Nutrition Final

Saturated Fat and Cholesterol interventions to slow progression of kidney function loss

- A diet low in saturated fat and cholesterol, regular physical exercise (30 min/day), healthy weight maintenance, no smoking, no more than 1 alcoholic beverage per day, and low-fat cooking methods (bake, broil, steam) - To reduce hypertriglyceride, a diet modified in fat carb, and encourage to exercise -Avoid saturated and trans-fat and increase intake of monounsaturated fat

When are K restrictions added in chronic kidney disease?

- A potassium restricted diet is typically about 2000 milligrams per day - Need to restrict K generally increases in clients with decreased urinary output -If > 5 or 6.5 level, then restrict to < 2.4 g/day - When urinary output is 100-500 mL and serum potassium is 5.5 or 6.5, a 40-60 mEq intake is suggested - Anuria or when serum potassium exceeds 6.5, dietary intake of 20-25 mEq/L (780-975 mg) suggested - Before reducing diet, check meds and hemodialysis

Interventions for clients with COPD

- Avoid gas-causing foods (carbonated, cruciferous, fried) - Daily calcium intake - Eat little amounts frequently; six small-energy dense meals a day - Maintain adequate hydration to assist in thinning secretions - Choose foods that are easily prepared and chewed - Advise clients to clear their airways before eating - Limit sodium intake to prevent water retention - Chew slowly to avoid swallowing air - Drink fluid between meals - Sit upright at a table for all meals - Wear oxygen via NC during meals to increase oxygen level

Importance of nutrition support in GI surgery

- Because of its role in tissue building and healing, protein is crucial in surgical clients. Protein depletion increases the risk of: 1. Infection because body cannot manufacture enough WBC 2. Shock because the low serum albumin prevents the return of interstitial fluid to the blood vessels 3. Wound dehiscence because local edema persists and interferes with healing

Prevention/Treatment of renal stones: oxalates

- Calcium oxalate is most common constituent of kidney stones - Diet excluding foods high in oxalates frequently prescribed for clients with kidney stones if lab analysis shows that removed or passed stones high in oxalate - Reducing sodium to 2300 and limiting animal protein in diet are recommended because excess sodium and protein cause kidneys to excrete calcium in urine - Having enough calcium in diet, 800 mg/day, helps prevent calcium oxalate stones

Prevention/Treatment of renal stones

- Drink water, 6-8 cups per day - Primary reason for increasing fluid intake is to prevent formation of concentrated urine, in which crystals are more likely to combine and precipitate

Gastroparesis management

- Eat small, frequent meals - Eat slowly, chewing food thoroughly, sitting upright after meals - Reduce fat ingested (which remains in stomach longer than carb or protein) - Decrease fiber intake - Drink plenty of water (1-1.5 L/day), avoiding carbonated beverages and alcohol - Avoid smoking and tobacco smoke - Gentle exercise (walking) after meals

Kcal needs in critical care

- Energy expenditure is the number of kcal that an individual uses to meet the body's demand for fuel - The most accurate method for measuring energy expenditure is indirect calorimetry - The number of kcal is calculated by either kcal/kg or one of several different predictive formulas - Research has found that predictive formulas often are only 37% - 65% accurate in estimating caloric needs of critically ill clients - Propofol is a commonly used med to sedate mechanically ventilated clients o Administered parenterally in a 10% fat emulsion o It is important to consider the number of calories derived from fat in this medication and include them when assessing the total overall kcal the client received

Key Recommendation 1: covid

- Estimated needs: 1. 15-20 kcal/kg actual body weight (ABW)/day (70-80% of needs) 2. 1.5-2,0 g protein/kg ABW/day 3. Indirect calorimetry not recommended to limit transmission - If refeeding syndrome risk is present: 1. Start at 25% of caloric goal with slow increase 2. Monitor serum phosphate, magnesium, and potassium levels frequently - Rationale: 1. These guidelines should be followed for patients receiving either EN or PN 2. Critically ill patients with severe COVID-19 may be older and have multiple comorbidities or preexisting malnutrition 3. Such patients are often at risk of refeeding syndrome

Key recommendation 10: covid

- Extracorporeal membrane oxygenation (ECMO); use EN gastric feeding 1. Start early, low dose 2. Slow advancement to goal over 1st week 3. If patient is septic, increasing vasopressor requirements: hold feedings - Rationale: 1. In largest observational study of EN during venoartieral ECMO, early EN was associated with improvement in 28-day mortality rate and zero incidence of bowel ischemic compared with delayed EN 2. Increased in EN calories and protein delivered were associated with decreased risk of 90 day mortality

