Assessment of nutrition status, enteral

and parenteral nutrition

Emmanuel Mang’ombe
UDOM
 Assessment of nutrition status

• In community pharmacies, pharmacists

routinely counsel patients on matters of
nutrition
• It is well recognized that poor dietary choices
contribute to obesity and many chronic
conditions, including hypertension, coronary
heart disease, sleep apnea, and type 2
diabetes mellitus
 Body Mass Index (BMI)

• The initial phase in managing the overweight

or obese patient is an assessment of the
degree of excessive weight
• Body mass index (BMI) is accepted as the
clinical standard or judging excessive weight
and obesity
• BMI is defined as body weight in kilograms
divided by the square of height measured in
meters
• According to the National Institutes of
Health(NIH),individuals with a BMI (kg/m2)
• ≤18.5 (kg/m2) is considered underweight
• 18.5 to 24.9 (kg/m2) is considered normal
• 25.0 to 29.9 (kg/m2) is considered overweight
• 30.0 to 39.9 (kg/m2) is considered obese
• ≥40 (kg/m2) is considered extremely obese
• Calculate the BMI of a person 4 feet 11 inches
in height and weighing 98 lb
• Calculate the BMI of a person 6 feet 0 inches
in height weighing 210 lb
 Enteral and parenteral nutrition

• Pharmacists are increasingly involved in

providing enteral and parenteral nutrition
services in the institutional as well as in the
home care setting
• In this role, pharmacists may take part in the
selection o the nutritional formula, prepare
the product or use, and/or participate in its
administration
 Enteral nutrition

• Enteral nutrition is a method of providing

nutritional support via tubes inserted into the
stomach or small intestine
• It finds application in patients who have an
inability or decreased ability to ingest
nutrients by mouth
• Nasogastric tubes may be used, or tubes may
be inserted through surgical openings into the
stomach, duodenum, or jejunum
• Enteral nutrition may be used for total
nutrition, or supplemental nutrition, or as a
transitional phase for patients transitioning
from parenteral nutrition
• Enteral nutrition takes into account a patient’s
caloric requirements and his or her need for
protein, carbohydrate and fat, vitamins and
minerals, dietary fiber, electrolytes, and fluids
 Parenteral nutrition

• Parenteral nutrition (PN) or intravenous

hyperalimentation (IVH or HAL) is the feeding of a
patient by the intravenous infusion of fluids and
basic nutrients
• Partial parenteral nutrition (PPN) is nutritional
support that supplements oral intake and provides
only part o daily nutritional requirements
• Total parenteral nutrition (TPN) provides all the
patient’s daily nutritional requirements
• Parenteral nutrition is used or patients who
cannot obtain adequate nutrition by oral
means
• Typically, parenteral nutrition formulas contain the
following:
• Macronutrients:
• Carbohydrate (e.g., dextrose) Protein (e.g., amino acids) Fat
(e.g., lipid emulsions)
• Micronutrients:
• Electrolytes
• Vitamins
• Trace elements
• Sterile water for injection
 Nutritional requirements

• Nutritional requirements are the quantities of

macronutrients and micronutrients needed or
a patient to obtain or maintain the desired
nutritional status
• The quantitative amounts of fluid and specific
nutrients required vary with an individual’s
age, gender, physical parameters, disease
state, and current nutritional status
 Fluid Requirements

• Total body water in adult males normally

ranges between 50% and 70% of body weight
depending on the proportion of body fat
• The greater the proportion of fat, the lesser
the proportion of water
• Values or adult women are about 10% less
than those or men
• Of the adult body’s water content, up to two-
thirds is intracellular and one-third is
extracellular
• For an adult, approximately 2500 mL of daily
water intake ( from ingested liquids and foods
and from oxidative metabolism) is needed to
balance the daily water output
• A factor of 30 to 35 mL/kg of body weight,
1500 mL per square meter of body surface
area, or 1 mL/kcal of nutrition required is
among the methods used to estimate an adult
patient’s daily fluid or water requirement
• A daily requirement o between 2 and 3 L per
day is usual or adults
 Examples

• Calculate the daily fluid requirement range for

a patient weighing 162 lb
• Calculate the daily fluid requirement for a
patient who is 5 feet 2 inches tall and weighs
114 lb
 Caloric Requirements

• The kilocalorie (kcal) is the unit used in

metabolism studies
• By definition, the kilocalorie (or large
Calorie,C,or Cal.) is the amount of heat
required to raise the temperature of 1kg of
water by 1°C
• The caloric requirements for patients vary,
depending on their physical state and medical
condition
• T he Harris-Benedict equations, which follow,
are commonly used to estimate the daily basal
energy expenditure (BEE) requirements for
nonprotein calories
• The BEE is also referred to as the resting
metabolic energy (RME) or the resting energy
expenditure (REE)
• As an alternative to the use of the Harris-
Benedict equations, clinicians can estimate
the BEE for adults as 20 to 25 kcal/kg/day for
otherwise healthy patients with mild illness,
25 to 30 kcal/kg/day for nonobese patients
with moderate illness, and 30 kcal/kg/day or
greater for severely burned patients
• Energy requirements for infants, children, and
teenagers are different than those for adults
and vary according to age, growth rate, and
clinical/ metabolic status
 Examples

