Enteral and Parenteral Nutrition Support
Enteral and Parenteral Nutrition Support
Chapter 23Chapter 23
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Enteral Nutrition DefinitionEnteral Nutrition Definition
Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.
Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.
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Oral SupplementsOral Supplements
Between meals
Added to foods
Added into liquids for medication pass by nursing
Enhances otherwise poor intake
May be needed by children or teens to support growth
Between meals
Added to foods
Added into liquids for medication pass by nursing
Enhances otherwise poor intake
May be needed by children or teens to support growth
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Conditions That Require OtherNutrition SupportConditions That Require OtherNutrition Support
Enteral
—Impaired ingestion
—Inability to consume adequate nutrition orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral tolerance or accessibility
Enteral
—Impaired ingestion
—Inability to consume adequate nutrition orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral tolerance or accessibility
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Conditions That Often Require Nutritional SupportConditions That Often Require Nutritional Support
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Conditions That Often Require Nutritional Support –cont’dConditions That Often Require Nutritional Support –cont’d
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Conditions That Often Require Nutritional Support –cont’dConditions That Often Require Nutritional Support –cont’d
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Algorithm for Decisions Algorithm for Decisions
Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL, Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.
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Considerations in Enteral NutritionConsiderations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
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Formula SelectionFormula SelectionThe suitability of a feeding formula should be evaluated based on The suitability of a feeding formula should be evaluated based on
Functional status of GI tract
Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte needs or restriction
Cost effectiveness
Functional status of GI tract
Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte needs or restriction
Cost effectiveness
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Enteral Formula CategoriesEnteral Formula Categories
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Factors to Consider When Choosing an Enteral FormulaFactors to Consider When Choosing an Enteral Formula
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Enteral Access: Clinical ConsiderationsEnteral Access: Clinical Considerations
Duration of tube feeding
—Nasogastric or nasoenteric tube for short term
—Gastrostomy and jejunostomy tubes for long term
Placement of tube
—Gastric
—Small bowel
Duration of tube feeding
—Nasogastric or nasoenteric tube for short term
—Gastrostomy and jejunostomy tubes for long term
Placement of tube
—Gastric
—Small bowel
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Placement SitePlacement Site
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning
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Enteral Tube PlacementEnteral Tube Placement
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Advantages—Enteral NutritionAdvantages—Enteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with disease state
Intake easily/accurately monitored
Provides nutrition when oral is not possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with disease state
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More Advantages—Enteral NutritionMore Advantages—Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial translocation
Preserves immunologic function of gut
Increased compliance with intake
Preserves gut integrity
Decreases likelihood of bacterial translocation
Preserves immunologic function of gut
Increased compliance with intake
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Disadvantages—Enteral NutritionDisadvantages—Enteral Nutrition
GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax
Costs more than oral diets
Less “palatable/normal”
Labor-intensive assessment, administration, tube patency and site care, monitoring
GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax
Costs more than oral diets
Less “palatable/normal”
Labor-intensive assessment, administration, tube patency and site care, monitoring
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Complications of Enteral FeedingComplications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)
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Aspiration PneumoniaAspiration Pneumonia
Can result from enteral feeds
High-risk patients
—Poor gag reflex
—Depressed mental status
Can result from enteral feeds
High-risk patients
—Poor gag reflex
—Depressed mental status
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Reducing Risk of AspirationReducing Risk of Aspiration
Check gastric residuals if receiving gastric feeds
Elevate head of the bed >30 degrees during feedings
Postpyloric feeding
—Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance
—Transgastric jejunostomy tube
Check gastric residuals if receiving gastric feeds
Elevate head of the bed >30 degrees during feedings
Postpyloric feeding
—Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance
—Transgastric jejunostomy tube
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Rate and Method of Delivery*Rate and Method of Delivery*
Bolus—300 to 400 ml rapid delivery via syringe several times daily
Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe
Cyclic—via pump usually at night
Continuous—via gravity drip or infusion pump
*Determined by medical status, feeding route and volume, and nutritional goals
Bolus—300 to 400 ml rapid delivery via syringe several times daily
Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe
Cyclic—via pump usually at night
Continuous—via gravity drip or infusion pump
*Determined by medical status, feeding route and volume, and nutritional goals
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Consideration of Physical Properties of Enteral FormulasConsideration of Physical Properties of Enteral Formulas
Residue
Viscosity
—Size of tube is important
Osmolality: consider protein source
—Intact (do not affect osmolality)—soy isolates; sodium or calcium casein; lactalbumin
—Hydrolyzed (more particles)—peptides or free amino acids
Residue
Viscosity
—Size of tube is important
Osmolality: consider protein source
—Intact (do not affect osmolality)—soy isolates; sodium or calcium casein; lactalbumin
—Hydrolyzed (more particles)—peptides or free amino acids
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Renal Solute LoadRenal Solute Load
Normal adult tolerance is 1200 to 1400 mOsm/L
Infants and renal patients may tolerate less
Normal adult tolerance is 1200 to 1400 mOsm/L
Infants and renal patients may tolerate less
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Lower OsmolalityLower Osmolality
Large (intact) proteins