Post-op clear liquid indication

- IV Fluids are continued after surgery - Minimum replacement is 2 L of 5% glucose in water in 24 hours (100 g of glucose and delivers 340 kcal) - Guidelines recommend the early DC of IVF in the postop period, after recovery room discharge, and the encouragement of clear fluids as tolerated

Prevention/Treatment of renal stones: calcium

- If stone high in calcium, a low-calcium diet was prescribed 600 mg/day - Today, it is known that kidney stones are not caused by dietary calcium - Consuming 800 mg/day of calcium helps prevent kidney stones and also helps maintain bone density

Return to feeding protocol post-op

- Lack of evidence of peristalsis being an indicator for oral nutrition (used to be the prime indicator) - Early enteral nutrition therapy has been shown to be associated with significant reductions in infection, hospital LOS, and mortality - Those with elective colorectal surgery be offered a regular diet immediately after surgery - Early feeding (<24 hours) accelerates GI recovery and decreased LOS, complications, and mortality - "sham feeding" (chewing sugar-free gum for > 10 min 3-4 times per day) after colorectal surgery also demonstrates small improvements in GI recovery and may be associated with a decreased LOS, possibly due to an increase in bowel motility - Clients progress from clear to full liquids, a soft diet, and regular diet as soon as possible - If "diet as tolerated" is ordered, ask client what foods sound appealing - Clients with elective major upper GI surgery, enteral feeding is considered as most desirable form - In well-nourished clients, early PN nutrition provides no benefit and may cause har; however, in malnourished clients who cannot be fed enterally, PN may reduce complications and mortality

Metabolic alterations in critical care

- Metabolically the body responds to starvation by decreasing energy expenditure and to hypermetabolism by increasing energy expenditure - Fat metabolism generates less CO2 than metabolism of carbs, which is a benefit to the client - Clients who are hypermetabolic have an increased need for kcal - Client with hypermetabolism has an increased need for protein - Infection may alter metabolism (sepsis) - The body needs extra kcal and fluids during fever because it takes more energy to support the higher metabolic rate - Studies show that the hypermetabolic state may remain elevated for 1-2 years after a severe thermal injury - Degree to which the metabolic rate increases is directly related to the body surface area burned - Cancer, major surgery, burns, infections, and trauma are physical

Key recommendation 9: covid

- Prone position: use EN rather than ON 1. Use isotonic high-protein formula, starting at 10-20 ml/h 2. Keep HOB elevated (reverse Trendelenburg position) at least 10-25 degrees with gastric feeding -Rationale: 1. No increased risks of GI or pulmonary complications have been noted in patients in prone position 2. Increasing HOB elevation will decrease risk of aspiration of gastric contents, facial edema, and intra-abdominal hypertension

MNT and COPD

- Research has shown that clients with COPD, the presence of lower body mass index <20 increases 1-year mortality 4-fold higher when compared to overweight or obese > 25 clients with COPD - it has been estimated that clients with COPD used 10 times the amount of calories to breathe than those without pulmonary disease - Low bone density is problematic in clients with COPD (glucocorticoids, reduced physical activity, history of tobacco use, inadequate calcium and vitamin D, and pulmonary disease itself) - Often need fluid restriction with COPD and acute respiratory failure o Assists in control of pulmonary edema

GERD Management

- Small, frequent feeding thickened with cereal o 6 small meals; chew thoroughly, limit liquids with meals if causing distention or early satiety o Decrease eat within 3 hours of bedtime - Upright positioning 30 minutes after feeding o Relax at mealtime- sit down o Use blocks to elevate head of bed 6 inches o Decrease lying down in hour after eating - Burp after 1-2 ounces of formula or after nursing from each breast - Avoid fat, chocolate, peppermint, spearmint, caffeine, alcohol, and tobacco

Prevention/Treatment of renal stones: uric acid stones

- Stones with this form when urine is persistently acidic - Animal protein is rich in purines, which may increase uric acid in urine -Meat consumption should be limited to 6 ounces per dau - Purines are sometimes a complication of gout, a hereditary metabolic disease that is a form of arthritis; Symptom is inflammation of joints - Metabolism of uric acid is related to dietary purines, product of protein digestion - Purine restricted diet common for gout (many physicians do not prescribe this because condition can be more effectively controlled with meds)

Metabolic response in critical care

- The metabolic response of the immune system to infection or injury is called the inflammatory response - The s/s are: Swelling, redness, heat, pain - C-reactive protein (CRP) is released by the liver during acute phase of the inflammatory response and alters: o Metabolism, HR, BP, body temperature, immune cell function o Frequently measured in critical care clients -Inflammatory response needs to run its course before anabolism begins again

