Metabolic Alterations in the
High-Acuity Patient
Chapters 5, 30, & 31
Nursing 487 – Spring, 2017
Sharon D. Landry, MSN, RN, CPAN
Objectives
• Describe the major nutritional alterations and assessment
of nutritional deficiencies in the
high-acuity patient.
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• Formulate appropriate nursing diagnoses and interventions
for patients with nutritional imbalances.
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• Describe the nursing care for a patient receiving enteral or
parenteral nutrition in the high-acuity setting including
complications.
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• Examine the neuroendocrine response that influences
nutrition and metabolism during stress from acute illness.
Normal Metabolism
Metabolism: processes to produce
energy in our body from nutrients
• CHO, protein, Lipid -- nutrients
• Catabolic/anabolic processes
• Aerobic Metabolism (oxygen)
Anabolism
• Anabolism: (About Building) constructive metabolic
process whereby simple molecules are converted
into molecules that are more complex
– Involves synthesis of cell components
– Contributes to tissue building
– Anabolic events require energy
Catabolism
• Catabolism: (Causes Breakdown) process by which
complex nutrients are converted into more basic
elements such as glucose, fatty acids, and amino
acids
– Occurs when energy is required by the body
– Generates energy
Anaerobic Metabolism
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Glycolysis
Energy is created by oxidation of glucose
Inadequate Cellular Oxygenation
Pyruvate is converted to lactic acid
Elevated Lactate Acid Levels (NML < 2 mmol/L)
Stress response = Altered Metabolic state
Stress response to illness, injury, or infection is an
amplification of the fright-flight reaction.
The initial insult leads to local and generalized
inflammation and to activation of a very abnormal
hormonal response, characterized by a marked
increase in catecholamines and other stress
hormones that produce a hypermetaboliccatabolic state.
Figure 30–5 Neurologic, endocrine,
and Immune response to stress.
Figure 30–6
The body's
response to
STRESS.
Neurohormonal Stress response
Adrenal Medulla (SNS)
•Epinephrine & Nor-epinephrine
•Immediate stress response
Pituitary
•↑ ADH & Growth hormone
•Release of endogenous analgesia
•Stimulates thyroid gland (TSH) – T3 & T4
Neurohormonal Stress response
H-P-A axis: Cortisol & Aldosterone
•↑ Serum glucose & fats for energy
•↑ protein catabolism for energy
•↑ serum sodium - ↑ water/blood volume
•Alters CHO, fat, protein metabolism so that
energy ↑ for vital organs to work harder
Table 31-1
Metabolic Response to Illness
Metabolic Stress Response:
Ebb Phase
• Initially metabolic rate unchanged or
decreased in first 24 hours
• Exceptions burns & head injury
• Increases in glucose and lactate levels
common
• Research on enteral feedings
Metabolic Stress Response:
Flow Phase
• Begins 24-36 hours later
• Peaks 3-4 days
• Increased oxygen consumption and calorie
demands for wound healing
• Hypermetabolism
• Patient's condition worsens as
hypermetabolism persists
Metabolism & Immune function
• Persistent, abnormal hypermetabolism
ultimately results in suppression of immune
responses.
 Aggressive
tx now practiced (i.e. SIRS
guidelines)
• Immunonutrition - immunonutrient mixes may
help in hypermetabolic disease states
Factors Affecting the Adult
Immune System
• Malnutrition
– Elderly experience malnutrition as part of aging
– Components of calorie and protein intake play key roles
in formation of T cells and immunoglobulins
• Stress
– Affects immune system, primarily through effects of
cortisol
– Adrenal glands produce more cortisol in response to
needs, thus suppressing the immune system
Factors Affecting the Adult
Immune System
• Aging
– Functionality Declines with Aging
– Thymus Gland Begins to Atrophy
life
– More Autoimmune Diseases
• Trauma
– Suppress T-cell and B-cell activity
early in
are seen
High-Acuity Patients At Risk for
Starvation
• Condition that fails to meet minimum body
requirement
• Energy expenditure and gluconeogenesis are
decreased
• Fatty acids are mobilized
• Ketone production is increased
• The degree of starvation determines the extent and
type of malnutrition
Reversing Stress response/
Hyper- Catabolism
1. Provide optimum nutrition early
2. Use anabolic agents if needed to increase
the rate of anabolic activity
3. Provide exercise stimulus to muscles
(an added anabolic stimulus)
Providing optimum Nutrition
Nutritional support decisions
Assessment can be divided into several
components:
1. energy or caloric requirements
2. protein requirements
3. micronutrient requirements.
Table 5 – 1: clinical findings with
nutritional deficiencies
Energy Requirements for High
Acuity patient
Goal of nutrition support: avoid catabolism during
metabolic stress
Healthy patient: 25 kcal/kg/day; 0.8-1 GM protein/day.