Large starch molecules
Large (intact) proteins
Large starch molecules
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Higher OsmolalityHigher Osmolality
Hydrolyzed protein or amino acids
Disaccharides
Hydrolyzed protein or amino acids
Disaccharides
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ToleranceTolerance
Signs and symptoms:
—Consciousness
—Respiratory distress
—Nausea, vomiting, diarrhea
—Constipation, cramps
—Aspiration
—Abdominal distention
Signs and symptoms:
—Consciousness
—Respiratory distress
—Nausea, vomiting, diarrhea
—Constipation, cramps
—Aspiration
—Abdominal distention
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Tolerance—cont’dTolerance—cont’d
Other signs and symptoms
—Hydration
—Labs
—Weight change
—Esophageal reflux
—Lactose/gluten intolerances
—Glucose fluctuations
Other signs and symptoms
—Hydration
—Labs
—Weight change
—Esophageal reflux
—Lactose/gluten intolerances
—Glucose fluctuations
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How to Determine Energy and ProteinHow to Determine Energy and Protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
Example: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/mlExample: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml
1 kcal/ml x 200 ml = 200 kcal
0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal = 7.65 g protein
1 kcal/ml x 200 ml = 200 kcal
0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal = 7.65 g protein
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Energy in FormulasEnergy in Formulas
1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration
1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration
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ProteinProtein
From 4% to 26% of kcal is possible
14% to 16% of kcal is usual
18% to 26% of kcal—considered to be high-protein solution
From 4% to 26% of kcal is possible
14% to 16% of kcal is usual
18% to 26% of kcal—considered to be high-protein solution
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Recommended WaterRecommended Water
Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to 85% water
Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration
Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to 85% water
Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration
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Sources of Fluid (“Free Water”)Sources of Fluid (“Free Water”)
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs
—Example: “flush with 200 cc tid”
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs
—Example: “flush with 200 cc tid”
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Administration: Feeding Rate Administration: Feeding Rate
Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)
Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)
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French Units—Tube SizeFrench Units—Tube Size
Diameter of feeding tube is measured in French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types and administration techniques.
Diameter of feeding tube is measured in French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types and administration techniques.
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Examples of Special FormulasExamples of Special Formulas
Pediatrics
Low residue
High protein
Volume restriction
Diabetic
Pulmonary/COPD
Pediatrics
Low residue
High protein
Volume restriction
Diabetic
Pulmonary/COPD
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Enteral Nutrition MonitoringEnteral Nutrition Monitoring
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Routes of Parenteral NutritionRoutes of Parenteral Nutrition
Central access
—TPN both long- and short-term placement
Peripheral or PPN
—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis
<2000 kcal required or <10 days
Central access
—TPN both long- and short-term placement
Peripheral or PPN
—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis
<2000 kcal required or <10 days
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PPN vs. TPNPPN vs. TPN
Kcal required(10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated
Kcal required(10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated
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Venous Sites from Which the Superior Vena Cava May Be AccessedVenous Sites from Which the Superior Vena Cava May Be Accessed
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Advantages—Parenteral NutritionAdvantages—Parenteral Nutrition
Provides nutrients when less than 2 to 3 feet of small intestine remains
Allows nutrition support when GI intolerance prevents oral or enteral support
Provides nutrients when less than 2 to 3 feet of small intestine remains
Allows nutrition support when GI intolerance prevents oral or enteral support
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Indications for Total Parenteral NutritionIndications for Total Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food
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ContraindicationsContraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)
GI tract works
Terminally ill
Only needed briefly (<14 days)
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Calculating Nutrient NeedsCalculating Nutrient Needs
Avoid excess kcal (> 40 kcal/kg)
Adults
kcal/kg BW
Obese—use desired BMI range or an adjusted factor
Avoid excess kcal (> 40 kcal/kg)
Adults
kcal/kg BW
Obese—use desired BMI range or an adjusted factor
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Adjusted Body WeightAdjusted Body Weight
Adjusted IBW for obesity
Female:
([actual weight – IBW] x 0.32) + IBW
Male:
([actual weight – IBW] x 0.38) + IBW
Adjusted IBW for obesity
Female:
([actual weight – IBW] x 0.32) + IBW
Male:
([actual weight – IBW] x 0.38) + IBW
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Parenteral ComponentsParenteral Components
Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml
Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml
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Protein RequirementsProtein Requirements
1.2 to 1.5 g protein/kg IBW mild or moderate stress
2.5 g protein/kg IBW burns or severe trauma
1.2 to 1.5 g protein/kg IBW mild or moderate stress
2.5 g protein/kg IBW burns or severe trauma
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Carbohydrate RequirementsCarbohydrate Requirements
Max. 0.36 g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems
Max. 0.36 g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems
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Lipid RequirementsLipid Requirements
4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid
Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg
4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid
Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg
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Other RequirementsOther Requirements
Fluid—30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements
Fluid—30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements
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Calculating the Osmolarity of a Parenteral Nutrition SolutionCalculating the Osmolarity of a Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L
