mass
Burns Add fats, nuts, dried fruits: raisins & cereals
HIV-AIDS Sugar and high calorie desserts
COPD, respiratory failure Snacks in between meals: milkshakes and
instant breakfast
Debilitating dse

9. SODIUM-RESTRICTION DIET
Indications Nsg Consideration
HPN Mild restriction: 2T-4T mg Na/day
CHF Moderate restriction: 1T mg Na/day
Kidney dse Strict & seldom prescribed: 500 mg Na/day
Cardiac dse
Liver cirrhosis
Cereals allowed:
Dried or instant cereals Puffed wheat Puffed rice Shredded wheat
Na-free Spices and Flavorings
Allspice Caraway seeds Garlic (powder) Marjoram
Almond extract Cinnamon Ginger Mustard powder
Bay leaves Curry powder Lemon/Maple extract Nutmeg

10. PROTEIN-RESTRICTION DIET

Indications Nsg Consideration
Acute renal failure 40-60 g CHON/day
Chronic Renal Dse High quality CHON
Liver cirrhosis CHO provide added energy
Hepatic coma Veggies and fruits contain some protein
Special Low CHON products:
pasta bread cookies wafer Gelatin from wheat starch
Limit:
milk meat bread starch exchange

11. HIGH PROTEIN DIET

Indications Nsg Consideration
Tissue building - burns To correct CHON loss or assist tissue repair
Liver dse May need CHON supplements
Older clients
meat fish fowl dairy products

5
12. LOW CALCIUM DIET
Indications Nsg Consideration
Prevent renal calculi Ca intake
Avoid:
Whole grains Milk and dairy products Green leafy veggies

13. HIGH CALCIUM DIET

Indications Nsg Consideration
Bone growth Primary Ca dietary sources: dairy products
Osteoporosis in adulthood W/ lactose intolerance= incorporate other
sources than dairy products

14. LOW PURINE DIET

Indications Nsg Consideration
Treat gout Purine-precursor to uric acid: forms stones
and crystals
Avoid fish:
anchovies herring mackerel sardines scallops
glandular meat gravies meat extracts wild game goose sweet bread

15. HIGH IRON DIET

Indications Nsg Consideration
Anemia Fe dietary intake
organ meats eggyolk leafy veggies legumes
meat whole wheat products dried fruits

16. DIET FOR DIVERTICUALR DISEASE

Indications Nsg Consideration
Symptomatic diverticulitis = avoid fiber to Liberal fluid intake: 2500-3T mL/day unless
avoid bowel irritation contraindicated
Asymptomatic diverticular dse = fiber to Avoid seeds & nuts: trap in diverticula and
avoid constipation cause irritation
Avoid Gas-Forming Foods:
Apples Brussels sprouts Figs Onions
Artichokes Cabbage Honey Radishes
Barley Celery Melons Soybeans
Beans Cherries Milk Wheat
Bran Coconuts Molasses Yeast
Broccoli Eggplant Nuts

17. FLUID RESTRICTION

Indications
Acute renal failure – oliguric phase Liver cirrhosis CHF
Chronic renal disease Hepatic coma Cardiac disorders
Restrict:
carbonated bev. milk frozen yogurt ice milk soup
coffee tea gelatin popsicles cream
juice water Ice cream sherbet liquid meds

6
 MEASURES TO RELIEVE THIRST
Chew gum or suck hard candy Add lemon juice to water - more refreshing
Freeze fluid so they take longer to consume Gargle with refrigerated mouthwash

18. CARBOHYDRATE CONTROLLED DIET

Indications Nsg Consideration
Maintain normal glucose level Exchange System for Meal Planning -
DM guide to control DM & manage weight
Hypoglycemia grp foods accdg to: CHO, Fats & CHON
Lactose intolerance Major food groups:
Galactosemia CHO grp
Dumping syndrome Meat & meat substitute grp
Obesity Fat grp

19. MISCELLANEOUS DIETS

HIGH IN SODIUM (Na)
HIGH IN POTASSIUM (K)
HIGH IN MAGNESIUM (Mg)
HIGH IN PHOSPHORUS (P)

20. VEGETARIAN DIETS

Nsg Consideration
Ensure sufficient amount of varied foods to Ensure energy intakes-ensure dietary CHON
meet normal nutrient & energy needs used for protein synthesis
Vegetable Protein intake: provide essential amino acids
whole grains legumes seeds nuts veggies
LACTO-OVO LACTO- VEGANS
VEGETARIANS VEGETARIANS
Plant foods Plant foods Strict vegetarian
Dairy products Dairy products No animal foods
Eggs Without Egg Entirely plant foods
May eat fish
Occasional poultry

21. ENTERAL NUTRITION – liquefied food into GI tract via tube

Indications Nsg Consideration
GI tract is functional but oral intake is not Lactose-intolerance should be on lactose-free
feasible formulas
Swallowing problems
Burns
Major Trauma
Liver failure
Severe malnutrition

Nutrition�the provision of nutrients�and malnutrition�the result of extended inadequate intake or

severe illness on body composition and function�affect all systems of the body.

7
 Introduction
The selection of an enteral formula must be patient specific. The functioning and
capacity of the GI tract, underlying disease states and patient tolerance must be assessed
to determine which formula should be selected. Many formulas are very similar in
composition, varying only slightly in nutrient content. It is important to be familar with
the properties of commonly used enteral formulas.

Nutrient composition

Carbohydrate

Carbohydrate sources must be soluble, digestible and have a low osmolality. Commonly used
carbohydrate sources include corn syrup solids, hydrolyzed cornstarch, maltodextrins and other
glucose polymers. Some specialty formulas include various types of fiber, fructose, and
fluctooligosaccarides. Simple sugars (sucrose and glucose) enhance the palatability of oral
supplements but increase osmolality.

The percentage of total calories from carbohydrate varies from 30% to 90% depending on the
condition for which the product was formulated. The majority of enteral nutrtion products do not
contain lactose so should not be a concern in lactose-intolerant patients.

Lipids

Lipids provide an isotonic, caloric dense energy source. Corn and soybean oil are commonly used
lipd sources in enteral formulas. Canola and safflower oils may also be found. These vegetable oils
contain mostly long-chain triglycerides. They contribute essential fatty acids, limit osmolality, and
enhance palatability.

Fat content of enteral formulas varies from 1% to 55% of total calories according to the formula's
intended use. For example, products designed for pulmonary disease and glucose intolerance are
high in fat, whereas products designed for intestinal malabsorption contain decreased amounts of
total fat.

Medium-chain triglycerides (MCT) do not require bile salts or pancreatic lipase for absorption and
may be used in patients with lipid malabsorption disorders. However, MCT oil does not contain
essential fatty acids and may cause delayed gastric emptying, leading to poor tolerance.

Protein

Protein may be delivered as intact protein, partially digested protein, or free amino acids. Choice of
product is based on the patient's disease state and the ability to absorb the protein. Commonly used
protein sources include caseinates and soy protein isolates. Polymeric formulas contain these intact
proteins. Oligomeric formulas contain enzymatically hydrolyzed casein or whey. Monomeric or
elemental formulas contain free amino acids.

The protein content of formulas ranges from approximately 4% to 32% of total calories. Products
designed for renal disease may contain virtually no protein, whereas stress and immune-enhancing
formlas contain up to 80g/1000kcal.

