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ED 321 993 SE 051 501

AUTHOR Hurley, Roberta Smith; Gallagher-Allred, CharletteR.

Nutritional Care of Deteriorating Patients. Nutritionin Primary Care Series, Number 15.

INSTITUTION Ohio State Univ., Columbus. Dept. of FamilyMedicine.

SPONS AGENCY Health Resources and Services Administration(DHHS/PHS), Rockville, MD. Bureau of HealthProfessions.

PUB DATE 80CONTRACT 232-78-0194NOTE 32p.; For related documents, see SE 05' 4'36-502. See

SE 051 503-512 for "Nutrition in Health Promotion"series.

PUB TYPE Guides - Classroom Use - Materials (For Learner)(051)

EDRS PRICE MF01.PCO2 Plus Postage.DESCRIPTORS Biochemistry; Cancer; *Chronic Illness; *Dietetics;

Disease Control; Health Education; *independentStudy; *Medical Education; *Medical Evaluation;Medicine; Nutrition; *Nutrit.,.on Instruction;

Physiology; Preventive Medicine; Science Education;Special Health Problems; Therapeutic Environment;Therapy

ABSTRACTNutrition is well-recognized as a necessary component

of educational programs for physicians. This is to be valued in thatof all factors affecting health in the United States, none is moreimportant than nutrition. This can be argued from variousperspectives, including health promotion, disease prevention, andtherapeutic management. In all cases, serious consideration ofnutrition related issues in the practice is seen to Je one means toachieve cost-effective medical care. These modules were designed toprovide mcre practical knowledge for health care providers, and inparticular primary care physicians. This module is designed topresent a variety of modes of nutritional intervention that can beused to forestall or correct the progressive stages of nutritionaldeterioration frequently seen in patients with chronic illness. Also,a longitudinal model of nutritional intervention is presented to helpthe physician choose the best form of dietary intervention fortypical longitudinal-care patients. Highlighted is the nutritionalcare of cancer patients. Included are learning goals and objectives,self-checks of achievement with regard to goals, references for thephysician and for the physician to give to the patient, and a list oflaboratory signs of nutritional deficiency helpful in determiningnutriture. (CW)

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15 Nutritional Care ofDeteriorating Patients

Roberta Smith Hurley

Charlette R. Gallagher-Allred

Nutrition in Primary Care Department of Family Medicinemi The Ohio State University11111 Columbus, Ohio 43210

A

BEST COPY AVAILABLE

The Nutrition in Primary CareSeries Contains These Modules:

1. Nutrient Content of Foods, NutritionalSupplements, and Food Fallacies

2. Appraisal of Nutritional Status3. Nutrient and Drug Interactions4. Normal Diet: Age of Dependency5. Normal Diet: Age of Parental Control6. Normal Diet: Ac' alescence7. Normal Diet: Pregnancy and Lactation8. Normal Diet: Geriatrics9. Dietary Management in Obesity

10. Dietary Management in Diabetes Mellitus11. Dietary Management in Hypertension12. Dietary Management in Hyperlipidemia13. Dietary Management in Gastrointestinal

Diseases14. Dietary Management for Alcoholic Patients15. Nutritional Care of Deteriorating Patients16. An Office Strategy for Nutrition-Related

Patient Education and Compliance

Department of Family MedicineCollege of Medicine The Ohio State University456 Clinic Drive Columbus, Ohio 43210

3


Roberta Smith Hurley M.S., R.D.Project DirectorComputer Assisted Instruction ProjectThe Ohic State UniversitySchool of Allied Medical ProfessionsMedical Dietetics DivisionColumbus, Ohio

Charlette R. Gallagher-Allred, Ph.D., R.D.Assistant ProfessorThe Ohio State UniversitySchool of Allied Medical PrcfessionsMedical Dietetics DivisionColumbus, Ohio

Project Staff

Tennyson Williams, M.D.Principal InvestigatorLawrence L. Gabel, Ph.D.Project DirectorPatrick J. Fahey, M.D.Family Medicine CoordinatorCharlette R. Gallagher-Allred, Ph.D., R.D.Nutrition CoordinatorJoan S. HickmanProject AssistantMade lon Timmons Plaistedrroduction CoordinatorWendy WallutGraphics Coordinator

Contract Number: 232-78-0194

U.S. Department of Health and Human ServicesPublic Health -Jervice Health Resources AdministrationBureau of Health Professions Division of Medicine

Project Officer: Margaret A. Wilson, Ph.D.

Acknowledg-ments

Advisory Committee

Paul Dorinsk_y, M.D., Resident, Department of Family Medicine, The Ohio StateUniversity, Lolumbus, OhioDavid R. Rudy, M.D., Director, Family Practice Residency Program, RiversideMethodist Hospital, Columbus, OhioMaria Steinbaugh, Ph.D., Associate Director, Nutrition Services, Ross Labor-atories, Inc., Columbus, OhioCarl D. Waggoner, M.D., Resident, Department of Family Medicine, The OhioState University, Columbus, OhioWilburn H. Weddington, M.D., Family Physician, Columbus, Ohio

Nutritional Consultants

John B. Allred, Ph.D., Professor, Food Science and Nutrition, College of Agri-culture, The Ohio State University, Columbus, OhioRobert E. Olson, M.D., Ph:D., Professor and Chairman, Edward A. Doisy De-partment of Biochemistry, St. Louis University Medical Center, St. Louis, Mis-souri

Educational Consultants

C. Benjamin Meleca, Ph.D., Director, Division of Research and Evaluation inMedical Education, The Ohio State University, Columbus, OhioA. John Merola, Ph.D., Professor, Department of Physiological Chemistry, TheOhio State University, Columbus, Ohio

A special note of appreciation is extended to persons in family practice residencyprograms and universities throughout Ohio for reviewing the materials, and tothe faculty and residents where the materials were piloted:Grant Hospital, Columbus, OhioRiverside Methodist Hospital, Columbus, OhioUniversity Hospital, Columbus, Ohio

Production Assistants

Carol Ann McClish, Lynn Copley-Graves, Chris Bachman , Linda Farnsworth

Cohaposition: Pony-X-Press, Colombus, OhioCamera Work: Printers' Service, Columbus. OhioReproduction and Binding: PIP, Sore 523, Columbus, Ohio

Library of Congress Catalog Card Number. 80.82859

Copyright © 1980 by the Department of Family Medicine of The Ohio State Umversit:.AU rights reserved.


Nutrition in Primary Care

6

Tables Table 15-1 Nutrient Content of Available Commercial Nutritional Supple-ment Products 4

Table 15-2 Nutrient Content of Commercially Available Tube Feedings andHomemade Formula Recipe Appropriate for Functional GutUse 7

Table 15-3 Nutrient Composition of Commercially Available ElementalDiets 8

Table 15-4 Recommended Amino Acid Intake for Patients RequiringTPN 11

Table 15-5 Nutrient Composition for Products Used in Total ParenteralNutrition Solutions 12

Table 15-6 Recommended Monitoring for TPN Patients 14Table 15-7 Sample Nutritional Support Regimen Using Combination of

Nutntioil Intervention Modes 10

Introduction The chronically ill patient is a prime candidate for malnutrition. There-fore, you must be constantly aware of the chronically ill patient's nutri-tional well-being and keenly alert to the early signs of nutritional failure.In addition, you must be knowledgeable of modes of dietary interventionwhich can help preclude the development of malnutrition or, if neces-sary, correct its presence.

Malnutrition, or cachexia, is characterized by anorexia, loss of total bodyweight, lean body mass, and adipose tissue. Other characteristics includeelevated metabolic rate, altered carbohydrate metabolism, fluid and elec-trolyte imbalance, and anemia. Malnutrition can occur whether it is Clueto food deprivation or illness that precludes optimal intake or utilizationof foodstuffs. Early dietary treatment of malnutrition is generally lesstraumatic to the patient than vigorous dietary treatment in correctingmalnutrition. Therefore, the purpose of this module is to present a vari-ety of modes of nutritional intervention that can be used to forestall orcorrect the progressive stages of nutritional deterioration frequently seenin patients with chronic illness. Also, a longitudinal model of nutritionalintervention is presented to help you choose the best form of dietary in-tervention for typical longitudinal-care patients. The nutritional care ofthe cancer patient provides an excellent model to demonstrate both thepreventive and therapeutic aspects of cachexia.