2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L
3. Fat is isotonic and does not contribute to osmolarity.
4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L
1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L
2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L
3. Fat is isotonic and does not contribute to osmolarity.
4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L
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Compounding MethodsCompounding Methods
Total nutrient admixture of amino acids, glucose, additives
3-in-1 solution of lipid, amino acids, glucose, additives
Total nutrient admixture of amino acids, glucose, additives
3-in-1 solution of lipid, amino acids, glucose, additives
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AdministrationAdministration
Start slowly(1 L 1st day; 2 L 2nd day)
Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)
Cyclic give 12 to 18 hours per day
Start slowly(1 L 1st day; 2 L 2nd day)
Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)
Cyclic give 12 to 18 hours per day
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Monitoring and ComplicationsMonitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome
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Refeeding SyndromeRefeeding Syndrome
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest
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MonitorMonitor
Weight(daily)
BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases
Weight(daily)
BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases
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Monitor—cont’dMonitor—cont’d
BloodTwice/week Ammonia Mg Plasma transaminasesWeekly Hgb Prothrombin time Zn Cu Triglycerides
BloodTwice/week Ammonia Mg Plasma transaminasesWeekly Hgb Prothrombin time Zn Cu Triglycerides
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Monitor—cont’dMonitor—cont’d
Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)
Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)
Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)
Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)
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ProblemsProblems
PPNSite irritation
TPN1. Catheter sepsis2. Placement problems3. Metabolic
PPNSite irritation
TPN1. Catheter sepsis2. Placement problems3. Metabolic
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PediatricPediatric
EnergyInfant
50 to 60 kcal/kg/day maintenance70 to 120 kcal/kg/day growth
Child >1yrBEE
1to 8 yrs 70 to 100 kcal/kg/day8 to 12 yrs 60 to 75 kcal/kg/day12 to 18 yrs 45 to 60 kcal/kg/day
Injury factors1.25 mild stress1.50 nutritional depletion2.00 high stress
EnergyInfant
50 to 60 kcal/kg/day maintenance70 to 120 kcal/kg/day growth
Child >1yrBEE
1to 8 yrs 70 to 100 kcal/kg/day8 to 12 yrs 60 to 75 kcal/kg/day12 to 18 yrs 45 to 60 kcal/kg/day
Injury factors1.25 mild stress1.50 nutritional depletion2.00 high stress
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Pediatric—cont’dPediatric—cont’d
Protein:Infant
2.4 to 4 g/kg/day <1500 g weight2.0 to 2.5 g/kg/day 0 to 12 months
normal weight
Child >1 year 1 to 8 years 1.5 to 2.0 g/kg/day 8 to 15 years 1.0 to 1.5 g/kg/day
Protein:Infant
2.4 to 4 g/kg/day <1500 g weight2.0 to 2.5 g/kg/day 0 to 12 months
normal weight
Child >1 year 1 to 8 years 1.5 to 2.0 g/kg/day 8 to 15 years 1.0 to 1.5 g/kg/day
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Pediatric—cont’dPediatric—cont’d
Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rate
Fat Infants: 0.5 to 1.0 g/kg/day min for EFA needs 2 to 3 g/kg/day max
Vitamins and minerals:See tables in textbook
Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rate
Fat Infants: 0.5 to 1.0 g/kg/day min for EFA needs 2 to 3 g/kg/day max
Vitamins and minerals:See tables in textbook
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Pediatric—cont’dPediatric—cont’d
Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day
2 to 4 mmol/kg/day for electrolytes
Other infants and children
Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day
2 to 4 mmol/kg/day for electrolytes
Other infants and children
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Document in ChartDocument in Chart
Type of feeding formula and tube
Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and corrective actions
Patient education
Type of feeding formula and tube
Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and corrective actions
Patient education