Determining energy needs of patients in critical care

- The optimal method of determining energy needs for critically ill patients is INDIRECT CALORIMETRY. - The body increasingly uses protein obtained from internal body stores (lean body mass) to meet energy needs and depletes lean body mass - Once feeding begins, estimating nutritional needs of critically ill patients is extremely important. - Both over and underfeeding have severe consequence for the patient. - For example, an over-fed ventilated patient has a poor chance of weaning from the vent. - An under-fed patient may catabolize respiratory muscles to meet energy needs- again, preventing weaning from the vent. - Surgery needed to repair soft tissue trauma requires 14-37% increase in kcal

Hormonal response in critical care

- The stress response in hypermetabolism is also mediated by hormones - The catecholamines, glucagon, and cortisol oppose insulin and are typically referred to as counter-regulatory hormones o These hormones influence glucose and fat metabolism by causing the breakdown of glycogen and amino acids to product glucose and triglycerides from body fat stores o The body products glucose so that it has the fuel to respond to stress - 2 other hormones, aldosterone and ADH, also respond to stress and the result is the retention of both water and sodium

Phosphate Binders

- There are many different kinds of phosphate binders: Pills, chewable tablets, powders, and liquids are available. Some types also contain calcium, while others do not. You should only take the phosphate binder that is ordered by your doctor or dietitian. - may be added to a clients regiment if dietary modification does not produce desired results; especially stages 3-5 - - Meds that bind phosphorus in GI tract, allowing resulting complex to be eliminated in stools - Must be taken while clients eats meals

FODMOP diet

- diet is recommended for irritable bowel syndrome - Fermentable Oligosaccharides, disaccharides, monosaccharides, and polyols - Effective for managing IBS -Target restrictions of short chain carbs shown to induce abd. Pain, bloating, flatus, and diarrhea due to poor absorption, osmotic activity, and rapid fermentation -Richest sources of FODMOPs: o Fructooligosaccharides (fructans): wheat, rye, onions, garlic, artichokes o Galactooligosaccharides (GOS): legumes (soy, beans, chickpeas, lentils) cabbage, brussel sprouts o lactose : milk, dairy products, beer, prepared soups and sauces o Fructose- honey, apples, dates, mangoes, papaya, pears, prunes, watermelon, high fructose corn syrup o Sorbitol- apples, pears, stone fruits, sugar free mints/gums o Mannitol- mushrooms, cauliflower, sugar free mints/ gums

Pre-op importance of nutrition support for GI surgery

- undernutrition is linked to post op complications -Most at risk for complications: >5% weight loss in 1-3 months, BMI <18.5, and/or 25%-75% reduction in oral intake; take steroids, and have cancer or immunosuppression. - Obese or over weight are instructed to lose weight before surgery to reduce risks of surgery -Anemia- iron supplementation may be prescribed -At least 2-3 weeks for effectiveness of nutritional therapy before surgery -Clinical application 20-1 pg 351 relates on possible cause of malnutrition in surgical patients. -Preventative malnutrition is effective for malnourished surgical clients or those whose oral intake will be compromised after surgery. -Clients undergoing major GI surgery, perioperative nutritive therapy for 7 days before surgery (> 10 kcal/kg/day) is associated with 50% reduction in nosocomial infection and total complications.

Iron interventions to slow progression of kidney function loss

-Anemias may be due to: 1. Lack of kidneys production of erythropoietin 2. Decreased oral iron intake which commonly occurs as a result of dietary restriction 3. Blood loss -Epoetin alfa may be used to increase RBC production and thereby correct anemia -Treatment is oral or IV form and a increase in dietary sources of iron -Diagnosis of iron-deficiency anemia made by lab measure of ferritin (storage form of iron found primarily in liver) o Lab value of > 100 mcg pe mL is recommended for CKD clients, ensuring adequate iron for erythropoietin stimulated production of RBC

Vitamin and mineral supplementation interventions to slow progression of kidney function loss

-Chronically uremic clients are prone to deficiencies of water-soluble vitamins -Losses most notable with pyridoxine, ascorbic acid, and folic acid -Potential problem for toxicity with fat-soluble vitamins

Key recommendation 6: covid

-EN via gastric feeding preferred over postpyloric feeding 1. Gastric feeding: requires minimal expertise, allows use of existing NG or OG tube placed at time of intubation 2. Continuous rather than bolus feeding: causes less diarrhea, optimizes blood glucose control, requires less staff interaction -Rationale: 1. Less staff time is required for NG/OG tube placement as opposed to postpyloric tube placement, limiting virus exposure 2. Large-bore tubes carry less risk of tube occlusion than small=bore tubes 3. Continuous feeding requires less patient interaction thus limits exposure

