Running head: ARTICLE SUMMARIES 1

Article Summaries and Reflections

Kacy Shaffer

Fontbonne University
ARTICLE SUMMARY AND REFLECTIONS 2

American Diabetes Association. (2017). 14. Diabetes care in the hospital. Diabetes Care,

40(S120-S127). doi:10.2337/dc17-S017

Summary

Hypoglycemia and hyperglycemia are associated with adverse outcomes, including death

in hospitalized patients. Therefore, it is important for standards to be set to promote the best

outcomes in patients with diabetes. On admission, history and type of diabetes should be stated,

A1C should be tested if not in the past three months, knowledge should be assessed and diabetes

self-management education (DSME) should be provided. To prevent errors and increase

efficiency in medication administration, computerized physician order entry (CPOE) should be

used. In hospitalized patients, a blood glucose level greater than 140 mg/dL indicates

hyperglycemia while less than 54 mg/dL indicates clinically significant hypoglycemia. Decisions

regarding insulin doses should be based on clinical judgement and assessment of the patient's

clinical status.

Continuous intravenous insulin infusion is shown to be the best method in the critical

care setting. Scheduled insulin regimens are recommended outside of critical care units. Here,

insulin injections should align with meals and glucose testing should be performed right before

meals. For patients with type 1 diabetes, dosing insulin should account for basal insulin

requirements and caloric intake by basing it on body weight. Hypoglycemia prevention and

treatment should be adopted, with individualized plans for each patient. Blood glucose levels of

less than 70 mg/dL should be addressed immediately. The goals of meeting metabolic demands,

glycemic control, personal food preferences, and creating a discharge plans with realistic goals
ARTICLE SUMMARY AND REFLECTIONS 3

are addressed by medical nutrition therapy. It is important to consider special circumstances such

as enteral or parenteral feeding, glucocorticoid therapy, perioperative care, diabetic ketoacidosis,

and hyperosmolar hyperglycemic state. By having protocols and a team to address all of this,

adverse outcomes can be prevented in hospitalized patients.

Reflection

A lot of the recommendations from this article were used at BJSP. However, sometimes it

seems there was an oversight and a patients chart would not DM in their history, but did not

specify whether it was type 1 or 2. The RD told me that they usually just assume it is type 2. We

were consulted for education often for diabetes. A lot of the time, we would go to talk to the

patient initially and provide consistent carb education, then the RN CDE would also see the

patient. Every patient who I saw that had diabetes was on insulin in the hospital. We would send

them home with a consistent carb education piece and recommend they come see the outpatient

RD once they are discharged and able (this piece of education can be found in the clinical section

under Rotation Artifacts). The patients with diabetes had blood glucose and glucose POC in

their labs. This would give us an indication if their blood sugars were trending up, down, or

remaining high, low, or normal.

Powers, M., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., Vivian, E.

(2015). Diabetes self-management education and support in type 2 diabetes: A joint

position statement of the American Diabetes Association, the American Association of

Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy

of Nutrition and Dietetics 115(8), 1323-1334.

ARTICLE SUMMARY AND REFLECTIONS 4

A person with diabetes must make several decisions to manage this chronic disease. To

help those living with diabetes better manage the disease and improve health outcomes, diabetes

self-management education and support (DSME/S) are used. DSME involves promoting

knowledge, skill, and ability a person needs for self-care of their diabetes. DSMS is the support

that is necessary to implement and sustain behaviors and coping skills to manage the disease on a

continuous basis. There are DSME/S programs designed to address health beliefs, cultural

needs, knowledge, physical limitations, emotional concerns, family support, financial status,

medical history, health literacy, numeracy, and other factors that affect disease management

ability (p. 1323).

This position statement focuses on those with type 2 diabetes and how DSME/S should

be used to improve health outcomes and health care costs associated with diabetes. DSME/S can

be given in a variety of settings to ensure convenience for the person with diabetes. A health care

team who uses clear communication and effective collaboration is important so goals are clear,

interventions are appropriate, and progress toward the goals can be made. DSME/S can get

reimbursement through Medicare, Medicaid, and private payers if they meet certain

requirements. It is important to know the four critical times to assess, provide, and adjust

DSME/S 1) with a new diagnosis of type 2 diabetes, 2) annually for health maintenance and

prevention of complications, 3) when new complicating factors influence self-management, and

4) when transitions in care occur (p. 1327). Although DSME/S is shown to be beneficial, not

enough people who need it are receiving it. It is important to implement this in ways that

removes barriers to access such as connecting directly with primary care.