• Using the Harris-Benedict equation, calculate

the BEE for a 78-year-old male patient,
measuring 5 feet 8 inches in height and
weighing 160lb
• Calculate the TDE for the patient in example
problem 1 factoring in an activity factor of 1.2
(confined to bed) and a stress actor of 1.2
(surgery)
• Calculate the BEE for the above patient using
the alternative method for 25 kcal/kg/day
 Carbohydrate Requirements

• Carbohydrates are the primary source of

cellular energy
• In formulas for parenteral nutrition, dextrose
provides 3.4 kcal of energy per gram; for
example, each 100 mL of a 25% dextrose
injection provides 85 kcal of energy
• For enteral nutrition, the factor used is 4
kcal/g
 Protein Requirements

• In TPN, protein is provided as amino acids

• The purpose of the protein support is not to
produce energy, although energy is produced
by proteins by a factor of 4 kcal/g, but rather
to build tissues and body strength
• The daily quantity of protein required in adults
is generally estimated to be;
• 0.8 g/kg/day in an unstressed patient
• 1 to 1.5 g/kg/day for most patients over 60
years old
• 1.5 to 2 g/kg/day for a patient with a critical
illness, infection, or trauma
• 0.5 g/kg/day for a patient with liver failure
 Lipid (Fat) Requirements

• Lipids may be used to provide energy when

the body cannot obtain all the necessary
energy requirement from carbohydrates
• The proportion of calories provided by lipids is
usually restricted to 20% to 40% of the total
daily calories
• Lipids provide 9 kcal of energy per gram
• Lipids are generally administered parenterally
in the form of an emulsion containing
carbohydrate-based emulsifying agents, which
also contribute to the caloric content
• It has been determined that a 10% lipid
emulsion provides 11 kcal/g of total energy for
1.1 kcal/mL, and a 20% to 30% lipid emulsion
provides 10 kcal/g of total energy (2 kcal/mL
and 3 kcal/mL, respectively)
 Fiber Requirements

• Dietary guidelines generally recommend a

daily intake of 14 g of fiber for each 1000
calories consumed
• This translates to approximately 21 to 25 g of
daily fiber for women and between 30 and 38
g for men
 Electrolytes

• The standard quantities of electrolytes may be

used or modified by the following parameter,
or other
• Sodium 1 to 2 mEq/kg/day
• Potassium 1 to 2 mEq/kg/day
• Calcium 10 to 15 mEq/day
• Magnesium 8 to 20 mEq/day
• Phosphorus 20 to 40 mmol/day
 Example Calculations of Enteral Nutrition

• The nutritional requirements for a 76-year-old

male who is 6 feet 2 inches tall and weighs
201 lb have been determined to be as follows:
• A ready-to-drink nutritional liquid product is
selected for this patient. A one-quart
container provides 37 g protein, 143 g
carbohydrates, 37 g lipids, and 1.06 kcal/mL
a) How many milliliters of the product should
this patient receive daily to meet his caloric
requirements?
b) How many grams each of protein,
carbohydrates, and lipids would this volume
provide?
c) If the product contains 85% free water, does
it meet the patient’s daily water
requirement?
d) If the formula is to be delivered continuously
over a 24-hour period, what would be the
flow rate in mL/h?
e) If the patient is to continue receiving this
formula at home by intermittent feedings
over 40 minutes every 4 hours, what volume
would be administered with each feeding,
and what would be the flow rate in mL/h?
 Example Calculations of Parenteral Nutrition

I. Calculate the TDE required using the Harris-Benedict

equations, and apply the appropriate stress or activity
actors
II. Calculate the daily quantity (g) of amino acids
(protein) required based on 0.8 g/kg of body weight
III. Calculate the number of calories supplied by the
amino acids ( from St ep 2) at 4 kcal/g. This step may
be omitted if protein calories are not included in the
TDE
IV. Calculate the kcal of lipids required at 20%
to 40% of the TDE
V. Calculate the volume of lipid emulsion
required ( from Step 4) based on 1.1
kcal/mL (10% lipid emulsion), 2 kcal/mL
(20% lipid emulsion), or 3 kcal/mL (30%
lipid emulsion)
VI. Calculate the quantity of carbohydrate
required based on 3.4 kcal/g after
accounting for the contribution of the lipids
VII.Calculate the daily fluid requirement using
30 to 35 mL/kg/day
 Examples

• Calculate the parenteral nutrition and fluid

requirements for a 58-year-old woman who is
5 feet 3 inches tall and weighs 140 lb. She is
ambulatory(activity actor=1.3)and has under-
gone surgery(stress actor=1.2).The solutions
to be used for the macronutrients are 8.5%
w/v amino acid solution, 20% w/v lipid
emulsion, and 70% w/v dextrose solution
• The formula for a TPN solution calls for the
addition of 2.7 mEq of Ca2+ and 20 mEq of K+
per liter. How many milliliters of an injection
containing 20 mg of calcium chloride
dihydrate per milliliter and how many
milliliters of a 15% (w/v) potassium chloride
injection should be used to provide the
desired additives?
• A potassium phosphate injection contains a mixture
of 224 mg of monobasic potassium phosphate
(KH2PO4) and 236 mg of dibasic potassium
phosphate (K2HPO4) per milliliter. If 10 mL of the
injection are added to a TPN solution containing
500 mL each of 7% amino acid solution and D10W
(10% dextrose in water for injection), (a) how many
milliequivalents of K+ and (b) how many millimoles
of total phosphate are represented in the prepared
solution?