Specialized enteral formulas may be enhanced with branch-chain amino acids, glutamine, or arginine.

Water

Caloric density of a formula is dictated by the amount of water contained in the formula. Formulas that
provide 1 kcal/ml are approximately 85% water. Formulas that provide 2 kcal/ml are approximately
70% water.

Micronutrients

When provided in adequate volume, nutritionally complete products meet 100% of the RDA for
vitamins and minerals. Howerver, the volume required to provide the RDA varies greatly among
products from one to four liters. Also, be aware that some disease-specific enteral formulas are not
nutritionally complete.

8
Fiber

Fiber is added to enteral formulas to improve stool consistency. The most commonly added fiber is
soy polyscaccaride, an insoluble fiber. Other insoluble fibers are cellulose, hemicellulose, and lignans.
Soluble fibers are guar gum, oat fiber, and pectin. The effectiveness of fiber-containing formulas in
improving incidence or duration of diarrhea has not been proven. Fiber-containing formulas can
create complications in patients who are fluid restricted or have delayed GI transit.

Formula categories

Presented here is one of many different schemes for classifying enteral nutrition formulas.

Enteral formula categories

Category Subcategory Characteristics Indications
Similar to average
Standard Normal digestion
diet
 Catabolism
Protein > 15% of total
High nitrogen
kcal
 Wound healing
 Fluid restriction
Polymeric  Volume
intolerance
Caloric dense 2 kcal/ml
 Electrolyte
abnormalities
Regulation of bowel
Fiber containing Fiber 5-15 g/L
function
Partially
hydrolyzed One or more nutrients
Impaired digestive and
Monomeric are hydrolyzed.
Elemental absorptive capacity
Composition varies.
Peptide based
Less protein, low
Renal Renal failure
electrolyte content
High BCAA, low AA,
Hepatic
Hepatic low electrolyte
encephalopathy
content
Higher % of calories
Disease- Pulmonary ARDS
from fat
specific
Diabetic Low CHO Diabetes mellitus
 Metabolic
Arginine, glutamine, stress
Immune-
omega-3 FA,
enhancing
antioxidants  Immune
dysfunction

Special populations

Diabetes

 Maintain glucose levels between 100 - 220 mg/dL

 Give 30% of total kcal as fat

9
  Gastric atony and delayed emptying is typical in type 1 diabetes

Renal disease

 Fluid restriction (2 kcal/ml formula)

 Pre-dialysis= low protein (0.6 - 0.8 g/kg/day)
 Dialysis= standard protein (1 - 1.2 g/kg/day)

Pulmonary disease

 Calories: 20 - 30 kcal/kg
 Give 30% - 50% of total kcal as fat
 Protein: 1 - 2 g/kg

Hepatic disease

 High calorie intake (35 kcal/kg/day)

 If no encephalopathy, standard protein (1 - 1.2 g/kg/day)
 If encephalopathy, protein resteriction (0.6 g/kg/day)
 Sodium restriction if ascites or edema

Cardiac disease

 Avoid overfeeding
 Fluid restriction (2 kcal/ml formula)

Types of malnutrition

Malnutrition has two forms: protein malnutrition (kwashiorkor or hypoalbuminemic malnutrition) and
protein-calorie (marasmus or protein-energy) malnutrition.

Protein malnutrition is usually caused by inadequate nutrient intake in conjunction with the stress
response. Common causes include chronic diarrhea, renal dysfunction, infection, hemorrhage,
trauma, burns, and critical illness. Protein malnutrition can result in:

 Marked hypoalbuminemia.
 Anemia.
 Edema.
 Muscle atrophy.
 Delayed wound healing.
 Impaired immunocompetence.

Protein malnutrition is not as easily recognized as protein-calorie malnutrition, but is associated with
significant increases in the rates of morbidity and mortality.

The patient with protein-calorie malnutrition is typically emaciated, elderly, and chronically ill. Long-
term nutritional repletion is usually required. Protein-calorie malnutrition usually results in:

 Weight loss.
 Reduced basal metabolism.
 Depletion of subcutaneous fat and tissue turgor.
 Bradycardia.
 Hypothermia.

Although the distinction between protein malnutrition and protein-calorie malnutrition is not always
clear, these conditions can usually be differentiated on the basis of time course, etiology, and clinical
signs.

Risk factors for malnutrition

10
Any prolonged decrease in nutrient intake should alert the clinician to the possibility of malnutrition.
Common risk factors for malnutrition:

Medical problems

 Recent surgery or trauma

 Sepsis
 Chronic illness
 Gastrointestinal disorders
 Anorexia, other eating disorders
 Dysphagia
 Recurrent nausea, vomiting, or diarrhea
 Pancreatitis
 Inflammatory bowel disease
 Gastrointestinal fistulas

Psychosocial problems

 Alcoholism, drug addiction

 Poverty, isolation
 Disability

Abnormal diet

 Fad or limited diet

 Recent decrease in food intake

Consequences of malnutrition

Malnutrition places stressed patients at a greatly increased risk for morbidity and mortality. Numerous
reports have documented the association between malnutrition and clinical outcome in a variety of
clinical settings.

Some complications are considerably more common in malnourished patients and those with
inadequate nutrient intake than in well-nourished individuals. These complications include:

 A longer recovery period.

 Impaired host defenses and sepsis.
 Impaired wound healing.
 Anemia.
 Impaired GI tract function.
 Muscle atrophy.
 Impaired cardiac function.
 Impaired respiratory function.
 Reduced renal function.
 Brain dysfunction.
 Delayed bone callus formation.
 Atrophic skin.

TPN SOLUTION REQUIREMENT

The primary goal of parenteral nutrition (PN) is to provide patients with adequate
calories and protein to prevent malnutrition and its associated complications. A normal
diet provides individuals with an adequate mix of carbohydrates, fats and proteins for
energy and tissue development. Parenteral nutrition therapy must provide patients with
these same dietary components with:
 Protein in the form of amino acids
 Carbohydrates in the form of glucose
 Fat as a lipid emulsion

In addition to protein, carbohydrates and fat, PN provides other dietary components, including:

11
  Water
 Electrolytes
 Vitamins
 Trace minerals

Because a number of factors can affect the amount of each of these components that the patient
needs, each component of PN must be evaluated and ordered separately.

Patient selection
General indications
TPN therapy is indicated for patients:

 Requiring long-term (>10 days) supplemental nutrition because they are unable to
receive all daily requirements through oral or enteral feedings.
 Requiring total nutrition because of severe gut dysfunction or inability to tolerate
enteral feedings.

Specific indications
TPN therapy is part of routine care in:

 Patients who cannot eat or absorb nutrients through the GI tract because of:
o Massive bowel resection
o Diseases of the small bowel
o Radiation enteritis
 Malnourished patients undergoing high-dose chemotherapy or radiation therapy.
 Patients with severe necrotizing pancreatitis when enteral feeding is not possible.
 Patients with severe malnutrition and nonfunctional gut.
 Malnnourished patients with AIDS who have intractable diarrhea.
 Severely catabolic patients whose gut cannot be used within 5 to 7 days.

When enteral feeding cannot be established, TPN is usually helpful:

 After major surgery.

 In patients with enterocutaneous fistulas, both high and low.
 In patients with inflammatory bowel disease.
 In patients with hyperemesis gravidarum.
 In patients with small bowel obstruction secondary to adhesions.