ARTICLE SUMMARY AND REFLECTIONS 5

Reflection

BJSP has a good set up for patients with diabetes. The RDs provide education to

inpatients and refer them to see the outpatient dietitian when they are discharged, which is in the

same building. The CDE who is an RN also coordinates with the RDs in patient education and

does outpatient counselling sessions and classes for patients with diabetes. They do these both

together as a team and separate, depending on what the patients needs are. The CDE also works

with the hospitalized patients, especially those in the ICU. She is there for most care team rounds

in the ICU. They are also starting a whole new system for patients with diabetes and preparing a

filing cabinet for the educations. I did not get to learn much about this before I left, but I believe

it probably has to do with DSME/S.

Delano, M. J. & Moldawer, L. L. (2006). The origins of cachexia in acute and chronic

inflammatory diseases. Nutrition in Clinical Practice, 21(1), 68-81.

Cachexia has been recognized for hundreds of years as a deterioration of the body

associated with many disease states, severe illnesses, sepsis, and stress. It contributes to adverse

outcomes in several diseases. It is a complex metabolic state that includes progressive weight

loss with depletion of adipose tissue and skeletal muscle stores. An inflammatory process is the

main requirement for the development of cachexia. Alteration of normal metabolic states from

biologically active compounds, primarily inflammatory cytokines, are thought to play the main

role in the development of cachexia. Antagonism of these cytokines has not been shown

effective at reversing the cachectic state.

Decreased food intake, like that from anorexia is not exclusively responsible for all the

metabolic alterations of cachexia. Even with education and nutrition supplementation,

ARTICLE SUMMARY AND REFLECTIONS 6

progressive weight loss is not prevented with cachexia. With parenteral nutrition, weight gain is

from water and fat, but not protein. In cachexia, protein catabolism is promoted, which causes

muscle wasting and lean body mass depletion. This differs from starvation, where fat stores

would be used first.

Macronutrient metabolism is altered in cachexia. Glucose metabolism is altered, which

can include glucose intolerance, abnormal insulin responses, and hyperglycemia. Lipid

metabolism is altered, which can include increased lipolysis and hyperlipidemia. Fat is the

preferred fuel source in septic states. Protein metabolism is also altered, including deterioration

of skeletal muscle and increase in liver protein mass. In cachexia, the body is less efficient in

sparing protein as it is in starvation states.

Reflection

This article improved my understanding of cachexia. However, at BJSP, the RDs never

looked for cachexia. They only looked for and documented malnutrition. When seeing oncology

patients, we looked for malnutrition and gave them education on how to improve their intakes

and address the alterations in taste. The oncology dietitian from Siteman Cancer Center would

come work with us often and she gave me handouts on this for the oncology patients who had

inadequate oral intake. We discussed tips for how they can get more calories and help address

the taste changes, such as using a special mouth rinse before eating and not drinking out of or

eating with metal dishes.

ARTICLE SUMMARY AND REFLECTIONS 7

White, J.V., Guenter, P., Jensen, G., Malone, A., Schofield, M. (2012). Consensus statement of

the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral

Nutrition: Characteristics recommended for the identification and documentation of adult

malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics. 112(5),

730-738.

Summary

This article focuses on undernutrition, using malnutrition as a synonym for

undernutrition. Identifying malnutrition is difficult because there are many approaches to doing

so and there is not a universally accepted approach to diagnosing and documenting it. The

authors say it is common but frequently unrecognized. Malnutrition has several negative

consequences, including increased morbidity, increased mortality, decreased function, decreased

quality of life, increased frequency and length of hospital stay, and higher health care costs. The

Academy and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recognizes

that the varying approaches to diagnose malnutrition result in confusion and possible

misdiagnosis, so they see the need to standardize the approach of diagnosing malnutrition.

