Advanced Care
What do you need to be cautious of when using EN or PN in a pt with DKA?
BG levels
-EN: monitor, adjust formula as needed
-PN: dextrose adjustment or insulin added to formula bag
Special concerns for bariatric pt
dumping syndrome
vomiting
dehydration
gas/bloating/belching
diabetic pt (hypoglycemia)
reflux
lactose intolerance
*discuss ways to manage these
energy/pro/fluid guidelines
dependent on individual/condition
Fluid guidelines
Many pt on fluid restriction d/t congestive HF or renal failure (1500-2000ml)
energy guidelines
supplementation for alcoholic liver disease and cholestatic liver diseases
MSJ w/ 1.1-1.2 SF (based on dry wt)
alcoholic liver disease- B1, B6, B12, folate, Zn
cholestatic liver diseases- ADEK
Pro guidelines
- wounds
- pancreatitis
- liver disease
What is...
wounds: 1.25-1.5g/kg
pancreatitis: 1.5 g/kg
liver disease: 1.0-1.5g/kg
Pro guidelines
Fluid guidelines
60-80 g/d
48-64 oz/d
If a pt is taking MAOIs, what nutrient is a concern? What can occur? Which medications are of particular concern?
Consuming excessive tyramine (more than 6 mg/day) can cause a sudden hypertensive crisis and therefore should be limited.
Tyramine restriction is necessary when Nardil, Parnate, and Marplan are prescribed at doses of 9 mg/day or 12 mg/day
Pro guidelines
- % kcal AND g/kg for cardiac pt
-g/kg for nourished HF pt vs g/kg for cachectic HF pt
16-20% kcal
1-1.2 g/kg (different for HF pt: 1.12g/kg for nourished pt; 1.37g/kg for cachexia)
Pro guidelines
-acute/chronic hepatitis
-liver disease w/o encephalopathy
-liver disease w/ encephalopathy
-critically ill liver disease
acute/chronic hepatitis: 1-1.5
liver disease w/o encephalopathy: 1-1.5
liver disease w/ encephalopathy: 0.6-0.8
critically ill: 1.5
Kcal guidelines (critically ill)
Provide equations and kcal/kg (obese and non-obese)
What is... dependent on condition:
non-obese: 25-30 kcal/kg OR Penn State 2003b
obese <60 yo: Penn State 2003b
obese >60 yo: Penn state 2010
Kcal guidelines (up to 1 yr post op)
What is...1200-1400 kcal/d
side effects of psychotropic medications and drug-nutrient interaction
dry mouth, wt gain, constipation
grapefruit (inhibits breakdown of drug)
Kcal guidelines
(MSJ and kcal/kg)
MSJ with 1-1.2 SF
25-30 kcal/kg
Oral diet considerations
Small/frequent meals
≤2000 mg sodium daily if ascites/edema present
If steatorrhea restrict fat to <30% of tot kcal
May require fluid restriction with hyponatremia
Oral diet for a pt with DKA
What is diabetic low/med/high diet?
Kcal guidelines (4-6 wks and 6wks-6mo post-op)
4-6 wks: 400-600 kcal
6wks-6mo: 800-1000 kcal
side effects of topamax
can cause taste changes and anorexia
Dietary considerations for HF pt
Less than 2 gm Na daily. Fluid restriction <2L daily for patients with serum Na <130 mEq/L.
Consider appropriate supplementation for diuretic use.
EN considerations
-explain formula and placement
Standard, energy-dense formula
Avoid formula’s containing Glutamine
PEG tube relatively contraindicated
Typical Dx(s) of an advanced care pt
What is DKA, Hypoglycemia, hypokalemia, cerebral edema, GI complications, liver failure, sepsis, pancreatitis, and wounds.
Often these patients move to this unit as a step down from ICU care.
Vitamin and mineral supplementation for SG and RYGB
B1: 12 mg/d
B12: 350-100 mcg/d
folate: 400-800 mcg/d
Calcium citrate: 1200-1500 mg/d
vitamin A: 5000 IU/day (up to 10,000 for RYGB)
vitamin E: 15 mg/d
vitamin K: 90-120 mcg/d
vitamin D: at least 3000 IU/d
iron: at least 18 mg/d from MVI
zinc: 8-11 mg/d
copper: 1-2 mg/d
Nutrition-related side effects of antipsychotics
increases in appetite, undesirable wt gain, insulin resistance, hyperlipidemia
Commonly used diets in this unit (and disease state they are used for)
TLC: disorders of lipid metabolism
DASH: HTN
**bonus points if you can explain them**
PN considerations (hyperglycemia, cholestasis, regimen, solution)
If hyperglycemia present, limit glucose to 2-3 g/kg/d and <1 g/kg/d lipids
Limit manganese and copper in setting of cholestasis
Cyclic regimen may be recommended
Concentrated solution to prevent fluid overload