Critical care - Nutritional therapy: Nursing

Nutritional therapy is an intervention used to meet nutrient requirements in critically ill patients who are unable to consume or tolerate oral nutrition or can't digest or absorb food.

The two main types of nutritional therapy are enteral nutrition and parenteral nutrition. As the nurse youll provide patient centered care while providing nutritional therapy to critically ill patients.

Now, enteral nutrition also known as tube feeding involves the delivery of temporary or long term nutrition through a tube directly into the gi tract.

This is indicated for patients who have some digestive function but are unable to consume adequate nutrients by mouth like intubated patients, patients with nervous system disorders that impact chewing or swallowing or patients with increased caloric needs due to major surgery or burns.

A common temporary route for enteral nutrition is through a nasogastric or NG tube, which enters through the nose and goes into the stomach for patients at increased risk of aspiration or with impaired gastric emptying.

A small bowel feeding tube can be inserted directly into the small intestine. On the other hand, if long term or permanent enteral feeding is needed, a tube can be placed through a surgical opening in the abdominal wall and into the stomach, known as a gastrostomy tube or G tube.

One common type of gastrostomy tube is the percutaneous endoscopic gastrostomy tube, also called a peg tube. Tubes can also be inserted into a part of the small intestine called the Jejunum, known as a jejunostomy tube or AJ tube.

For short. There are other conditions where a patient can't digest and absorb any food via the gi tract due to conditions like g trauma or surgical procedures, as well as other illnesses like intestinal cancer.

In these cases, parenteral nutrition is prescribed where liquid nutrition formulated based on the nutritional needs of the patient is infused intravenously.

The most common type of parenteral nutrition is total parenteral nutrition or TPN where all nutrients including protein, fat minerals, electrolytes, water and carbohydrates are delivered through a catheter into a large vein, close to the heart, like the superior vena cava.

Since TPN can be corrosive to the peripheral veins, it must be administered using central venous access devices like a peripherally inserted, central catheter or PICC line or port.

Another type is peripheral parenteral nutrition or PPN where less calorically dense nutrition is delivered via peripheral veins.

PPN is used less often due to risk of infection and phlebitis or inflammation of the veins, but it can be indicated in the short term for patients without a central venous access device when caring for your critically ill patient receiving nutritional therapy.

Your goals of care include safely administering nutrition, monitoring for complications and evaluating your patient's ongoing nutritional status.

Begin by assessing your patient's baseline nutritional status by recording their height and weight and calculating intake and output.

Check their laboratory test results including electrolytes, bun creatinine and complete blood count. Also auscultate their heart and lung sounds and assess for edema and inspect for signs of malnourishment such as skin breakdown, impaired wound healing, hair loss and brittle nails.

Now, there are a variety of enteral nutrition formulas available depending on the patient's nutritional needs like low glucose formulas for patients with diabetes or soy based mixtures for those with lactose intolerance.

On the other hand, parenteral nutrition is individually mixed for each patient. Be sure to collaborate with the nutritionist pharmacist and health care provider to determine which enteral nutrition formula or parenteral formulation is most appropriate for your patient before administering.

Remember to compare the feeding bag label with the order to confirm that it contains the right mixture. Next, examine the insertion site of the feeding access device.

Look at the surrounding skin for signs of breakdown and infection like swelling, redness or drainage. If your patient has an enteral access device, ensure that tube placement has been confirmed using an appropriate method for newly inserted tubes.

Be sure there's X ray confirmation of correct placement before first use. Otherwise check proper placement every four hours.

You can do this by measuring the external tube length and comparing it to the recorded length at the time of placement for parenteral access, determine the patency prior to use by flushing the line with saline and checking for blood return.

Then collect the necessary equipment and prime the type of tubing based on the type of therapy. Check the mixture bag for any obvious punctures or leaks for TPN.

Inspect the contents of the bag for any particles or clumps and check to make sure the contents of the bag haven't separated into layers.

If you notice damage or other imperfections to the solution, notify the pharmacy. So a new bag can be prepared, then connect the tubing to the administration site and confirm the rate of administration as ordered during therapy.

Monitor for complications for enteral nutrition. Look for signs and symptoms of aspiration, like coughing or shortness of breath.

You can help prevent aspiration by elevating the head of the bed to at least 30 degrees during feedings unless contraindicated.

Also watch for signs of feeding intolerance like abdominal pain, bloating, nausea or diarrhea. Be sure to watch for a serious complication called re feeding syndrome.

This can happen with either enteral or parenteral nutrition that is initiated for a patient who's malnourished and receives nutrition too quickly, causing rapid shifts in fluids and electrolytes.

Symptoms can include dyspnea, altered mental status, cardiac arrhythmias and seizures. You can reduce the risk of refeeding syndrome by slowing the solution administration rate.

Patients receiving parenteral nutrition are also at risk for hyperglycemia. So be sure to check blood glucose as ordered.

Lastly, perform an ongoing evaluation to determine the effectiveness of treatment, monitor your patient's vital signs, daily weight and fluid balance while trending laboratory test results as indicated.

All right. As a quick recap, nutritional therapy is a therapeutic intervention used to meet nutrient requirements in critically ill patients who can't consume or tolerate oral nutrition or are unable to digest or absorb food.

The two main types of nutritional therapy are enteral nutrition and parenteral nutrition. When caring for your critically ill patient receiving nutritional therapy.

Your goals of care include safe administration, monitoring for complications and evaluating your patients ongoing nutritional status.