Nutritional Support in the Critically Ill Flashcards by Katy Peterson

What is the first thing we need to think about when a malnourished pt is admitted?

Does their GI system work?

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Risk factors for malnutrition

Older adults
NPO x5 days
20% weight loss
Chronic disease states, chronic stress
Dementia / altered LOC
Chronic alcohol abuse (choosing alcohol over nutrition)
Disease exacerbation (trauma, burns, sepsis)
Altered albumin/prealbumin

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What albumin level shows long term malnutrition

<2.8

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What level of prealbumin shows a pt is at high risk for malnutrition?

11-15

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What level of prealbumin shows a pt has acute malnutrition?

15-35

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What doesn’t giving prealbumin to a pt with low albumin levels help?

It will take 3 months for it to be converted to albumin

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Signs of malnutrition

Dry skin
Brittle nails
Frequent infections
Poor wound healing
Bleeding gums
Dry coarse hair
Reduced appetite
Loss of fat, muscle mass, & body tissue

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*What would vital signs/lab values be like for a patient with malnutrition?

Increased pulse
Increased RR
Decreased BP
Low SpO2 (b/c inadequate RBCs, so giving O2 won’t help)
Potassium out of range
Decreased skin turgor
Concentrated urine (amber, not cloudy)

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Signs of volume depletion

Dry skin / decreased turgor
Altered LOC
Pallor
Tachycardia
Hypotension
Concentrated urine
Dry mucous membranes

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3 parts of a nutritional assessment

H&P
Lab data
Anthropometric measurements (height & weight)

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*How to weight a patient

1st: check pt’s weight from yesterday to compare
Look at documentation to see how pt was weighed and weight in the same way (ex: chair scale, bed scale)
Need to take pillow, sheet, pads, and covers (only keep 1 pad & 1 sheet)
Move everything off bed
Zero bed
Get weight
If variance of 5 lb + need to reweigh
(May be previous nurse’s fault, pass info onto next shift)

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Minimum grams of protein for a healthy adult

98 grams

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Minimum grams of protein for a critically ill pt

164 grams

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Nutritional support is a team effort, who is involved and what are their roles?

Dietician (type, amt, & orders r/t feeding. In charge of tube feedings)
Nurse (team leader)
Pharmacist (in charge of TPN, PPN parenteral feedings, will calculate & make parenteral feedings)
Physician

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Malnutrition goals of nutritional support

Provide minimal kcal/protein support
Evaluate tolerance to nutrition
Stabilize weight (prevent decline)
Prealbumin > 16 mg/dl

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How much should prealbumin increase each day?

2 mg/d (about 65% of daily Kcals)

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What indicates a poor prognosis for prealbumin levels?

In they increase by < 4 mg/dl in 8 days

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Role of the dietician for a pt with enteral tube feedings?

Evaluate nutritional status
Select appropriate enteral feeding formula
Monitor and follow, watch for complications/changes

Role of the nurse for a pt with enteral tube feedings?

Insert tube/check initial placement (RN only)
Give medications (RN/LPN)
Give feedings, bolus and/or flush (RN/LPN)
Monitor for symptoms of intolerance (RN/LPN)
Tube discontinuation (RN/LPN)

Decision tree for determining the appropriate route for a pt’s nutrition

1: does the gut work?

Yes = oral nutrition
No = parenteral nutrition

How to determine if a pt’s gut works

Listening to bowel sounds
*Must be *Normoactive in all 4 quadrants

If no bowel sounds in a quadrant, need to listen for 5 min & document

If unsure about bowel sounds, listen again, if still unsure, get another nurse to listen

Guidelines for when to start a pt on enteral feeding

For those unable to meet nutritional needs orally for more than 3 days
*Ideally, begin in first 24 hours or pt arrival
Prealbumin <11 indicated need for aggressive therapy with enteral or parenteral nutrition

Types of tubes for tube feeding

Nasogastric (large bore)
Orogastric (large bore)
Nasointestinal (small bore)
Gastrostomy or jejunostomy (surgically inserted)

How is placement of ALL feeding tubes checked?

Chest xray
Must have “ok to use”

How should you check placement of feeding tube before giving meds (after initial placement is confirmed)?

Aspirate and test for acidic pH Inject air into stomach

Important things to remember about placing a nasointestinal tube

Has a small, flexible wire to make it go down Has black, weighted tip on end *Once it’s inserted, check placement, get “ok to use”, THEN wire is removed. *DO NOT remove wire before placement is approved Called “Dobhoff” Anchor tube while pulling wire

What should you do if a feeding tube gets clogged?

Flush tube Can try something carbonated like sprite to help break up solid clots If still can’t get it unclogged, need to pull tube out and insert new tube

*Components of the tube feeding safety bundle

Prevent aspiration Rinse tube well Care of nose Check residuals per policy Check BG per protocol

*How do we prevent aspiration while tube feeding?

Keep HOB elevated *Do not transport pt anywhere while tube feeding. Need to stop it, and leave it behind

*How do you rinse the feeding tube?

*Follow flush orders (Ex: 50 mL sterile water q6hr minimum) *Can use any kind of water (tap, saliene, free water, etc.) *Record all rinses on I&O

*How do you care for a pt’s nose while tube feeding?

For NG tube, use alcohol to get goop off nose, use wet 4x4 around tube and nostril For OG tube, standard oral care, change OG tube if pt needs to be reintubated

*Why should we check a pt’s blood glucose who is being tube fed?

- All tube fed patients will have a high BG because there is a lot of sugar in the milk in the tube feed - will usually check every 4 hours (Some pts will need insulin even if they’re not diabetics)

What is a possible side effect for pt’s skin integrity while being tube fed?

Open wounds are more likely to get infected since the tube feed has so much sugar in it Need to clean them really well

Patients who are at risk for intolerance of tube feeding

Intubated/airway issues Greater than 70 years old Decreased LOC Supine position (cannot tolerate HOB being up) Reflux Transport (need to turn it off and leave it behind)

How would you check a patient’s residuals?

Turn tube feeding off Take syringe and pull back to see how much you get Color should be greenish/bile with tube feeding in it

What should you do if a patient has 250 mL of residuals?

Put feeding on hold, look at order, follow order, and then call someone If >30, but not super high, use nursing judgement and see how pt is tolerating

*Symptoms of tube feeding intolerance

Residuals >30 mL N/V Hyperactive bowel sounds *that are ongoing Abdominal distention/cramping (These all ^ require nursing judgement) Absent bowel sounds (no judgement needed, must stop tube feed)

Tube feeding complications

Aspiration Fluid volume excess Dehydration Electrolyte imbalances Glucose imbalances

When would a pt need parenteral nutrition?

If they are unable to tolerate enteral or PO nutrition (Decision made by physician)

How is parenteral nutrition given?

Via a central line: - subclavian - internal jugular (IJ) - PICC

On the central line, which hole does the TPN go into?

The hole closest to the pt which is most distal

Differences between TPN and PPN

TPN contains large amt of sugar/nutrients (total) PPN contains half as much sugar TPN is caustic to peripheral veins (can only be given central line/PICC b/c of all of the sugar) PPN is temporary and not used long term

Similarities of TPN and PPN What are the only things that can be added to them?

Both are types of parenteral nutrition Both require intense blood glucose follow up IV lipids and albumin infusions may accompany (be added) to either

Parenteral nutrition care of bag, line, and patient

Observe fluid balance (at huge risk of fluid volume overload) Routine blood sugar levels Infection control (sepsis is high risk b/c of sugar) Meticulous IV care Nothing in IV line except for lipids