Goals As a result of this unit of study, you should be able to:

1. Describe the various moues of nutritional intervention oral supplements,tube feedings, and total parenteral nutrition which are appropriate for careof the chronically ill patient;

2. Identify the risks and benefits of each mode;

3. Identify the nutrient composition of each mode when given a typical intake;and

4. Plan an appropriate nutritional intervention regimen after evaluating thenutritional status and eeds of a cancer patient.

8 1

2 Nutrition in Primary Core

Assessing Nutritional StatusThere are a number of ways of detecting diver-

gence from optimal dietary intake. The most obvi-ous clue is loss of body weight and anorexia be-cause the patient cannot, c r will not, eat.

Even though the patient may appear "healthy,"less obvious clues of malnutrition can be detectedbiochemically o. by anthropometric measures(see Module 2 on appraisal of nutritional status).Sanstead, Carter, and Darby, physicians fromVanderbilt University, have recommended appro-priate biochemical tests which are the best indica-tors if nutritional status (see Appendix A at theend of this module). A clinical dietitian can recom-mend these biochemical tests when appropriateand accurately assess the anthropometric meas-ures; these tests and measures are invaluable inassessing a patient's nutritional well-being. how-ever, many physicians do not have a fulltime orconsulting dietitian and must rely on their ownknowledge or more basic techniques to assess apatient's nutritional weil-being.

The evaluation of the patient's typical daily in-take is the first assessment parameter which ispractical for physicians or nurses to perform in thephysician's office when a patient complains of an-orexia or slow weight loss. Evaluation usually isbest done by eliciting a 24 hour recall and thenasking the patient to indicate how the recall isdifferent from a typical week's intake. An accuratemethod of obtaining an overall picture of a pa-tient's dietary habits is taking a diet history offoods typically consumed over a week's period oftime; however, it is time consuming and perhapsnot feasible for you to accomplish. Suggestionsoffered in Module 1 on nutrient content of foodswill help you elicit diet history information in areasonable and rapid manner.

It is appropriate to use the Basic Four FoodCroups as a guide for assessment of the elicited re-call or history. The four groups and number ofdaily servings recommended for the adult are:

1. Milk group (2 servings).2. Meat group (2 2-ounce servings).3. Fruit and vegetable group (2 fruits, 1 a citrus

fruit or juice daily, and 2 vegetables, 1 a deepgreen leafy or yellow vegetable every otherday).

4. Bread/grain group (4 servings).

Questions to which you should seek answerswhen properly assessing your patient's dietarystatus include:

How many times a week are milk, meats, fruitsand vegetables, and breads and cereals con-sumed by the patient?Does the patient have difficulty planning a well-balanced diet? If so, how and why?Does the patient have difficulty purchasing awell-balanced diet?Does the patient live alone? Are finances ortran portation a problem in obtaining food?Does the patient have chronic diarrhea or consti-pation?Does the patient find that food does not tastegood? Has the patient's appetite changed re-cently?

Other questions you may want to ask yourselfinclude:

Is the patient elderly and functioning independ-ently?Does the patient have a satisfying amount of so-cialization?Has the patient suffered a recent major illness? Isanyone else in the family seriously ill?Is the patient about to undergo major medicaltreatment or surgery?Is the patient receiving radiation therapy, chem-otherapy, or any medications that could causenausea, vomiting, malabsorption, anorexia?Hai the patient lost weight recent] ? If so, has itbeen a rapid or a slew progressive loss?

The answers to these questions can help iden-tify those individuals w'lo may not show overtsigns of malnutrition yet who may be high riskcandidates for nutritional deterioration. It is at thispoint that the development of cachexia may be prevented!

Modes of Dietary InterventionIf you suspect, based on the results of a 24 hour

recall or diet history or answers to the questionsposed above, that your patient is nutritionally de-prived or is at high risk for nutritional deprivation,you need to select an appropriate mode for dietaryintervention which will meet your therapeuticgoals and be within t1. patient's ability to follow.

15. Nutritional Care of ,r)eterioratmg Patents 3

The three basic modes of dietary interventionwhich may be combined or used separately in-clude the following:

1. Oral foods with or without nutritional supple-mentation.

2. Tabe feedings through any of a number ofavailable anatomical sites.

3. Total parenteral nutrition or hyperalimenta-tion through either a central venous line or pe-ripheral hyperalimentation line.

Oral Formulas

The most desirable means of treating thepatient who is malnourished or sus-pected to be of high nutritional risk is to"push" oral intake. In other words, ifthe gut is functioning, use it.

How do you choose the most appropriate modeor modes of therapy?

If meals appear to be inadequate through evalu-ation of the elicited 24 hour intake or diet history orfrom answers to questions listed above and if thepatient's gastrointestinal tract is functioning, it iswise to begin counseling the patient on ways to in-crease intake through oral foods with or withoutnutritional supplements.

Suggestions which are helpful to the patient inincreasing oral intake, depending on the patient'sfinancial status, include adding between-mealsnacks such as fruits, juices, milk, milkshakes,eggnogs, custards, puddings, and sandwichesnade of meat or cheese or peanut butter. You mayalso suggest nutritional supplementation of thesesnacks by:

Adding 2 Tablespoons dried skim milk powder tomilk, milkshakes, or eggnogs.Adding 1 to 2 Tablespoons table sugar to juices,especially sour lemonade, limeadegrapefruit juices.Adding cream to fruit.Using double portions of butter, margarine, jelly,jams, or preserves on sandwiches or toast.

To make palatable yet inexpensive additioi.s tothe diet of the older, depressed, poor-eatingpatient, the following suggestions might beoffered:

10

Use cooked legumes (pinto beans, navy beans,lima beans, white beans, and cow peas).Use enriched macaroni and cheese.Use enriched cooked cereal with milk.Use powdered fruit juice mixes which are high invitamin C and need reconstitution with water.Increase use of eggs and nonfat dry milk.Use peanut butter on enriched or whole grainbreads.Buy day-old enriched or whole grain breads.Buy non-brand-name or lesser known brandname foods.

When you encourage patients to cook and eatfor themselves, they will increase their interest inself-care. This has a positive influence on adher-ence to other suggested health care measures. Ithas been the exoerie ice of dietitians that it is oftherapeutic irnpoi !..,r.ce to stress to the patient thathe should eat and maintain weight status. Loss ofweight results in anorexia; conversely, "the bestway to keep the appetite good is to feed it!"

If the patient's intake is inadequate because of:hewing and swallowing problems (such as ill-fitting dentures, surgery, or cancer), soft andsemiliquid foods may help (puddings, custards,whole milk, milkshakes, eggnogs, juices, mashedpotatoes, and puréed foods). Dairy productsor other nutritious beverages, especially eggnogs,appear to be most acceptable to the cancer patientwho is anorectic due to altered taste sensation.Again, nutritional supplementation as suggestedabove may be used to increase the protein andenergy content of the diet.

Often, the patient is not motivated or is other-wise unable to prepare frequent feedings orspecial food products. Utilization of the clinical di-etitian is especially important in these cases. If del-egation to the dietitian is possible, the physicianshould not lose contact of this aspect of patientcare. When delegation is not possible, commercialsupplements suitable for oral ingestion should beadded to or may completely replace other oral in-take if necessary. Commercial supplements arelisted in Table 15-1; as noted in the far righthandcolumn, some products contain lactose and mighttherefore be contraindicated in patients with lac-tose intolerance or those suspected to be intoler-ant due to genetic background (Mediterranean,Oriental, black, Asian, and South American popu-lations).

4.

