Nutrition Support

GENERAL CONSIDERATION
a. Purpose of Nutrition Support - to achieve and/or maintain optimal nutritional status.
b. Indication - nutrition support is indicated for patients who:
i. Exhibit recognized nutritional deficits;
ii. Are at nutritional risk;
iii. Are in a hypermetabolic state;
iv. Have nutritional requirements that cannot be met by usual oral intake.
c. Methods - Nutrition support can be provided by:
i. Enteral feeding (oral diet supplementation or tube feeding)
ii. Parenteral feeding or
iii. A combination of enteral and parenteral feeding.

STEPS IN PROVIDING NUTRITIONAL SUPPORT

a. Assessment of nutritional status

This steps include:

i. Patient interview to obtain nutrition-related data, e.g.
1. Weight:current weight, typical adult weight,weight preferences, recent
changes, and comparison with ideal weight
2. Appetite: appetite changes and factors affecting appetite
3. Eating patterns: typical pattern and changes in eating patterns
4. Estimation of typical calorie intake and /or pertinent nutrients
ii. Physical examination for clinical symptoms of malnutrition
iii. Nitrogen balance determination, if facilities are available. The procedure
involves:
1. Determination of 24-hour nitrogen (N) intake by chemical analysis of
duplication sample of the diet;
2. Collection of 24-hour urine for analysis of urinary urea nitrogen(UUN).

N balance = N intake - UNN - (2g non-urea N losses + 2gm non-urine N losses)

iv. Somatic protein reserves evaluation

1. Ideal body weight (IBW) is established based on the patient’s height,
sex, and body frame.
2. Anthropometric measurements of arm muscle circumference using
upper dominant arm
a. Midpoint is determined between the acromion structure of the
scapula and the olecranon structure of the ulna.
b. Midupper arm circumference (MAC) is measured in
centimeters.
c. Triceps skinfold (TSF) is measured in millimeters using an
accurate skinfold caliper such as the Lange.
d. Arm muscle circumference (AMC) is calculated using the
formula:
AMC = MAC cm. - (TSF mm. X 0,10 ​ñ) or MAC cm. - (0,314 x TSF)

3. creatinine/height index (CHI) may be used as an assessment of lean

body mass. This involves:
a. 24-hour urine collection for determination of total creatinine (U
Cr)
b. Determination of ideal U Cr: may be obtained form a table or
calculated as follows:
Men: 23mg/kg IBW
Women: 18mg/kg IBW

Actual U Cr
CHI =​ x 100
Ideal U Cr
v. Biochemical measurements to determine extent of depletion of visceral
protein reserves (normal values may vary with different institutions).
1. Albumin
a. Normal 3.5-5.0gm/dl
b. Severe depletion <3.0 gm/dl
2. Total iron binding capacity (TIBC)
3. Transferrin
4. Total lymphocyte count (TLC). A complete count (CBC) with
differential will provide data on white blood cells (WBC) and %
lymphocytes.

W BC x % lymphocytes
TLC =​
100
a. Normal >1500
b. Severe depletion <900

vi. Cell-mediated immune function tests (e.g. use of skin test antigens for
delayed hypersensitivity reaction)
1. Skin test battery is applied intradermally using four or fice common
recall antigens.
2. Diameter of the induration is measured at 224, 48, and (if desired) 72
hours.
3. Interpretation of response:

Cellular immunity: a positive response to one or more antigens.

Anergy:L a negative response to all antigens (a diameter of <10mm indicates a negative
response)

vii. Determination of physiological changes with implications on nutritional

Assessment, e.g.:
changes implications /interventions

Decreased basal metabolic rate. Decreased caloric need, but foods that are
eaten must be high in nutrients.

Decreased muscle mass, decreased Balanced diet in combination with adequate

skeletal structure, increased fat stores. exercise may be beneficial. Adequate
calcium intake is important to prevent
osteoporosis.

Decreased biting, chewing ability, These changes may result in decreased

decreased sense of taste and smell,
decreased saliva, decreased
neuro-muscular control, changes in
esophageal function
ability to ingest food and decreased
emotional satisfaction with eating.
Encourage foods that are nutritious, as well
as soft, moist, and easy to chew. Assure
proper positioning of patients for eating.

Decreased gastric secretions and motility There may be digestive and absorptive
problems in some individuals.