The Academy and A.S.P.E.N. categorized three types of malnutrition; starvation-related,

chronic disease-related, and acute disease or injury-related malnutrition. They agreed on six

characteristics to detect and diagnose malnutrition; insufficient energy intake, weight loss, loss of

muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and

diminished functional status measured by hand grip strength. They note that laboratory data is

not recommended as an indicator of malnutrition because it is more an indicator of inflammatory

response independent of nutritional status. They recommend identification of two or more of

ARTICLE SUMMARY AND REFLECTIONS 8

these characteristics to diagnose malnutrition. These characteristics can be used to distinguish

between severe and non-severe (moderate) malnutrition in each of the three categories of

malnutrition.

Jensen, G. L., Hsiao, P. Y., & Wheeler, D. (2012). Adult nutrition assessment tutorial. Journal of

Parenteral and Enteral Nutrition, 36(3), 267-274.

Summary

The three malnutrition syndromes include starvation-associated malnutrition, chronic

disease-associated malnutrition, and acute disease/injury-associated malnutrition.

Starvation-associated malnutrition involves chronic starvation without inflammation. This occurs

when a person is not eating enough, such as in anorexia nervosa or major depression. Chronic

disease-associated malnutrition occurs when chronic inflammation is mild or moderate, such as

in organ failure or sarcopenic obesity. Acute disease/injury-associated malnutrition occurs when

acute inflammation is severe, such as in major infection or trauma. A patient can have more than

one of these syndromes and can change from one to the other.

They give a systematic approach to nutrition assessment which includes history and

clinical diagnosis, clinical signs and physical examination, anthropometric data, laboratory

indicators, dietary data, and functional outcomes. The history and clinical diagnosis includes

medical or surgical history which can help to indicate inflammation or a patients risk of

becoming malnourished. The clinical signs and physical examination can help identify edema,

weight gain or loss, nutrient deficiencies, and muscle or subcutaneous fat loss. Anthropometric

data includes weight and height measurements to monitor trends and body composition

assessment methods to evaluate musculature. Laboratory indicators must be interpreted with

ARTICLE SUMMARY AND REFLECTIONS 9

caution because serum albumin and prealbumin are not specific to nutritional status. Dietary data

can be collected from the patient, medical records, family, or caregivers to detect inadequate

nutrient intakes. Functional outcomes related to malnutrition can be detected such as declines in

strength or physical performance.

Case scenarios are given, where this systematic approach is used to look at each of the

factors. In the anorexia nervosa case, the patient was determined to have starvation-associated

malnutrition because of the anorexia nervosa and no significant inflammatory response, the signs

and physical examination, weight loss, underweight status, mid-arm muscle circumference, and

dietary intake being consistent with this malnutrition syndrome. The next case includes a patient

with cirrhosis with portal hypertension and ascites who was determined to have chronic

disease-associated malnutrition because of evidence of reduced dietary intake, unintended weight

loss masked by ascites, reduced grip strength, and loss of muscle and subcutaneous fat. The next

case includes a frail older person with sarcopenic obesity who was determined to have chronic

disease-associated malnutrition because of evidence of reduced dietary intake, unintended weight

loss, and functional limitations. The last is a multiple trauma victim who was determined to have

high risk for acute disease or injury-associated malnutrition because they are at risk for reduced

dietary intake, have marked edema, and are at high risk for loss of muscle.

Reflection for Both Articles Above

It was interesting to see how they approached nutrition assessment and malnutrition at

BJSP. The nutrition assessment was mostly what I expected. We looked up each patients

medical history, admitting diagnosis, meds, and labs before going to see them. We would ask

about appetite, intakes, and weight history each time. When it came to malnutrition, they handled
ARTICLE SUMMARY AND REFLECTIONS 10

it a little differently than I expected. For one patient, I asked about checking for edema and it

seemed that they had never considered looking at edema for malnutrition before. For

malnutrition, they strictly look at PO intakes, physical assessment, and weight loss. They have a

special note for documenting malnutrition which shows up in the HEN doc viewer section of

the charting that all the healthcare team members look at for patients. This is the section that you

look at to read the doctors notes. The RD, speech path, RN, PT, OT, and other team members

notes show up in a different area, that the RDs told me that the doctors do not really read.