Fluid requirements
Before TPN is initiated, and throughout the duration of TPN therapy, careful assessment of
fluid status is imperative. Often, between meeting the caloric, protein, and electrolyte needs,
sufficient, if not excessive, water is provided. However, in circumstances where water needs
are elevated or reduced, or the patient's body size is abnormally large or small, fluid
requirements become an extremely important consideration.

Fluid requirements
Increased in Decreased in
Fever Renal failure
Congestive heart
Fistulas
failure
Diarrhea Cirrhotic ascites

12
 NG suction Pulmonary disease

Calorie and protein requirements

Since protein is needed for tissue synthesis and repair, amino acids are not routinely used for
basic energy requirements. Dextrose and lipids are typically used to provide a patient's
energy needs. The preferred mixture combines 70%-85% of calories from dextrose and 15%-
30% from lipids. The inclusion of protein in the calculation of energy, called "total calories"
versus "nonprotein calories", is controversial. However, in the hypermetabolic patient with
excessive energy needs, protein may be utilized for energy.

Macronutrient requirements
Standard Range Maximum
Infants = 90 - 100
Calories Children = 70 - 100
Adults = 40
kcal/kg/day Adolecents = 40 - 55
Adults = 28 - 30
Infants = 2.0 - 2.5
Children = 1.5 - 2.0
Protein
Adolecents = 0.8 - 2.0 Adults = 2.0
g/kg/day
Adults = 0.8 - 1.0
Dextrose rate 4 - 5 mg/kg/min 7 mg/kg/min
Fat 15 - 30% kcal 60% kcal

Micronutrient requirements
Electrolytes

Initial electrolyte doses in a PN order must be individualized for each patient. Starting doses
of electrolytes should be at maintenance levels and evaluated daily during initial startup of
PN therapy. As the patient demonstrates tolerance and as electrolyte needs stabilize, less
frequent monitoring may be performed.

Electrolyte requirements
Usual adult range Infants/children
Sodium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Potassium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Magnesium 8 to 40 mEq/day 0.25 to 0.5 mEq/kg/day
Calcium 10 to 30 mEq/day 0.5 to 3 mEq/kg/day
Phosphorus 10 to 40 mMol/day 0.5 to 2 mMol/kg/day
As needed to
Chloride maintain acid-base Same as adults
balance
As needed to
Acetate maintain acid-base Same as adults
balance

13
Vitamins

Vitamins are an essential component of a patient's daily PN regimen because they are necessary for
normal metabolism and cellular function. Traditional "MVI-12" adult multivitamin preparations contain
the daily requirements for all vitamins except Vitamin K. Therefore, patients receiving MVI-12 should
receive supplemental Vitamin K. There are many methods used to meet Vitamin K requirements, for
example, weekly administration of 5 to 10mg by subQ or IM injection. In 2001 FDA approved a new
multivitamin formula, "MVI-13", which contains 150mcg of Vitamin K. This is a significantly lower dose
of Vitamin K compared to traditional weekly supplementation. Patients who are on warfarin are best
supplanted with a consistent daily dose of Vitamin K.

Pediatric multiple vitamin preparations have always contained Vitamin K, and are dosed
according to weight:

Pediatric mulivitamin dosage

Manufacturer AMA
Weight (kg) Dose (ml) Weight (kg) Dose
<1 1.5 < 2.5 2 ml/kg
1-3 3.25 >2.5 5 ml
>3 5

Occasionally, a patient will need to be treated with a therapeutic dose of a vitamin. Since long term
patients are susceptible to developing vitamin deficiencies, they are more like to require vitamin
therapy.

Trace elements

Trace elements are metabolic cofactors essential for the proper functioning of several enzyme
systems. Suggested daily intake for parenteral trace minerals is presented below. As with
vitamins, long-term PN is more likely to be associated with deficiencies, therefore, additional
trace mineral supplementation may be required in these patients.

Daily trace mineral requirements

Adults Peds < 5 years Peds 5 - 12 years
Copper 300 to 500 mcg 20 mcg/kg 200 to 500 mcg
Manganese 60 to 100 mcg 2 to 10 mcg/kg 50 to 100 mcg
Zinc 2.5 to 5 mg 0.1 mg/kg 2 to 5 mg
0.14 to 0.2
Chromium 10 to 15 mcg 5 to 15 mcg
mcg/kg
Selenium 60 mcg 2 to 3 mcg/kg 30 to 40 mcg
Molybdenum As needed 0.25 mcg/kg As needed
Iodine As needed 1 mcg/kg As needed
Iron As needed As needed As needed

Trace mineral administration should be decreased or withheld in patients with impaired ability to
excrete them. In patients with renal impairment, selenium, chromium, and molybdenum may be
omitted. In patients with severe hepatic disease, manganese and copper may be withheld.

Special populations

14
Diabetes

Diabetes is neither a relative nor an absolute contraindication to TPN, but careful monitoring of
therapy to avoid hyperglycemia is obligatory. In both diabetic and nondiabetic patients, any benefit of
TPN is compromised significantly by persistent hyperglycemia.

As with any other patient, in diabetic patients, vital energy substrates and protein should be
administered in accordance with immediate metabolic needs. Insulin may be added to the parenteral
admixture and combined with sliding-scale insulin administration to achieve an appropriate blood
glucose level.

Reasonable glucose control should ensure a blood glucose level greater than 100 mg/dL (to minimize
the risk of hypoglycemia) and less than 220 mg/dL (to reduce the harmful effects of hyperglycemia on
metabolism, immunocompetence, and fluid balance). This guideline is applicable to any patient
receiving TPN.

Acute renal failure

Patients with acute renal failure are hypercatabolic, hypermetabolic, and frequently afflicted by
coexisting multiple-system organ failure. Therefore, nutritional substrates should be administered in
accordance with metabolic needs.

Protein intake should not be limited arbitrarily. The presumption of impaired removal of nitrogenous
waste does not mean that the patient has a reduced daily need for protein. Underfeeding of critically
ill patients with renal failure perpetuates catabolism and exacerbates an already difficult, unstable
situation.

Patients with acute renal failure must be assessed carefully for signs of fluid overload and electrolyte
abnormalities, particularly hyperkalemia, hyperphosphatemia, and hypermagnesemia. TPN volume
and composition may require modification.

Protein is provided at approximately 1- 1.2 g/kg/day, and dialysis is used as indicated to control
uremia. Limitations should be guided by data gathered from careful assessment of nitrogen losses in
urine, dialysate, and other sources.

Specialized formulations of amino acids (e.g., branched chain, essential and nonessential, and
mixtures) are widely available. However, no reduction of mortality rates is seen with either mixtures or
essential amino acids alone. Branched-chain amino acids (BCAAs; e.g., leucine, isoleucine, valine)
may be combined with other amino acids to improve protein use.

Pulmonary disease

Patients with significant pulmonary dysfunction, and those who require ventilator support present
therapeutic challenges for nutrition support. Increased catabolic needs, if unmet by feeding, pose
threats to the pulmonary musculature and the ability to fuel the work of breathing. Overfeeding may
increase CO2 production, complicate respiratory function, and impede weaning from ventilator
support.