Nutrnion in Primary Care

Table 15-1 Nutrient Content of Available Commercial Nutritional Supplement Products*

Product Company

Carbohydrate Protein FatKilocalories Grams per Grams per Grams perper Liter Liter Liter Liter

Sustacal

Lnsure

Mead Johnson & Company 1,0002400 W. Pennsylvania Ave.Evansville, IN 47712

134 59 12

Ross Laboratories 1,000 144 37 37625 Cleveland Ave.Columbus, OH 43215

Ensure Plus Ross Laboratories 1,500 196 54 54625 Cleveland Ave.Columbus, OH 43215

Meritene Doyle Pharmaceutical 1,000(liquid) Company

Hwy. 100 & W. 23rd St.Minneapolis, MN 55416

Vital

115 60 33

Ross Laboratories 1,000 183 42 10625 Cleveland Ave.Columbus, OH 43215

Polycose Ross Laboratories 2,000 500625 Cleveland Ave.Columbus, OH 43215

Kilocalories Carbohydrate Protein Fat Gramsper 6 oz of Crams per 6 Grams per 6 per 6 ozWater oz of Water oz of Water of water

Citrotein Doyle Pharmaceutical 125CompanyHwy. 100 & W. 23rd St.Minneapolis, MN 55416

23.3 7.67 Trace

* Requires that 1.5 to 2 liters are consumed daily to meet the Recommended Dietary Allowances (RDA) for the adult.

11

15. Nutritional Care of Deterior';7 Patients

Approx1980cost per

1,000 kilo-calories

$3.40

$1.70

$2.00

$2.00

$6.10

Other Comments

Nutritionally complete!"

Nutritionally complete.*No lactose.

Nutritionally complete.*No lactose.

Nutritionally complete.*

Hydrolyzed protein product.Nutritionally complete?'

$3.40 Glucose polymers. Caloricsupplement useful withfruits, juices. Not nutri-tionally complete.

Cost perServing

$ .5n One serving equals onepacket in 6 ounces water.Supplement to be addedto water or orange juice,slushes, carbonated bever-ages. Not nutritionallycomplete.

5

Products listed in Table 15-1 are available atmost pharmacies and some supermarkets. A de-tail person representing a pharmaceutical manu-facturer also can request that a store coi i venient tothe patient carry the products. Most products canbe delivered to the pharmacy or supermarketwithin 24 to 48 hours of request. Recipes utilizingthese products are available on request from thecompanies; addresses are given in the Resourcesfor the Patient section at the back of this module.

Tube Feeding Formulas

If the gut is functioning but oral intakeis compromised, tube feedings may bethe most feasible means of dietaryintervention.

The patient may come to you already cachecticso that his nutritional status cannot be improvedby oral intake alone. Oral lesions, strictures of theesophagus or pylorus of the stomach, dysphagia,or stroke may prevent intake of sufficient nutritionby mouth. A nasogastric tube or gastrostomy tubemay be necessary for feeding patients with theselimitations. These tube feedings allow use of theremaining functional gastrointestinal tract for di-gestion and absorption. Homemade or commer-cial formulas can provide the essential nutrientswith a consistency suitable to pass through a tube.A list of nutritionally compete tube feeding prod-ucts which require a functioning gastrointestinaltract for digestion and absorption is included in Ta-ble 15-2.

Tube feedings prepared at home may be less ex-pensive than commercial products. The patientusing home-prepared feedings may choose to usea tube-feeding solution made from recipes such asthe one given in Table 15-2 or may choose to useregular table food by blenderizing each item sepa-rately and forcing the blender: .ed food throughthe tube into the gastrointestinal tract by using afeeding syringe. Homemade products should bestrained before being placed into the tube sothat the tube will not become clogged; foods withseeds, nuts, whole grains and hulls, fresh fruits,and fresh vegetables must be avoided for thissame reason. All homemade products and openedcommercial products must be kept refrigeratedand, if not used, discarded after 24 hours.

6 Nutrition in Primary Care

Unopened cans of commercial products do notneed to be refrigerated, nor do commercial prod-ucts need to be strained before they are placei intothe feeding tube.

Tube Feeding Patient Work-up

Peristalsis of the gastrointestinal tract must bepresent prior to tube feeding administration.Assessment of gastrointestinal function should in-clude auscultation of bowel sounds, observationof abdominal distention, and questioning thepatient to ascertain recent bowel movements (con-stipation or diarrhea) and flatulence.

The patient should be sitting upright for bothtube insertion and for feeding. He should be toldto warm the feeding to room temperature if it hasbeen refrigerated. The patient should also be in-structed to insert the feeding syringe into the tubegnd elevate it 3 to 6 inches above the head. Anyhigher may cause too rapid gravity flow of wateror formula into the gastrointestinal tract. One-fourth cop of water should be run through thetube before feeding to be sure that the tube is notplugged.

Tube Feeding Regimen

Tube feeding composition, volume, andrate of administration are based on thelength cf time the gastrointestinal tracthas been at t and the location of theindwelling tube.

The time interval since the last ingestion of foodand the location of the indwelling tube should Ixconsidered when choosing the type of formula, itvolume, aid:I the methoci of administration. Forpatients in whom the gastrointestinal tract hasbeen at rest for more than three days, the initialtube feeding of isotonic formula, su,:h as Osmoliteor Isocal diluted to 1/2 kilocalorie per milliliter,should be instituted at approximately 240 millili-ters given over a four-hour period of time (60 milli-liters per hour) followed by 120 milliliters of water.If the feeding is well tolerated, the volume or con-centration, but not both, should be increased be-sinning an hour later. For this next feeding, Y4 kil-ocalorie per milliliter may be given at 60 -tillilitersper hour for the next 2 four-hour shifts, eachfollowed by 120 milliliters of water. Full strength, 1

kilocalorie per milliliter, may be attempted 24hours after institution of the tube feeding if nosigns of patient intolerance occur. Use of fullstrength formulas which are higher in osmolalitythan isotonic formulas are advised as the nextstep. Volume should then be increased first up to75 milliliters per hour for four hours and then begiven at the rate of 100 milliliters per hour, which,if given by continuous drip, would equal 2,400 kil-ocalories per 24 hours.

Beginning a tube feeding at the standard 1 kilo-calorie per milliliter is usually safe for patients inwhom the gastrointestinal tract has been at restless than three days. A wise progression would beto begin the standard formula by administering240 milliliters ver a two-hour period (120 millili-ters per hour), followed by 120 milliliters of water,wait one hour, and then institute continuous orbolus feedings equaling 120 milliliters per hourwhich would result in a potential intake of 2,8Lkilocalories.

Tube Feeding Administration Methods

Tube feedings can be administered ei-ther by continuous drip m,:chod or bythe patient-administered piston syringemethod.

1M.

Continuous drip and piston syringe bolusadministration are the two major types of tubefeeding administration. With the continuous dripmethod, administration of the formula is accom-plished over a calculated time period. Continuousdrip is used preferably to initiat.: and progresstube feedings until the patient can assuie admin-istration via a piston syringe. Advantages ofcontinuous drip feeding include increased con-sumption of kilocalories over a 24 hour period, ad-ministration of formula without waking the pa-tient, and minimized symptoms of intolerance.Piston syringe feeding, on the other hand, is a bo-lus administration of formula over a short periodof time and is best given over a 15 to 30 minuteminimum period. It is used for patient-administered tube feedings and administration ofmedication via an indwelling tube. It also allowsfor increased mobilization of the patient.

When a patient is receiving bolus tube feedings,water must be supplied in sufficient amounts to

13

15. Nutritional Care of Deteriorating Patients 7

Table 15-2 Nutrient Content of Commercially Available Tube Feed digs and HomemadeFormula Recipe Appropriate for Functional Gut Use

Product Company

Approx1980Kilo- Carbohydrate Protein Fat Grams cost

calories. Cramsper Cramsper per per 1,000per Liter Liter Liter Liter kilocalories Comments

Compleat-B Doyle .narmaceuticalCompanyHwy. 100 & W. 23rd Ave.Minneapolis, MN 55416

Formula-2 Cutter Laboratories, Inc.4th and Parker Scs.Berkeley, CA 94710

Carnation Carnation Company

Instant 5045 Wilshire Blvd.