However, malnutrition is important for the doctors to see, so this special charting section is the

exception. This section asks about albumin levels, which Becca explained that even though it

does not show malnutrition for us, the doctors still want to keep track of it to see how it may

relate somehow. I learned so much by seeing patients in real life for nutrition assessment and

malnutrition rather than learning about them in a classroom.

Moya, D. A., Gaitan, A. P., Camacho, D. O., & Humberto, A. M. (2016). Hospital malnutrition

related to fasting and underfeeding: Is it an ethical issue? American Society for

Parenteral and Enteral Nutrition, 31(3), 316-324.

The authors discuss the consequences of malnutrition and point out that misguided

nutrition practices increase risk of malnutrition. They apply four principles of ethics to hospital

nutrition; nonmaleficence, beneficence, autonomy, and justice. For nonmaleficence, they explain

that a lack of nutrients (fasting, underfeeding, or inadequate nutrition therapy) can harm the

patient, which violates this ethical principle. For beneficence, they explain that we need

sufficient resources and adequate nutrition training, teamwork, and collaboration to provide

optimal nutrition therapy. For autonomy, we should give the patients the right to decide what is
ARTICLE SUMMARY AND REFLECTIONS 11

in their best interest and allow them to participate in decisions regarding their nutrition. For

justice, patients should have access to safe and quality food and nutrition therapy without any

kind of discrimination. Nutrition should be more of a priority and physicians should be educated

on nutrition to help avoid ethical violations.

Reflection

BJSP does a great job of making sure that the patients get to decide what they want to eat

and providing them with nutrition supplements when they are having trouble eating enough.

They problem with this comes into play in the ICU. I saw two cases where a patient went 7 days

without any nutrition support. We did mention it every day in rounds, encouraging the doctor to

consider nutrition support, but often they do not see it as a priority. There were other times where

patients would go 5 to 6 days without any nutrition. I do see that there are some circumstances

where nutrition support may be more harmful than helpful, but I think it is important to pay close

attention and determine what is best for the patients overall health.

Fontbonne University
ARTICLE SUMMARY AND REFLECTIONS 12

Millen, B.E., Wolongevica, D. M., de Jesus, J.M., Nonas, C.A. & Lichtenstein, A. H. (2014).

2013 American Heart Association/American College of Cardiology guideline on lifestyle

management to reduce cardiovascular risk: Practice opportunities for registered dietitian

nutritionists. Journal of the Academy of Nutrition and Dietetics. 114(11). 1723 - 1729.

Summary

Healthy lifestyle behaviors are very important for disease prevention and management.

Heart-healthy nutrition behaviors for adult American men and women include a dietary pattern

that highlights intake of vegetables, fruits, and whole grains, has low-fat dairy products, poultry,

fish, legumes, nontropical vegetable oils and nuts, while limiting intake of sodium, sweets, and

red meats. This can include following the DASH dietary pattern, USDA Food Pattern, or AHA

diet. Heart-healthy physical activity (PA) includes engaging in 2 hours and 30 minutes per week

of moderate-intensity PA or 1 hour and 15 minutes of vigorous-intensity or aerobic PA or a

combination of the two. It is also important to achieve and maintain a healthy weight. Those who

would benefit from LDL lowering should get 5 to 6% of calories from saturated fats while

reducing percent of calories from saturated fat and trans fat. Those who would benefit from

lowering blood pressure should lower sodium intake and combine this with a DASH dietary

pattern. Evidence shows the support of RDNs in preventative lifestyle intervention and weight

management. Those who would benefit from lipid or BP lowering should be referred to an RDN.

Reflection

At BJSP, I gave a lot of patient educations to patients who the RDs received a heart

healthy education consult. The education material that BJSP uses for heart healthy diet includes

all the things from the dietary pattern mentioned in this article: fruits, vegetables, and whole
ARTICLE SUMMARY AND REFLECTIONS 13

grains, low-fat diary, poultry, fish, legumes, nontropical vegetable oils and nuts, while limiting

intake of sodium, sweets, and red meats. This piece of education material can be found in the

Clinical Rotation section of the e-portfolio. I think this is helpful for patients, because they have

a guide to go home with and we also referred them to come back when they are feeling better to

see the outpatient RD.