The amount of carbohydrate administered to patients with pulmonary disease should be carefully
controlled. Carbohydrate metabolism is associated with a relatively greater production of CO2 than
metabolism of other substrates. The delivery of excess carbohydrate energy also stimulates
lipogenesis, which further increases CO2 production and may contribute to hypercapnia, increased
work of breathing, and ongoing degradation of respiratory function.

The goal of nutritional therapy in these patients is to provide adequate carbohydrate calories to meet
energy needs and (with fat) promote protein sparing, but not to produce unacceptably high levels of
CO2. An acceptable strategy is to increase the proportion of calories supplied by fat and to restrict the
administration of carbohydrate to 4 mg/kg/min. Protein needs should be estimated at 1.5 g/kg/day.

Hepatic disease

The liver performs a central role in metabolism, and impairment of this organ has profound
consequences for nutrition support. Cirrhosis and alcoholism are associated with significant pre-
existing malnutrition. This malnutrition is exacerbated by critical illness, surgery, and other stressors.

15
Lipid, carbohydrate, protein, and vitamin metabolism is sharply altered in patients with hepatic failure.
Lipid clearance is defective, with decreased lipolytic activity, increased triglyceridemia, and decreased
removal of free fatty acids. Glucose intolerance and insulin resistance, which are prevalent in this
patient population, may occur in approximately 80% of patients with cirrhosis. Despite this
background of broad dysfunction, intolerance to protein presents the greatest challenge to nutritional
management.

Many patients with liver failure have fluid overload that may require restriction of TPN volume. Protein
needs in patients with liver failure and mild or no encephalopathy should be calculated at 1.5
g/kg/day. These patients usually can tolerate a conventional parenteral amino acid formula with a full
complement of essential amino acids.

Protein needs in patients with significant encephalopathy are reduced to 1.0 g/kg/day. BCAAs are
useful sources of protein energy because they do not require hepatic metabolism. Their effect on the
mortality rate is unclear; however, patients with pronounced encephalopathy should be given a
modified amino acid formula containing a high percentage of BCAAs.

Cardiac disease

In addition to prolonged malnutrition, patients with long-standing cardiac disease are vulnerable to a
typical wasting (cardiac cachexia). Impaired baseline cardiac function and pre-existing malnutrition, in
conjunction with acute illness and other stressors, demand that patients with cardiac disease receive
careful adjustment of TPN solutions and strict monitoring of infusions.

Calories should be provided to satisfy, not exceed, daily energy needs. The total volume of
TPN solution is generally restricted to 1000 to 1500 mL/day in patients with severe
congestive heart failure secondary to valvular dysfunction, coronary artery disease, or
cardiomyopathy.

Nutritional support in the home is a logical extension of support provided to

hospitalized patients. It has allowed successful management of patients with diseases
that would otherwise have resulted in repeated or prolonged hospitalization. Nutritional
therapy in the home can save health care dollars and improve clinical outcome.
However, these services require careful assessment, planning, monitoring, and follow-
up in order to be successful.

HOME NUTRITIONAL SUPPORT

An interdisciplinary team of health professionals must assess, implement, monitor, and maintain
home nutrition therapy. The treatment team should include:

 A physician
 A nurse
 A dietician
 A pharmacist
 A home care company

Indications
Indications for long term nutritional support are the same as those for hospitalized patients, with the
additional consideration of the capabilities of the patient and family members as well as the safety of
the home environment.

Home enteral nutrition is indicated when there is disease or impairment of digestion or absoprtion of
nutrients resulting in the need for tube feedings to provide sufficient nourishment to maintain
appropriate weight or growth and to support life.
Home parenteral nutrition is indicated when the GI tract does not allow adequate absorption or
transport of sufficient nutrients to maintain appropriate weight or growth and to support life.

Considerations

16
Several medical and social factors must be considered when selecting a patient for home nutritional
support.

Stable medical condition

The patient's medical condition must be stabilized for safe discharge to home.

Acceptance by patient and caregivers

The patient and caregivers must understand and accept the risks and responsibilities for home
nutrition therapy. It must be emphasized that compliance with therapy is essential in order for it to be
successful.

Capabilities of patient and caregivers

The patient and caregivers must have the dexterity and cognitive ability to perform required care.
They must be able to troubleshoot minor problems or call for assistance.

Adequacy of support system

The support system includes the health professionals involved in caring for and monitoring the
patient; other individuals such as family, friends, clergy, or others who may be of assistance to the
patient; and the provider of nutrition and medical products.

1. There is an adequately trained support network of family members, friends, and

caregivers.
2. There is a reliable provider, with 24-hour availability, for nutrition and medical
products, services, and other necessary supplies.
3. Adequate insurance coverage and eligibility for reimbursement must be considered.

Adequacy of home environment

The home must be a clean, safe environment for storage, preparation, and administration of
nutritional support.

1. Hot and cold running water.

2. Dependable refrigeration.
3. Appropriate and adequate dry storage space.
4. Adequate lighting and electricity.
5. Phone service and access to emergency medical service.

Nutrition support care plan

Once it is decided that a patient is a candidate for home nutrition support, the specifics of care should
be established through a nutrition plan of care. Factors that should be included in this plan are:

1. Define the individual's nutritional goals.

2. Create a patient-specific nutrient prescription.
3. Select the appropriate route for providing nutrients.
4. Select the appropriate access device.
5. Establish schedule for infusion of enteral or parenteral nutrition therapy.
6. Establish appropriate preparation and administration techniques for the patient caregivers.
7. Determine a plan for safe storage and preparation of formulas, for management of
equipment, and for site care.
8. Establish and document a plan for monitoring nutrition therapy.

Long term complications

17
In addition to the complications mentioned in previous sections of this tutorial, the home patient is
susceptible to metabolic complications from long-term nutritional support, particularly PN.

Metabolic bone disease

Metabolic bone disease is particularly pertinent to parenteral nutrition patients. It has been
suggested that 40 to 100% of patients on long term PN have decreased bone density or evidence of
metabolic bone disease. Bone pain and spontaneous fractures are hallmarks of this disorder.
Although aluminum contamination was once suspected as the cause, little is actually known about the
pathogenesis and treatment of this disorder. The mineral and vitamin D status of long term PN
patients should be evaluated. The patient should be encouraged to be mobile, get exposure to the
sun, and exercise.

Essential fatty acid deficiency

Essential fatty acid deficiency, like MBD, is particularly pertinent to PN patients. It may be prevented
by giving a minimum of 1g/kg/week of IV fat emulsion.

Vitamin K deficiency

Because Vitamin K is not included in the adult multivitamin injection, PN patients are at risk of
developing a deficiency. There are various methods of administering Vitamin K to prevent deficiency:

 10mg subcutaneously once weekly

 10mg added to PN once weekly
 0.25 to 1mg added to PN daily

Folic acid and Vitamin B-12 deficiency

Macrocytic anemias are common in long-term PN patients. Folic acid and B-12 deficiencies must be
ruled out in any patient with a macrocytic anemia. Patients with malabsorption disorders are always
considered to be of high risk of FA and B-12 deficiency. Therapeutic doses of these vitamins are
required for several weeks until the anemia is corrected. Patients with short-bowel syndrome will
need B-12 injections if they lack the terminal ileum.