Breakfast Los Angeles, CA 90036

MeriteneLiquid

Doyle PharmaceuticalCompanyHwy. 100 & W. 23rd Ave.Minneapolis, MN 55416

Nutri-1000 Cutter Laboratories, Inc.4th and Parker Sts.Berkeley, CA 94710

Sustacal'.squid

Ensure

EnsurePlus

Isocal

Mead Johnson & Company2400 W. Pennsylvania St.Evansville, IN 47712

Ross Laboratories625 Cleveland AvenueColumbus, OH 43215

Ross Laboratories625 Cleveland AvenueColumbus, OH 43'15

990 120 40 40 $3.40

1,000 121 38 40 $3.00

1,120 140 60 32 $1.25

1,000 115 60 33 $2.00

1,000 94.5 37.8 52 $1.81

1,000 134 59 12 $2.75

1,000 144 37 37 $1.70

1,500 196 54 54 $2.00

Mead Johnson & Company 1,000

2400 W. Pennsylvania Sc.Evansville, IN 47712

Osmolice Ross Laboratories625 Cleveland AvenueColumbus, OH 4i215

Sample Homemade Formula

Evanorated milk - 2 1/2 cupsSugar - 50 gmPureed liver - 1 jar ;baby jar)Dried skim milk powder - 2 tablespoonsWhole eggs - 1 jarPureed vegetables - 1 jar (baby jar)Water - 1/2 cupMultiple vitamin concentrate - 0.6 cc

Nuttitionally completed Containsbeef and nonfat milk, corn oil,sucrose, vegetables, fruits andjuices. Moderate residue.

Nutritionally complete,. Containsnonfat milk, beef, corn oil, eggyolks, sucrose, vegetables,juice, farina. Moderate residue.

Nutritionally complete.* Containsnonfat milk, soy protein sucrose,torn syrup solids. Low residue.Figures include 32 oz milk.

Nutritionally complete.* Containsskim milk, vegetable oil,sucrose, corn syrup solids. Lowresidue.

Nutritionally complete.* Containsskim milk, corn oil, sucrose,corn syrup solids. Low residue.

Nutritionally complete.* Containscasein, corn syrup solids, soyprotein, soy oil, sucrose.Low residue. Now lactose-free.

Nutritionally completes.* Contains

no lactose, contains Casein, soyprotein, corn oil, corn syrupsolids, sucrose. Low residue

Nutritionally complete*. Contains

casein, soy protein, corn oil,corn syrup solids, sucrose. Lowresidue. Contnino no lactorc.

132 34 44 $2.65 Nutritionally complete.* Containsno lactose. Contains casein,soy protein, soy oil, MCT, corn

syrup solids. Is isotonic withblood plasma.

1.000 144 37 37 $3.00 Nutritionally complete.* Containsno lactose. Contains corn syrupsolids, casein, MCT, corn oil.soy protein, soy oil. Isotonicsolution, 300 mOsm/kg. water.

Low electrolytes and residue.

1,065 70 62 60 51.00 Nutritionally complete.* Containslactose and moderate residue.

* Requires that 1 5 to 2 liters are Lonsurned dally to meet the Recommended Dietan Allo%%ances (RDA) for the adult

14

Nutrition in Primary Care

keep the patient optimally hydrated and to ensurea clear tube prior to and after each feeding. A gen-eral rule of thumb when calculating how muchfluid to supply is to give half as much water perfeeding as the number of kilocalories in the feed-ing.

For example:

For 100 milliliters tube feeding containing 100 kil-ocalories, give 50 milliliters water.

For 200 milliliters tube feeding containing 100 kil-ocalories, give 50 milliliters water.

The patient receiving bolus feedings may keepthe tube in at all times or, if he desires, may insertprior to each feeding and withdraw following thefeeding. Tube Feeding: Tips and Techniques (see theResources for the Physician section at the back ofthis module) is an excellent reference for teachingthe patient how to insert and care for tubes.

Tube Feeding Monitoring and ProblemsThe purpose in providing the tube feeding ini-

tially at a slow rate is to avoid sudden distentionand subsequent emptying of the stomach, whichcauses nausea, vomiting, cramps, and diarrhea.

Table 15-3 Nutrient Composition of Commercially Available Elemental Diets

Product Company

CarbohvKilo drate

calories Grams perper Liter Liter

ProteinGrams per

Liter

FatGrams

per MilliosmolesLiter per Liter

Vivonex Eaton Laboratories17 Eaton AvenueNorwich, NY 13815

Vivonex HN Eaton Laboratories17 Eaton Avenue

Norwich, NY 13815

Flexical Mead Johnson andCompany

2400 W. Pennsylvania St.Evansville, IN 47712

Vital

Vipep

Ross Laboratories625 Cleveland AvenueColumbus, Ohio 43215

Cutter Laboratories4th and Parker Sts.Berkeley, CA .4710

Precision Doyle PharmaceuticalCompany

Hwy. 100 and W. 23rd St.Minneapolis, MN 55416

1,000 287 21 2 820-2,100*

1,000 202 46 1 800-2,100*

1,000 155 22 31 835

1,000 183 42 10 450

1,000 175 25 25 520

1,000 215 21 0.7 600

. favor packets add considerably to osmolality.171MilPLM,

15


"Dumping" and diarrhea are frequent complaintsof the tube-fed patient. Dumping occurs with thetoo rapid arrival of a hypertonic solution into thejejunum. The hypertonic fluid in the bowel causesmovement of extracellular fluid from the plasma tothe bowel lumen to achieve isotonicity, which inturn decreases circulating plasma volume aidresults in compensatory vasoconstriction. Symp-toms include nausea, vomiting, epigastric full-ness, pain, sweating, warmth, vertigo, faiiiting,and diarrhea.

You may advise the patient to slow down the.feeding, dilute the formula temporarily until the

Approximate 1980retail costper 1,000kilocalories

(liter) Composition

$6.40

$6.50

$6.10

$3.96

Amino acids, simple sugars,vitamins, minerals.

Amino acids, simple sugars,vitamins, minerals.

Hydrolyzed protein, aminoacids, simple sugars, soy andmediumchain triglycerides,vitamins, minerals.

Hydrolyzed protein, aminoacids, simple sugars, sunfloweroil, vitamins, minerals.

Hydrolyzed protein, aminoacids, simple sugars, rAiumchain triglycerides.

$6.80 Egg albumin, simple sugars,vitamins, minerals.

16

symptoms subside, or ideally, administer an iso-tonic tube feeding in which osmolality equa's nor-mal body fluids. The patient who complains of di-arrhea for other reasons may b: advised to addbulk-formirq foods to the feeding such as pectin (1Tablespoon per liter), methylcellulose (3 gramsper liter), applesauce (2 Tablespoons per liter),or bananas. Drugs that may be helpful includeLomotil, Paregoric, or Kaopectate.

Constipation may be a complication in tube-fedpatients. Causes of constipation may include de-hydration, low-residue tube feedings, or gastro-intestinal obstruction. Treatment may include ad-ministration of an enema or cathartic, increasedfruit or vegetable content of the tube feeding,increased water intake, or when appropriate, sur-gical intervention to relieve the obstruction.

You need to continually monitor the state ofhydration of the patient, and check fluid intakeand output, and serum osmolality. You shouldalso monitor blood glucose levels, and daily notethe presence of diarrhea or constipation.

Patients receiving tube feedings are often de-pressed by the change this type of feeding brings,especially if it must be a lifelong daily process.Much support, teaching, and reinforcement mustbe given to the patient and his family. It is desira-ble to have the patient and/or family become self-sufficient in tube feeding administration as soonas the patient is ready.