HIGH ACUITY PTS. amts. INCREASED
– Calculate BMR (age, weight, height)
– SVO2 - Oxygen consumption
– REE – Resting energy expenditure (Indirect calorimetry) or (HarrisBenedict equation)
– RQ – respiratory quotient – correlates with CHO use
**Indicators of Visceral
Protein Status**
• Serum albumin, prealbumin, and transferrin
– low levels indicate that muscle has been
catabolized for energy
– can result in serious multisystem complications
Protein requirements
• Norm = 0.8 g/kg per day
• Illness/injury = 2.0 g/kg per day.
• Monitor Protein indicators for protein
requirement
• achieve net positive nitrogen balance
• Adjustments needed for patients that
cannot manage protein: kidney failure,
hepatic encephalopathy
Albumin - 3.5-5.0g/dL
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Crucial for maintenance of intravascular volume
Major protein produced in liver
Low albumin levels  edema and ascites
15- to 20-day half-life
Influenced by hydration status and
hepatocellular injury
Prealbumin or Transthyretin
17-40mg/dL
• Periodic monitoring of prealbumin
• Aids in transport of thyroxine
• More reliable indicator of acute changes in
catabolism
• Less influenced by hydration, renal, or liver
status than is albumin
• Should increase within 4-8 days
Transferrin - 200-430
mcg/dL
• Half life 8 days – tracks response to nutritional
therapies quicker than albumin
• Plasma protein that binds with and transports
iron to cells
• Limited usefulness with Iron deficiencies
Nitrogen Balance
• Urinary nitrogen output is low in renal failure
• The goal of protein administration is to provide a
positive nitrogen balance
• Difference between nitrogen output and intake
• Indicator of protein status
• One gram of nitrogen = 6.25 grams of protein
• Urine urea nitrogen (UUN) test  24hr urine
Vitamin and Mineral Assays
• Low serum levels of vitamin A, zinc, and
magnesium common in acutely ill patients
• Assess fat-soluble vitamin (A, D, E) and
mineral (iron, folic acid) deficiencies
Total Lymphocyte Count
• Antibodies and lymphocytes contain significant amounts
of protein
• Functioning of immune system depends on protein
levels
• TLC - good indicator of overall immune status & protein
level
• Lymphocyte count of <1,500 mm3 = impaired immune
function
Nutritional Requirements for
LIVER FAILURE
• Hepatic encephalopathy  elevated ammonia
levels
• Corrected before initiating feeding
• High carbohydrate intake
• Normal-to-moderate protein intake (0.8-1.0
g/kg)
• Low fat intake
Nutritional Requirements for
Pulmonary Failure
• Malnutrition high in pulmonary failure
• Excessive carbohydrates = inc CO2
• Monitor:
– phosphorus levels
– sodium and fluid restrictions
– nitrogen balance
– blood urea nitrogen
– creatinine
• Carbohydrate intake limit
• Protein and lipids  increase
• Enteral feeding - Pulmocare
Nutritional Requirements for Acute
RENAl Failure
• Monitor albumin, prealbumin
• Severely malnourished – protein 1.5 -1.8
g/kg/day
• Low protein intake if not on dialysis protein
intake (0.6-0.8g/kg per day
• On dialysis protein intake (1.2 g/kg per day)
• Renal enteral feedings - Nepro
Nutritional Requirements for
Cardiac Failure
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Malnutrition affects the cardiac muscle
Decreases cardiac pumping effectiveness
Tissues are deprived of oxygen
Closely monitor nutritional needs
Gut needs increased blood supply for digestion
Continuous infusion instead of
bolus to avoid blood shunting
Gut Failure
• Inadequate intestinal perfusion produces
increased gut permeability
• Facilitates bacterial translocation – increased
mucosal permeability= GI flora into blood =
sepsis
Burns
• Patients with burns among highest energy,
protein, and fluid needs
• High-calorie, high protein
• Vitamin supplements (A, B complex, C &
zinc) for wound healing
• Massive fluid losses require fluid
resuscitation
Traumatic Brain Injury
• TBI causes in hypermetabolism and
hypercatabolism responses
• Highest in patients with:
– fever
– seizures
– decerebrate/decorticate posturing
• Nutrition is usually met with enteral feedings
Overnutrition
• Implementing a low-calorie diet is
inappropriate for acutely ill patient
– imbalance between energy intake and
energy consumption
• During acute illness, it is crucial to meet
the elevated nutrient needs of obese
patients
Enteral Nutrition (EN)
• Criteria for selecting EN:
– Gastrointestinal integrity and function
– Illness severity/duration
• Feed sooner; consider PEG
• Timing of nutrition support
– EN within 24-48 hours
– Don’t WAIT for bowel sounds
– BS is POOR indicator of small bowel motility &
nutrient absorbtion
Types of Enteral Feedings
• Commonly formulas (See table 5-9)
• Which formula for what disease state?