Iron deficiency

Eventually, a long-term PN patient who cannot eat or absorb nutrients will become iron deficient.
Because it may crack the emulsion, iron is never added to TNAs. There are several approaches to
treatment of iron deficiency. One is to administer the iron as a short, separate infusion while the PN
solution is not hanging. Another is to add 25mg to 100mg of iron three times a week to a PN solution
with the lipid omitted. The lipids are then administered the other four days of the week.

Liver and gallbladder disease

Other complications of long-term PN includes steatosis, cholestasis, and cholelithiasis. Steatosis is a

benign and reversible condition resulting from excess administration of dextrose calories. Cholestasis
results from the lack of enteric stimulation that occurs with long-term PN therapy. Biliary sludge has
been reported to occur in 100% of patients receiving long-term PN. The billiary sludge may eventually
form gallstones. Cholestasis is a chronic condition which may progress to irreversible liver disease.
Measures to prevent or treat this complication include:

 Avoid excess caloric load

 Decrease glucose intake
 Remove copper from PN
 Initiate some oral intake if possible

Monitoring
Because a variety of complications may develop in long-term nutritional support, diligent
patient monitoring is necessary. The following table is only a guideline, the frequency of

18
monitoring should be individualized to the patient's condition and potential for
complications.

Schedule for monitoring long-term nutritional support

Parenteral Enteral
Blood chemistry Monthly Every 6 months
Lytes, BUN,
Monthly Every 6 months
creatinine
Triglycerides Monthly Every 6 months
Glucose Monthly Every 6 months
Serum proteins Monthly Every 6 months
Weight Weekly Weekly
I&O Weekly Weekly
Nitrogen balance PRN PRN

TPNassist© is a clinical tool for pharmaceutical care which combines comprehensive

data-base functions and nutritional assessment into a single user-friendly package.

 TPNassist© has context sensitive help, so please take advantage of this feature by pressing
the F1 key.
 All program icons have tool tips, hold your mouse pointer over a button and after a few
seconds a description of the button will appear.

Program "How-to's"
The film-strip icon indicates a link from this page to a "video" which demonstrates a TPNassist©
function. You do not need to interact with the demo, however, there is a "VCR-style" control at the top
of the demo window which will allow you to pause, rewind, fast-forward, and exit the animated
sequence.

System requirements for viewing Program How-to's

Please be patient, these applets make take a few minutes to load, it all depends on the speed of your
internet connection. One last note, the demo's were created with an advertiser-supported program, I
apologize for the banner ads which appear at the top of the demo window, I have no control over
them.

Login
When you first start the program you will be asked to log-in. Enter your intials (up to 3 letters). The
first time you enter your initials the program will ask you for your name, title and contact numbers.
Thereafter you may log in with just your initials.

How to Log in and Add new user

Setup

19
Next, you will want to enter the Setup and customize the settings to your needs. Setup is accessed
via the menubar and is password protected. The program ships without a password, so choose one
that you will remember.

Database maintenance
Database maintenance functions are accessed via the menubar. All of these functions except the
physician data entry are password protected.

Function Description
Repair database Compress and repair db tables
Amino acid data Maintain db of AA brands
Enteral formula data Maintain db of formula brands
Maintain default notes for fax cover
Fax cover notes
sheets
Physician data Maintan physician db
TPN pathway data Maintain TPN "templates"
User data Maintain program user db
Setup and database maintenance

Patient data
To enter a new patient, click the [+] icon on the patient databar. You may enter peds (age 1 year)
to adults. Out of range patient data is flagged in red. This does not mean that the data is wrong,
it is only meant to alert you to any potential data entry error,

To retrieve a previously entered patient, click on the "Patient name" list box, then select the patient
from the list.

Retrieve and edit an existing patient

Assessment
After entering basic patient data, the next thing you must do is assess the patient. The nutritional
assessment is the basis of all the calculations. There are only 2 things needed for an
assessment, current weight and stress/activity level. The latter is a judgement call, you should get out
and see the patient, review the labs, gather as much information as you can.

Examples of stress levels:

Stress or activity level Descriptor Factor

Bed rest None 1.1
Minor surgery None to slight 1.1 - 1.3
Ambulatory Slight 1.3
Infection Slight 1.3
Fracture Slight 1.3
Major surgery Mild 1.5
Major trauma Moderate 1.7
Sepsis Moderate to severe 1.7 - 1.9
Burns Severe 1.9 - 2.1

20
Labs/anthropometrics
You may also enter Labs and Anthropometrics, note that these are not required, but are
optional parameters for monitoring the patient, the labs have context sensitive help with
some data relevent to nutritional assessment.

Enter a new patient, assessment, and labs

Enteral Rx entry
To enter an enteral tube feeding, click on the Enteral Rx icon, select a formula from the list,
strength and rate. The program will calculate the nutritional content supplied to the patient, you
can then compare this to the patient's nutritional needs assessment.

Enter a new Enteral Rx

TPN entry
TPN entry is via a wizard which takes you through each step in the TPN entry process:

1. Type
You may select a pathway, these are standard TPN's which are created and maintained *by
you* via the Database maintenance menu. Other choices are self explanatory.
2. Base
This is the most important step. Read this like you would a printed page, start at the top left
and read across and down. Note that you start with the patient's needs. Enter target kcal and
protein grams and the program will calculate how much dextrose and amino acid.
3. Lytes
You may enter electrolytes by salts or by their constituent anions/cations. If the later you must
"balance" the cations. Select the anion you wish to use, Cl, Ac, or both, then click balance.
4. Other
If a homecare patient you can select some of these adds to be "Patient adds".
5. Order notes
A free form text entry for recording progress notes, etc. related to the TPN.
6. Summary
An evaluation of the TPN you have just entered. You must view the summary before you can
save the TPN. Click the Finish button to save the TPN.

Summary values outside of normal flag in red. This does not mean that the TPN is wrong, it
is only meant to alert you to any potential order entry error!

Enter a new TPN Rx

Retrieve and edit an existing TPN

Reports
To print a report without screen preivew, click the print icon on the toolbar.To preview reports
on the screen, click Print on the menubar, then select a report. There are also keyboard
shortcuts to these previewed reports.

Reports include:

TPN worksheet
TPN and Enteral labels
TPN and Enteral assessment
TPN and Enteral Rx
Lab trends
Fax cover sheet

21
Nutritional assessment (NA) is the first step in the treatment of malnutrition. Specific data are
obtained to create a metabolic and nutritional profile of the patient. The goals of NA are identification
of patients who have, or are at risk of developing malutrition; to quantify a patient's degree of
malnutrition; and to monitor the adequacy of nutrition therapy.

The initial assessment of nutritional status requires a careful history, a physical examination, and
laboratory tests. With the patient assessment in hand, one can then determine the caloric, protein,
and fluid needs of the patient.

History

Foremost in nutritional assessment is the patient interview for determining clinical history. Attention
should be given to the disease state, duration of illness, intake of nutrients, and presence of such
gastrointestinal symptoms as nausea, vomiting, and diarrhea.

Weight loss is often the first clue to an underlying cause of malnutrition. The loss of more than 10%
of the patient�s usual weight necessitates a thorough nutritional assessment. Recent unintentional
loss of 10% to 20% of the patient�s usual weight indicates moderate protein-calorie malnutrition, and
loss of more than 20% indicates severe protein-calorie malnutrition.

Physical Examination

Evaluation of the patient�s overall appearance and thorough physical examination of the skin, eyes,
mouth, hair, and nails may provide a clue to the presence of malnutrition.