Elemental Formulas

Elemental diets for use in jejunostomytube feedings are used when the stom-ach is unavailable. These formulas arehigh in amino acids, Ample sugars, andother nutrients.

If the stomach is unavailable for mixing, severalalternatives exist for treating the patient.Jejunostomy tube feedings are frequently used;the formula should be introduced past the site ofentry of the common bile duct to avoid reflux, butthis limits the mixing of the formula with pancre-atic enzymes and bile.

Although costly, elemental formulas appropri-ate for jejunostomy tube feedings have been de-veloped. They are nutritionally complete formulaswhich need little or no digestion, contain readily

10 Nutrawn Prunary Care'

:..-1,-;,orbable nutrients, and are low in residue.The formulas contain amino acids or hydrolyzedprotein composed of amino acids and some di-and tri-peptides, simple sugars except lactose,medium-chain triglycerides or vegetable oils, vita-mins, and minerals. Table 15-3 contains the nutri-ent composition of several commercially availableelemental formulas, or "defined formula diets" asthey are often called.

The elemental diets that are composed of freeamino acids generally have an unacceptable fla-vor. The products are more palatable if mixed withjuices and served with ice or as a slush. Someproducts have accompanying flavor packets, andthus, increased acceptability, yet double theosmolality. Products composed of hydrolyzedprotein contain di- and tri-peptides and are moreacceptable to the patient than products composedof free amino acids; there iF evidence that thesepeptides are readily absorbable despite lack ofpancreatic enzymes. Because of their high freeamino acid content and, therefore, fast release intothe intestine from the stomach, sipping the ele-mental diets decreases the incidence of diarrhea,dumping, dehydration, and glucose intolerance.Uses of the elemental diet include patients withlimited digestive function, preoperative catabo-lism, post-operative catabolism, and for correctionof negative nitrogen balance with trauma, burnsor sepsis, or whenever anabolism is desired.

Total Parenteral Nutrition Solutions=acaMIM...1=! 111,,If the patient is severely malnourishedand bypassing a malfunctioning alimen-tary tract is desirable, total parenteralnutrition is an alternative mode of nutri-tional intervention. Parenteral nutritioncan provide the nutrients necessary tomaintain positive nitrogen balance andachieve weight stability or gain in adultsand normal growth and development ininfants and children even under cata-bolic conditions. Current clinical indica-tions for parenteral nutrition are numer-ous and basically are for support andmanagement of patients who cannot orwill not eat, who should not eat, or whocannot eat enough.

If the patient is severely malnourished and iforal or tube feedings are not enough to promoteweight gain and improvement of other parametersof nutritional status, feeding by the parenteralroute may be required. Total parenteral nutrition(TPN) is a means of providing nutrientsintravenously, the patient must be hospitalized toinstitute TPN.

It is well-established that the chronic or seri-ously ill patient may require up to twice the caloricneeds of healthy persons. Pending further study,appropriate parenteral nutrition should providean energy-nitrogen ratio of 150 kilocalories pergram nitrogen. The two most important sources ofenergy for TPN solutions are carbohydrates andfats. Usually a 25% or 35% dextrose solution isused in TPN. A minimum of100 grams of carbohy-drate per day has been shown to prevent ketosisand decrease protein catabolism. At present, nocarbohydrate source has been found to be moreeffective than glucose. Because hyperosmolarglucose solutions are used in TPN, they must begiven in a central vein. Problems associated withhyperosmolar glucose solutions are discussedlater in this module.

Due to the difficulty in infusing the requiredamount of energy in the form of carbohydrate, in-travenous fat emulsions in combinations with notless than 20% of the kilocalories from carbohy-drate have been shown to be advantageous. Thegreat advantage of fat emulsions is that a largeamount of energy (9 kilocalories per gram of fat)in an isotonic solution, which therefore has littleeffect on blood osmolality, can be given in a smallamount of fluid through the peripheral vein. Useof fat emulsions has been shown to decrease someof the problems associated with high glucoseadministration. Decreased thrombophlebitis, de-creased diuresis of nutrients, and prevention ofessential fatty acid deficiency have been shown tooccur with fat emulsion administration. Contra-indications for the use of fat emulsions includehyperlipidemia, advanced hepatic injury, bloodcoagulation disturbances, and allergies. Intralipid(a 10% soybean oil emulsion with egg yolk,phospholipids, and glycerol) or Liposin (asafflower oil emulsion) are the major fat sourcesused in the US.

Sources of nitrogen available for TPN solutionsinclude protein hydrolysates and mixtures of crys-

15. Nutritional Care of Deteriorating PatientsMoMMMMM

11

talline amino acids usually administered as 4.25e;solutions. Because the requirements for aminoacids depend on various metabolic and physio-logic conditions, amino acid requirements in-crease as protein catabolism increases. Table 15-4shows the amount of amino acids which are rec-ommended for TPN administration:

1171/-Table 15-4 Recommended Amino Acid Intake

for Patients Requiring TPN

Condition Amount Amino Acids

Renal insufficiencyAdultsInfants, pregnantwomen, and post-operative patients

Premature, hypo-trophic and post-operative neonates

Grams/Kilo grams

Body Weight/Day0 4-0.6O. 8-1. 6

2.0-3.0

2.0-4.0

For optimal utilization of the amino acids givenparenterally, energy requirements must be met bysimultaneous infusion of non-protein energysources. Recent research has indicated that thenitrogen-sparing ef:oct of glucose i , better thanthat of fat.

Table 15-5 includes several nutritional productsfrequently used in TPN solutions and a typicalstandard order for vitamin and mineral supple-ments. Remember that seriously ill patientsrequiring TPN may need amounts of vitamins andminerals greater than the levels suggested in Table15-5 for the following reasons:

1. To reverse prior depletion.2. To meet increased metabc' demands associa-

ted with fever, infection, ,tress.3. To support needs associated with anabolic

processes.4. To compensate for excessive urinary losses

secondary to TPN.

In order to assess the effectiveness of the vita-min and mineral content of TPN solutions. carefulmonitoring of blood levels and urinary loss is es-

18

sential. Table 15-6 lists several blood, urine, andother parameters which should be closely morn-tored in TPN patients and also suggests the fre-quency of monitoring. An excellent reference forhow to monitor patients on TPIV is Insights intoParenteral Nutrition (see Resources for the Physi-cian for this free booklet).

When initiating TPN it is best to begin with a10% glucose solution and a 4.25% amino acid solu-tion supplemented with vitamins and minerals, asshown in Table 15-5. Progression to 35% glucoseand 4.25% amino acids can be started a few hourslater. When discontinuance of the TPN solution is war-ranted, do not abruptly stop solution administration;,the decrease in solution administration should be ta-pered over three to four hours to allow for a decrease ininsulin levels and therefore avoidance of a hypoglycc;::;repisode. If Intralipid fat emulsion is to be insti-tuted, a peripheral line, or T-tube with the centralvenous line, may be established; administration ofIntralipid, or Liposin, 500 milliliter's every otherday or three tires weekly greatly helps to supplyadequate kilocalories. Signs of essential fatty aciddeficiency (skin lesions and altered triene-tetraenefatty acid ratio) can be seen within two weeks onTPN without fat administration; essential fattyacid deficiency is quickly reversed with Intralipidadministration. Deficiencies of fat-soluble vita-mins, water-soluble vitamins, and major mineralsshould not be seen if adequate amounts of thesenutrients are included in formulas. Deficiencies oftrace elements, copper, magnesium, chromium,and iodine, have recently been identified. Traceelements must be an integral component of TPN,especially when TPN is administered on a long-term basis.

Nutritional and metabolic complications withTPN do occur. The most common complication as-sociated with glucose stems from the body's ina-bility to utilize high concentrations of glucose.Hyperosmolar non-ketotic hyperglycemia andcoma can arise with surprising suddenness. Fever,osmotic diuresis, and blood sugars greater than700 milligrams/100 milliliters are not uncommon.These patients must be treated with large amountsof intravenous insulin and all glucose-containinginfusions stopped. Severe hypoglycemia may re-sult secondary to the slowing of the infusion be-cause of mechanical problems or because of exces-sive insulin infusion.