Rahman, A., Jafry, S., Jeejeebhoy, K., Nagpal, D., Pisani, B., & Agarwala, R. (2016).

Malnutrition and cachexia in heart failure. Journal of Parenteral and Enteral Nutrition,

40(4), 475-486.

Cardiac cachexia is severe muscle wasting associated with advanced heart failure (HF).

Malnutrition and cachexia are often used as interchangeable terms, although they are

mechanistically distinct. In cachexia, malnutrition is related to inflammation. However, it is

difficult to distinguish what is contributing to each in a single patient because loss of appetite is

often associated with inflammation. So, starvation related malnutrition often coexists with

cachexia. Many patients with HF are cachectic and/or malnourished. This is due to the metabolic

disturbances caused by the chronic inflammation. HF changes cytokine and hormonal regulation

which leads to more catabolism, eventually wasting skeletal muscle, fat, and bone tissues.

Micronutrient supplementation has been explored as a potential therapy for HF, to improve

cellular functions. Also treatment with anabolic hormones may be effective. They conclude that

the best option for those with HF is active screening for malnutrition and individualized dietary

interventions to ensure they are consuming adequate calories and sufficient micronutrients.

Reflection
ARTICLE SUMMARY AND REFLECTIONS 14

The RDs at BJSP automatically have to see every patient who comes in with CHF. This

seems to be a good way to screen for malnutrition and make sure it is caught and intervened for

early. When seeing the patients with CHF, we would do the standard nutrition assessment that

we did for most other patients by asking about appetite, PO intakes, and weight history as well as

looking for physical signs of malnutrition. They are doing most of what this article recommends

by making sure that the patients are getting adequate calories and recommending nutrition

supplements when needed. Most of the patients had micronutrients ordered that I saw in their

meds list. The RDs never looked for cardiac cachexia, only malnutrition. It would be interesting

to look more into cachexia in the acute care setting, what the evidence says, and how it is

addressed in various facilities.

Fontbonne University
ARTICLE SUMMARY AND REFLECTIONS 15

Shah, N. D., Parian, A. M., Mullin, G. E., & Limketkai, B. N. (2015). Oral diets and nutrition

support for inflammatory bowel disease: What is the evidence? Nutritional in Clinical

Practice, 30(4), 462-473. DOI: 10.1177/0884533615591059

Summary

Inflammatory bowel disease (IBD) is a group of disorders of the gastrointestinal (GI)

tract with chronic intestinal inflammation, the most common being Chrons disease (CD) and

ulcerative colitis (UC). There is an interest in fatty acids and their role in IBD due to the

proinflammatory properties of omega-6 and the immunomodulatory properties of omega-3 fatty

acids. However, studies do not support supplementation at this time. Studies reviewed do not

support low-fiber diets as have been recommended in the past. The effect of vegetarian diets on

IBD are of interest, but not supported by evidence at this time. Lactose reduction may help

improve symptoms in some with IBD. The low-FODMAP diet limits foods high in fermentable

carbohydrates such as those high in fructose, lactose, fructans/galactans, and polyols. Findings

show that low-FODMAP diets may help with functional symptoms, but there is no support for

effect on intestinal inflammation. For those who cannot orally get adequate nutrition, enteral

nutrition (EN) is the preferred route, but parenteral nutrition (PN) can provide nutrition support

as well. The evidence of a specific diet is inconclusive other than avoiding foods that aggravate

symptoms. Individualized nutrition counselling for guidance on diet would be more beneficial

for those with IBD. More studies are needed for diet and IBD.

Reflection

I did not see many patients with IBD in my time at BJSP. One patient was in there for a

Crohns inflammation and I ensured she was getting adequate nutrition. Some of the other
ARTICLE SUMMARY AND REFLECTIONS 16

patients had Crohns in their medical history, but it was not a priority while they were there. It

would be good to learn more about the research on IBD so that if I were to work with that

population one day, I could give them the most benefit.

Hill, C., Guarner, F., Reid, G, Gibson, G. R., Merenstein, D. J., Pot, B., Morelli, L., Canani, R.

B., Flint, H. J., Salminen, S., Calder, P. C., & Sanders, M. E. (2014). The International

Scientific Association for Probiotics and Prebiotics consensus statement on the scope and

appropriate use of the term probiotic. Advance Online Publication, 1-9.

