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Flashcards in Hospital-Based Nutrition Deck (16)
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Main considerations of when to begin feeding hospitalized patient

  • Patient's pre-existing nutritional status
  • Patient's level of illness
  • Consequences to the patient of inadequate nutrition


General rules of when to feed hospitalized patients 

  • Previously well-nourished adult with minimal acute medical illness:
    • 10-14 days without food before nutritional deficiencies develop
  • Previously undernourished adult with minimal medical illness OR previously well-nourished individual with serious acute medical illness:
    • Might go 5-7 days without food before nutritional deficiencies develop
  • Previously undernourished adults with serious medical illness:
    • May develop nutritional deficiencies in 3-5 days if not fed 


Premorbid nutritional status assessment - types of patients to consider feeding sooner

  • Patients who:
    • are alcoholics
    • are homeless
    • are underweight
    • have signs of muscle loss or cachexia
    • have chronic diarrhea or other GI disturbances
    • self-report poor dietary intake
    • have chronic medical problems that increase energy expenditure
    • have insensible losses of nutrients because of proteinuria, mucous production, bleeding
  • Patients who have:
    • Fever
    • WBC < 1500
    • Tachycardia
    • Rapid respiratory rate
    • Drainage from operative sites or sites of infection
    • Healing wounds
    • Substantial proteinuria


Pros and cons of different feeding methods

  • Key consideration is how they will be fed
    • Enteral: nasogastric (NG)
      • Benefit of being normal physiologic mechanism
      • Need nutrition to help health of gut epithelium, needed for protective barrier function
      • Drawback is danger of aspiration, trouble with placing food
    • Parenteral
      • Drawback is potential for infetion from central venous catheter


Approaches to estimating nutrient needs

  • Hospitalized patients typically have low levels of physical activity --> PAEE is low
    • However, medical illness can increase resting energy expenditure
    • TEE is about 22-25 kcal/kg/day for someone who is not that sick, increases to about 30-32 kcal/kg/day for someone who is very sick
  • Multiply person's weight in kg by number of kcal/day you think is appropriate based on patient's history and status
  • Enteral diets generally come in 1kcal/mL
    • Number of kcal/day = number of ml/day to infuse
    • Divide by 24 to calculate hourly infusion rate
  • Dr. Bessessen's Sick-o-Meter: sicker, larger people need more calories than smaller, healthier people
    • Range: 22-35 kcal/kg/day


Approach to writing order for nutritional support in hospitalized patient

  • Guesstimate how many kcal/kg/day patient needs
  • Multiply by patient's weight in kg
  • Subtract D5 calories
  • Divide by 24 - hourly infusion rate


Approach for determining if patient is receiving adequate nutritional support

  • Be sure what has been ordered is also what is delivered
  • Calculate total calories


Effects of overfeeding

  • Overfeeding causes hyperglycemia
    • May occur 1-2 days after increase in nutrient administration because glycogen storage pool buffers
    • May take several days to resolve because glycogen pool needs to deplete



Effects of underfeeding

  • Underfeeding causes negative nitrogen/protein balance
    • Muscle brokendown to provide AAs for gluconeogenesis
    • Protein breakdown can be measured by monitoring urinary nitrogen over 24 hours, if BUN is stable
      • Urinary nitrogen (in grams) X 6.25 (protein to nitrogen ratio) = grams of catabolized protein
    • Average protein requirement is 0.5-0.8 g/kg/day
    • May be increased to 0.8-1.8 g/kg/day in illness


Special issues in feeding patients with pulmonary/respiratory failure

  • Overfeeding could lead to excess nutrient use, increased CO2 production --> increased ventilation
    • Bad when the goal is to wean someone from ventilator
  • Underfeeding can lead to weakness of respiratory muscles
    • Hard to wean off ventilator
  • More CO2 is produced / O2 with carbohydates as compared to fat
    • More CO2 = increased work of breathing
      • Some say high fat diet is better for ventilated patients - no great studies on this


Special issues in feeding patients with liver failure

  • Pre-existing nutritional deficiency and insulin resistance common
  • Hepatic encephalopathy in part from increased blood ammonia level
    • May also have ascites due to salt/water retention --> may be good to limit salt, protein, water
    • Must be balanced to avoid underfeeding
  • Some end-stage complications may be due to false NTs resulting from high levels of aromatic AAs
    • Can be reason to advocate for diet high in branched chain AAs to provide protein while limiting false NT production


Special issues in feeding patients with renal failure

  • If kidneys are not working, BUN goes up
    • Protein catabolism is source of this nitrogen
    • Some "renal diets" reduce protein for this reason
    • Some say give normal protein, give dialysis for BUN


Special issues in feeding patients with cardiac disease

  • May be admitted due to CAD complications, acute MI, or CHF
  • May be a good time to discuss diet and fat restriction
  • For overweight patietns: may be important to restrict energy intake
  • CHF patients need reduced 2g Na+ diet or "cardiac diet" (low fat, sodium, saturated fat, cholesterol)


Special issues in feeding patients with diabetes

  • Vital to coordinate insulin delivery with carbohydrate intake
  • Also important to consider medication dosing based on patient diet as compared to what patient will be eating when they return home --> insulin dosage may not be correct



  • Standard of tube feeding at Denver Health
  • 1 kcal/mL
  • Contains fat, carbs, protein, micro and macronutrients


Special nutrients

  • May not be included in "house formula" 
  • Needed by certain patients depending on disease state
  • Arginine --> required for NO production
  • Glutamine --> improves gut barrier function
  • Long chain fatty acids --> precursors for PGs and LTs
  • Medium chain fatty acids --> C6-C12 --> don't transport in chylomicrons, go straight to liver --> may lower TGs