110111121MENCIM1111NMIIEMIEV7r

12 Nutrition iti Primarli Care

,........Table 15-5 Nutrient Composition for Prod acts Used in Total Parenteral Nutrition Solutions

Product Company

Kilo-calories

Amount per Liter

CarbohydrateGrams/Liter

Amino AcidGrams/Liter

ProteinGrams/Liter

FatGrams/Liter

Freamine II McGaw 1 liter 312 0 78 78 0

Travasol Travenol 1 liter 352 0 84 88 0(8.5%)

Glucose 1 liter 1,000 250 0 0 0(25%)

Intralipid Cutter 500 ml= 450 0 0 50 0(10%) 50 ml fat

Multi-vitamin, 5 ml 0 0 0 0Multi-mineral,and Trace ele-ments Supple-ment (added toTPN solutions)

06

1 9

15. Nutritional Care of Deteriorating Patients

Comments Standard Order

Electrolytes,

vitamins, andminerals must beadded

Available withand withoutelectrolytes;

vitamins andminerals mustbe added

Na 60 mEq/LK 40 mEq/LCa 18 mEq/LPO4 20 mEq/LAcetate 25 mEq/L

With electrolytes, addNa 70 mEq/LMg 10 mEq/LAcetate 100 mEq/LPO4 60 mEq/LCl 70mEq/L

Vitamin A 10,000 IUVitamin D 1,000 IUVitamin E 5 IUThiamine 50 mgRiboflavin 10 mgNiacin 100 mgB6 15 mgPantothenic Acid 25 mgAscorbic acid 500 mgAlso trace elements,especially copper,zinc, chromium, andManganese

20

Amino acid imbalances may also occur withTPN administration. Hyperchloremic metabolicacidosis may result from excessive chloride andmonohydrochloride content of crystalline aminoacids. Treatment includes administration of bicar-bonate, lactate, or acetate. Hyperarnmonemiamay also occur especially in premature infants, inpatients with hepatic disease, or as a result of toomuch ammonia in protein hydrolysates or too lit-tle amino acids essential for urea cycle functioningin crystalline amino acid solutions.

With regard to vitamin and mineral aberra-tions, hypocalcemia and hypophosphatemia mayresult from inadequate calcium and phosphorusadministration, respectively. Excessive calciumadministration with or without vitamin D may re-sult in hypercalcemia. Other vitamin and mineralcomplications may include hypo- or hyper-kalemia, hypo- or hypermagnesemia, anemia,and hypervitaminosis A.

Because of the costs of TPN and risks of sepsiswith use of a central venous catheter, this mode ofnutrition intervention should be used with cau-tion. Home TPN is available for patients who canafford it and can administer it properly. Use athome has its obvious advantages for the patientwho must improve nutritional status before orafter surgery. It may also be necessary for those forwhom TPN is their only means of nutritional sup-port.

Care Study.The cancer patient provides an excellekltmodel of the deteriorating patient whoseability to consume and utilize adequatenutrients is compromised. Early in can-cer therapy, the physician should en-courage food consumption, especially ofwell-tolerated foods such as eggs anddairy products.a

Mr. A.H., a 50-year-old man, was initially seenone year ago by his physician and diagnosed tohave cancer of the mouth. His height was 5 feet 11inches and weight, 190 pounds. At this time he re-ported some difficulty chewing and swallowingbut unfortunately no diet instructions were givenat that time. Radiation therapy was ordered.


111111==1=0M1.1=1/7/

Table 15-6 Recommended Monitoring for TPN Patients*

Parameter Freauencv of Monitoring

Urinary glucoseUrine specific gravityVital signsWeightNitrogen balance (strict intakeand output measurements)

BUNCalcium, phosphorus, magnesiumProthrombin timeBlood ammoniaSerum proteinSerum glucoseSerum electrolytesHemoglobin, WBC and platelet count

Every 6 hoursEvery 6 hoursDaily (with temperature 4 times per day)DailyDaily

DailyWeeklyWeeklyWeeklyDaily untilDaily untilDaily untilTwice a week

stable;

stable;

stable;

thenthen

then

2-3 times weeklytwice weeklytwice weekly

*Insights into Parenteral Nutntion, C 1977 Used with permission of Travenol Laboratories, Inc , Deerfield, IL

(Comment: At this time it would have beenwise for the physician to refer the patient to a reg-istered clinical dietitian or to counsel the patienthimself on the need to avoid any weight loss. Eventhough the patient was having difficulty chewingand swallowing, he should have been instructedto include between-meal supplements such aseggnogs, custards, gelatin products, ice cream,milkshakes, and others and to use supplementalproducts such as those listed in Table 15-1 to addkilocalories to his present diet. The goal for the pa-tient should have been weight maintenance!)

After six months the patient returned to hisphysician. Biochemical parameters were essen-tially normal. His weight was 175 pounds whichwas 100% of ideal body weight (113W). Ideal bodyweight for the adult male can be estimated as 106pounds for the first 5 feet in height plus 6 poundsfor each additional inch over 5 feet. Therefore, 106pounds plus 11 inches times 6 pounds per inch, or66 pounds, equals a total of 172 pounds approxi-mate ideal body weight for Mr. A.H. The 15 poundweight loss in six months represented an 8% lossof initial body weight. At this visit Mr. A.H. re-ported some typical eating-related problems asso-ciated with cancer. Typical of cancer patients, Mr.A.H. reported nausea at the odor and sight offood, vomiting, increased difficulty in chewing

food, and anorexia. Also, food did not "tasteright" a frequent expression of cancer patients.Radiation of the oropharyngeal area often causesdestruction of the taste buds, altering the tastethresholds for bitter, sweet, sour, and salt leadingto "mouth blindness." Patients frequently statethat meats, especially beef and pork, have a bittertaste. A good way to get protein into these pa-tients is to recommend consumption of milk andeggs either alone or in combination dishes sincethese foods appear to be well-tolerated. Othereffects of radiation therapy to the oropharyngealarea include poor dentition, mucositis, oral ulcers,stomatitis, and esophagitis.

Knowing that the intestinal tract of Mr. A.H.was intact, the physician suggested the patient trysmaller, more frequent feedings. Cold, high calo-rie, nutritious beverages such as those included inTables 15-1 and 15-2 were encouraged since theyseem to be acceptable to most cancer patients.Cancer patients frequently report increased toler-ance for cold beverages and foods, stating they donot have the odor that warm-hot foods haveand therefore are less anorexigenic. Highly sweetfoods frequently appear to be unacceptaule to can-cer patients although this effect tends to vary both1 vith the patient and the extent of the disease. Themore progressed the disease, the greater the taste

21

VeilIMIMIIII.


abnormalities. If the patient reports no aversion tosweets, products such as Polycose and regularsugars added to juices, fruits, desserts, and otherfoods should be suggested. If the patient says thatfoods have no taste, encourage him to experimentby adding spices for the purpose of increasing theflavor of foods.

The patient was seen again in three months.Weight had further decreased to 140 pounds,and the patient had lost 25% of his original bodyweight, he was assessed to be critically malnour-ished. Mr. A.H. reported further loss of appetiteand was obviously frustrated with his increasinglyapparent deterioration. At this visit, it was notedthat the tumor had increased in size so that the p-,tient could not chew and swallow without gnatdifficulty. The physician decided that surgery wasindicated. Because of the patient's ioss of weight,adipose tissue, and lean body mass, and the ap-pearance of edema due to a low serum albuminand oncotic pressure, the physician decided thatvigorous dietary therapy was in order to make thepatient a better surgical risk.

