Download Chapter_54

CHAPTER 54
Nutritional Supplements
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Nutrition Supplements




Dietary products used to provide nutritional
support
Can be given in a variety of ways
Vary in amounts and complexity of
carbohydrates, protein, and fat content
Electrolytes, vitamins, minerals, and
osmolality may also vary
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Nutrition Supplements (cont’d)

Malnutrition


Enteral nutrition


The body’s nutritional needs are not met by
nutrient intake
Provision of food or nutrients through the GI tract
Parenteral nutrition

Delivery of nutrients directly into the circulation by
means of an intravenous solution
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
3
Enteral Nutrition



Provision of food or nutrients through the GI
tract
Oral consumption is the most common and
least invasive route
Feeding tubes through various routes can be
used for enteral nutrition
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
4
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
5
Enteral Nutrition (cont’d)

Feeding tubes are used for those with:




Abnormal esophageal or stomach peristalsis
Altered anatomy secondary to surgery
Depressed consciousness
Impaired digestive capacity
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
6
Enteral Formulation Groups


Provide basic building blocks for anabolism
Supply complete dietary needs through the
GI tract by oral route or by feeding tube





Elemental
Polymeric
Modular
• Carbohydrate formulations
• Fat formulations
• Protein formulations
Altered amino acid formulations
Impaired glucose tolerance
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
7
Enteral Formulation Group:
Elemental




Vivonex Plus, Peptamen, Vital HN
Minimal digestion needed; residual is minimal
Used for pancreatitis, partial bowel
obstruction, irritable bowel disease, other
conditions
Hyperosmolarity of formulas may cause GI
problems
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
8
Enteral Formulation Group:
Polymeric



Ensure, Ensure-Plus, Isocal, Osmolite, Sustacal,
Jevity, others
Preferred over elemental formulations for
patients with fully functional GI tracts and few
specialized nutrient requirements; cause fewer
GI problems
Most closely resemble normal dietary intake
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
9
Enteral Formulation Group:
Modular

Three types





Carbohydrate: Moducal, Polycose
Fat: MCT oil, Microlipid
Protein: Casec, ProMod
Single nutrient formulas
Intended for use with monomeric or polymeric
formulations
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
10
Enteral Formulation Group:
Altered Amino Acid



Amin-Aid, Hepatic-Aid, Travasorb Renal,
Traum-Aid HBC
Contain varying amounts of specific amino
acids
Used for patients with diseases associated
with altered metabolism capabilities
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
11
Enteral Formulation Group:
Impaired Glucose Tolerance

Glucerna

Contains proteins, carbohydrates, fat, sodium,
potassium
 Used in patients with impaired glucose tolerance
(e.g., diabetic patients)
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
12
Enteral Nutrition:
Interactions



Various nutrients can interact with drugs to
produce significant food-drug interactions
Enteral nutrition can delay absorption of
some medications
Enteral nutrition may inactivate some
medications (e.g., tetracycline and nutrient
formulations that contain calcium)
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
13
Parenteral Nutrition


Totally digested nutrients are given
intravenously, directly into the circulatory
system
The entire GI system is bypassed, eliminating
the need for absorption, metabolism, or bowel
elimination
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
14
Parenteral Nutrition (cont’d)


Also known as total parenteral nutrition (TPN)
or hyperalimentation
Formulations vary according to individual
patient nutritional needs




Amino acids
Carbohydrates
Lipids
Trace elements
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
15
Parenteral Nutrition (cont’d)

Amino acids




Nonessential amino acids
Essential amino acids
Semi-essential amino acids
Trace elements


Chromium
Iodine


Copper
Manganese
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
16
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
17
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
18
Parenteral Nutrition (cont’d)

Peripheral total parenteral nutrition



Temporary, short term (less than 2 weeks)
Dextrose concentration generally less than 10%
Central total parenteral nutrition


Long-term use (over 2 weeks)
Dextrose concentrations may be 10% to 50%, but
are commonly 25% to 35%
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
19
Peripheral TPN


Used to provide nutrients to patients who
need more nutrients than present oral intake
can provide
Indicated for:





Procedures that restrict oral feedings
Anorexia caused by chemotherapy or radiation
treatments
GI illnesses that prevent oral food intake
Postsurgical patients
When nutrition deficits are minimal, but oral
nutrition will not be started for more than 5 days
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
20
Peripheral TPN:
Adverse Effects

Phlebitis is the most devastating adverse
effect


Can lead to loss of a limb
Fluid overload
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
21
Central TPN

Delivered through a large central vein



Subclavian
Internal jugular
Long-term use (more than 2 weeks)
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
22
Central TPN (cont’d)


Disadvantages are the risks associated with
central line insertion, use, and maintenance
Higher risk for infection, catheter-induced
trauma, metabolic alterations
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
23
Central TPN (cont’d)

Delivers total dietary nutrients to patients who
require nutritional supplementation



Patients with large nutritional requirements
(metabolic stress or hypermetabolism)
Patients who need nutritional support for more
than 2 weeks
Patients who are unable to tolerate large fluid
loads
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
24
Central TPN:
Adverse Effects

Most common are those surrounding the use
of the central line for the delivery of TPN



Infection
Catheter-induced trauma
Greater chance for hyperglycemia because of
the larger and more concentrated volumes
given
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
25
Nursing Implications


Ensure that a complete nutritional
assessment is taken, including a dietary
history, weekly and daily food intakes, and
weight and height measurements
Consult with a registered dietitian
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
26
Nursing Implications (cont’d)




Assess baseline laboratory studies, such as
total protein, albumin, BUN, RBC, WBC,
cholesterol, and so on
Collect anthropometric data
Assess for allergies to components of enteral
nutritional supplements (such as whey, egg
whites)
Assess for lactose intolerance
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
27
Nursing Implications (cont’d)


If administering enteral nutrition by tube
feedings, follow facility policy for ensuring
proper tube placement and for checking
residual before giving a feeding
Follow procedures for flushing tubing to
prevent clogging the feeding tube with
formula
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
28
Nursing Implications (cont’d)



Carefully monitor how the patient is tolerating
enteral feedings
Keep in mind that most enteral feedings are
started slowly, and the rate is increased
gradually
Monitor for signs of lactose intolerance




Cramping
Diarrhea
Abdominal bloating
Flatulence
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
29
Nursing Implications (cont’d)


Follow facility policies and procedures for
care and maintenance of TPN IV lines,
including tubing and dressing changes
Monitor patient’s temperature; report any
increase immediately
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
30
Nursing Implications (cont’d)


Monitor blood glucose levels with a
glucometer
Monitor for hyperglycemia


Headache, dehydration, weakness
Monitor for hypoglycemia

Cold, clammy skin, dizziness, tachycardia, tingling
of the extremities
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
31
Nursing Implications (cont’d)



While on TPN, the pancreas provides
increased amounts of insulin to cover the
increased glucose levels
If TPN is discontinued abruptly, rebound
hypoglycemia may occur until the pancreas
has time to adjust to changing glucose levels
If TPN must be discontinued abruptly, then
infuse 5% to 10% glucose to prevent
hypoglycemia
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
32
Nursing Implications (cont’d)

Monitor for fluid overload while on TPN

Weak pulse
 Hypertension
 Tachycardia
 Confusion
 Decreased urine output
 Pitting edema

Monitor daily weights and intake and output
volumes
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
33
Nursing Implications (cont’d)

Monitor for therapeutic responses to
nutritional supplementation



Improved well-being, energy, strength, and
performance of activities of daily living
Increased weight
Laboratory studies that reflect a more positive
nutritional status
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
34