Key Recommendation 2 and 3: covid

-Initiate enteral nutrition (EN) early 1. Within 24-36 hours of ICU admission 2. Within 12 hours of intubation -EN preferred over PN 1. If patient can be successful fed via gastric route -Rationale: 1. Provision of early EN in ICU patients has resulted in improved mortality rates and reduced infections compared with delayed or withheld EN 2. Meta-analysis demonstrated less infectious risk with EN use compared with PN use in ICU patients 3. EN can be safely provided in patients with sepsis and shock in the absence of escalating vasopressors and symptoms of gastric ileus

Post-op importance of nutritional support for GI surgery

-Iv fluids continued after surgery -Minimal replacement is 2L of 5% glucose in water in 24 hours -Contains 100g of glucose and delivers 340 kcal; wont meet resting energy expenditure, but it will prevent ketosis -Guidelines recommend the early discontinuation of IV fluids in post op period, after recovery room discharge, and encourage clear fluids as tolerated - Early feeding (< 24 hours) accelerates GI recovery and decreases LOS, complications and mortality. -Sham feeding ( chewing sugar free gum>/= 10 mins 3-4 x/day ) after colorectal surgery also demonstrates small improvements and may be associated with a decreased LOS, possibly due to an increase in bowel motility. -Clients undergoing elective major upper GI surgery requiring postoperative nutritional support, enteral feeding is the most desirable form of post operative feeding -Malnutrition clients can't be fed enterally, providing parenteral nutrition may reduce complications and mortality -Removal of a part of the GI tract, such as stomach, duodenum, jejunum, or ileum may result in malabsorption of special nutrients -Bile salts are absorbed in the ileum, prolonging impaired absorption of bile salts resulting in failure to absorb fat and fat soluble vitamins

Hemodialysis nutrition management

-Malnutrition in hemodialysis clients associated with increased morality and morbidity -Moderate to severe estimated in approximately 34% of clients on hemodialysis - Reasons: Increased catabolism, Metabolic changes caused by excretion changes in different nutrients, Decreased food intake because of restrictions and/or poor appetite, Low economic status - They need an increased protein intake because results in loss of 1-2 g of amino acids per hour - Restrict fluids to 500-1000 mL plus 24 urine output (allows for fluid gain of 2-2.5 kg between dialysis treatments - Kcal/kg/day: < 60 years= 35 OR > 60 years = 30-35 - Protein (g/kg/day) = 1.2-1.3; 50% HBV - Fat (% total kcal)= 30-35% clients considered highest risk for CVD; emphasis on saturated fat, PUFA, MUFA; 250-300 mg cholesterol/day - Sodium (mg/day)= < or equal to 1500 mg - Potassium (mg/day)= 2000-3000 (8-17 mg/kg/day) - Calcium (mg/day)= <2000 from diet and meds - Phosphorus (mg/day)= 800-100 adjusted for protein

Acceptable sodium foods

-Natural cheese (1-2 oz per week) -Homemade or low-sodium soups, canned food without added salt Homemade casseroles without added salt, made with fresh or raw vegetables, fresh meat, rice, pasta, or unsalted canned vegetables -Low-salt deli meats (if you need to limit phosphorus, these are likely high in phosphorus) -Fresh beef, veal, pork, poultry, fish, eggs -Homemade or low-sodium sauces and salad dressings; vinegar; dry mustard; unsalted popcorn, pretzels, tortilla or corn chips -Fresh garlic, fresh onion, garlic powder, onion powder, black pepper, lemon juice, low-sodium/salt-free seasoning blends, vinegar

Fluid interventions to slow progression of kidney function loss

-Renal insufficiency and most dialysis require restricted fluid intake because kidneys can no longer excrete excess fluid -Hemodialysis are restricted to 500-1000 mL plus 24-hr urine output o Allows for fluid gain of 2-2.5 kg between dialysis treatments - CAPD fluid restriction is as tolerated according to daily weight flunctuations and BP

Key recommendation 4 and 5

-Start a standard EN isotonic (1 kcal/ml) high-protein formula 1. Start slowly at 10-20 ml/h, advancing to 80% of goal by end of first week with medical stability 2. Hold at trophic rate with worsening hemodynamics -Do not check gastric residual volume (GRV) -Rationale: 1. Escalating vasopressors with a mean arterial pressure < 65, rising lactate levels, or when high pressure respiratory support is required (noninvasive ventilation, continuous positive airway pressure, or positive end-expiratory pressure) increases the risk of ischemic bowel and a potential for aspiration 2. GRV is not reliable, and checking several times daily may increase risk of virus transmission

Key Recommendation 7 and 8: covid

-Switch to PN when EN via gastric feeding is not an option 1. Try motility agent to improve tolerance 2. If signs of ileus persist, change to PN 3. If vasopressor requirement is escalating, change to PN -Limit soybean oil lipids in the 1st week 1. Use alternative lipids, or limit or withhold soybean lipids 2. Monitor triglyceride levels early in PN course (like on propofol) - Rationale: 1. Threshold for switching to PN for patient with COVID may need to be lowered, especially if sepsis or shock is present 2. These patients will likely require a prolonged ICU stay; without adequate feeding, they will develop a large calorie and protein deficit 3. As the patients condition improves, gastric EN should be reattempted 4. The omega-6 fatty acids found in soybean oil have a proinflammatory profile and should be limited in acute phase of critical illness.

