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Optimization of Nutrient Intake in Hospitalized Adult Patients

Melanie Horbal Shuster, PhD, CRNP Allegheny Health Network Center for Digestive Health-Medical Nutrition Pittsburgh, PA

There is no anti-malnutrition pill!

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Objectives: 1. List physical findings necessary to diagnosis malnutrition

2. Identify and describe nutritional and pharmacologic interventions to

prevent and treat malnutrition in the hospitalized adult patient.

3. List indications and rationale for the use of nutritional and pharmacologic interventions to prevent and treat malnutrition in the hospitalized adult patient.

4. Describe prescriptive and evaluative parameters for nutritional therapies.

5. Correctly prescribe pharmacological agents to treat malnutrition.

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Malnutrition: Definition Occurs when nutritional intake does not provide

adequate calories, protein, and other nutrients for tissue maintenance, function, and growth, or nutrients are not fully utilized due to illness.

No nutrition intervention Average well nourished patient on admission

Nutrition intervention

Malnourished on admission

Length of stay > 5-7 days

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Nursing Nutrition Responsibilities

Identifying the signs and symptoms of malnutrition

Assisting with oral intake

Administering medications to decrease the GI symptoms

Administering nutritional therapy Enteral nutrition

Parenteral nutrition

Monitoring for side effects and complications

Monitoring the effectiveness of nutritional interventions

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CNS Nutrition Goals During Hospitalization

Promote nutrition

Prevent malnutrition

Treat malnutrition

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CNS Nutrition Goals During Hospitalization

Promote nutrition by: Assessing for adequate intake

Prescribing oral nutritional supplements

Prevent malnutrition by: Limiting NPO status

Advance the diet as soon as possible

Prescribe appropriate medications for GI symptoms,

nutritional supplements,

enteral nutrition including tube feedings or

parenteral nutrition

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CNS Nutrition Goals During Hospitalization

Treat malnutrition by: Prescribing Medications

Nutritional supplements

Enteral access device for enteral feedings

Vascular access device for parenteral nutrition

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Nutrition Management

Interprofessional Collaboration

Interprofessional Team:

Nurses

Dieticians

Pharmacists

Physicians/Advanced Practice Providers

Others: PCTs, diet technicians 1

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Overview I. Oral Nutritional

Supplements (ONS)

Nutrient enhancement Protein

Energy

Meal replacement

Vitamins

Minerals

II. Adjuncts

(Appetite stimulants) Anti-depressants

Appetite stimulants

Endocrine

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Overview III. Gastrointestinal Agents

Motility agents Prokinetics

Anti-diarrheals

Narcotics

Secretory inhibitors Histamine blockers

Proton pump inhibitors

Hormone therapy

Pancreatic enzymes

Antibiotics

Bile acid binders

IV. Invasive Nutritional Support

Enteral therapy

(Tube feedings)

Parenteral therapy

(PPN-TPN)

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I. Oral Nutrition Supplements When to administer

Meal replacement

Between meals

Vitamins Thiamine

B12

Vitamin D5

Minerals Iron

Calcium

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II. Adjuncts Drug Categories

Antihistamine

Anti-emetics

Antidepressants Mertazapine 15 mg tablets Q HS

Synthetic Hormones Appetite stimulants Dronabinol 2.5 mg BID

Megestrol 625 mg Q day

Glucocorticoid treatment

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III. Gastrointestinal Agents Gastrointestinal symptoms often affect nutrient intake

Examples:

Nausea

metoclopramide 5 mg TID

ondansetron 4-8 mg every 8 hours

Diarrhea

Shorten intestine

Maldigestion

Malabsorption

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II. Adjuncts Synthetic Hormones Growth Hormone

Cachexia HIV associated 0.1 mg/kg SC Q HS

Oxandrolone 2.5 -20 mg PO BID-QID maximum dose 20 mg/day – 10mg BID Elderly 5 mg BID

Testosterone Transdermal patch 2-4 mg /24 hours Topical 2% 30mg/1.5 mL pump Measure serum testosterone Begin 2 mg or 1 pump daily

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III. Gastrointestinal Agents Drug Categories

Motility agents Anti-diarrheals

Narcotics

Secretory inhibitors Histamine blockers

Proton pump inhibitors

Hormone therapy

Pancreatic enzymes

Antibiotics

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III. Gastrointestinal Agents

Motility Agents Secretory Inhibitors

Anti-diarrheals

Loperamide

2 mg BID-QID

Diphenoxylate-atropine

1-2 tablets BID-QID

Narcotics

Codeine sulfate

15-30 mg BID-QID

Histamine blockers Ranitidine

20-40 mg PO QD-BID

Proton pump inhibitors Insurance driven

Hospital formulary

Hormone therapy Octreotide

50 mcg SQ TID

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III. Gastrointestinal Agents Pancreo-Biliary Agents Antibiotics Bile acid binders: Cholestyramine

1 gm q day or BID increase to maximum dose of 4 gms QID

Pancreatic enzymes administer with meals Pancrelipase

Lipase/protease/amylase 6K/19K/30K to 36K/114K/180K

Lipase/protease/amylase 4.2K/10K/17.5K to 21K/37K/61K

Lipase/protease/amylase 10.44K/39.15K/39.15K to 20.88K/78.3K/78.3K

Rotational oral antibiotics

Cephalexin

250-500 mg PO BID

Metronidazole

250 mg PO BID

Ciprofloxacin

250 mg PO BID

Doxycycline

100 mg PO BID

Trimethoprim/ sulfamethoxazole

80/400 mg 1 PO BID

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IV. Artificial and Invasive Nutritional Support

Enteral Therapy (tube feedings)

