You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > REHABILITATION PROTOCOLS Nutritional Management in the Rehabilitation SettingArticle Last Updated: Sep 24, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Segun T Dawodu, MD, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School, Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain & Sports Medicine Associates Segun T Dawodu is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine, and Royal College of Surgeons of England Coauthor(s): Daniel D Scott, MD, Program Director, Department of Rehabilitation Medicine, Associate Professor, University of Colorado Health Sciences Center; Marcie Chase, BS, RD, Clinical Dietitian, Department of Nutrition and Foodservice, Veterans Affairs Medical Center, Denver, Colorado Editors: Milton J Klein, DO, MBA, Consulting Physiatrist, Sewickley Valley Hospital, Allegheny General Hospital, Harmarville Rehabilitation Center, Ohio Valley General Hospital and Aliquippa Community Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center Author and Editor Disclosure Synonyms and related keywords: enteral, parenteral, enteral nutrition, parenteral nutrition, total parenteral nutrition, TPN, peripheral parenteral nutrition, PPN, Harris-Benedict formula, basal energy expenditure, actual body weight, ideal body weight, Body Mass Index, BMI, malnutrition INTRODUCTIONSection 2 of 9
  Nutrition in a rehabilitation setting often involves patients who could be on either end of the nutritional spectrum, with debilitated patients who are undernourished at one end, and patients who have recently been admitted for complications of obesity, such as coronary artery disease and stroke, at the other end. In between are patients in whom current clinical conditions require optimum nutritional support for recuperation and to enable effective participation in rehabilitation exercise programs. This discussion will focus mainly on relevant nutritional issues ranging from standard nutritional intervention to aggressive nutritional support, available nutritional interventions, and the process of nutritional screening and support as they pertain to rehabilitation medicine. There is no discussion of nutritional rehabilitation per se, but some of the issues discussed are of great relevance. While nutritional support is often through the oral route, there may be instances in which this route is not available and others may need to be used. There are special nutritional issues peculiar to the elderly and mentally handicapped owing to a variety of factors, such as poor intake, poor chewing abilities, swallowing difficulties, associated debilities, and mental apathy. NUTRITIONAL SCREENINGSection 3 of 9
Malnutrition in the hospital setting exists today despite numerous advances in the medical and nutritional arenas. Surveys have found that 40-50% of patients admitted to hospitals are at risk for malnutrition and up to 12% are severely malnourished. These statistics probably represent a fair number of the patients who transfer from the acute care wards to the rehabilitation unit for ongoing treatment. These patients tend to be debilitated as well. Nutritional screening has become a primary tool to identify at-risk patients and should be performed when the patient is admitted to a rehabilitation unit. While a standard nutritional screening tool has not been established, there are several tools available that can be incorporated easily into routine clinical practice. It is often necessary at a minimum to do a mini-nutritional assessment of the patient at the point of admission into a rehabilitation unit, since poor nutritional status could lead to greater debility and an inability to fully participate in intensive in-patient rehabilitation therapies. Assessments include the following:
Screening Criteria The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifies that nutritional screening should be completed within 24 hours of admission of all hospital patients. This standard ensures that nutrition is addressed early and that intervention is provided in a timely manner and on an ongoing basis. Patients considered to be at nutritional risk may exhibit any of the following:
NUTRITIONAL ASSESSMENTSection 4 of 9
Patients who are considered to be at nutritional risk are required to undergo a comprehensive nutritional assessment, a process consisting essentially of the following 4 steps:
EVALUATION OF NUTRITIONAL STATUSSection 5 of 9
Height and weight measurements are probably the most important set of vital signs in nutritional assessment. Height A patient's height is the key component in the determination of IBW. (See information below on the determination of IBW using one of three methods). No matter which calculation method is used, IBW needs to be adjusted for frame size, spinal cord injury (SCI), and amputation, as follows:
Weight Body weight at admission is probably the most reliable weight when determining a patient's actual body weight, assuming that weight is a dry body weight. Weight status becomes an unreliable measure postoperatively or during an acute crisis, because of the administration of fluids or the development of an edematous state. As a chronic marker, one can assume that a weight gain or loss is related to an increase or decrease in lean body mass.