Phosphorus, vitamin D, calcium interventions to slow progression of kidney function loss

-Vitamin D cannot be activated, which leads to low serum calcium level and elevated serum phosphorus -Calcium released from bones because of increased PTH which leads to renal osteodystrophy and vascular calcification (faulty bone formation and CVD) -Clients with hypocalcemia and hyperphosphatemia are given activated vitamin D orally or IV if on dialysis o Cannot be given when serum calcium or phosphorus levels are very high or vascular calcification may result - Extra phosphorus in the body pulls calcium from bones making bones brittle - Phosphorus found in: dairy, high-protein, whole-grain, inorganic, phosphate additives -Additives have 100% absorption rate o Found in fast food, processed foods, and canned/bottle beverages -Protein limitation also affects phosphorus limitation -Phosphate binders may be added to a clients regiment if dietary modification does not produce desired results o Meds that bind phosphorus in GI tract, allowing resulting complex to be eliminated in stools o Must be taken while clients eats meals - Calcimimetic may also be added because it acts directly on parathyroid hormone gland to reduce release of PTH

Nephrotic syndrome s/s

-a result of a variety of diseases that damage the glomeruli capillary wall -proteinuria -severe edema -low serum potassium levels -anemia -hyperlipidemia (usually the higher than lipidemia, the higher the proteinuria) -caused by degenerative changes in kidneys capillary walls, which consequently permit passage of albumin into glomerular filtrate -water & sodium are retained= edema -degree of malnutrition is hidden until excess fluid is removed

American Cancer Society recommendations?

-consume plant-based diet -eliminating or limiting processed and red meat consumption -adopting a physically active lifestyle -maintain a healthy weight throughout life

Potassium interventions to slow progression of kidney function loss

-hypokalemia must be avoided because it may introduce cardiac arrhythmias and cardiac arrest -salt substitutes are very high in K and are avoided -avoid water softeners -need to restrict K generally increases in clients with decreased urinary output -ACE inhibitors reduce albuminuria, but may exacerbate hyperkalemia -recommended intake is 2-3 g/day -if > 5-6.6, then restrict < 2.4 g/day -when urinary output is 100-500 mL and serum potassium is 5.5-6.5,a 40-60 mEq intake is suggested -anuria or when serum potassium exceeds 6.5, dietary intake of 20-25 mEq/L(780-975 mg) suggested -before reducing diet, check meds and hemodialysis -this is water soluble; therefore, large amounts of water to prepare veggies and to discard water after cooking decreases veggies potassium content for low potassium diets -free fruit contains more potassium than canned fruit

Sodium interventions to slow progression of kidney function loss

-intake depends on individual circumstances -serum sodium is not a reliable indicator of sodium intake for CKD -levels based on BP and fluid balance -sodium is restriction in most -avoid water softeners -sodium 1500 mg/day or less -because glomerulonephritis is more likely to product HTN and fluid retention, sodium restriction is often necessary -low levels of sodium, absence of edema, and normal or low BP commonly characterize pyelonephritis

Prolonged starvation in critical care

-most body organs switch to a less-preferred fuel source - Body becomes more efficient in reusing amino acids for protein synthesis - Urea nitrogen excretion decreases during prolonged starvation - Rate of tissue breakdown also decreases because metabolic rate and total energy expenditure decrease to conserve energy and prolong life

Kcal interventions to slow progression of kidney loss

-need additional kcal -absence of diabetes, clients on high kcal diets are usually given all the simple carbs and monounsaturated and polyunsaturated fat -inadequate nonprotein kcal however will encourage tissue breakdown and aggravate uremia -need 35-40 kcal/kg per day for renal insufficiency -use of specialized oral supplement such as Suplena, a low protein, high calorie product, is one example of appropriate oral supplement for clients unwilling or unable to eat enough food -with diabetes and renal diseases, need good control of blood sugar levels -can be high in simple sugars -in some cases, primary goal is to reduce uremia, and BG control may become less important

Vegetarian diet

-plentiful in plant proteins increases survival rates, decrease proteinuria, GFR rate, renal blood flow, and histological renal damage -high in potassium and phosphorus -goal is to eat right combo of plant proteins while keeping potassium and phosphorus under control