Summary

The appropriate use of the term probiotic is important in avoiding misuse and

exploitation of the term and misinterpretation and confusion among consumers. The International

Scientific Association for Probiotics and Prebiotics (ISAPP) re-examined the concept of

probiotics to address this. They list well-studied species shown to impart health benefits:

Bifidobacterium (adolescentis, animalis, bifidum, breve and longum) and Lactobacillus

(acidophilus, casei, fermentum, gasseri, johnsonii, paracasei, plantarum, rhamnosus and

salivarius). Something that claims it contains live and active cultures is not necessarily a

probiotic. A product that claims, contains probiotics must contain members of a safe species

with evidence of beneficial effect for humans. For a probiotic product to have a health claim,

there must be evidence from well-conducted studies. For a probiotic drug to give a health claim,

there must be a defined strain of the live microbe and appropriate trials to meet regulatory

standards for drugs. Better research, communication, and regulation of probiotics is needed to

ensure that benefits are properly communicated to consumers and patients.

Relfection
ARTICLE SUMMARY AND REFLECTIONS 17

During my time at BJSP, we did not discuss probiotics with patients. However, for

patients who need probiotics, such as those who were given antibiotics, it is important that they

get probiotics that are going to produce a health benefit. This article shows me that it is important

to do more than just recommend that a patient get probiotics. It is important to understand which

ones are supported by evidence and will actually benefit the patient.

Fontbonne University
ARTICLE SUMMARY AND REFLECTIONS 18

Kraft, M. D., Btaiche, I. F., & Sacks, G. S. (2005). Review of the refeeding syndrome. Nutrition

in Clinical Practice, 20(6), 625-633.

Refeeding syndrome (RS) describes a collection of metabolic alterations that result from

giving nutrition to an individual who is underweight, severely malnourished, or starved. These

metabolic alterations include fluid and electrolyte disorders, particularly hypophosphatemia and

complications associated with it, which affect multiple organ systems. After 72 hours of

starvation, energy is derived from ketone production from fatty acid oxidation rather than

glucose. By reintroducing carbohydrate, a sudden shift back to glucose as the main energy source

creates a high demand for red blood cell ATP while fat metabolism is suppressed. Phosphate is

important for the production of ATP. These shifts contribute to the hypophosphatemia and other

electrolyte abnormalities like hypokalemia, hypomagnesemia, and sodium retention seen in RS

which each have several clinical manifestations. Severe hypophosphatemia and hypokalemia in

RS can lead to cardiac and respiratory problems, and death. Hypomagnesemia in RS can cause

cardiac problems and death. Sodium retention in RS can lead to fluid overload and cardiac

decompensation.

Taking measures to prevent RS is important when giving nutrition support to prevent

complications and death. To prevent RS, correct any electrolyte abnormalities before initiating

nutrition support, then start low and go slow by estimating needs and providing 25% of goal

needs on day 1. This should be gradually increased over 3 to 5 days. Electrolyte, vitamin, and

phosphate supplementation should be provided per the patients needs. It is important to monitor

for signs of RS and interrupt nutrition support if any signs or symptoms of RS appear. Dextrose

10% in water can be given to prevent hypoglycemia and specific electrolyte abnormalities should
ARTICLE SUMMARY AND REFLECTIONS 19

be treated. Give a single dose of IV thiamin if there are neurologic changes in the patient. Give

supplemental oxygen for respiratory symptoms or distress. Cardiac changes should be treated

immediately and fluid overload should be treated appropriately. After treating all problems and

patient is free of symptoms and stable, nutrition support should be restarted with great caution.

Reflection

For patients who are started on enteral feeding, the RD keeps a close eye on lab values,

particularly those to detect hypophosphatemia and other electrolyte abnormalities like

hypokalemia, hypomagnesemia. The RD also starts at a low rate and gradually increases to goal.

If the labs indicate refeeding or risk for refeeding, the RD will consult the MD. The MD at BJSP

is the one to order phosphate, electrolyte, vitamin supplementation, and dextrose. The RD has

privileges there to order and alter tube feedings and TPN, but Becca recommends the RDs use it

with caution to avoid conflict with the doctors. So, she will usually talk to the MD before

initiating nutrition support or making any changes to it.