Weight is one of the most useful elements of the physical examination for the assessment of
nutritional status. Body weight is expressed as a value relative to established norms in the general
population. Use of these standards may facilitate the diagnosis of significant protein-calorie
malnutrition (85% of ideal body weight). The major variable that limits the usefulness of weight and
height as indicators of nutritional assessment is water retention, which can occur in many disease
states. Fluid retention is a major concern in patients with protein malnutrition as a result of
impairments in aldosterone, antidiuretic hormone (ADH), and insulin metabolism.

Anthropometrics are used to estimate subcutaneous fat and skeletal muscle stores objectively.
Anthropometric measurements, such as triceps skinfold thickness (TSF) and mid-arm muscle
circumference (MAMC), estimate fat and lean tissue mass, respectively. Anthropometry is a useful
adjunct in nutritional assessment which is simple, safe, and easily applied at the bedside.
Anthropometric data are used in two ways in nutrition assessment:

 To compare measured values with standardized controls.

 To compare serial measurements over time in the same patient.

Three anthropometric parameters pertaining to the mid-upper arm are useful in the nutritional
assessment of hospitalized adults(16): mid-upper arm circumference (MAC), TSF, and MAMC. They
are useful in identifying the most severely malnourished patients, especially those with fluid retention
as a result of disease. TSF alone is not a sensitive indicator of malnutrition because many normal
adults have less than 5% body fat. However, it is required to calculate MAMC:

MAMC (cm) = MAC (cm) � 3.14 x TSF (mm) � 10 -[(3.14 x TSF (mm)) � 10]

MAMC is easily determined and provides a readily available parameter for nutritional assessment. An
MAMC measurement of less than the fifth percentile according to national standards indicates severe
protein-calorie malnutrition. An MAMC measurement less then the tenth percentile indicates
moderate protein-calorie malnutrition

Labs

22
Measurements of serum protein levels are used in conjunction with other assessment parameters to
determine the patient�s overall nutritional status. Serum proteins used in nutritional assessment
include:

 Albumin
 Transferrin
 Prealbumin

Albumin is a complex, high-molecular-weight protein produced by the liver. Because measurement of

serum albumin is easy and inexpensive, it is widely used in nutritional assessment. Decreased
albumin levels have been shown to correlate with increased morbidity and mortality in hospitalized
patients. For this reason it is often used as a prognostic indicator.

Despite the use of serum albumin level as a standard indicator of nutritional assessment, there is
some controversy about its sensitivity. The serum albumin level often shows little or no response to
nutrition support in the setting of continued sepsis or stress. On the other hand, the serum albumin
level changes promptly with refeeding in protein malnutrition if significant stress is not present.
Because the serum half-life of albumin is 18 to 20 days and the fractional replacement rate is about
10% per day, in the absence of stress, an improvement in serum albumin level with nutritional
repletion is generally observed within 2 weeks. There are other limitations to using the serum albumin
level as an indicator of nutritional status. If exogenous albumin is administered, then the serum
albumin level loses its predictive value. In addition, certain states of major albumin loss (e.g., severe
nephrosis and protein-losing enteropathy) and impaired synthesis (e.g., severe hepatic insufficiency)
may limit its usefulness.

Serum transferrin is a beta-globulin that transports iron in the plasma. It has a serum half-life of 7 to
10 days. Serum levels of transferrin are affected by nutritional factors (as are serum levels of albumin
during a stress response) and iron metabolism. The shorter half-life of transferrin gives it a theoretical
advantage over albumin as a nutritional marker. However, clinical studies do not show any significant
difference in their value.

Serum transferrin levels, like albumin, are inversely correlated with the risk or morbidity and mortality
in hospitalized patients. One disadvantage is that serum transferrin levels also respond to iron status.
High serum transferrin levels are found in patients with iron deficiency. Low levels are found in those
with iron overload. Thus, a patient with coexisting iron deficiency and protein malnutrition may have a
higher serum transferrin level than another patient with a similar degree of protein malnutrition.

Prealbumin functions in thyroxine transport and as a carrier for retinol-binding protein. Its serum half-
life is 2 to 3 days. Measurable changes occur in prealbumin levels within 1 week of a change in
nutrient intake. Changes occur more rapidly with metabolic stress.

Disadvantages associated with the use of prealbumin for nutritional assessment include an increased
level in renal failure and a failure to respond to malnutrition in the same way as the other secretory
proteins (albumin, transferrin, and retinol-binding protein). In addition, the prealbumin level can vary
unpredictably with the carbohydrate content of the diet and during metabolic stress.

Immune function
It is well known that malnutrition leads to a decline in immune function. Total Lymphocyte Count is a
clinical measure of immune function that is often used in NA. TLC is an indicator of immune function
that reflects both B cells and T cells. TLC is calculated using the following equation:

TLC = [% lymphocytes x WBC] / 100

A TLC less than 900 indicates severe depletion, 900 to 1500 is moderate, and 1500-1800 is mild
depletion. TLC is increased with infection and leukemia, and decreased following surgery, and in
chronic disease states. Because TLC is not specific to nutritional status, it is not useful for
assessment of a hospitalized patient.

Estimating energy/calorie needs

To create a tailored nutrition prescription, one must determine the patient's energy/calorie
requirements. Indirect calorimetry is the most reliable and readily available method of determining
an individual's caloric needs. However, if calorimetry is unavailable, methods to calculate energy
requirements are available.

23
Basal Energy Expenditure
Even in the most physically active people and the most hypermetabolic patients, Basal Metabolic
Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy
requirements. BEE is determined largely by body size and body composition. Gender and age also
affect BEE. The Harris-Benedict equation is a mathematical formula used to calculate BEE:

Adult males:
BEE (kcal/day) = 66 + (13.7 x wt in kg) + (5 x ht in cm) - (6.8 x age).
Adult females:
BEE (kcal/kcal) = 655 + (9.6 x wt in kg) + (1.7 x ht in cm) - (4.7 x age).
There are more than 100 different variations of the Harris-Benedict equation in the literature.
Because of the many conflicting versions of the Harris-Benedict equations and since the
major factor which determines BEE is patient weight, some clinicians prefer to use an
estimate of 25 kcal/kg for BEE.
Harris-Benedict formulas frequently
overestimate caloric requirements of
hospitalized patients.

Total Energy Expenditure

The next step in determining a patient's energy/caloric needs is to calculate the total energy
expenditure (TEE). Surgery, infection, trauma or other stresses to the body add to energy
requirements, as does physical activity:

TEE (kcal/day) = BEE x stress/activity factor

Stress or activity
Factor
level
Bed rest 1.1
Minor surgery 1.1 - 1.3
Ambulatory 1.3
Infection 1.3
Fracture 1.3
Major surgery 1.5
Major trauma 1.7
Sepsis 1.7 - 1.9
Burns 1.9 - 2.1

Calorie sources
Approximately 60 to 80% of the caloric requirement should be provided as glucose, the remainder as
lipids. Whether to include protein calories in the provision of energy is controversial. Overfeeding is
an increasingly recognized complication of nutritional support. Providing more nutrients than needed
may be more harmful than semistarvation. Also, in the hypermetabolic patient with increased energy
needs, protein is frequently used for energy.