Protein interventions to slow progression of kidney function loss

-primary goal is controlling nitrogen intake -examples of food containing protein of high biologic value: eggs, meat, dairy -vegetarian diet has been proven beneficial for clients with renal failure -protein restrictions effective only if client consumes adequate kcal -predialysis stage usually requires a restriction or modification of protein intake -diabetes who have early stages of CKD should consume no more than 0.8-1 g protein/kg of body weight -nondiabetics with CKD 0.9 g/kg should be consumed -hemodialysis clients need increased protein because results in loss of 1-2 g of amino acids per hour -client with CAPD has an even higher protein need because of continuous dialyses

Causes of renal inflammation

-trauma -infection -birth defects -medications -chronic disease (atherosclerosis, diabetes, HTN) -toxic metal consumption -genomics

Parenteral nutrition: type

1. 3 most common: 1. PN: amino acid dextrose formula 2. TNA (total nutrient admixture): amino acid dextrose lipid formula 3. Lipids: provide fatty acids 2. Depends on client specific nutritional needs

Parenteral nutrition: how?

1. 3 routes: 1. Peripheral 1. Not most desired route due to infection risk 2. Dextrose > 10% not given this route 3. Less than 2 weeks 2. Central 1. Preferred choice 2. Catheter into subclavian vein: PICC, percutenous, triple lumen catheter 3. Atrial 1. Possible route but not common 2. Administered into RA

Metabolic alterations in critical care? ketosis

1. Accumulation of ketones 2. Results from incomplete metabolism of fatty acids, from carb defc.

Metabolic alterations in critical care? lipolysis

1. Break down of adipose tissue for energy, releasing free fatty acids into the bloodstream 2. Prolonged starvation: adaptive mechanisms conserve body protein stores y enabling a greater portion of energy needs met by increased fatty acids, with decreased requirement for glucose

Parenteral nutrition: interventions

1. Change IV tubing and filter every 24 hours 2. Keep solutions refrigerated 3. Warm solutions to room temperature prior to administer 4. If new solution unavailable, use 10% dextrose and water temporarily to avoid rebound hypoglycemia 5. Monitored closely: check daily weight, glucose, temp, I/O 6. Check 3 times a week: BUN, electrolytes (Ca and Mg) 7. Check once a week: CBC, platelets, prothrombin time, liver function (AST/ALT), serum albumin

Why is nutrition an integral component of supportive care in ICU?

1. Critical illness exists in phases: early acuteà late acuteà postacute 2. During the acute phases, hyper catabolism is the general rule and leads to energy deficits 3. Amino acids are mobilized predominantly from muscle, which leads to negative nitrogen balance and acquired sarcopenia 4. Critical illness induces gut dysfunction and dysbiosis, which accentuates the inflammatory response and organ dysfunctions downstream

Conclusion for covid nutrition

1. Delivery of nutrition therapy to patient with severe acute respiratory syndrome caused by COVID should follow basic principles of critical care nutrition as recommended by European and North American societal guidelines 2. Early use of continuous gastric feedings, avoiding GRV checks, and early use of PN in patients intolerance to gastric feeding (to avoid endoscopic/fluoroscopic placement of post-pyloric tube) are strategies that help cluster care, reduce frequency of interactions between healthcare provider and patients, and minimize contamination of additional equipment, while promoting optimal nutrition therapy for these patients

Stages of kidney failure

1. GFR > 90= some kidney damage with normal or elevated GFR 2. GFR 80-90= kidney damage with mildly decreased GFR 3. GFR 30-59= mild to severe loss of kidney function with decreased GFR 4. GFR 15-29= severe loss of kidney function with decreased GFR 5. GFR < 15= kidney failure *GFR < 25 usually requires dialysis or transplantation

Parenteral nutrition: complications

1. Hyperosmolar coma 2. Pneumothorax 1. Not started until chest x-ray validates placement 3. Sepsis 4. Fluid overload 5. Air embolism

Parenteral nutrition: rate of infusion

1. Initial rate 50ml/hr 2. Increase to 100-125 ml/hr as tolerated 3. Always use a pump at constant rate 4. Increased rate- hyperosmolar state (HA, nausea, fever, chills, malaise) 5. Reduce rate- rebound hypoglycemia (confusion, tremors, hypotension, tachycardia, cool clammy skin)

Liver failure management

1. Malnutrition commonly seen 2. AVOID alcohol 3. Ingestion of 4-6 meals/ day late evening snack to avoid fasting associated catabolism 4. Protein intake of 1-1.5g/kg 5. Sufficient kcal to avoid muscle catabolism 6. Provision of liquid supplement if client has diagnosed malnutrition or is unable to consume enough kcal from food 7. Monitor vitamin status and supplement PRN 8. Sodium restrictions based on ascites level

Parenteral Nutrition: when?