If you were the physician, what would be themost logical choice of nutritional intervention atthis point for this hospitalized patient? The easiestfor the patient is a nasogastric tube feeding usii.ga commercial product. Because the gut has beenused within the past three days, you should orderfull-strength formula at a caloric density of 1 kilo-calorie per milliliter (see Table 15-2). The patient'sbasal energy needs plus an elevated metabolic ratewith the catabolic cancer state indicate high kilo-calorie requirements. As a rule of thumb, youshould strive for 50 kilocalories per kilogram bodyweight per day or a minimum of 2,500 kilocaloriesper day. Normal kilocalorie needs of an adultmale with moderate exercise and without diseasewould be approximately 30 kilocalories per kilo-gram per day. If you order a continuous tubefeeding regimen of 350 milliliters every two hoursat a standard concentration of 1 kilocalorie per mil-liliter from 8:00 a.m. through midnight, will thismeet the energy needs of Mr. A.H.? Yes, hope-fully! Calculating the caloric content of thisfeeding regimen, you find that it provides 2,800kilocalories in 2,800 milliliters (350 milliliters times8 feedings times 1 kilocalorie per milliliter equals2,800 kilocalories).

More appropriate for this cancer patient is an

22

intake of 50 kilocalories per kilogram body weight(50 kilocalories per kilogram at 64 kilogramsequals 3,200 kilocalories) which would require ap-proximately 3.5 liters of formula per day! If 300 to350 milliliters very two hours were given continu-ously around the clack at 1 kilocalorie per millili-ter, this would be an appropriate diet request andwould supply 3,600 to 4,200 kilocalories per day.

If this amount of tube feeding is not possible orif the patient can take oral supplements in addi-tion to the tube feeding, a combination of feedingtechniques may be acceptable. Table 15-7 lists acombination of modes of nutrition intervention.

Use of additional glucose (5% to 1070) by pe-ripheral route can supplement the above nutri-tional support plan but, in some patients, may be-come an appetite depressant and negate anyimprovement in oral intake. TPN may be appro-priate for Mr. A.H. since he is debilitated and hasreceived preoperative radiation therapy.

After the patient has the tumor removed, hewill need postoperative nutritional rehabilitation.The surgical patient has specific nutritional needswhich are determined in part by changes in hor-mone balance as a result of the stress of surgery.Energy and protein needs are high; at least 40 to 50kilocalories per kilogram body weight per day and2.5 grams protein per kilogram body weight perday are recommended. These will need to be ad-justed according to future changes in nutritionalstatus. Nitrogen balance is usually negative fol-lowing surgery secondary to hormonal involve-men', and despite the high intake of calories andprotein. Increased fluid needs accompany in-creased energy and protein in the diet. TPN mayagain be recommended immediately postopera-tively since this patient will not be able to resumeoral intake soon enough to preserve body cellmass and promote wound healing. Tube feedingsmay be reinstated to assist in nutritional repletion.

Since Mr. A.H. has a partial glossectomy andhemimandibulectomy, he will have to learn to eatonce again. What are the best foods to offer thispatient initially? You might think that liquids arethe best choice but that is not so! Foods of a thickerconsistency seem to be easier for the patient to ma-nipulate as he learns to eat. Semisolids such asmashed potatoes, puddings, custards, and finelyground meats should be suggested. Patients maybe able to take liquids by using a straw.

16 Nitiitiiii in Primary Care

.3111,=MTable 15-7 Sample Nutritional Support Regimen Usinc; Combination of Nutrition Interven-

tion Modes

Product Density Amount Kilocalories

ProteinGrams perTotal Volume

Ensure

Freamine II

Intralipid

TOTAL

Full strength

4.25%25%

10%

2,400 milli-liters

1 liter

500 milli-liters

2,400

1,000 non-protein kilo-calories450

3,850

88

43

131

It is your responsibility to frequently follow upwith Mr. A.H. and encourage him to resume asmuch of his usual lifestyle as possible; by doing so,it may be that the patient will learn to eat mostfoods again. Keep in mind that a glossectomyaffects taste and salivary function. It may be thattube feedings will be the only means of nutritionalsupport for Mr. A.H. If so, you must make surethat the formula is nutritionally adequate, is fed ata rate to maximize nutrient absorption, and ispleasing in aroma and taste. Be sure to consult with aregistered clinical dietitian, either at your local hospitalor public health department. Not only can dietitians helpprescribe appropriate dietary intervention but they willalso work closely with the patient through all phases ofhealth care and rehabilitation.

SummaryThe indication for the various modes of nutri-

tion intervention are numerous as are the nutri-tional support regimens for the chronically ill pa-tient. The patient who appears healthy may in facthave anorexia and weight loss. This patient mustbe treated early since prevention of malnutrition isfar easier to achieve than repletion. Remember,too, that any patient who requires special feedingprograms may feel depressed. Not only is he illbut he may no longer have full control over one ofthe basic comforts of life eating. The dietitianshould no' be overlooked as a resource person. Di-etitians are educated to evaluate the nutritionalstatus of patients and plan and provide sound nu-tritional care to healthy and ill persons.

23


Test YourKnowledge

Mrs. P.S. is a 70-year-old woman who has been diagnosed as having cancer ofthe cervix. She is currently living in a nursing home. Her only son and his wifelive nearby. Mrs. P.S. is receiving only social security and is on a limited budget.Her diet prior to admission has been a regular diet She is 5 feet, 3 inches tall andweighs 102 pounds. She has lost 10 pounds within the past three months. Shecomplains of anorexia and has refused to eat on several occasions. She appearsanemic, and the nursing home reports that she is weak and apathetic.

Pertinent laboratory data include:

Test Patient's Values Normal Values

HemoglobinHematocritRBC countSerum ironTotal iron binding capacitySerum folateMean corpuscular volumeTotal proteinAlbuminGlobulin

Mrs. P.S. was ordered to receive

6.4 12.0-16.0 gm/100 ml26.7 36.0-47.0 ml /100 ml

2.74 4.0-5.6 millions/mm328 56-183 micrograms/100 ml

250 277-379 micrograms/100 ml1 6.0 nanograms/ml

100 80-94 cubic microns5.8 6.0-8.0 grams/100 ml1.8 4.3-5.6 grams/100 ml2.0 1.3-2.7 grams/100 ml

a course of radiation and chemotherapy as anoutpatient. Her appetite worsened and malabsorption became evident.

1. What is the patient's ideal body weight?

2. What would be her normal (non-disease state) caloric needs?

3. What are her caloric needs secondary to her disease state?

4. Mrs. P.S. has decreased total protein, albumin, and total iron binding capac-ity secondary to malabsorption, weight loss, and poor kilocalorie and pro-tein intake. What nutrition-related signs can result from depressed serumand tissue protein levels?

24

amminn18

...1,Nutrition in Primary Care

5. What dietary protein level would you recommend for Mrs. P.S. knowing sheis protein and calorically malnourished?

6. What are the characteristics of cancer cachexia?

7. If the patient is receiving radiation therapy generalized to the gastro-intestinal tract, what diet modifications may be appropriate and why?

8. Anorexia, nausea and vomiting, stomata's, mucositis, malabsorption, anddiarrhea are common nutrition-related side effects of chemotherapy. TPNhas been shown to decrease the deleterious effects of some chemotherapeu-tic agents, increase tolerance to chemotherapy, and prolong life. How doyou explain Mrs. P.S.'s anorexia?

9. What suggestions can vou offer which will attempt to maximize the chancesthat Mrs. P.S. will receive adequate nutrition while undergoing radiationand chemotherapy?

10. Once the patient has completed radiation and chemotherapy, what meanscan be employed to maintain or improve nutritional status?

25

.1111Ir


Bibliography Blackburn, G.L.,, Caldwell, M.D. and Sherman L.O.: "Foods as the First Thera-peutic Step." Patient Care, 11(18):22, 1977.

Fleming, C.R., Smith, L.M. and Hodges, R.E.. "Essential Fatty Acid Deficiencyin Adults Receiving Total Parenteral Nutrition." American Journal of Clinical Nutri-tion, 29:976, 1976.

Gormican, A.: "Tube Feeding: An Overview." Dietetic Currents, 2(2):1, 1975.