Decreased muscle tone and motor function Constipation may occur. Encourage
of large bowel. adequate fiber and fluid in diet. Encourage
exercise within individual limitations. Mild
laxatives may be used when appropriate.

Decrease renal function Dehydration can occur more quickly in older

adults. Encourage fluids/maintain adequate
fluid balance.

Many older adults have one or more chronic Chronic illness may affect dietary intake
illnesses. because of prescribed special diet,
medications (possible food/drug
interactions) or limited mobility.

viii. Psychological assessment to determine factors which may affect food intake,
hence nutritional status.

Categories of nutritional status

1. Well nourished
2. Protein malnutrition, kwashiorkor-like
3. Nutritional marasmus
4. Severe protein-calorie malnutrition (PCM), kwashiorkor-marasmus mix

B. Planning Nutritional support

This involves determination of nutritional requirements, goals and management

 Categories of Nutritional Status and Management

Nutritional Status examples Goal Nutritional

Management

No nutritional Stroke; Neutral N balance Dependent on

deficits but clinical chemotherapy or appetite and GI
condition places the radiation therapy; function: diet
person at nutritional greater than 5 days supplementation,
risk NPO enteral or parenteral
feeding or a
combination of
nutrient
requirements.

Somatic and/or Anorexia nervosa; 4+ to 6+ N balance Enteral or parenteral

visceral protein cachexia PCM hyperalimentation:
deficits 40-45 kcal/kg DBW;
1.5-2gm pro/kg
DBW

Hypermetabolic with Trauma; burns; Neutral to > + 4 N Enteral or parenteral

or without nutritional surgery; infection balance, depending hyperalimentation:
deficits on need for tissue up to 55Kcal/kg
repair DBW; over 2gm
pro/kg DBW.

C. Implementation of Nutritional support

D. Monitoring and Evaluation
The monitoring and evaluation of Enteral feeding essentially follow the same
procedures as for any nutritional care plan.

PRINCIPLES OF ENTERAL NUTRITION

a. Definition: provisions of ntrutient via the gastrointestinal tract: includes oral and tube
feeding but more commonly used to refer to the latter.

Modes of enteral support

1. Oral supplementation - suitable for persons who are able to meet nutritional
requirements through solid food.
a. Types of oral supplementation
i. Nutritionally complete with lactose: powders (designed to be mixed
with water) or liquid containing milk
ii. Nutritionally complete, lactose-free: powders (designed to be mixed
with water) or lactose-free liquids
iii. Substrate modules: individual sources of carbohydrate, protein, or fat
designed to be mixed with other supplements (or with food) to
increase the nutrient content of the diet.
b. Effectiveness of oral supplementation depends on individual acceptance.
 c. Problems encountered in oral supplementation
i. Diarrhea
ii. Bloating
iii. Retention
2. Tube feeding - a form of enteral nutrition support designed to provide adequate
nutrition in a form that can be administered through a tube, used for persons who are
unable to tolerate an oral diet or who have inadequate oral intake and have a
functioning gastrointestinal tract.

Benefits of enteral over parenteral feeding

Enteral feeding has the following advantages:
1. Intraluminal effect. The presence and absorption of nutrients in the GIT help prevent
atrophy of the intestinal mucosa.
2. Safety. There is less chance of infection and fluid electrolyte imbalance if the
gastrointestinal tract is used as opposed to direct infusion of the nutrients into the
veins.
3. Normal insulin-glucagon ratio. Absorption of carbohydrates through the intestines
helps to keep the blood levels of glucagon and insulin normal
4. Reduced cost. Feeding by the enteral route requires less staff and equipment than
parenteral nutrition.

b. contraindications
Enteral nutrition is contraindicated when there is need to rest the GIT or where there
is altered GIT integrity and/or function, such as in”
1. Diffuse peritonitis
2. Intestinal obstruction
3. Intractable vomiting
4. Paralytic ileus/hypomotility of the intestine
5. Severe diarrhea with or without malabsorption
6. Gastrointestinal bleeding
7. Certain small bowel fistulas
8. Severe acute pancreatitis
9. Shock
10. Client (or legal guardian) does not desire aggressive nutrition support
11. Prognosis does not warrant enteral support