1. Preoperative if client has poor nutritional status 2. GI problems: Crohns, UC, short bowel 3. Adverse effects of oncology therapy: N/V, stomatitis 4. Alcoholism 5. Depression 6. Eating disorders 7. Malnourished 8. Head and neck surgery

Metabolic alterations in critical care? gluconeogenesis

1. Production of glucose from noncarb stores 2. Primary source of glucose in early starvation, causes a reduction in lean body mass

CF Management

1. Supportive care is foundation of CF treatment with the overall goal that every client should achieve normal growth. Children under 2 not growing well should receive trial zinc supplement 2. Pancreatic enzyme replacement, CF patients can maintain nutrition status with normal diet 3. Advance pulmonary manifestations may require enteral feeding ( improved muscle strength and lung function) 4. Energy needs may be 110-200% of normally recommended, with unlimited fats 5. Oral nutritional supplements or Enteral feedings to meet estimated daily energy requirements 6. Yearly monitoring of serum Vit. A,E, and D and supplement PRN, hypervitaminosis A has been reported 7. Adequate salt intake and monitoring of electrolytes

Guiding principles relevant to COVID-19

1. cluster care", meaning all attempts are made to bundle care to limit exposure 2. Adhere to CDC recommendations to minimize exposures to covid 19 positive patients 3. Preserve use of PPE

BG range for CCU patient

140-180

Malnutrition is present in how much at diagnosis and up to 80% in advanced stages of diseaes?

15-40%

Pre-op clear liquid indication

2 hours before surgery

Up to how many patients receiving chemo will experience nausea?

80%

Low Potassium Foods

Apple (1 medium) Apple Juice Applesauce Apricots, canned in juice Blackberries Blueberries Cherries Cranberries Fruit Cocktail Grapes Grape Juice Grapefruit (½ whole) Mandarin Oranges Peaches, fresh (1 small)canned (½ cup) Pears, fresh (1 small)canned (½ cup) Pineapple Pineapple Juice Plums (1 whole) Raspberries Strawberries Tangerine (1 whole) Watermelon (limit to 1 cup) Alfalfa sprouts Asparagus (6 spears raw) Beans, green or waxBroccoli (raw or cooked from frozen) Cabbage, green and redCarrots, cooked Cauliflower Celery (1 stalk) Corn, fresh (½ ear) frozen (½ cup) Cucumber Eggplant Kale Lettuce Mixed Vegetables White Mushrooms, raw (½ cup) Onions Parsley Peas, green Peppers Radish Rhubarb Water Chestnuts, canned Watercress Yellow Squash Zucchini Squash Rice Noodles Pasta Bread and bread products (Not Whole Grains) Cake: angel, yellow Coffee: limit to 8 ounces Pies without chocolate or high potassium fruit Cookies without nuts or chocolate Tea: limit to 16 ounces

High potassium foods

Apricot, raw (2 medium)dried (5 halves) Avocado (¼ whole) Banana (½ whole) Cantaloupe Dates (5 whole) Dried fruits Figs, dried Grapefruit Juice Honeydew Kiwi (1 medium) Mango(1 medium) Nectarine(1 medium) Orange(1 medium) Orange Juice Papaya (½ whole) Pomegranate (1 whole) Pomegranate Juice Prunes Prune Juice Raisins Acorn Squash Artichoke Bamboo Shoots Baked Beans Butternut Squash Refried Beans Beets, fresh then boiled Black Beans Broccoli, cooked Brussels Sprouts Chinese Cabbage Carrots, raw Dried Beans and Peas Greens, except Kale Hubbard Squash Kohlrabi Lentils Legumes White Mushrooms, cooked (½ cup) Okra Parsnips Potatoes, white and sweet Pumpkin Rutabagas Spinach, cooked Tomatoes/Tomato products Vegetable Juices Bran/Bran products Chocolate (1.5-2 ounces) Granola Milk, all types (1 cup) Molasses (1 Tablespoon) Nutritional Supplements:Use only under thedirection of your doctoror dietitian. Nuts and Seeds (1 ounce) Peanut Butter (2 tbs.) Salt Substitutes/Lite Salt Salt Free Broth Yogurt Snuff/Chewing Tobacco

Key nutrients for wound healing in critical care

B12, zinc, vitamin D, vitamin C, iron

Metabolic alterations in critical care? glycogenolysis

Breakdown of glycogen ( liver carb stores); releasing glucose into the blood stream. Body's glucose stores only last a few hours.

What increases risk of colorectal cancer?

