MEDICAL NUTRITION THERAPY

Transcription

1 MEDICAL NUTRITION THERAPY

2 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

3 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

4 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

5 Fluid Requirements Normal unless underlying disease requires restriction Estimation of requirements: Monitor daily for signs of edema (overloading can cause pulmonary edema)

6 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.

7 Inflammation Modulating Diets High EPA found in fish oil High GLA found in borage oil High antioxidants

8 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

9 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

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11 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

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14 Nutritional Support Therapy Start nutrition support early Monitor for Refeeding Syndrome Continually monitor weight and use indirect calorimetry to estimate energy needs

15 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

16 Oxygen Oxygen required for proper digestion and absorption of food Inadequate Oxygen can cause: anorexia early satiety malaise bloating constipation diarrhea May lead to energy deficiency

17 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

18 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

19 Quality of Life Good prognosis=good Quality of life Possible side effects one year after discharge: Muscle wasting and weakness most common side effectswhy? Shortness of breath, cough, need for oxygen therapy Majority have full recovery of lung function Side effects normally abate after a year

20 Quality of Life Cognitive Impairment Anxiety Depression

21 CASE STUDY

22 Case Study Client name: Daishi Hayato DOB: 7/14 Age: 65 Sex: Male Education: Bachelor's degree Occupation: Retired manager of local grocery chain Hours of work: N/A Household members: Wife age 62, well; four adult children not living in the area Ethnic background: Asian American Religious affiliation: Methodist Referring physician: Marie McFarland, MD (pulmonary)

23 Lung Function of Case Study With decreased lung function. This means what for the individual? His lung function: 36 bpm. What can he expect?

24 Claudication Pain 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

25 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.

26 NUTRITION ASSESSMENT OF CASE STUDY

27 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

28 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

29 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.

30 Medical Intervention Endotracheal Intubation Positive pressure ventilation Volume-cycled ventilator of 15 breaths/minute Mask used to ventilate Pt with high-flow oxygen

31 Nutritional Intervention Increase protein to g/kg (83-11g protein) Monitor K, Ca, and Mg Ensure adequate calorie intake Needs g protein Estimated BEE 1275 kcal, TEE 1658kcal If po intake is not enough, use enteral feeding Oxepa

32 Monitor and Evaluation (Monitor) Monitor understanding of weight loss, appetite, and health. (Evaluation) Further weight loss or gain. Loss, or regain of appetite.