De Brito-Ashurst, I., & Preiser, J. (2016). Diarrhea in critically ill patients: The role of enteral

feeding. Journal of Parenteral and Enteral Nutrition, 40(7), 913-923.

In critically ill patients, diarrhea is a common and prevalent problem but management is

not simple. There are many types and definitions of diarrhea and many causes. Enteral tube

feeding is common in the intensive care unit (ICU) and has diarrhea as a complication.

Preventing and treating diarrhea is important in these patients because it can affect rehabilitation

therapy and nutrition status, increase risk of skin breakdown and ulcers, increase fluid and

electrolyte loss, and increase length of stay. It is important to have definitions of diarrhea to

distinguish the types and have a treatment protocol so that it can be treated properly. The types
ARTICLE SUMMARY AND REFLECTIONS 20

can include dysmotility, inflammatory/exudative, malabsorptive, osmotic, and secretory. The

diagnosis and feeding plan should be taken into account and a guide for enteral feeding should be

used. It may be necessary to consider bolus or intermittent feedings rather than continuous to

reduce frequency of bowel motions. Types of feed other than polymeric should be considered.

Parenteral nutrition should only be considered in the most severe cases to treat diarrhea.

Reflection

In the ICU, care team rounds were done for each patient, every day. They would discuss

bowel movements and diarrhea. The nurses kept a close eye on the patients bowel habits and

would figure out the best way to approach it each day in rounds by discussing it with the MD.

Although in this setting, it was more an area that the RN and MD dealt with, I imagine in

different facilities, the RD plays more of a role in making decisions to address diarrhea in

critically ill patients who are on enteral feeding.

Derenski, K., Catlin, J., & Allen, L. (2016). Parenteral nutrition basics for the clinician caring for

the adult patient. Nutrition in Clinical Practice, 31(5), 578-595.

Parenteral nutrition (PN) is often used to provide nutrition to patients who cannot be

nourished orally or enterally. However, the decision to give PN to a patient is multifactorial,

taking into account patients desires, attitude toward therapy, overall prognosis, nutrition status,

and subjective quality of life (p. 578). These factors can change, so they should be reassessed

periodically. Vascular access type should be evaluated prior to initiation of PN. Duration and

frequency of therapy, activity level and lifestyle, surgical history of head and neck, psychological

issues, and ability to care for the device should also be considered. The patients specific needs

should be carefully considered before selecting a formula for PN. Indirect calorimetry is
ARTICLE SUMMARY AND REFLECTIONS 21

preferred to predict metabolic needs, but other equations may be appropriate. It is important for

the clinician to be familiar with new methods of feeding, therapy options, and systems of

delivery. One example is to provide less calories than needs but adequate protein in some

critically ill patients. Routine evaluation and assessment of the clinical condition of a patient on

PN, focusing on nutrition and metabolic effects of PN, is important.

Reflection

During my time at BJSP, I only saw one patient who received TPN. One of the days that I

took ICU rounds while Becca was gone, I noticed that a patient was on day 5 NPO. This is one

of the policies on the prioritization for assessment sheet where we need to intervene. During

rounds, I mentioned that the patient is day 5 NPO and asked what the plan for feeding was. The

MD let me know that he suspected mesenteric ischemia, so they are not going to feed until they

get that figured out. When Becca came back, I let her know. By day 7 NPO, Becca strongly

urged them to start some form of nutrition and to consider TPN. The next day, the MD started

TPN for the patient, but after a few days, they were saying her prognosis was not good. It was

clear during my time here that they use TPN only as a last resort when enteral feedings are

unacceptable.

Kozeniecki, M., & Fritzshall, R. (2015). Enteral nutrition for adults in the hospital setting.

Nutrition in Clinical Practice, 30(5), 634651.