Gormican, A. and I iddy, E.: 'Nasogastric Tube Feeding." Postgraduate Medicine,53(7):71, 1973.

Kark, R.M.: "Liquid Formula and Chemically Defined Diets." Journal of the Amer-ican Dietetic Association, 64:476, 1974.

Law, D.H.: "Total Parenteral Nutrition." New England Journal of Medicine,297(20):1104, 1977.

MacFadyen, B.V. and Dudrick, S.J.: "Total Parenteral Nutrition of the CriticallyIll Patient." Dietetic Currents, 5(1):1, 1978.

Sanstead, H., Carter, J.T. and Darby, W.J.: "How to Diagnose NutritionalDeficiencies." Nutrition Today, 4(2):26, 1q69.

Schneider, N.A., Anderson, C.E. and Coursin, D.B. (eds.) Nutritional Support ofMedical Practice, Hagerstown, MD, Harper & Row,, 1977.

Shils, ME.: "Nutritional Problems in Cancer Patients." Nutrition in Disease,Columbus, Ross Laboratories, 1976.

26

........20

pNutrition in Primary Cate

Resources forthe Physician

Defined Formula Diets for Medical Purposes (1977)

American Medical Association535 North Dearborn St.Chicago, IL 60610

Handbook of Total Parenteral Nutrition, Grant, J. (1980)

W.B. SaundersW. Washington SquarePhiladelphia, PA 19105

hisightc Into Parente; al Nutrition (1977)

'Travenol Laboratories, Inc.1 Baxter Pkwy.Deerfield, IL 60015

Nutritional Problems in Cancer Patients (1976)

Ross Laboratories625 Cleveland Ave.Columbus, OH 43215

"Parenteral and Enteral Nutrition," Fischer, J.: Disease-A-Month, 24(9):June, 1978

Tube Feeding: Tips and Techniques (1973)

Eaton Laboratories17 Eaton Ave.Norwich, NY 13815

27

15. Nutritional Care of Deterioniting Patients

Resources forthe Patient

21

Akers, S.: A Guide to Good Nutrition Dining and /WO Chenuitheiapy and Radiation(1976)

Medical Oncology Unit, Dietary Dept.Fred Hutchinson Cancer Research Center1124 Columbia St.Seattle, WA 98104

Nutrition: A Helpful Ally in Cancer

Ross Laboratories625 Cleveland Ave.Columbus, OH 43215

For recipes using nutritional products, your physician may contact the local rep-resentative of the pharmaceutical manufacturers or you may contact them at thefollowing addresses:

Customer Relations DepartmentCarnation Company5045 Wilshire Blvd.Los Angeles, CA 90036

Customer Relations DepartmentCutter Laboratories, Inc.4th and Parker Sts.Berkeley, CA 94/10

Customer Relations DepartmentDoyle Pharmaceutic ' CompanyHwy 100 and W. 23rd St.Minneapolis, MN 55416

Customer Relations DepartmentEaton Laboratories17 Eaton Ave.Norwich, \TY 13815

Customer Relations DepartmentMead Johnson & Company2400 W. Pennsylvania St.Evansville, IN 47712

Customer Relations DepartmentRoss Laboratories625 Cleveland Ave.Columbus, OH 43215

For patient education materials, the American Cancer Society is an excellent re-source:

American Cancer Society219 E. 42nd St.New York, NY 10017

28


Answers 1. The patient's ideal body weight is about 115 pounds, or 52 kilograms. Thisfigure was calculated from the rule of thumb using 100 pounds for the first 5feet plus 5 pounds for each additional inch over 5 feet.

2. Normal kilocalorie needs for a moderately active, healthy, adult woman areapproximately 30 kilocalories per kilogram of body weight per day. At 30 kil-ocalories per kilogram body weight per day, Mrs. P.S.'s normal caloric needsare 1,400 to 1,500 kilocalories per day.

3. Using the rule of thumb of approximately 50 kilocalories per kilogram bodyweight per day for combating hypermetabolism associated with disease, theenergy needs of Mrs. P.S. are about 2,300 kilocalories or greater per day.

4. Plasma proteins, especially total iron binding capacity, transferrin, and lipidcarrying proteins, are highly responsive to improvement in protein nutri-ture; total protein and albumin will return to normal at a rate slower thanfast-turnover proteins. Mrs. P.S. has anemia which should be treated withsupplemental iron and adequate protein and kilocalorie intake.

5. Ideally, up to 2.5 grams protein per kilogram of body weight per day is rec-ommended for Mrs. P.S. This will be difficult to meet if supplementation isnot employed. Remember that cancer patients have an aversion to proteina-ceous foods, but tube feedings and drinking nutritional supplements thatare egg- and milk-based are well tolerated in addition to being high in pro-tein and kilocalories.

6. Some characteristics of cancer cachexia include:

Anorexia.Taste acuity changes and food aversion.Increased basal metabolic rate.Total body weight loss.Loss of lean body mass.Loss of body fat.Altered carbohydrate metabolism.Fluid and electrolyte imbalances.Anemia.Depression and lethargy.Ldema.

7. If the patient can tolerate oral feedings or tube feedings, these are most ap-propriate. If not, the elemental diet is an appropriate means of dietary treat-ment if the gastrointestinal tract, due to its sensitivity to radiation, must bekept at rest. A high kilocalorie, high protein, and high bulk diet, if constipa-tion occurs,, is necessary. The elemental diet requires minimum digestivefunction. TPN should be used if oral feedings, tube feedings, and elementaldiets are not feasible. Remember the axiom: If the gut works, use it!

8. Probable causes of Mrs. P.S.'s anorexia include her depression and apathy,chronic illness, weakness, nausea, and vomiting secondary to radiation andchemotherapy. She also has altered taste sensations and states that fooddoes not taste good.

29


9. First of all, consult a dietitian! Involve the family in the feeding regimen ofthe patient whenever possible. Be sure that any supplemental products youorder for the patient are available. And stress the hazards of cachexia to thenursing home personnel so that they will be more aware of the need to en-courage Mrs. P.S. to eat.

10. Once Mrs. P.S. has completed therapy, encourage frequent oral feedingsusing nutritious beverages (homemade or commercial). Tube feedings maybe used to supplement oral feedings, using elemental diets if necessary. Ifthe gut continues to need rest, continue TPN. A most important point toconsider is the psychological effect of both the disease process and the treat-ment on Mrs. P.S. All health care professionals and the family must workwith her providing emotional support and encouragement to eat. Follow-upcare is essential:

30

Appendix A

Laboratory Signsof NutritionalDeficiency Helpfulin DeterminingNutriture*

Blood and Serum Tests

Red blood cell count and hematocritHemoglobin and hematocritSerum ironSerum iron-binding capacitySerum albuminSerum vitamin ASerum caroteneSerum vitamin ESerum vitamin CSerum vitamin B12Serum folic acidAlkaline phosphatase

Excretory Tests

CreatinineIodideN-methylnicotinamideRiboflavinIniamin

*Sans.....41, H H , Carter, J P , and Darby, W.J.. "How to Diagnose Nutritional Deficiencies Nutrition Today (Summer), 1969, p 26.Use,4 with permission of Nutrition Today, Inc.,, 0 1969, Annapolis, MD.am,

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Some Abbrevations Used in theNutrition in Primary Care Series

ATP adenosine triphosphatec cupcc cubic centimeterCNS central nervous systemFDA Food and Drug Administrationgm gramIBW ideal body weightIU International Unitskcal kilocaloriekg kilogramlb poundlg largeMCV mean corpuscular volumeMDR minimum daily requirementmed mediummEq milliequivalentmg milligramMJ megajouleml milliliteroz ounceRDA Recommended Dietary AllowancesRE retinol equivalentssl slicesm smallTbsp TablespoonTPN total parenteral nutritiontsp teaspoonUSDA United States Department or Agriculture

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author hurley, roberta smith; gallagher-allred, charlette › fulltext › ed321993.pdfcharlette r....

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