The following scale presents categories of the nutritional status of patients, using ABW as a percentage of IBW:
The BMI is a very practical and useful measurement that allows easy determination of categories of weight status. Table 1. Weight Classifications
Protein Status Measurements of visceral and somatic protein status are biochemical indices used to evaluate nutritional status. Visceral protein parameters include albumin, transferrin, and prealbumin. According to Charney, serum albumin is perhaps "the most studied biochemical parameter used in nutrition screening and assessment."1 Albumin is an osmotic protein that constitutes 40% of the total body protein pool of 4-5 g/kg and is maintained largely in the intravascular compartment, with the remainder distributed in extravascular tissues. The serum albumin level is not a definitive measure of visceral protein status, but it reflects the complex relationship between synthesis, degradation, and distribution. Key albumin levels are distributed as follows:
Albumin does have limitations as a nutritional marker because of its lengthy half-life of 21 days and the numerous factors that decrease albumin levels, independent of nutritional status. Non-nutritional factors that affect albumin levels include the following:
Because of its long half-life, serum albumin cannot be used effectively for monitoring acute response to nutritional therapy. Albumin levels should be included on the initial chemistry profile for nutritional screening purposes and monitored during hospitalization for visceral protein repletion trends or as a chronic marker for nutritional status. Owing to its shorter half-life (8-9 d) and smaller body pool size, transferrin makes a better nutritional marker of visceral protein status than does albumin. Normal levels of transferrin range between 200-400 mg/dL, and a level of 150 mg/dL is considered a nutritional decision point, or a point when nutritional support should be considered or adjusted. Transferrin levels are decreased in the following situations:
Transferrin levels are increased in the following situations:
The serum concentration of transferrin is about 0.8 times the total iron binding capacity (TIBC). If the direct measurement of transferrin is not possible because of the high cost and limited availability of the equipment needed, the transferrin level can be easily calculated from the TIBC, using the following formula:
The third measure of visceral protein is prealbumin, which is synthesized in the liver and catabolized in the kidney. Prealbumin has a small total body pool and a very short half-life (2 d), making it an excellent nutritional marker. Prealbumin has been used increasingly as a marker of response to nutritional therapy. Reference range values for prealbumin are from 16-35 mg/dL. A nutritionally significant value of prealbumin is 11 mg/dL. A value below this level signifies malnutrition. The failure to increase prealbumin above 11 mg/dL with nutritional therapy is an indication that nutritional needs are not being met. Concentrations should increase nearly 1 mg/dL daily or should double in a week when adequate therapy is being provided. Non-nutritional factors that decrease prealbumin include the following:
Table 2 summarizes the 3 visceral proteins in relation to the degree of malnutrition. Table 2. Degree of Malnutrition
Somatic protein measurements include the CHI and nitrogen balance studies. Protein status can be assessed biochemically by using the CHI, which measures the 24-hour urinary creatinine excretion and compares it to an ideal value based on ideal weight for height. Nitrogen Balance Studies Nitrogen balance studies measure the net change in the body's total protein. An estimate of nitrogen balance can be obtained by measuring urinary urea nitrogen (UUN) and comparing it to nitrogen intake during that same time.
If calculated nitrogen balance equals the following:
Hematological Measurements Serum hemoglobin and hematocrit may reflect a generalized state of malnutrition. As with the visceral and somatic visceral proteins, non-nutritional factors (eg, blood loss, chronic infection, overhydration) must be considered as a potential etiology of decreased serum concentrations. Malnutrition The determination of malnutrition can be categorized using the following definitions:
CALCULATION OF NUTRITIONAL NEEDSSection 6 of 9
Nutritional needs include the need for energy, the need for protein, and the need for hydration, with vitamins and electrolytes part of the essential requirements. Energy Needs Energy requirements are assessed in a variety of ways. The Harris-Benedict formula has for many years been considered the criterion standard for predicting calorie requirements in acutely ill hospitalized patients, although it may overestimate energy needs. The formula is outlined in the following sample calculations: Harris-Benedict Formula
