NUTRITIONAL SUPPORT IN CRITICALLY ILL Prof. Mehdi Hasan Mumtaz.
Nutritional needs of the chronically ill Nutritional needs of the chronically ill Jana Hermanova 3...
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Transcript of Nutritional needs of the chronically ill Nutritional needs of the chronically ill Jana Hermanova 3...
Nutritional needs of the Nutritional needs of the chronically illchronically ill
Jana Hermanova3rd Faculty of Medicine
Charles University, Prague
What does it involve?What does it involve?Nutritional intakeEating habitsAltered nutritionNutritional
assessmentNutritional care
planning
Healthy foodsSpecial dietsArtificial feedingNutrition and the
end-of-life care
Factors affecting nutritionFactors affecting nutritionEating habits and food
preferences are the major factors Eating habits are influenced by: developmental stagegenderethnicity and culturebeliefs about foodpersonal preferences
factors influencing food intakefactors influencing food intake(continued)(continued)religious practiceslifestylemedications and therapyhealthalcohol consumptionadvertisingpsychologic factors
Altered nutritionAltered nutritionMalnutrition
undernutrition (BMI < 19)– insufficient nutrient intake
overnutrition – (BMI > 26) – overweight, obese, morbidly obese, (obese people can suffer from undernourishment!)
BMIBMIWeight in kilograms
BMI = ________________
(Height in meters)2
60 kilograms___________ = 26.61.5 x 1.5
Guide for BMI evaluationGuide for BMI evaluation< 16 malnourished16–19 underweight20-25 normal26-30 overweight31-40 moderately to severely
obese> 40 morbidly obese
B. Kozier, 2004
UndernutritionUndernutrition
Causesinadequate food
intakeimproper
digestion and absorption of food – (conditions?)
Related symptomsweight lossweaknessdecreased
functionsdelayed wound
healingprone to infectionimpaired
pulmonary functions
Causes of inability to eatCauses of inability to eatHemiparesisImpaired fine motor skillsVision impairmentAnorexiaSwallowing problemsLack of energyLethargyEnvironmental factors
OvernutritionOvernutritionIncreases the stress on body
organs
Predisposes to chronic problems (e.g. hypertension, diabetes mellitus)
May present complications in providing care
Let’s talk multidisciplinary!Let’s talk multidisciplinary!
NursesDoctorsNutritional therapists Physiotherapists
Asses – plan – intervene – evaluate!
Who is missing?
Ergotherapists/OT
Social workersPsychologists Pharmacists
Nutritional assessmentNutritional assessmentnurse, physician,
dietitian (nutritionist)
components:general appearancenutritional
screeningnursing historyphysical
examinationcalculating
percentage of weight loss
dietary history laboratory data anthropometric
measurement
Care planningCare planningGoals
Maintain optimal status Promote healthy practices Prevent complications of malnutrition Decrease weight Regain weight
InterventionsInterventionsReinforce teaching of the
dietitian/nutritionistCreate an atmosphere that encourages
eatingAssist with eatingMonitor the client’s appetite and intakeAdminister enteral and parenteral
feedingConsult with the physician and
dietitian
““We were only feeding the We were only feeding the patients…”patients…”
“giving a cup of coffee or water can be a spiritual work”
Special dietsSpecial dietsConsistency modifications
Clear liquid – water, tea, broth, clear juices,popsicles, coffee
Full liquid – ice cream, yogurt, cream soups, butter, peanut butter, scrambled eggs
Soft diet – chopped shredded meat, mashed potatoes, canned fruit, pasta
Czech dietary systemCzech dietary system
Special diets0-S tea (clear
liquids)1-S liquid, high
calorie4-S strict low fat9-S diabetic light
Basic diets0 – liquid1 - soft
2 – light3 - regular4 – low fat5 – low residue6 – low protein8 – low calorie9 – diabetic10 – low salt,
light11 – high calorie
Utensils for feeding people Utensils for feeding people with weak grip and other with weak grip and other problemsproblems
When patients cannot eatWhen patients cannot eatMrs. E, 37, has had
her first cycle of treatment for AML. She has not tolerated her treatment very well, has been vomiting a lot, had diarrhea and has developed painful stomatitis…
Mr. H, 59, has suffered from a degenerative muscle disease. He has come to the point that it is very difficult for him to swallow anything…
Enteral feedingEnteral feedingNG nasogastric
tubeNE nasoenteral
tubePEG – percutaneous
endoscopic gastrostomy
PEJ – percutaneous endoscopic jejunostomy
Intermittent ContinuousCyclic
By gravityBy syringe – bolusBy enteral feeding
pump
Aspiration precautions
Parenteral feedingParenteral feedingCentral line (CVC)Peripheral line –
limited to a short time and low osmolarity solutions
10 - 20% G (D5W)TPN (all-in-one)Fat emulsion
Continuous feeding
Cyclic feeding
Risks of TPN◦ Infection◦ Occlusion of the
catheter◦ Intestinal disuse
When patients don’t want When patients don’t want to eatto eatMrs. A, 96, on
admission to nursing home states: “I am not going to eat and I do not want you to feed me or use any other means of providing nutrition”
Mrs. B, 78, with deteriorating dementia. Few weeks ago she was interested in finger-foods but recently has been refusing meals and has become combative during feeding attempts
End-of-life care – ethical End-of-life care – ethical considerationsconsiderationsArtificial nutrition – yes or no?What about fluids?Does hunger and thirst hurt?When to withdraw?Who decides?