Fluid requirements

Fluid needs are affected by the patient's functional cardiac, pulmonary, hepatic, and renal status.
Fluid requirements increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin
integrity (ie, burns, open wounds). Whereas patients with cardiac, pulmonary or renal disease may
require less fluid intake.

The average adult requires approximately 35-45 ml/kg of water per day, the NRC recommends 1 to 2
ml of water for each kcal of energy expenditure. Baseline fluid requirements are determined by the
amount of calories administered. Often, meeting the caloric, protein and electrolyte needs of the
patient, sufficient, if not excessive, water is provided. Subsequent fluid needs are determined by
careful monitoring, particularly:

 Patient's physical appearance

24
 o Dry mucous membranes with volume depletion
o Edema with volume excess
 Serum sodium concentrations
o Hyponatremia may occur in the presence of excess, normal or depleted fluid volume.
o Hypernatremia may result from pure water loss, pure salt gain or hypotonic fluid loss.
 BUN : Creatinine ratio
o Normal BUN:SrCr ratio is 10:1 to 15:1.
o Renal failure or abnormalities in fluid volume may alter this ratio.
 Intake and output
o Urine output
o Other fluid losses (vomiting, diarrhea, skin losses and fistula drainages)

Protein needs

The average adult requires about 70-80 grams of protein per day, however protein needs may
be greatly increased in times of stress. The initial protein goals are estimated according to the
following general guidelines.

Stress or activity Initial protein req

level (g/kg/day)
Baseline 1.4
Little stress 1.6
Mild stress 1.8
Moderate stress 2.0
Severe stress 2.2

Subsequent protein needs should be detemined by Nitrogen Balance studies.

Disease State Considerations

The next step is to individualize a patient's nutritional requirements with regard to any concurrent
disease states.

Renal insufficiency and ESRD reduces the elimination of nitrogen, produced from the breakdown of
protein. Accumulation of nitrogen increases the BUN leading to altered mental status and worsening
renal failure. Suggested protein requirements are 0.8-1.0 g/kg/day in patients not receiving dialysis, 1-
1.2 g/kg/day in patients receiving hemodialysis and 1.2-1.5 g/kg/day in peritoneal dialysis patients to
compensate for actual increases in protein loss into the dialysate solution. Decreased tolerance of
carbohydrate and fat substrate is also common since many patients have renal failure secondary to
diabetes or cardiovascular disease. Patients may also require decreased amounts of renally
eliminated electrolytes (K+ , Mg++, Phos) and acidic anions (Cl-) due to decreased ability of the kidney
to reabsorb bicarbonate (HCO3). Fluid restriction may also be necessary in ESRD.

Patients with hepatic insufficiency or failure may have decreased glycogen stores potentially resulting
in hypoglycemia and need for increased carbohydrate as a part of their nutritional support. It has
been proposed that encephalopathy occurs because of a deceased ability to metabolize aromatic
amino acids, which can cross into the brain and act as false neurotransmitters. This theory, and the
preferential use of branch-chain amino acids, which are metabolized peripherally, have not been
proven.

Respiratory insufficiency such as severe COPD, may necessitate a reduction in the amount of
calories given as carbohydrates and a reduction in total fluid volume. Carbon dioxide, a byproduct of
carbohydrate metabolism eliminated through expiration, may accumulate and cause increased
respiratory drive and respiratory acidosis. Fat produces the lowest amount of CO 2 and allows less
volume to be given per calorie. Avoidance of over feeding of total calories appears to be just as
important and effective at minimizing this complication.

25
Nitrogen balance studies

Nitrogen Balance (NB) is an important calculation for assessing nutritional response. NB is used to
evaluate the adequacy of protein intake as well as to estimate current protein requirements. Nitrogen
Balance is a measure of the daily intake of nitrogen minus the daily excretion. NB is determined with
the following formula:

Nitrogen Balance = Nitrogen intake � Nitrogen losses

Nitrogen intake = Protein intake (g/day) / 6.25

Nitrogen losses = Urinary Urea Nitrogen (g/day) + 4g*

UUN is determined from a 24 hour urine collection
*4g is a "fudge factor" to account for miscellaneous nitrogen losses

A positive NB indicates an anabolic state, with an overall gain in body protein. Conversely, a negative
Nitrogen Balance indicates a catabolic state, with a net loss of protein. With adequate feeding, a
Nitrogen Balance between 0 and �5 g/day indicates moderate stress, whereas NB greater than �5
g/day indicates severe stress.

Monitoring response

For nutritional support to be effective, it is necessary to ensure that the nutrients being provided are
adequate and are being used properly. It is important to determine whether the goals established in
nutritional assessment are being met.

Nitrogen balance may be the most responsive nutritional indicator. Anthropometric measurements are
of limited value if performed more frequently than monthly. In the absence of severe stress, serum
protein levels change according to their individual half-lives. Thus, improvements in the prealbumin
level may occur after 2 to 3 days, and improvements in the transferrin level may occur after 7 to 10
days.

Parameters that are monitored include:

 Daily to every-other-day weight measurements to detect excess fluid retention.

 Estimates of caloric and protein intakes to achieve nutritional goals.
 Measurement of serum glucose level, acid�base balance, and serum levels of electrolytes,
calcium, magnesium, and phosphorus.
 Daily temperature to assess possibility of catheter-related infection.
 Weekly prothrombin time, partial thromboplastin time, and platelet count to optimize catheter
management.

Section 1 - Nutritional assessment

The selection of an enteral formula must be patient specific. The

functioning and capacity of the GI tract, underlying disease states and
patient tolerance must be assessed to determine which formula should
be selected. Many formulas are very similar in composition, varying
only slightly in nutrient content. It is important to be familar with the
properties of commonly used enteral formulas.

Nutrient composition
Carbohydrate

26
Carbohydrate sources must be soluble, digestible and have a low osmolality. Commonly used
carbohydrate sources include corn syrup solids, hydrolyzed cornstarch, maltodextrins and other
glucose polymers. Some specialty formulas include various types of fiber, fructose, and
fluctooligosaccarides. Simple sugars (sucrose and glucose) enhance the palatability of oral
supplements but increase osmolality.

The percentage of total calories from carbohydrate varies from 30% to 90% depending on the
condition for which the product was formulated. The majority of enteral nutrtion products do not
contain lactose so should not be a concern in lactose-intolerant patients.

Lipids

Lipids provide an isotonic, caloric dense energy source. Corn and soybean oil are commonly used
lipd sources in enteral formulas. Canola and safflower oils may also be found. These vegetable oils
contain mostly long-chain triglycerides. They contribute essential fatty acids, limit osmolality, and
enhance palatability.

Fat content of enteral formulas varies from 1% to 55% of total calories according to the formula's
intended use. For example, products designed for pulmonary disease and glucose intolerance are
high in fat, whereas products designed for intestinal malabsorption contain decreased amounts of
total fat.

Medium-chain triglycerides (MCT) do not require bile salts or pancreatic lipase for absorption and
may be used in patients with lipid malabsorption disorders. However, MCT oil does not contain
essential fatty acids and may cause delayed gastric emptying, leading to poor tolerance.

Protein

Protein may be delivered as intact protein, partially digested protein, or free amino acids. Choice of
product is based on the patient's disease state and the ability to absorb the protein. Commonly used
protein sources include caseinates and soy protein isolates. Polymeric formulas contain these intact
proteins. Oligomeric formulas contain enzymatically hydrolyzed casein or whey. Monomeric or
elemental formulas contain free amino acids.