Jeejeboy and Cerra suggest an alternative approach that uses body weight (kg) alone as the key determinant and omits the variable of age, sex, and height as used in the Harris-Benedict formula. This type of estimate has been proven to be accurate and time efficient. Another technique, using indirect calorimetry to calculate energy expenditure, employs the measurement of respiratory gas exchange. Using a metabolic cart, this method allows the measurement of VO2 to calculate 24-hour BEE, as O2 use is directly proportional to energy use in aerobic environments. This technique is useful in burn and septic patients because it allows the clinician to specialize macronutrients based on substrate use. Two groups of researchers—Ireton-Jones and Turner and Owen and colleagues—developed specific formulas for the obese patient.2, 3 Standard formulas may overestimate their needs because of the increased fat mass in this population. Protein Needs The following factors need to be considered when estimating protein needs:
Two ways to determine protein needs based on stress levels follow. Formulas Based on Stress Table 3. Blackburn's General Guide for Protein Needs Based on Stress Level
Table 4. Cerra's Guide for Protein Needs Based on Stress Level
Certain disease states have different protein requirements. Table 5. Disease States and Protein Requirements
Hydration or Fluid Needs This must be addressed within each nutritional assessment because it effects lab interpretation and nutritional intervention. Several methods exist to determine fluid requirements. The most common ones are listed below. Table 6. Fluid Requirements
(From the Manual of Clinical Dietetics, 6th ed. Chicago, Ill: American Dietetic Assn; 2000) NUTRITIONAL INTERVENTIONSection 7 of 9
Oral Nutrition When a patient is hospitalized, whether as an acute or a rehabilitation admission, oral intake is altered from the norm. Hospital food may be unacceptable, or it may be tolerable, but it is never exactly what the patient is accustomed to eating at home. Sometimes patients do eat 100% of their meals. These patients are usually the exception and are typically categorized as "not at nutritional risk." Some patients may start out in this category, but during a lengthy admission, intake can begin to decline. Nutritional intervention plans usually follow a progression from oral to enteral to parenteral. Oral nutrition is the starting point of all interventions. If the gut works, use it. Oral nutritional intervention consists of dietary change, as well as the addition of between-meal snacks and nutritional supplements. A regular diet at any facility is considered a balanced diet with respect to the major macronutrients and food groups. It meets the nutritional needs of a general population, which consist of approximately 55% of calories coming from carbohydrates, 15% coming from protein, and 30% coming from fat. The regular diet has no alterations in texture, no specialized foods, and no electrolyte/mineral restrictions. Therapeutic diets are an alteration from the regular diet. Some examples of therapeutic diets are illustrated in Table 7. Table 7. Therapeutic Diets
The goal of a prescribed diet is to optimize intake while the patient is hospitalized, to promote wound healing and to provide enough energy to allow the patient to undergo therapy. A therapeutic diet may be contraindicated despite the fact that the patient's history includes an illness that generally calls for dietary alterations. Many of the diets listed above are unpalatable because of their composition and are limited in the variety of foods that can be provided. Optimal nutrition cannot be achieved if the patient is not inspired to eat the foods provided. Complicated diet prescriptions need to be the exception, not the rule. The more diets that are prescribed (eg, mechanical soft, cardiac [sodium/cholesterol restricted], renal [protein/potassium/phosphorous restricted] with a 2-liter fluid restriction), the less likely it is that a patient will eat. Nutrition is the 1 treatment modality over which the patient usually has control. A liberal attitude should be maintained, providing a diet that the patient will eat but that will not endanger his or her condition. Adjusting a patient's diet is the initial intervention. If intake does not improve with dietary modification, the next step is to provide between-meal snacks. Again, snacks should be provided based on the patient's preferences, not arbitrarily given. Snacks differ from facility to facility, but they usually are given 3 times per day, at morning, afternoon, and evening intervals. Small, frequent meals should be provided, since this generally optimizes daily intake. Snacks are a very cost-effective intervention. The provision of a nutritional supplement is definitely not a first-line management technique for poor oral intake. Supplements should be an alternative rather than an automatic intervention. When prescribed appropriately, supplements easily can optimize intake. The goal is to provide a supplement that is appropriate to the patient's condition and that the patient will consume. Supplements should never be overprescribed. Nothing is more overwhelming to a patient than constantly receiving supplements and having them pile up by his or her bedside. This tends to have the reverse effect on intake. The more supplements the patient receives, the less likely the individual is to eat them. Food is not always the source of a patient's intake problems; these could instead be related to the act of eating. Upper extremity capabilities must be present to