Requires placement of an enteral access device

Nasoenteric

Gastric

Jejunal

Parenteral therapy (PPN-TPN)

Requires placement of vascular access device

Peripheral

Midline

Central

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IV. Artificial and Invasive Nutrition Support Enteral Feeding Product selection

Nutritional needs GI function

Administration schedule Bolus: 2 cans QID Intermittent: 100 ml/hr x 12

hours Q HS Continuous: 83 ml/hr x 24

hours

Prescribe water flushes Tube patency Hydration needs Intake and Output

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IV. Artificial and Invasive Nutrition Support

Parenteral Feeding

Partial or peripheral Parenteral Nutrition (PPN)

Larger volume

Osmolality 600-800

Total or central Parenteral Nutrition (TPN)

Volume varies

Continuous

Night cycle

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IV. Artificial and Invasive Nutrition Support Enteral Feeding Parenteral Feeding Product selection

Nutritional needs GI function

Administration schedule Bolus: 2 cans QID Intermittent: 100 ml/hr x 12

hours Q HS Continuous: 83 ml/hr x 24

hours

Prescribe water flushes Tube patency Hydration needs Intake and Output

Partial or peripheral Parenteral Nutrition (PPN)

Larger volume

Osmolality 600-800

Total or central Parenteral Nutrition (TPN)

Volume varies

Continuous

Night cycle

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Ordering Parenteral Nutrition Determine weight8

Ideal

Actual

Adjusted

Determine energy needs Example 30 kcal/day X 70kg= 2100 Kcal/day

Determine hydration needs: Example: 30 ml/kg X 70 kg= 2100 ml/day

Determine protein needs Example 1.5 grams/Kg/day = 105 grams/day

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Ordering Parenteral Nutrition Example

70 kg patient

Total calorie @ 30/Kg/day = 2100 kcal

Water needs @ 30 ml/Kg/day =2100 ml

Protein @ 1.5 grams/Kg/day = 105 grams

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Ordering Parenteral Nutrition Energy = 2100 Kcalories Protein = 105 grams/day

Protein = 4 Kcalories/g

Dextrose = 3.4 Kcalories/g

Fat = 9 Kcalories/g

Fat emulsion

Soybean oil

Egg phospholipid

Glycerol

10% = 1.1 Kcalories/ml

20% = 2 Kcalories/ml

30% = 3 Kcalories/ml

Calculate the energy from protein 105 x 4 = 420 Kcalories

Subtract protein calories from total calories 2100-420 = 1680

1680 Kcalories to be provided from carbohydrate and fats

60% as Carbohydrate 1680 x 0.6 = 1008/3.4 = 297 g

40 % as Fat 1680 x 0.4 = 672/9 = 59 g

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Electrolytes Sodium- 1-2 meq/kg/d (For the example 70-140

meq/day)

Potasium-1-2 meq/kg/day (For example 70-140 meq/day)

Magnesium-16 meq/day

Calcium Gluconate-10 meq/day

Phosphorous- 30 mmol/day (as Na phosphate or K phosphate)

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Additional Additives To Consider Based on the situation, most patients may require:

Multivitamins- 10 ml/day

Trace elements- 1 ml/day

Insulin

Start with an initial dose of 0.1 to 0.2 unit/gram of dextrose

Thiamine-100 mg /day for 3 days if the patient has been without eating for > 1 week and or if vomiting.

Famotidine-20-40 mg/day

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Patient Evaluation Monitor:

Daily oral intake

Daily intake and output

Baseline data C - reactive protein (CRP)

Pre-albumin

Liver function tests

CMP

Magnesium

Phosphorus

Ionized calcium

HA1c

POC glucoses every 6 hours

Serum triglycerides the morning after to first dose of TPN with lipid emulsion

Daily laboratory results

Weekly weights

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References: 1. National CNS Competency Task Force. 2010. Clinical nurse specialist core competencies. Executive Summary 2006-2008. 2. The Academy of Nutrition and Dietetics. (2015). Retrieved from http://sc.eatrightpro.org/uncategorized/malnutrition-

resource-center. 3. Malone, A, Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral

Nutrition [ASPEN] consensus malnutrition characteristics: Application in practice. Nutrition clinical practice, 28(6), 639-650. 4. Hamilton, C. & Boyce, V. (2013). Addressing malnutrition in hospitalized adults. Journal of parenteral and enteral nutrition, 37

(6), 808-813. 5. National Guideline Clearinghouse (NGC). Guideline summary: Evaluation, treatment, and prevention of vitamin D deficiency:

an Endocrine Society clinical practice guideline. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2011 Jul 01. [cited 2016 Dec 15]. Available: https://www.guideline.gov

6. Lochs, H, Dejong, C, Hammarqvist, F, Hebuterne, X, Leon-Sanz, M, Schutz, T, van Gemert, W, van Gossum, A, Valentini, L, Lu, H, Bischoff, S, Engelmann, N, Thul, P. (2006). Clinical Nutrition, 25, 260-274. Guidelines on Enteral Nutrition: Gastroenterology http://espen.info/documents/ENGastro.pdf

7. Matarese, LE, O’Keefe, SJ, Kandil, HM, Bond F, Costa, G, Abu-Elmagd,K. (2005). Short Bowel Syndrome: Clinical Guidelines for Nutrition Management. Nutrition Clinical Practice, 20 (5), 493-502.

8. National Guideline Clearinghouse (NGC). Guideline summary: A.S.P.E.N. clinical guidelines: nutrition support of hospitalized adult patients with obesity. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Nov 01. [cited 2016 Dec 15]. Available: https://www.guideline.gov

9. Bozzetti, F. Forbes, A. (2009). ESPEN Guidelines on Parenteral Nutrition. Clinical Nutrition, 24 (4), 359-364.

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