The protein content of formulas ranges from approximately 4% to 32% of total calories. Products
designed for renal disease may contain virtually no protein, whereas stress and immune-enhancing
formlas contain up to 80g/1000kcal.

Specialized enteral formulas may be enhanced with branch-chain amino acids, glutamine, or arginine.

Water

Caloric density of a formula is dictated by the amount of water contained in the formula. Formulas that
provide 1 kcal/ml are approximately 85% water. Formulas that provide 2 kcal/ml are approximately
70% water.

Micronutrients

When provided in adequate volume, nutritionally complete products meet 100% of the RDA for
vitamins and minerals. Howerver, the volume required to provide the RDA varies greatly among
products from one to four liters. Also, be aware that some disease-specific enteral formulas are not
nutritionally complete.

Fiber

Fiber is added to enteral formulas to improve stool consistency. The most commonly added fiber is
soy polyscaccaride, an insoluble fiber. Other insoluble fibers are cellulose, hemicellulose, and lignans.
Soluble fibers are guar gum, oat fiber, and pectin. The effectiveness of fiber-containing formulas in
improving incidence or duration of diarrhea has not been proven. Fiber-containing formulas can
create complications in patients who are fluid restricted or have delayed GI transit.

Formula categories

27
Presented here is one of many different schemes for classifying enteral nutrition formulas.

Enteral formula categories

Category Subcategory Characteristics Indications
Similar to average
Standard Normal digestion
diet
 Catabolism
Protein > 15% of total
High nitrogen
kcal
 Wound healing
 Fluid restriction
Polymeric  Volume
intolerance
Caloric dense 2 kcal/ml
 Electrolyte
abnormalities
Regulation of bowel
Fiber containing Fiber 5-15 g/L
function
Partially
hydrolyzed One or more nutrients
Impaired digestive and
Monomeric are hydrolyzed.
Elemental absorptive capacity
Composition varies.
Peptide based
Less protein, low
Renal Renal failure
electrolyte content
High BCAA, low AA,
Hepatic
Hepatic low electrolyte
encephalopathy
content
Higher % of calories
Disease- Pulmonary ARDS
from fat
specific
Diabetic Low CHO Diabetes mellitus
 Metabolic
Arginine, glutamine, stress
Immune-
omega-3 FA,
enhancing
antioxidants  Immune
dysfunction

Special populations
Diabetes

 Maintain glucose levels between 100 - 220 mg/dL

 Give 30% of total kcal as fat
 Gastric atony and delayed emptying is typical in type 1 diabetes

Renal disease

 Fluid restriction (2 kcal/ml formula)

 Pre-dialysis= low protein (0.6 - 0.8 g/kg/day)
 Dialysis= standard protein (1 - 1.2 g/kg/day)

Pulmonary disease

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  Calories: 20 - 30 kcal/kg
 Give 30% - 50% of total kcal as fat
 Protein: 1 - 2 g/kg

Hepatic disease

 High calorie intake (35 kcal/kg/day)

 If no encephalopathy, standard protein (1 - 1.2 g/kg/day)
 If encephalopathy, protein resteriction (0.6 g/kg/day)
 Sodium restriction if ascites or edema

Cardiac disease

 Avoid overfeeding
 Fluid restriction (2 kcal/ml formula)

Section 2 - Enteral formulas

Routes of nutrition support

The nutritional needs of patients are met through a variety of delivery routes and with an array of
nutritional formulation components and administration equipment.

Enteral nutrition (EN)

Long-term nutrition:
 Gastrostomy
 Jejunostomy

Short-term nutrition:
 Nasogastric feeding
 Nasoduodenal feeding
 Nasojejunal feeding

Parenteral nutrition (PN)

 Peripheral Parenteral Nutrition (PPN)

 Total Parenteral Nutrition (TPN)

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In many patients, either the enteral route, the parenteral route, or a combination of both routes
(combination feeding) should be used to meet nutritional needs.

Enteral nutrition

The gastrointestinal tract is always the preferred route of support, i.e., "If the gut works, use it".
Most would agree that EN is safer, more cost effective, and more physiologic that PN. Improvements
over the past few years have greatly expanded choices in enteral formulas, equipment, and
techniques.

Potential benefits of enteral nutrition over PN include:

1. Physiologic
o Nutrients are metabolized and utilized more effectively via the enteral than
the parenteral route.
o The gut and liver process enteral nutrients before their release into systemic
circulation.
o The gut and liver help maintain the homeostasis of the amino acid pool as
well as the skeletal muscle tissue.
2. Immunologic
o Gut integrity is maintained by enteral nutrients through the prevention of
bacterial translocation from the gut, sytemic sepsis, and potential increased
risk of multiple organ failure.
o Lack of GI stimulation may promote bacterial translocation from the gut
without concurrent enteral nutrition.
o Provision of early enteral nutrition may minimize risk of gut related sepsis.
3. Safety (avoid complications related to intravenous access):
o Catheter sepsis
o Pneumothorax
o Catheter embolism
o Arterial laceration
4. Cost
o Cost of EN formula is less than PN.
o Cost of equipment and personnel for preparation and administration is less.

However, there are contraindications to enteral nutrition support:

 Expected need less than 5-10 days

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  Severe acute pancreatitis
 High-output proximal fistulas
 Inability to gain access
 Intractable vomitting or diarrhea

Formula selection

Selection of an enteral formula must be patient specific. The functioning and capacity of the GI tract,
underlying disease states and patient tolerance must be assessed to determine which formula should
be selected. Many formulas are very similar in composition, varying only slightly in nutrient content. It
is important to be familar with the properties of commonly used enteral formulas.

Parenteral nutrition

Parenteral nutrition is the provision of nutrients intravenously. It is used in patients who cannot meet
their nutritional goals by the oral or enteral route. When the gut is not working, PN is also used for
long-term nutrition support in the home setting. The principle forms of PN are peripheral and central
(TPN).

PN should only be initiated in patients who are hemodynamically stable and who are able to tolerate
the fluid volume, protein, carbohydrate, and lipid doses necessary to provide adequate nutrients.

Conditions warranting cautious use of PN:

 Azotemia
 Congestive heart failure
 Diabetes Mellitus
 Electrolyte disorders
 Pulmonary disease

Central PN (TPN) is a concentrated formula which is hyperosmolar and must be delivered into a
central vein. TPN provides:

 Carbohydrates in the form of glucose.

 Protein in the form of amino acids.
 Lipids in the form of triglycerides.
 Electrolytes.
 Vitamins and trace minerals.

Peripheral PN has similar nutrient components as TPN but in a lower concentration so it may be
delivered by peripheral vein. Large fluid volumes must be administered to provide comparable
nutrients. PPN is typically used for short periods (up to two weeks) because of limited tolerance.

Combination Feeding

Combination feeding can be used as a bridge between parenteral and enteral (or oral) nutrition in
patients whose clinical status does not warrant full enteral nutrition, but whose nutritional status is
best managed with some form of enteral nutrition. Thus, patients following a combination feeding
regimen receive parenteral and enteral nutrition simultaneously. Even a small amount of enteral
nutrition will preserve the entero-hepatic circulation and barrier function of the GI tract.

Section 1 - Types of nutrition support

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