feed. If the patient has any upper extremity disabilities, independent feeding may be an issue. Oral capacity also affects food intake, including in patients who may have the appetite to eat. Difficulty chewing food can result from a number of problems, including ill-fitting dentures, missing teeth, poor dental hygiene, oral infections, and discomfort following an oral procedure. Changes in food consistency are prudent in these situations, but only when they have been discussed with the patient. Medication Issues Medications cannot be overlooked when patients are not eating well. They affect intake in a variety of ways and, with prolonged use, eventually cause changes in nutritional status. Some drugs are secreted into saliva, causing an unpleasant taste. Some are unpalatable (eg, potassium preparations, cholestyramine), and some may cause a taste disorder by altering receptor function (eg, captopril, penicillamine). Facilitating relief by masking the drug's taste with food should be considered. Some examples of drugs and their possible side effects include the following:
Prolonged use of antihistamines and bronchodilators may decrease olfactory receptor response. Additionally, medications may alter the oral environment and result in decreased intake. For example, antidepressants may cause dry mouth and broad-spectrum antibiotics may lead to candidiasis. Consider decreasing dry, salty foods; offer moist, soft foods. Liquids should be increased at meal times, and spicy and acidic foods should be avoided. Any medication taken orally can potentially cause gastric irritation (eg, nonsteroidal anti-inflammatory drugs [NSAIDs]). Drugs may stimulate or depress the appetite. Appetite stimulants include antihistamines and psychotropic drugs. The antineoplastic drug megestrol acetate often is prescribed to stimulate appetite. Numerous drugs have the secondary effect of decreasing appetite. These agents include dextroamphetamine and methylphenidate. Antineoplastic agents, levodopa, and sulfasalazine are a few drugs that may cause disagreeable symptoms (eg, nausea, vomiting). Digitalis derivatives can stimulate chemoreceptor triggers directly and initiate vomiting. Suggestions include offering small quantities of foods that are easily digestible, serving carbonated liquids as the patient requests, maintaining adequate hydration, offering cold foods instead of hot foods (if the aroma of hot foods causes problems), and avoiding fried, greasy foods. Constipation The main offenders include anticholinergics, sedatives, hypnotics, and narcotics. To aid relief, adequate hydration should be maintained, daily fiber intake should be increased, and dependency on laxatives should be avoided. Diarrhea Cancer chemotherapeutic agents, antibiotics, laxatives, and antacids have the potential to cause diarrhea. To aid relief, a bland diet should be provided in small amounts, and the following should be avoided:
Eating Environment Although a patient's dining environment is probably the easiest problem to solve, it is the issue that is the most likely to be overlooked. If the patient dines at his or her bedside, the clinician should assess the surroundings. Cleanliness Clutter on the bedside tray makes eating an unpleasant and difficult experience. Care needs to be taken to make sure the patient's bedside tray table is clear of extraneous items (eg, urinals, tissues, newspapers, magazines). The dining experience should be made into one that can be enjoyed. Lighting Proper lighting should be emphasized. Open the patient's curtains. Turn on the lights. Let the patient see what he or she is going to eat. Seating Eating from a bed is very difficult. An easy solution is to transfer the patient to a chair for meals if possible. Perhaps the tray table does not adjust to proper height for the chair or bed. A quick adjustment to the level of the bedside table can make all the difference in the world. Positioning Comfort is the key. Patients need to be relaxed, and proper positioning improves the comfort level. Increased comfort creates an increased ability to sit up and eat; optimally, this means increased oral intake. Room Occupancy Arguments have been made for privacy and for company when it comes to pleasurable dining. The ideal environment should be discussed with the patient, and attempts should be made to accommodate dining wishes. If a roommate is acceptable but the roommate has a medical condition that prevents quality dining, such as a persistent cough, vomiting, diarrhea, or flatulence, consider an adjustment of the meal location. With cafeteria-style dining, the same issues are present. The cafeteria needs to be clean, to have adequate lighting and comfortable chairs, and to be wheelchair accessible. Again, table assignments need to be discussed. If patients are not comfortable with their dinner company, their intake will suffer. Encourage family members to visit at mealtime, perhaps bringing in a favorite dish or dessert. The dietitian should make daily meal rounds. This type of direct observation provides significant information and often provides clues as to why a patient may not be eating. Enteral Nutrition When the patient is unable to consume adequate nutrition orally, more aggressive support needs to be considered. Going back to the saying, "If the gut works, use it," enteral support is an alternate route of intervention. A patient with a functional GI tract is a candidate for enteral support when he or she will not, should not, or cannot take nutrition orally. The benefits of enteral support include the following:
The feeding route is the first consideration in enteral support (see Table 8). This decision is based on the duration of feeding, the patient's medical status, and the risk of aspiration. Short-term feeding is considered to be less than 6 weeks, and long-term feeding is greater than 6 weeks. Table 8. Enteral Feeding Routes
Continuous/Bolus Feedings Feedings may be continuous or bolus. Continuous feeding is a more reliable route of nutrient delivery, as a feeding pump is required. Feedings are given over 16-24 hours. This method has been associated with lower residual volumes, a decreased incidence of diarrhea, and a decreased risk of aspiration. Continuous feeding is recommended at the initiation of enteral support, as it is much better tolerated than a bolus infusion. As the small bowel tends to be sensitive to large volumes, the continuous feeding method is recommended when feeding postpylorically. Bolus infusions via gravity or syringe generally are used in the medically stable patient, as well as in the homebound or rehabilitation patient. Feedings are given quickly (2 cans over 30 minutes, 4-6 times per day), mimicking a regular meal. The maximum amount recommended is 400-500 mL per feeding; however, 250-400 mL is the most common infusion amount. Establish tolerance with continuous feeding, and then transition to bolus feedings when tolerance has been established. Initiation and Advancement Schedule Prior to the initiation of tube feeding, placement of the nasogastric feeding tube must be verified. Radiographic confirmation is the most reliable method of determining placement. Use of a promotility agent (unless contraindicated) before insertion increases the chances of transpyloric placement, which is better tolerated initially. The following agents are recommended 30 minutes before placement:
No standard initiation/advancement schedules appear in the literature; however, reasonable schedules can be recommended based on the type of feeding formula, location of the feeding, the type of patient, and the patient's condition. Examples include the following:
Tube feeding initiation should also be based on the type of patient.
Initial infusion rates and the subsequent advancement schedule also depend on the overall condition of the patient, as follows:
All hospitals have an enteral formulary. Physicians should obtain a formulary card to help make product decisions. Several formula categories should be considered when selecting a product for enteral nutrition support. Complications Complications associated with enteral support are largely preventable through formula selection, proper administration, and careful monitoring. Complications fall into gastrointestinal, mechanical, and metabolic categories, as follows:
Table 9. Metabolic Complications of Enteral Support
Transition From Enteral to Oral Feeding The goal of rehabilitation is to return the patient to normal function. Return to normal function is the goal of nutritional management as well. The goal with enteral support is a gradual transition from tube feeding back to an oral diet, if that is a possibility. The following options are suggested to accomplish an effective transition without compromising the patient's nutritional status:
Parenteral Nutrition This type of nutritional support is indicated for patients with a nonfunctioning GI tract and an inability to tolerate oral or enteral nutrition. As with enteral nutrition, duration of support is the decision between the 2 available routes (peripheral parenteral nutrition [PPN] and central or total parenteral nutrition [TPN]). PPN is considered to be a short-term/adjunct intervention. A time frame of less than 14 days is recommended, as PPN is used for transitional therapy when the patient's oral intake is improving but still is inadequate to support his or her nutritional needs or when tube feeding is only partially successful. TPN is intended for full nutritional support and is recommended for a minimum of 7 days for improvement in patient outcome to occur. Access for aggressive nutritional support is dependent on the duration of therapy, as discussed above, as well as the patient's medical condition, energy requirements, and fluid tolerance. Peripheral access may be obtained by nonsurgical staff using a standard venipuncture method. The patient must have adequate peripheral veins and be able to tolerate hypertonic solutions, as PPN solutions are generally 600-900 mOsm/L. Peripheral access is hard to maintain; hence, the 2-week limit is enforced. Central access is determined by the expected duration of nutritional support. Short-term access is available using single-, double-, or triple-lumen catheters. The tip of the central catheter is positioned in the superior vena cava. Peripherally inserted central catheter (PICC) lines can be placed by a trained nurse and do not require a surgical procedure. The line is placed in the antecubital