In such cases, parenteral feeding is used to provide nutritional support

c. Factors to consider in tube feeding

1. Conditions indicating tube feeding or special enteral formulas

condition examples

a. psychiatric/eating disorders, when Anorexia nervosa

patient refuse or cannot take food by Severe depression
mouth Dementia or alzheimer’s disease
 insanity

b. Impaired swallowing Central nervous system disorders

Cerebrovascular accident
Neoplasms affecting central nervous
system
Trauma
Inflammation
Demyelinating disease
Coma
Motor disorders of the esophagus
Cerebral palsy

c. Increased nutritional losses or Fever and infection

needs Sepsis
Surgically or medically related stresses
Cancer
AIDS
Severe undernutrition
Cachexia
Burns

d. Gastrointestinal disorders Gastrointestinal diseases associated with

malabsorption
Short-bowel syndrome
Inflammatory bowel disease
Bile acid-induced diarrhea
Pancreatitis (without ileus)

e. Oropharyngeal-esophageal Oropharyngeal-esophageal neoplasms

disorders Inflammations
Maxillofacial fractures or other types of
trauma
Head and neck radiation
Radical-head and neck surgery
Chemotherapy
Esophageal obstruction

f. Specialized nutritional needs Renal failure

Liver failure
Respiratory failure
Chemotherapy
radiotherapy

g. Chronic obstructive pulmonary Cystic fibrosis

disease Respirator-dependent patients

h. Other conditions characterized by Supplement to parenteral or oral feeding

inadequate oral/parenteral intake Impaired nutritional status
Geriatric conditions
prematurity/growth failure in infants
 Inborn errors of metabolism/congenital
anomalies in infants

2. Routes of Access
a. Nasoentric feeding tubes
i. Nasogastric - tube extending from nose into the stomach
ii. Nasoduodenal - tube extending from the nose through the pylorus into
the duodenum
iii. Nasojejunal - tube extending from the bose through the pylorus into
the jejunum: placed radioscopically.
b. Tube enterostomy - surgical incision is necessary and tube placement often
done at time of other surgical procedures.
i. Esophagostomy - surgical opening into the neck through which a
feeding tube is packed into the esophagus and down into the stomach
ii. Gastrostomy - placement of tube into the stomach
iii. Jejunostomy - types include needle catheter placement, direct tube
placement and creation of a jejunal stoma which can be intermittently
catheterized.
c. Percutaneous endoscopic gastrostomy
i. Under endoscopic guidance, a feeding tube is percutaneously placed
into the stomach and secured by rubber “bumpers" or an inflated
balloon catheter.
3. Properties of enteral nutritional formulations
a. Osmolality
b. Digestibility
c. Caloric density
d. Lactose content
e. Viscosity
f. Fat content
4. Types of enteral formulations
Types/indication for use Characteristics

a. Intact formulas (polymeric formulas) - Also called “Meal replacement

For patients who are able to digest and
absorb nutrients without difficulty.
● Standard polymeric formulas
● High nitrogen polymeric formulas
● Fiber-containing formulas
● Blenderized formulas
formula”
- Lactose free; low osmolality
- Lactose free; low to moderate
osmolality;
- Designed to meet increased protein
demands.
- Contain fiber from natural food
sources or formo added soy
polysaccharide; lactose free; low
osmolality.
- Composed of a mixture of ordinary