Enteral nutrition (EN) can provide short or long term delivery of nutrients to the digestive

tract for patients who cannot meet needs orally. This is beneficial because the digestive tract is

still being stimulated which supports the functional and structural integrity of the gut. Prior to

initiation of EN, a complete nutrition assessment is important to document baseline nutrition

ARTICLE SUMMARY AND REFLECTIONS 22

parameters, identify risk factors for malnutrition and specific nutrient deficits, establish

individual nutrition needs, and identify any factors that may influence the provision of nutrition

support therapy (p. 634). Timing of EN should be based on the patients needs including

nutrition and disease state, medical condition, and risks and benefits. The clinician should watch

for complications of EN such as RS, N/V, aspiration pneumonia, diarrhea, and constipation, and

treat appropriately. Techniques for prevention of clogged feeding tubes should be carefully

practiced. If clogged, the tube should be replaced or unclogged. Transition to oral intake should

be done with consideration of the patients specific needs. Before stopping EN, the patients oral

intake should be adequate (consuming 60-75% of estimated energy and protein needs). If the

patient is to remain on EN, proper education should be given before transitioning to home or

alternate healthcare setting.

Reflection

At BJSP, the patient was discussed in rounds and all the medical and nutritional factors

were considered, especially when initiating EN. As mentioned, the patients were monitored for

RS. They also checked tolerance with gastric residuals and watched for diarrhea, vomiting, and

aspiration. One doctor came in and discussed the new evidence for checking gastric residuals,

which was interesting, but after he left nobody followed what he had to say. Most of the patients

during my time there who were on nutrition support were ICU patients who were sedated,

usually with propofol. Only two patients who we initiated nutrition support for was on the

medical unit. She was refusing to eat, so her husband agreed to an NG tube. However, after the

tube was placed, she began eating so she could get it out. She never got any nutrients through the
ARTICLE SUMMARY AND REFLECTIONS 23

tube. The other patient was also refusing to eat and totally accepting of nutrition support via an

NG tube.

Fontbonne University
ARTICLE SUMMARY AND REFLECTIONS 24

Moctezuma-Velazques, C., Garcia-Juarez, I., Soto-Solis, R., Hernandez-Cortes, J., & Torre, A.

(2013). Nutritional assessment and treatment of patients with liver cirrhosis. Nutrition,

29(11/12), 1279-1285.

In liver cirrhosis, there is a development of regenerative nodules and fibrosis which can

eventually lead to overt end-stage disease. In patients with liver cirrhosis, malnutrition is a

common complication (present in more than half of these patients) which is associated with

mortality and poorer quality of life. Multiple factors lead to protein-energy malnutrition in these

patients: appetite suppression, early satiety, poor calorie intake, malabsorption of fat, impaired

synthesis and storage functions of the liver, and hypercatabolic state. Nutritional status is very

important in these patients. The most recommended methods for assessing nutritional status are

anthropometry, bioelectrical impedance, biochemical parameters, Subjective Global Assessment

(SGA), hang-grip strength, and L3 skeletal muscle index. Edema and ascites can make some

anthropometric measures less reliable. In patients with cirrhosis, malnutrition reference values

are altered: no ascites BMI < 22, mild ascites BMI < 23, and tension ascites BMI < 25.

The number of calories needed should be tailored according to each patients degree of

malnutrition and prolonged fasts should be avoided. The daily protein recommendation in these

patients is 1 to 1.2 g/kg with a maximum of 100g. Vegetable-derived and branched-chain amino

acids (BCAA) are preferred while animal-derived and aromatic proteins are discouraged.

Micronutrient deficiencies are common and should be supplemented if needed. Sodium

restriction is recommended for those with ascites or edema and water restriction should only be

used in significant hyponatremia. Diet adherence is an important determinant of nutritional status

improvement.
ARTICLE SUMMARY AND REFLECTIONS 25

Reflection

There were a lot more patients than I expected to see with health conditions related to

alcohol abuse. I saw several patients with pancreatitis and a few with cirrhosis or ESLD. I saw

one patient who had a liver transplant a few years back due to a hepatitis infection. We

automatically had to see patients with severe pancreatitis within 48 hours and do a nutrition

assessment on them. Usually, they would be NPO, but they would start to eat when ready. We

did not automatically see patients with liver cirrhosis, but this was often in the medical history of

those with pancreatitis along with alcohol abuse. One lady who we saw with ESLD was only 36

years old and had three children. She had alcoholism and her prognosis was very poor. They had

to talk to the family about making decisions as they did not know if she would survive much

longer. She was drinking Ensure supplements though.