• Consider the calories, protein, carbs,
sugar, fat, & electrolytes in solutions
– Most formulas are 1.0-2.0 kcal/ml
• TF for high acuity patients
– NG/OG tube – short term –in stomach
– PEG tube – long term – inserted into stomach
or small intestine. Can be done at the bedside
in ICU with portable endo guidance
Solutions
•
Free Water ?
• Jevity
Nepro
Pulmacore
Glucerna
Feeding Tube Placement
• Methods to determine tube location
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Observe for signs of respiratory distress.
Capnography, gastric aspirate, pH
Confirmatin with ausculation of air instillation not reliable
Mark tube location
X-ray confirmation mandatory prior to its initial use
for feedings or medications
• Check tube location at 4-hour intervals after feedings
are started by checking residuals, review of recent
CXRs, checking for insertion mark
Complications of Enteral Nutrition
TABLE 5-10 pg. 107-108
• Gastrointestinal
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N/V
High Residuals – How much is too much?
Diarrhea - ? C. difficile cytotoxin
Aspiration
• Nutritional
• Malnutrition
• Hypoalbuminemia
• Adjust calories, protein, fat, carbs e-lytes, water
based on weight
Complications of Enteral Nutrition
TABLE 5-10 pg. 107-108
• Mechanical
• Tube obstruction, disconnection
• Metabolic
• Altered glucose, electrolyte imbalances
• Infectious
• Aspiration pneumonia
• PEG site infections
Parenteral Defined
• Used when oral or enteral
not possible
nutrition is
• A nutritionally complete IV solution:
– Macronutrients (carbs, protein, fat)
– Micronutrients (e-lytes, vits, minerals)
– water
Contraindications to TPN
• Functioning GI tract
• Needed for < 5 days
• Aggressive therapy not warranted
• Risks outweigh benefits
Delivery
• TPN with > 10% dextrose – CVC
• PPN with < or = 10% dextrose - Peripheral
Infectious Complications CatheterRelated Sepsis (CLABSI)
• 35% mortality rate
• Longer, more expensive hospital stays
• Common reasons
– lack of sterility during placement of central lines
– inadequate precautions taken
during maintenance
• Signs and symptoms
• Review from SEPSIS content
Infectious Complications
• Prevention
• STRICT sterile precautions with insertion
• Sterile dressing changes
• Change tubing Q 12 hr for any fluids with lipids (TPN ,
Diprivan)
• “Scrub the Hub”
• Treatment
• Removal of (suspected) infected central cath
• Culture cath
• ANTIBIOTICs STAT!! (within 1 hr)
Metabolic Complications of TPN
• Hyperglycemia  high dextrose conc
• Prerenal azotemia – too much protein leads to
increased nitrogen level in blood
– signs and symptoms – increased BUN and NA,
clinical signs of dehydration
– Monitoring – I&O, daily wt, protein levels
Hepatic Dysfunction
• Secondary to the macronutrient
concentrations – too much glucose = fatty
liver, gall stones
• Elevated serum liver function tests – elevated
liver enzymes
Mechanical Complications of TPN
• Pneumothorax (most common)
– signs and symptoms
• Catheter fracture
• Artery puncture
• Air embolism
• Dysrhythmias
Administration of Solution
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Verify MD order with solution
Check expiration date on solution
Use filter & infusion pump
Refrigerate until 1 hour before administer
Tubing change with each new bag
Gradual increase/decrease rate
NEVER STOP INFUSION ABRUPTLY
Nursing Management TPN
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Monitor vital signs Q 2-4 hrs.
Weigh patient daily
Monitor labs daily
Catheter site dressing change
Monitor blood glucose
Administer insulin per sliding scale
Monitor for complications
Refeeding syndrome
 Complication
associated with reinitiating
nutritional support to a person who is
significantly or chronically malnourished
of refeeding syndrome 
hypophosphatemia, hypomagesemia,
hypokalemia
 Hallmark
 Refeeding
should begin slowly (3-7 days)
Refeeding Syndrome
• At-risk patients: Cancer, HIV/AIDS, anorexia, etc.
– Prevention is key
– Initial and frequent evaluation of serum
phosphorus, potassium, and magnesium
– Can result in FATAL CARDIAC ARRYTHMIAS
– Increase INTAKE SLOWLY, NOT > 20KCAL/KG/DAY of
ACTUAL BODY WEIGHT
– Increase caloric intake by 10-25% per day over 3-7
days
Refeeding Syndrome:
To Review:
High-Acuity Patients and Nutrition
• Have increased need for nutrients and calories
because of the stress response
• High levels of stress and starvation alter
metabolism
• Older adults or those with chronic illness
• Starvation is a nosocomial problem
• Provision of nutrition is a nursing priority