b. Hydrolyzed formulas
(predigested/monomeric) or
elemental formulas
For patients who cannot digest
certain nutrients or who have
smaller than normal areas for
absorbing nutrients.
c. Modular formulas
For patients who have specific
metabolic or fluid imbalances that
preclude the administration of a
standard formula
d. Specialty formulas
For patients who require different
proportions or types of protein,
amino acids, carbohydrate, fat, and
electrolytes (i.e. patients with liver,
renal, and pulmonary diseases and
diabetes)
5. Guidelines for route of administration
a. Patient symptomatology or clinical status
b. Mechanical considerations
c. Economical considerations
6. Selection of enteral formula according to patient’s clinical status
Clinical status
● Normal Gi tract, normal metabolic
rate
● Inability to eat (such as CVA,
anorexia, esophageal/oropharyngeal
surgery)
● Increased metabolic rate
● Abnormal GI tract (such as
pancreatic insufficiency, short bowel
syndrome,, enterocutaneous fistula,
inflammatory bowel disease)
foods (meat fruit, vegetable, whole
or nonfat dry milk solids) with oils,
vitamins and minerals added as
necessary; usually contain lactose;
high viscosity; moderate osmolality.
- Usually hyperosmolar; lactose free;
generally low in total fat and may
contain branched-chain amino
acids;
- Have unpleasant taste; more
expensive than standard formulas
with intact nutrients
- Composed of single predigested
nutrients (e.g. protein, carbohydrate
or fat), may be added to another
formula;
- Do not contain vitamins, minerals,
and electrolytes and may require
supplementation of these.
- Some are unpalatable; most are
very expensive;
- May be constructed from modular
formulas.
Recommended enteral formula
- Polymeric (preferably lactose-free
such as isocal or ensure) or
modular.
- Polymeric, lactose-free, preferably
isotonic.
- Larger quantities of the above
- Monomeric solutions such as flexical
and vivonex
 7. Technical aspects of enteral feeding
a. Continuous infusion rate or bolus feedings
b. Head elevated 30 degrees
c. Flush catheter with water or saline when stopping feeding
d. Monitor as patients on TEN
8. Feeding administration methods
a. Continuous drip. Tube feeding is administered at a constant, steady rate
usually over a 24-hour period. Use of an infusion pump is recommended as
accuracy of volume delivered is assured. However, most enteral feedings can
be administered by gravity.
b. Intermittent infusions. The feedings are usually given by gravity frip over a
30-minute to 1-hour time span.
c. Bolus feedings - refers to rapid instillation of a feeding into the Gi tract by
syringe or funnel.
9. Common complications of tube feeding and their management

Common complications corrective/preventive measures

a. Mechanical problems
i. Occlusion or clogging of the - Irrigate feeding tube regularly with
feeding tube warm water or with saline or other
solutions: (a) before and after a
feeding; (b) when feeding apparatus
is being changed; (c) when
administering medications; or, (d)
every 8 hours when feeding is
administered by continuous infusion
ii. Misplacement of feeding - Verify tube location (through air
tube auscultation, residual checks and
periodic x-rays) before feeding is
begun and recheck at regular
intervals.
iii. Skin irritation around feeding - Daily care of the ostomy site;
ostomy site prevent leakage around the tube
opening, keep the tube stabilized.
And check the tube position
regularly.
b. Physical problems
i. Diarrhea - Start with a dilute formula and
progress gradually to the
appropriate concentration, and
feeding rate.
- Observe proper hygiene in the
preparation, storage, and delivery of
formulas to prevent bacterial
contamination
- Administer antidiarrheal and
anti-spasmodic medications, if
infectious origin has been ruled out.
 ii. Constipation, nausea and - Reduce feeding rate and determine
abdominal distention and the cause.
discomfort
iii. Vomiting - Stop the feeding immediately and
consult the physician
iv. Aspiration of tube feeding - Elevate the patient’s head at least
formula 320 to 45 degrees: position the tube
into the small intestine; and check
frequently the gastric residual with
subsequent adjustment in the
feeding plan.
- Use appropriate drugs to increase
gastric emptying.
c. Metabolic Problems
i. Electrolyte and metabolic - Monitor regularly fluid, electrolyte
abnormalities (i.e. and metabolic parameters, and
hyperglycemia, hypokalemia, adjust formula accordingly.
hypophosphatemia, etc.)
ii. dehydration - Provide adequate fluids

10. Advantages and disadvantages of blenderized tube feedings.

advantages disadvantages

a. Less costly a. Special equipments are needed,

b. Increased amounts of fiber can be
provided
c. Sense of “being different” is
lessened since the patient can use
the same table foods as his or her
family.
such as blender, measuring utensils,
refrigeration facilities.
b. Blenderized feedings require more
time and energy to prepare than
commercial products.
c. Feedings must be prepared daily
d. Daily ingredient selection must be
carefully made to ensure nutrition
adequacy of diet.
e. May need vitamin and mineral
supplementation
f. Likelihood of contamination if
sanitary procedures in preparation
and storage are not observed.

All efforts must be exhausted to feed the patient by mouth with a standard diet with
supplements, if necessary, before resorting to enteral tube feeding. Initiating tube feeding,
the patient’s specific nutritional needs should be identified through a thorough nutritional
assessment and identification of conditions that warrant the need for tube feeding.

