medical nutrition therapy - shannon adair's dietetic...
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MEDICAL NUTRITION THERAPY
Goals of Nutritional Care
Meet basic nutrient requirements
Preserve LBM
Restore respiratory muscle mass and strength
Maintain fluid balance
Improve resistance to infection
Facilitate weaning
Nutritional Needs
Body fluctuation is common
Many patients lose significant amounts of weight
Increased energy needs measured by indirect calorimetry (HB okay at first)
Nutritional needs vary widely based on the underlying condition
Nutritional Needs ctd.
Protein:
typically in negative Nitrogen balance
1.5-2g/kg
be careful because PN and EN proteins and amino acids affect the RQ
Water, CHO, and fat requirements determined by the underlying condition
Fluid Requirements
Normal unless underlying disease requires restriction
Estimation of requirements:
Monitor daily for signs of edema (overloading can cause pulmonary edema)
Micronutrient Needs
Micronutrients:
Meet RDI’s of most nutrients
Carefully monitor minerals that are electrolytes due to respiratory alkalosis and acidosis
K, Ca, and Mg are often lost in urine as a side effect of medicines.
Inflammation Modulating Diets
High EPA
found in fish oil
High GLA
found in borage oil
High antioxidants
The Use of an Inflammation-Modulating Diet in Patients With Acute Lung Injury or Acute Respiratory Distress
Syndrome: A Meta-Analysis of Outcome Data
Inflammation modulating diets:
Reduced risk of developing new organ failure
Decreased time on mechanical ventilation
Decreased ICU stay
Decreased mortality
Oxepa
High EPA, DHA, and GLA decreases:
immune response
inflammation in the lungs
neutrophils and total cell count in lungs
Converts cell membrane to less inflammatory profile
Oxepa Only IEF proven to work. Clinically shown to:
decrease pulmonary inflammation and edema
facilitate pulmonary vasodilation
decreased time on ventilators
improve oxygenation
reduce new organ failures
lower mortality rates (by 19.4%)
earlier exit from ICU
Nutritional Support Therapy
Start nutrition support early
Monitor for Refeeding Syndrome
Continually monitor weight and use indirect calorimetry to estimate energy needs
Feeding Strategies
Patients who are not intubated or have tracheostomies can meet requirements by mouth
Feed them small, frequent portions of their favorite foods to increase oral intake
Monitor for appropriate calorie levels and AMDR
OxygenOxygen required for proper digestion and absorption of food
Inadequate Oxygen can cause:
anorexia
early satiety
malaise
bloating
constipation
diarrhea
May lead to energy deficiency
Feeding Strategies ctd.Many patients require tube feedings
GI feedings preferred
Aspiration and bacterial overgrowth
continuous feeding
tube placement in duodenum
use small-bore NG tube
elevate chest at least 45 degrees
frequent evaluation of gastric residuals
Prognosis
Outlook Good
Lung Function likely returns to normal within 3-6 months. Can take up to a year for some
35% fatal as compared to 50-70% mortality rate from 20 years ago
Trauma infection patients fair better than sepsis
Quality of LifeGood prognosis=Good Quality of life
Possible side effects one year after discharge:
Muscle wasting and weakness most common side effects-why?
Shortness of breath, cough, need for oxygen therapy
Majority have full recovery of lung function
Side effects normally abate after a year
Quality of Life
Cognitive Impairment
Anxiety
Depression
CASE STUDY
Case StudyClient name: Daishi HayatoDOB: 7/14Age: 65Sex: MaleEducation: Bachelor's degreeOccupation: Retired manager of local grocery chainHours of work: N/AHousehold members: Wife age 62, well; four adult children not living in the areaEthnic background: Asian AmericanReligious affiliation: MethodistReferring physician: Marie McFarland, MD (pulmonary)
Lung Function of Case Study
With decreased lung function. This means what for the individual?
His lung function: 36 bpm.
What can he expect?
ClaudicationPain and/or cramping in the lower leg due to inadequate blood flow (oxygen) to the muscles
Usually causes the person to limp
Pain can be mild to extremely severe
Most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms
Occurs while walking and is relieved by rest
Can also affect the arms
Bruits
The term for the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery when the sound is auscultated with the bell portion of a stethoscope.
NUTRITION ASSESSMENT OF CASE
STUDY
Assessment
History of emphysema, COPD for many years secondary to chronic tobacco use
Pt was working in yard and could not breathe Wife brought to emergency room
Had tension pneumothorax in the left lung
Has distended jugular veins and trachea shifted to the right
Harsh breathing sounds from right lung and none from left
The patient has lost 13# and has been experiencing a decrease in appetite
Assessment ctd.
UBW 135# and current body weight 122#
Current BMI: 21
Biggest meal is breakfast and usually does not consume very much throughout the day
Each meal he drinks hot tea w/milk and sugar
Nutrition Diagnosis
Unintentional weight loss related to poor appetite and increased energy expenditure as evidenced by patient report of a loss of 13 pounds from his usual body weight.
Medical Intervention
Endotracheal Intubation
Positive pressure ventilation
Volume-cycled ventilator of 15 breaths/minute
Mask used to ventilate Pt with high-flow oxygen
Nutritional Intervention
Increase protein to 1.5-2 g/kg (83-11g protein)
Monitor K, Ca, and Mg
Ensure adequate calorie intake
Needs 92-123g protein
Estimated BEE 1275 kcal, TEE 1658kcal
If po intake is not enough, use enteral feeding
Oxepa
Monitor and Evaluation
(Monitor) Monitor understanding of weight loss, appetite, and health.
(Evaluation) Further weight loss or gain. Loss, or regain of appetite.