vein and threaded into the subclavian vein. Single-, double-, or triple-lumen catheters are also available for long-term access. The catheter is placed surgically and tunneled subcutaneously away from the insertion site. The exit site is in the chest wall. PICC lines may be used for long-term access as well. Unlike enteral support, parenteral nutrition should be infused continuously over a 12-24 hour period. Cyclic infusion rates are reserved for the more stable patient or the patient who is likely to be discharged on TPN. Since PPN is restricted to a maximum of 10% dextrose (5% final concentration), patients can tolerate initiation of the infusion at the target rate. TPN, with its higher concentrations of dextrose, requires an advancement schedule. Skipper's recommendations for initial parenteral infusion rates for the first 48 hours of infusion are outlined in the following list4:
Table 10. Summary of Recommendations for Infusion
The optimal infusion schedule is not less than 12 hours. Dextrose is the carbohydrate source, as well as the major source of nonprotein calories (NPC) in parenteral nutrition. The carbohydrate load provided should be adequate to spare protein for wound healing/metabolic demands without exceeding patient tolerance (hyperglycemia). Table 11. Summary of the Various Dextrose Concentrations
Intravenous lipid infusions are necessary as a source of essential fatty acids. They are also a concentrated source of NPC. The calories yielded depend on the concentration of the lipid emulsion used. Examples of lipid emulsions and their calories yielded are 10% lipid (1.1 kcal/cc) and 20% lipid (2 kcal/cc). Lipid infusion schedules vary by institution and can range from twice a week to daily. Lipids are made up of egg phospholipid. Therefore, patients with an egg allergy may not tolerate lipid infusions. Table 12. Common TPN Schedules (500 cc)
NB: When using a 3-in-1 TPN, the lipids are added to the TPN daily. The role of protein in TPN is to maintain nitrogen balance, inhibiting the breakdown of skeletal muscle. The amount of protein necessary is based on a patient's metabolic needs, as discussed earlier. Note that an amount below 0.5 g protein/kg does not promote positive nitrogen balance. In a healthy population, protein should be provided as 11-20% of total kcal. In a stressed population, 40% of total kcal is common. Protein in TPN is in the form of crystalline amino acids that provide 4 kcal/g. All amino acid mixtures contain intrinsic electrolytes. The physician needs to contact the pharmacy service if specialized electrolytes are necessary. Table 13. An Example of the Intrinsic Electrolytes in Some Common Amino Acid Formulations
When a standard electrolyte formula is ordered, it is made up of the intrinsic electrolytes with a Hyperlyte mixture added. The following section on electrolytes further discusses this issue. The electrolyte composition in parenteral nutrition is designed to maintain normal body function. Customized electrolytes are an option based on the patient's underlying disease process/stressful situations. The available commercial preparations are intended to meet normal range requirements. Table 13 summarizes these requirements and standard amounts of electrolytes. TPN can affect the metabolic acid/base imbalance. Therefore, the chloride and acetate in the TPN can be adjusted. For a metabolic acidosis, the maximum acetate should be used. For a metabolic alkalosis, the maximum chloride should be employed. Table 14. Requirements and Standard Amounts of Electrolytes
Parenteral supplementation is based on recommendations from the American Medical Association Nutrition Advisory Group. The daily parenteral requirements for vitamins and minerals for adults are as follows:
Complications From Parenteral Nutrition Parenteral nutrition support has a lengthy list of potential metabolic complications, which is the reasoning behind the judicious monitoring of nutrition support teams. Table 15 provides a listing of the metabolic complications. Table 15. Metabolic Complications from Parenteral Nutrition (PN)
Consequences of protein calorie overfeeding are as follows:
Transition From Parenteral to Enteral to Oral Nutrition As with enteral support, the goal with parenteral support is a gradual transition back to tube feeding or oral nutrition. Treatment options have been developed to make the transition effective without compromising the patient's nutritional status. Recommendations for this transition include the following:
NUTRITION FOR SPECIFIC DISEASE STATESSection 8 of 9
