Unit I (J) Nutrition in Critical Care

Tanzeel Ul Rahman
Nursing Instructor
BSN, RN, M.Phil Public health

Copyright © 2017 by Tanzeel Ul Rahman

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Copyright © 2017 by Tanzeel Ul Rahman

All rights reserved. This Presentation or any portion thereof

may not be reproduced or used in any manner whatsoever
without the proper acknowledgment of the owner.
Tanzeel Ul Rahman
Nursing Instructor
BSN, RN, M.Phil Public health
Mr.Tanxeel@Gmail.com

Copyright © 2017 by Tanzeel Ul Rahman

Objectives

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 Prerequisite
• Please Review anatomy and Physiology of GI system

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 Introduction
• All critically ill patients are assumed to be at nutritional
risk
• Nutritional support is an important part of overall care
plan
• Physiological stressors, such as illness and injury, alter
the body’s metabolic and energy demands. Patients
can experience considerable weight loss (>10 kg)
during and after a stay in the critical care unit. This
unintentional weight loss may deplete vital nutrient
reserves, which may predispose the patient to
malnutrition.
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 What is Nutrition??
 A process of providing or obtaining the food necessary for
growth and health.
NUTRIENT:
 The substances which are used to fulfill this purpose are
known as nutrients.
– Carbohydrates
– Proteins
– Fats
– Water
– Electrolytes
– Vitamins
– Trace elements
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Consequences of Malnutrition for
the Hospitalized Patient

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 Nutritional Assessment
• Provides baseline subjective and objective data regarding
nutritional status- complete within 24 hour of admission
• Determines nutritional risk factors
• Identifies nutritional deficits
• Establishes nutritional needs
• Identifies medical, psychosocial, and socioeconomic
factors
• Anthropometric measurements (ie, height, weight, body
mass index [BMI], triceps skinfold thickness, and midarm
and arm muscle circumference)
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 Nutritional Assessment
Objective and Subjective Data
– Patient’s medical history – Gag reflex
– Physical exam(Review – Dysphagia
Table 7.1) – Adequate dentition
– Laboratory – Oral mucosa
values(Review Table 7.2) – Hydration status
• What is important?
– Nitrogen balance
• Review laboratory alert
• Positive
– Input and output
• Negative
– Daily weight: the single
most important indicator
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of nutritional status
 Critical Thinking Challenge
• Which team members would the nurse consult to
assist with the nutritional support of critically ill
patients?

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 Goals for Nutritional Support

Prevention and treatment of macro and micro

nutrients deficiencies

Maintenance of fluid and electrolytes balance

Reduction in patient mortality and morbidity

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 Nutrition Care Plan
• Determine:
– Patient’s calorie, protein, and fluid needs
– Intake targets
– Route of administration
• Set measurable short- and long-term goals
– Weight gain
– Stable laboratory values

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Routes for Nutritional Support
1. Enteral Nutrition

2. Parenteral Nutrition

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1. Enteral Nutrition

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 1. Enteral Nutrition
• A method in which any form of nutrition
delivered to the gastrointestinal tract through
a feeding tube placed in to the stomach or the
small intestine.
• Any patients who cannot meet their
nutritional needs orally should be started on
enteral nutrition in the first 24 to 48 hours.

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Enteral Nutrition (Cont.) (Benefits)
• Delivery of nutrients to GI tract
• Preferred method
– Lower risk of infection
– Less expensive
– If not used GIT atrophied
– Easier, safer,
– Less costly to administer than parenteral nutrition

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 Enteral Nutrition (Cont.)
Indications of Enteral Nutrition Contraindications
• Dysphagia Absolute Contraindications
• Mechanical obstruction
• If one not taking adequate Relative Contraindications
oral intake • Severe hemorrhagic
• Anorexia pancreatitis
• Necrotizing enterocolitis
• Nausea
• Prolonged ileus
• Any critical illness • Severe diarrhea
• Protracted vomiting
• Enteric fistulas
• Intestinal dysmotility
• UlIntestinal
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 Enteral Tube Feeding
1. Short-term enteral feeding
(Nasoenteral Feeding Tubes)
• Nasogastric route
• Nasoduodenal route
• Nasojejunal
• A nasoenteric tube is indicated for short-term use (ie,
less than 4 to 6 weeks). The small diameter of the
nasoenteral tube may help prevent reflux and lessen
the risk for aspiration and regurgitation
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Complications of Nasoenteral Tubes:
• Sinusitis
• Epistaxis
• Erosion of the nasal septum or esophagus
• Otitis
• Vocal cord paralysis
• Distal esophageal strictures.
What are the method to confirm Nasoenteral Tube
placement?
1. Radiograph 2. injecting air and auscultating
3. Ph Monitoring
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Nursing Care and considerations of
Nasoenteral Tubes
• Nasoenteral tubes can be accidentally placed in the trachea
or bronchial tree.
• Before initiating tube feeding with a nasoenteral tube or in
case of any doubt, proper tube placement must be
confirmed by an abdominal radiograph.
• Because a nasoenteral tube may shift position, ongoing
assessment of tube placement is required.
• After confirming proper positioning radiographically, the
tube’s exit site from the nose or mouth is marked and
documented to facilitate ongoing assessment. An increase in
the external length of the tubing can signal that the tube’s
distal tip has dislocated
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2017 by Tanzeel Ul the gastrointestinal tract
 Enteral Feeding Tubes
2. Long-term enteral feeding (Enterostomal Feeding
Tubes)
• If therapy is expected to last a month or more, a
more permanent enterostomal device can be
inserted through the abdomen into the stomach
(gastrostomy) or jejunum (jejunostomy)
– Gastrostomy tube (PEG)
– Jejunostomy tube

