MEDICAL NUTRITION THERAPY

Goals of Nutritional Care

Meet basic nutrient requirements

Preserve LBM

Restore respiratory muscle mass and strength

Maintain fluid balance

Improve resistance to infection

Facilitate weaning

Nutritional Needs

Body fluctuation is common

Many patients lose significant amounts of weight

Increased energy needs measured by indirect calorimetry (HB okay at first)

Nutritional needs vary widely based on the underlying condition

Nutritional Needs ctd.

Protein:

typically in negative Nitrogen balance

1.5-2g/kg

be careful because PN and EN proteins and amino acids affect the RQ

Water, CHO, and fat requirements determined by the underlying condition

Fluid Requirements

Normal unless underlying disease requires restriction

Estimation of requirements:

Monitor daily for signs of edema (overloading can cause pulmonary edema)

Micronutrient Needs

Micronutrients:

Meet RDI’s of most nutrients

Carefully monitor minerals that are electrolytes due to respiratory alkalosis and acidosis

K, Ca, and Mg are often lost in urine as a side effect of medicines.

Inflammation Modulating Diets

High EPA

found in fish oil

High GLA

found in borage oil

High antioxidants

The Use of an Inflammation-Modulating Diet in Patients With Acute Lung Injury or Acute Respiratory Distress

Syndrome: A Meta-Analysis of Outcome Data

Inflammation modulating diets:

Reduced risk of developing new organ failure

Decreased time on mechanical ventilation

Decreased ICU stay

Decreased mortality

Oxepa

High EPA, DHA, and GLA decreases:

immune response

inflammation in the lungs

neutrophils and total cell count in lungs

Converts cell membrane to less inflammatory profile

Oxepa Only IEF proven to work. Clinically shown to:

decrease pulmonary inflammation and edema

facilitate pulmonary vasodilation

decreased time on ventilators

improve oxygenation

reduce new organ failures

lower mortality rates (by 19.4%)

earlier exit from ICU

Nutritional Support Therapy

Start nutrition support early

Monitor for Refeeding Syndrome

Continually monitor weight and use indirect calorimetry to estimate energy needs

Feeding Strategies

Patients who are not intubated or have tracheostomies can meet requirements by mouth

Feed them small, frequent portions of their favorite foods to increase oral intake

Monitor for appropriate calorie levels and AMDR

OxygenOxygen required for proper digestion and absorption of food

 Inadequate Oxygen can cause:

anorexia

early satiety

malaise

bloating

constipation

diarrhea

May lead to energy deficiency

Feeding Strategies ctd.Many patients require tube feedings

GI feedings preferred

Aspiration and bacterial overgrowth

continuous feeding

tube placement in duodenum

use small-bore NG tube

elevate chest at least 45 degrees

frequent evaluation of gastric residuals

Prognosis

Outlook Good

Lung Function likely returns to normal within 3-6 months. Can take up to a year for some

35% fatal as compared to 50-70% mortality rate from 20 years ago

Trauma infection patients fair better than sepsis

Quality of LifeGood prognosis=Good Quality of life

Possible side effects one year after discharge:

Muscle wasting and weakness most common side effects-why?

Shortness of breath, cough, need for oxygen therapy

Majority have full recovery of lung function

Side effects normally abate after a year

Quality of Life

Cognitive Impairment

Anxiety

Depression

CASE STUDY

Case StudyClient name: Daishi HayatoDOB: 7/14Age: 65Sex: MaleEducation: Bachelor's degreeOccupation: Retired manager of local grocery chainHours of work: N/AHousehold members: Wife age 62, well; four adult children not living in the areaEthnic background: Asian AmericanReligious affiliation: MethodistReferring physician: Marie McFarland, MD (pulmonary)

Lung Function of Case Study

With decreased lung function. This means what for the individual?

His lung function: 36 bpm.

What can he expect?

ClaudicationPain and/or cramping in the lower leg due to inadequate blood flow (oxygen) to the muscles

Usually causes the person to limp

Pain can be mild to extremely severe

Most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms

Occurs while walking and is relieved by rest 

Can also affect the arms 

Bruits

The term for the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery when the sound is auscultated with the bell portion of a stethoscope.

NUTRITION ASSESSMENT OF CASE

STUDY

Assessment

History of emphysema, COPD for many years secondary to chronic tobacco use

Pt was working in yard and could not breathe Wife brought to emergency room

Had tension pneumothorax in the left lung

Has distended jugular veins and trachea shifted to the right

Harsh breathing sounds from right lung and none from left

The patient has lost 13# and has been experiencing a decrease in appetite

Assessment ctd.

UBW 135# and current body weight 122#

Current BMI: 21

Biggest meal is breakfast and usually does not consume very much throughout the day

Each meal he drinks hot tea w/milk and sugar

Nutrition Diagnosis

Unintentional weight loss related to poor appetite and increased energy expenditure as evidenced by patient report of a loss of 13 pounds from his usual body weight.

Medical Intervention

Endotracheal Intubation

Positive pressure ventilation

Volume-cycled ventilator of 15 breaths/minute

Mask used to ventilate Pt with high-flow oxygen

Nutritional Intervention

Increase protein to 1.5-2 g/kg (83-11g protein)

Monitor K, Ca, and Mg

Ensure adequate calorie intake

Needs 92-123g protein

Estimated BEE 1275 kcal, TEE 1658kcal

If po intake is not enough, use enteral feeding

Oxepa

Monitor and Evaluation

(Monitor) Monitor understanding of weight loss, appetite, and health.

(Evaluation) Further weight loss or gain. Loss, or regain of appetite.