Pressure Ulcers Patients who are at the greatest risk of developing pressure ulcers are those who are nonambulatory and have a compromised nutritional status. Disease states, such as cancer, diabetes, renal disease, and heart disease, may predispose patients to pressure ulcers secondary to the decrease in oxygen supplied to at-risk areas (eg, coccyx, elbows, heels). Assessment of serum albumin is key in this high-risk population, since hypoalbuminemia, if not corrected, has been associated with the development and progression of pressure ulcers. Nutritional intervention needs to include adequate protein and adequate calories to spare protein from wound healing. The goal is a serum albumin of greater than 3.5 g/dL. The amount of protein and number of calories need to increase as the stage of the ulcer increases. Supplementation with vitamin C should not exceed 200% of the US recommended daily allowance (RDA). Supplementation with zinc is consistent at 30 mg/day for men and 24 mg/day for women. Neurologic Diseases Not all patients with neurologic conditions have the same feeding problems; however, a common problem throughout this population is dysphagia, or difficulty swallowing. Observable symptoms that dysphagia may be present include drooling, choking, coughing (during or after meals), an absent gag reflex, and a gurgly voice quality. If undiagnosed, dysphagia can lead to malnutrition as a result of inadequate intake. Early detection and intervention are paramount. Nutritional intervention is performed with a team approach that centers primarily on the dietitian and the speech therapist. The speech therapist identifies treatment options; the dietitian adjusts diet consistency (liquids vs solids) to meet a patient's needs and ensures that palatability is not jeopardized in the process. Another common issue is a patient's limited ability to eat independently, as a result of problems such as hemiparesis, tremors, apraxia, and weakness. The associated medical concern is an increased risk of aspiration. To prevent aspiration, the best position for the patient is sitting upright as erect as possible, with both feet resting on the floor. Independence in self-feeding can be achieved with the use of a scoop plate if the patient has the strength to push food to the side of the plate. The plate is designed to allow food then to fall on the spoon. Enteral nutrition is a treatment option for this population when oral nutrition has been deemed unsafe due to aspiration risk or when the patient can no longer meet nutritional needs with an oral diet. Traumatic Brain Injury Most patients with traumatic brain injuries (TBIs) are well nourished prior to their injury; however, they become hypermetabolic and catabolic following injury. Therefore, aggressive nutritional intervention needs to be addressed very early. Patients who are not treated aggressively are likely to undergo rapid loss of lean body mass and immunosuppression. Energy requirements for patients who have sustained TBI generally are 40% greater than those estimated by the Harris-Benedict equation. Therefore, indirect calorimetry is recommended. Providing adequate protein is essential, but note that patients following TBI are likely to be in a negative nitrogen balance for the first 2-3 weeks postinjury, despite aggressive intervention. In general, a large percent of this population experience dysphagia, impaired gastric emptying, and alterations in normal eating patterns. Some patients are distracted easily, and meal times need to be extended. Some eat very rapidly and tend to consume excess quantities at meal times. Close monitoring during meals is essential. Parenteral and/or enteral support often is a necessary intervention during the early stages of treatment and during the transition period back to oral nutrition. Burns Nutritional support in this population is a challenge. These patients are at extraordinary risk of infection and intestinal ileus. Patients with burns are hypermetabolic and catabolic. Energy needs can increase by 100%, related to hypermetabolism. Protein needs are huge owing to the catabolic condition and because of protein losses through the wound itself. Patients with burns over less than 20% of their total body surface area (TBSA) usually are able to meet nutritional needs with a high protein/calorie diet. Patients with burns over greater than 20% of their TBSA require a more aggressive approach, such as TPN and/or tube feeding. If an ileus is present or the patient is unable to tolerate 100% of his or her nutritional needs enterally, TPN is the intervention of choice. Spinal Cord Injury Nutrition in acute SCI is a very complex issue. The following complications are associated with SCI and can affect the patient's ability to consume adequate nutrition:
Nutritional needs change frequently with this population because of stress response, sepsis, fever, infection, and surgery. Nutritional assessments need to be frequent, with ongoing diet alterations made to keep up with the patients' changing needs. Pulmonary Disease The major function of the respiratory system is to provide adequate oxygen to the body and to eliminate the carbon dioxide this process produces. The 3 macronutrients (ie, carbohydrate, fat, protein) all affect this ratio. The respiratory quotient (RQ) is a volume ratio between the oxygen consumed and carbon dioxide produced. The following are the RQs associated with each macronutrient substrate:
Overall energy needs and protein needs are based on the patient's goal to maintain lean body mass versus repleting lean body mass. In the situation of maintenance, energy needs are estimated at 25-35 kcal/kg, and protein needs are estimated at 1.2-1.9 g protein/kg. In the situation of repletion, energy needs are estimated at 35-45 kcal/kg and protein needs are estimated at 1.6-2.5 g protein/kg. REFERENCESSection 9 of 9
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||