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 Methods of Placement of
Enterostomal Tubes

1. Percutaneous Endoscopy
2. Surgery.
3. Laparoscopy
4. Fluoroscopy.

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 Nursing considerations for
Enterostomal Tube
• Enterostomal tubes are secured to the abdominal wall to prevent
dislodgment or migration.
• Prevent Buried bumper syndrome
• The length of the external tubing is documented to monitor for
migration of the tubing.
• Serosanguineous drainage may be expected for 7 to 10 days after
insertion
• The skin around the insertion site and the retention device is assessed
at least daily
• To avoid maceration, the site is kept clean and dry and lifting or
adjusting the tube is avoided for several days after the initial insertion
• Cleansing the site with soap and water is adequate.
• If an enterostomal tube becomes accidentally dislodged, the physician
must be notified immediately so that the tube can be reinserted quickly
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before the tract closes.
 Providing Enteral Nutrition
Enteral formula selection is based on the
patient’s clinical status, nutrient requirements,
fluid and electrolyte restrictions, and
gastrointestinal function; the location of enteral
access; the expected duration of enteral feeding;
and cost. All enteral formulas contain proteins,
carbohydrates, fats, vitamins, minerals, trace
elements, and water
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 Methods for Enteral Feeding:
 Bolus Feeding:

 Continuous Feeding:

 Bolus intermittent:

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 Bolus Feeding:
Considered the most natural physiologically,
entail using a syringe to administer a large
volume of formula (eg, up to 400 mL) over 5
to 10 minutes, five to six times a day.
• It is not well tolerate because of large
volume accompanied by nausea, bloating,
cramping, diarrhea, or aspiration
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 Bolus Intermittent Feeding
• Alternatively,300 to 400 mL of formula may be
administered by slow gravity drip over a
period of 30 to 60 minutes, four to six times a
day (this is termed bolus intermittent
feeding).

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 Continuous Feeding:
• Administered over 24 hours using a feeding pump to ensure
a constant flow rate.
• Continuous feeding is the preferred method when the
feeding tube is placed in the intestines because delivery to
the intestines that is too rapid may lead to “dumping
syndrome” (osmotic diarrhea, abdominal distention, cramps,
hyperperistalsis, lightheadedness, diaphoresis, and
palpitations).
• The small intestine can usually tolerate feedings at a rate of
150 mL/h.
• Continuous feedings are best suited for critically ill patients
because they allow more time for nutrients to be absorbed
in the intestine and may act prophylactically to prevent
stress ulcers and metabolic complications.
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Nursing Care of Enteral Feeding
• Check for feed advice
• Assess tube placement
• Assess bowel sound
• Warmth feeding
• Administer feeding
• Flush the feeding tube
• Maintain high fowler position
• Hold feeding in regurgitation, vomiting, or aspiration.
• Do not use stylet Copyright
to open © 2017 bya tube
Tanzeel if clogged
Ul Rahman
 Enteral Formulas
• Standard 1 calorie/mL
– Contain protein, fats, carbohydrates, vitamins, and
trace elements
• Specialized formula examples
– Elemental
– High protein
– Fiber enriched
– Wound healing
• Immune-enhancing formulas

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Tolerance of Enteral Nutrition
• Presence of bowel sounds in four quadrants, as
determined by auscultation
• Presence of bowel motility or bowel movements
• Palpation of a soft abdomen
• Percussion of the abdomen revealing tympanic
findings

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 Signs of Intolerance
• Nausea or vomiting
• Absent bowel sounds
• Abdominal distension
• Cramping
• Diarrhea

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Complications of Enteral Nutrition
• Diarrhea
• Nausea
• Vomiting
• Bloating
• Abdominal discomfort
• Constipation
• Fluid and electrolyte imbalance
• Hyperglycemia
• Hypoglycemia (if feedings are abruptly terminated)
• Aspiration

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 Preventing Complications
• Enteral tube obstruction
• Aspiration and improper tube placement
• Diarrhea
– Consider Clostridium difficile
• Dumping syndrome
• Hyperglycemia
• Electrolyte imbalances

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2. Parenteral Nutrition

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Parenteral nutrition:
• Parenteral nutrition or intravenous feeding is a
method of getting nutrition into your body
through the veins.
• It is indicated when oral or enteral nutrition is not
possible.
• When absorption or function of GIT is not
sufficient.