11. Characteristics of an ideal enteral formula

In addition to the previously discussed factors in selecting the most appropriate formula for a
specific condition, the following are the general characteristics of an ideal enteral formula:
 a. Low cost
b. Bacteriologically osmolality
c. With caloric density equivalent to 1kcal/ml for standard adult formulas and ⅔ kcal/ml
for most infant formulas
d. With suitable calorie to nitrogen ratio for stressed patients; recommendation is
between 120kcal: 1gm N and 180 kcal: 1gm N (1 gm N = 6.25gm of protein
equivalent);
e. Nutritionally adequate and balanced; with additional vitamins, minerals, and
electrolytes when indicated;
f. With suitable viscosity and homogenization
g. Convenient and easy to administer.

12. Rationale and benefits of early enteral feeding

a. Physiologic
i. More effective nutrient metabolism and utilization; small bowel
function is usually maintained; “when the gut works and can be use
safely, use it!”
b. Immunologic
i. Advantages of first-pass metabolism: liver serves as mediator for
substrate metabolism
ii. Maintain gut integrity; prevents bacterial translocation and minimize
risk of gut related sepsis.
c. Biochemical
i. Glutamine: the preferred gut fuel during catabolism: most enteral
formula protein substrates contain glutamine or glutamate and
minimize atrophy of the intestinal villi.
ii. Fiber containing formulas
Fermentation of metabolizable fiber by bacteria → SCFA → intestinal
and colonic growth
d. Metabolic: lesser catabolic response; vasoactive agents such as gastrin and
growth hormone may affect intestinal permeability and gut integrity, glucagon
helps regulate glutamine metabolism in the gut and liver, stimulates
production of specific hormones beneficial for the proliferation of gut mucosal
cells.
e. Administration safely: cost

13. Termination of tube feeding

Once the patient is on the road to recovery, termination of tube feeding is best
accomplished by gradual weaning characterized by increasing oral intake and decreasing
the volume of the formula. The patient can either eat or drink the formula that was earlier
given by tube. Records of daily oral intake are important during this period to ascertain that
oral intake is adequate.

Monitoring and evaluation

The monitoring and evaluation of enteral feeding essentially follow the same
procedures as for any other nutritional care plan
PARENTERAL NUTRITION
a. Definition - delivery of nutrients by-passing the gastrointestinal tract e.g.
intravenously. It is:
i. Designed for individuals who can neither accept nor assimilate nutrients given
enterally because of non-functioning GI tract
ii. A team effort involving the doctor, nurse, pharmacist and nutritionist-dietician.
1. The role of the ND is in assessing the patient’s nutritional needs and
monitoring is nutritional status