Cooking meat at high temperatures (grilling/charring) forms heterocyclic aromatic amines and polycystic aromatic hydrocarbons and increases risk of this

Contributing risks for aspiration in critical care

Extubation from vent, swallowing dysfunction and a real risk of aspiration is present; may last several days

Sodium Limits

Table salt Seasoning salt Garlic salt Onion salt Celery salt Lemon pepper Lite salt Meat tenderizer Barbecue sauce Steak Sauce Soy sauce Teryaki sauce Oyster sauce Crackers Potato chips Corn chips Ham Salt pork Bacon Sauerkraut Pickles, pickle relish Lox & Herring Olives Pretzels Tortilla chips Nuts Popcorn Sunflower seeds Hot Dogs Cold cuts, deli meats Pastrami Sausage Corned beef Spam Canned TV Dinners Canned raviolis Chili Macaroni & Cheese Spaghetti Commercial mixes Frozen prepared foods Fast foods

What significantly reduced cancer-related fatigue?

aerobic exercise

What are leading contributors to the major types of cancer?

alcohol and overweight

High phosphorus food to limit or avoid

beer/ale cocoa drinks made with milkcanned iced teas bottled beverages with phosphate additives Lower phosphorus alternatives to enjoy: water, coffee, tea, rice milk (unenriched), apple juice, cranberry juice, grape juice, lemonade, ginger ale, lemon lime soda, orange soda, root beer chocolate drinks dark colas pepper type soda (Dr Pepper) cheese custard milk cream soups Lower phosphorus alternatives to enjoy: rice milk, almond milk, cottage cheese, vegan cheese, sherbet, popsicles oysters beef liver fish roe Lower phosphorus alternatives to enjoy: chicken, turkey, fish, beef, veal, eggs, lamb, pork chocolate candycaramelsoat bran muffin Lower phosphorus alternatives to enjoy: apples, berries, grapes, carrot sticks, cucumber, rice cakes, unsalted pretzels, unsalted popcorn, unsalted crackers, pound cake, sugar cookies ice cream pudding yogurt (Greek type acceptable) sardines chicken liver organ meats most processed/prepared foods/deli meats/hot dogs/bacon/sausagepizzabrewer's yeastchocolatecaramel candies

In the US, most than 20% of cancer deaths are attributed to what?

body fatness, physical inactivity, excess alcohol consumption, and poor nutrition

Dietary soy intake reduces risk of what?

breast cancer

What improves appetite for cancer patients?

controlling the cancer disease

#1 cause of renal failure/disease

diabetic nephropathy (HTN & diabetes are the 2 most common)

Mouth ulcerations from cancer therapy can be helped by detouring liquids how?

drinking straws

Patients with head and neck cancer frequently require what?

enteral nutrition

What may help reduce diarrhea for cancer therapy?

foods high in pectin

In cancer therapy, gastric emptying is delayed when?

high fat foods are consumed which may contribute to N/V

Obesity causes a condition of chronic what?

inflammation

What can alleviate dry mouth from cancer therapy?

marinades, sugar-free candy, and frequent hydration

What medication can increase appetite in patients with anorexia?

megestrol

Stomach cancer is common in areas where?

nitrates and nitrites are prevalent in food (processed meat, high sodium foods, pickled food) and water

ETOH management

o Muscle wasting, weight loss, and nutritional defc. o Malnutrition common- 20-60% alcoholic cirrhosis, 100% in alcoholic hepatitis o Caloric needs determined by indirect calorimetry- provide frequent meals, night time snack, a daily protein intake of 1-1.5 g/kg/day o Avoid unnecessary restrictions: ex: sodium unless edema/ ascites present o Enteral nutrition preferred over parenteral nutrition o Defc commonly seen in ALD: § Folate § Thiamin (B1) § Cyanocobalamin (B 12) § Vitamin D § Glucose § Branch chain amino acids (BCAA)

what are phytochemicals?

plant chemicals responsible for color, aroma, and taste that reduce risk for cancer development

What are the overall nutrition goals for curing active cancer trearment?

resolution of nutrient deficiencies, preservation of lean body mass, minimize nutrition-related side effects of care and achieve/maintain a healthy weight

Taste alterations for cancer therapies may be addressed by

serving cold food, providing oral care before meals, using glass for cooking, and plastic utensils for eating, adding sauces and marinas and serving alternatives to beef and pork

What can help with n/v from cancer therapy?

serving liquids up to an hour after solid foods

What can help with satiety and anorexia during cancer therapy?

serving small, frequent calorie-dense meals varied in flavor and using oral supplements

What is cancer cachexia?

systemic inflammation, negative protein and energy balance, and involuntary loss of lean body mass

Micronutrient needs for people with ileostomy

they will have decreased fat soluble vitamins, bile acid, and vitamin B12 absorption; fluid and electrolyte losses