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Types or Methods of Perenteral
Nutrition :
Peripheral parenteral nutrition (PPN):
Is infused into a small peripheral vein and often
used for short term nutritional support.
• Because of the risk for phlebitis, concentrations of
PPN formulas must not exceed 900 mOsm/L
Total parenteral nutrition (TPN):
Also known as central parenteral nutrition, is
infused through a large central vein. The TPN formula
is highly concentrated and hyperosmotic.

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 Indications for PN
• Used for patients who are unable to tolerate enteral
feeding
– GI obstruction
– GI Surgery
– Intractable vomiting
– Intractable diarrhea
– NPO for an extended period of time (>1 week)
• Patients who are admitted very malnourished
– Start immediately, if unable to tolerate enteral feeding
• Unable to meet nutritional demands with EN

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 Formula Composition
TPN delivers all daily required nutrients to the patient in
the form of macronutrients (carbohydrates, lipids, and
amino acids) and micronutrients (electrolytes, vitamins,
and trace minerals). When all three macronutrients are
combined together in one TPN bag, the admixture is
referred to as a “3 in 1. Sometimes lipids are infused
separately. TPN formulation is based on the specific
needs of each patient; standard formulas are no longer
widely prescribed. While preparing the TPN formula, the
pharmacist can also add medications.
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 Formula Composition
• Carbohydrates
• Lipids
• Amino Acids
• Micronutrients
– Vitamins.
– Minerals.
– Electrolytes.

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 Guidelines for Administration of
Parenteral Nutrition

•There are two options for parenteral nutrition

administration: peripheral parenteral nutrition (PPN) or
total parenteral nutrition (TPN).
•For TPN central catheter (or central line) is placed into the
vascular system with the distal tip in the superior vena cava,
right atrium, or inferior vena cava; peripherally insert
central catheter (PICC), an external tunneled catheter, or a
subcutaneous port.
•Placement of these lines is verified by chest radiograph.
•Use a lumen devoted to the TPN only
•The solution is infused at a constant rate over a 24-hour
•If new TPN solution is temporarily unavailable, administer
10% dextrose in water to prevent Hypoglycemia
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• Tapering TPN is often initiated once the patient is able to
safely resume (and tolerate) enteral or oral nutrition
sufficient to meet approximately 50% to 75% of his
nutritional needs.
• Before TPN is discontinued, the infusion rate is decreased
by half for 30 to 60 minutes to allow a plasma glucose
response and prevent hypoglycemia. Checking blood
glucose for 30 to 60 minutes after discontinuation
facilitates identification and management of immediate
glucose abnormalities.

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 Complications of Parenteral
Nutrition

• Hepatic dysfunction (eg, hepatic steatosis, extrahepatic

cholestasis, cholelithiasis)
• Gastrointestinal atrophy
• Metabolic complications (eg, hyperglycemia,
hypoglycemia, hypophosphatemia, hypokalemia,
hypomagnesaemia , hypocalcaemia)
• Refeeding syndrome
• Local infection at the catheter insertion site
• Systemic bloodstream infection and sepsis
• Mechanical complications related to catheter insertion
(eg, vascular trauma, pneumothorax, thrombosis,
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 Nursing Care
• Assess patient’s ability to obtain or use nutrients
• If infection, look for malnutrition as cause
• Be alert for food-nutrient-drug interactions
• Assess for recent changes in health status
• Weigh daily
• Assess protein-energy malnutrition in the elderly
• Interpret laboratory findings cautiously

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 Nursing Care
• Risk of refeeding syndrome
• Risk for diabetes or glucose intolerance
• Monitor liver function for parenteral support

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 References
• Grossman, S., Porth, C.M., Conelius, J., Gerard, S.O.,
Moriber, N., O'Shea, E.R. and Wheeler, K., 2014.
Porth's pathophysiology: Concepts of altered health
states.
• Reference: Morton, P. G., & Fontaine, D. K. (2013).
Essentials of critical care nursing: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
• Sole, M.L., Klein, D.G., Moseley, M.J., Brenner, Z.R. and
Powers, J., 2009. Introduction to critical care nursing.
5th Edition St. Louis, Mo.: Saunders,
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