b. Routes of parental Feeding

1. Peripheral vein route - is used for patients with mild to moderate nutritional
deficiencies and those at risk of deficiencies. Peripheral vein nutrition
provides calories and nitrogen on a temporary basis. Uses include:
a. A calorie and nitrogen source for supplementary use with an oral diet
when a person will not accept oral supplements.
b. Additional calories and nitrogen while a person is being weaned onto
enteral or parenteral hyperalimentation
c. Short-term maintenance calories and nitrogen for a person who is
not hypermetabolic bt is taking nothing by mouth
Peripheral vein nutrition is unable to withstand hypertonic solution given peripherally,
such nutrition provides 1400 to 2400 kcal/day via amino acids, low concentrations of
dextrose (up to 10%) and appropriate additives infuse with fat emulsion.
2. Parenteral hyperalimentation (intravenous hyperalimentation IVH) - is an
intravenous feeding system designed to provide nutrients in sufficient quality
and quantity to persons who cannot or should not be fed through the
gastrointestinal tract.
c. Total parenteral nutrition(TPN) - designed for patients with increased nutritional
requirements and need parenteral nutrition support longer than 5-7 days.
1. Indications for TPN are:
a. Patients with inability to absorb nutrients via the GI tract, as in e.g.:
i. Massive bowel resection;
ii. Diseases of the small intestines;
iii. Radiation enteritis
iv. Severe diarrhea;
v. Intractable vomiting
b. Patients undergoing high-dose chemotherapy, radio-therapy or bone
marrow transplant.
c. Moderate to severe pancreatitis
d. Severe malnutrition in the face of non-functioning GIT
e. Severely catabolic patient with or without malnutrition when the GIT is
not usable within 5-7 days.
2. Components of total parenteral nutrition
Central venous total parenteral nutrition (TPN) can provide over 2400
cal/day. The hyperacaloric solutions are delivered through a silicone catheter inserted into
the subclavian vein and running through the superior vena cava into the right atrium. The
catheters are inserted at bedside, using strict aseptic technique, or in the operating room.
Following a surgical procedure:
a. Energy sources
Carbohydrate and fat are the principal calorie sources. For central venous infusions
final dextrose concentration of admixtures can range from 15% to 35. When fat is
used it can supply between 10% to 50% of the calories. (Because fat will not remain
stable if mixed with the amino acid-dextrose solution, it is infused at the same time
through a Y-connector, close to the infusion site).
● Dextrose. Adult TPN solutions are generally 40-70% dextrose. The larger
central vein can handle highly concentrated sugar. Exceptions:
hyperglycemia, respiratory failure when dextrose is decreased and fat
increased.
b. Lipids
Lipids provide essential fatty acids and kcal. About 4-10% of kcal from lipids will
prevent essentially fatty acid deficiency (EFAD). IV fats may be given periodically
(often two 500ml bottles per week) or during one shift daily to provide needed
calories. Fat isotonic and does not contribute to the osmolarity of the solution. Fat
emulsions provide lipids form egg yolk, phospholipids, and/or glycerol
● A 10% fat emulsion gives 1.1 kcal/cc or 550 kcal/500 cc bottle
● A 20% fat emulsion yields 2kcal/cc or 100kcal/500 cc bottle
● The maximum TPN lipids for adults is 2.5g kg body weight.
c. Nitrogen
With adequate caloric administration, 15 to 23g/day of nitrogen (equal to 94-144g
protein) in the form of amino acids are usually sufficient to meet the patient’s protein
needs.
d. Vitamins. Appropriate doses are added directly to the amino acid-dextrose admixture.
e. Electrolytes and trace elements are added to the amino acid-dextrose admixture.
f. Insulin. Some patients require insulin to maintain normal blood glucose when
receiving highly concentrated dextrose solutions. The appropriate insulin dose is
generally added directly to the amino acid-dextrose infusate. Intramuscular or
subcutaneous insulin is not recommended, as either can cause large serum glucose
fluctuations.
g. Heparin. Adding heparin to the parenteral solution can help prevent clotting in the
subclavian catheter and in the central line itself, can also enhance fat clearance.

3. Administration of Total Parenteral Nutrition

a. Continuous
b. Cyclic TPN refers to intermittent infusion of solution over a specific
amount of time. TPN is given for 10 to 18 hours and TPN is then
discontinued. This method allows more patient mobility and should
free up more nursing time during the day.
4. Prevention to complications

Complications Preventive Measures

Problems related to catheter misplacement Confirm catheter site in superior vena cava
 by an x-ray film before starting infusion

Pneumothorax Using an x-ray film, confirm that lungs are

not collapsed during central line placement.

Air embolism Place patient in Trendelenburg position and

have patient hold breath on inspiration
during placement of catheter and when
bottles and tubing are changed.

Infections (sepsis) Use strict aseptic technique during catheter

insertion and maintenance, while changing
the tubing and filter, and during storage of
PN solution (store at 4 degree celsius)

Metabolic problem Assure accurate metabolic assessment

before initiation of infusion, appropriate total
dose, accurate infusion rate, careful
monitoring of hematologic variables.

Glucose
a. Hyperglycemia Gradually increase (over 48 hours) the
concentration of dextrose, do not try to
catch up if infusion is late, insulin coverage
may be necessary.

b. Hypoglycemia Gradually decrease dextrose concentration

before TPN is discontinued (dropping 50
ml/hour for the last 30 minutes)

Essential Fatty Acid (EFA) Deficiency Provide fat emulsion at least twice weekly
or use cyclic TPN to prevent deficiency
(amount provided can range from 500 mol
one time/week to 250ml/day)

5. Evaluation of Parenteral Feeding

a. Estimate the achievement of nutritional therapy goals
b. Judge the accuracy of the intervention actions.