Table of Contents
Introduction…………………………………..
Clinical Nutrition Care Process………………
Identify Patients at Nutrition Risk……
How to Access Nutrition Assessment in
Physician Web Portal………………………
St. Luke’s Hospital Approved Diets………….
Tube Feeding Diet Orders …………………...
Adjusting Diet Order: Nutrition Protocol…….
Nutrition Assessment of Adult Patients
Anthropometrics……………………….
Adult Predictive Equations .………….
Refeeding Syndrome …………………
Biochemical Data……………………..
Criteria for Identification of Nutritional
Deficiencies/Malnutrition/BMI Coding .....
Enteral Nutrition (EN)
Indications for EN Support…………..
Contraindications for EN Support…..
Enteral Formula Selection……………
Initiation of EN Support………………
Monitoring of EN Support……………
Parenteral Nutrition (PN)
Indications for PN…………………….
Contraindications for PN……………..
Macronutrient Calculation in PN……..
Calculating a PN formulation…………
Monitoring of PN Support…………….
Contact a Dietitian ……………………………
References………………………………………
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Introduction
This reference provides a guide to the clinical nutrition
assessment procedures and provides a description of most
ordered diets offered at St. Luke’s University Hospital.
St Luke's clinical nutrition staff (RDs and diet
technicians) are avail to:
 Develop and implement a Nutritional Care Plan,
which includes a comprehensive nutrition
assessment: nutrient/Kcal requirements,
potential/actual identification of malnutrition and
nutritional deficiencies.
 Provide medical nutrition therapy (MNT) to
improve medical outcomes, reduce hospital LOS,
reduce morbidity/mortality and improve overall
health.
 As a nutrition resource to be the nutrition expert to
the health care team, patients and families.
When to request a Nutrition Consult:




When considering initiation of nutrition support of
enteral/parenteral feedings
When patient/family needs nutrition education for
diet modifications/restrictions. A 24 hour notice
requested. (Outpatient nutrition counseling is
available at all campuses)
When patient appears malnourished/high nutrition
risk (i.e. cachexia, presence of wounds/pressure
ulcers, poor kcal intake, weight loss, obesity etc.)
For a new nutrition related problem (i.e.
pancreatitis, diabetes, celiac sprue, short gut
syndrome, cancer, CHF, crohn’s, renal failure)
2
CLINICAL NUTRITION CARE PROCESS
Nutrition Screening – the process of identifying
characteristics known to be associated with nutrition
inadequacies. Its purpose is to identify persons who are at
increased nutritional risk and provide intervention.
Nursing completes the screen within 24 hours of
admission including triggers that may identify at nutrition
risk. The clinical nutrition staff utilizes the screening data
along with other criteria to determine the patients’
potential risk and need for a comprehensive nutrition
assessment and intervention.
Nutrition Assessment – is completed by clinical nutrition
when a patient has been identified at potential nutrition
risk via the screening process. A comprehensive nutrition
assessment is completed and a plan of care is devised to
improve nutritional status.
Nutrient Intake Analysis (calorie count) – calorie and
protein intake will be calculated. It is ordered for two
days. An intake analysis is appropriate for patients when
adequacy of intake is questionable or a change in therapy
is being considered. Examples might be transitioning
from enteral (EN) or parenteral (PN) feedings to oral
intake, or if initiation of EN or PN feedings are being
considered.
3
IDENTIFING PATIENTS AT NUTRITION RISK
Diets:
Eating :
Problems:
Weight:
Labs:
Skin
Dx:
Clear/NPO x 4 days, TPN, New Enteral or
parenteral feedings
Aspiration precautions, Poor PO, new tube
feed/parenteral nutrition
New choking/swallowing/chewing
difficulty
BMI (Body Mass Index) < 18.5, >40
HbA1c > 8
Stage III, IV, and unstageable wounds or
pressure sores, Fistula
Eating disorders: anorexia, bulimia
Malnutrition
Failure to Thrive
New HIV/AIDS
New Hepatic Diseases
DKA
Gestational Diabetes
Pediatric Diabetes
Cancer of the head/neck, GI tract
Short gut syndrome
Chronic Pancreatitis
New gasterectomy
New Renal with HD/PD
New Gastric bypass/Weight loss surgery
Pregnancy with hyperemesis
Active Crohns / IBS
New CVA
Trauma
4
How to Access Nutrition Assessment
In Physician Web Portal
1. Log in, choose a patient and then click
Flow sheet tab.
2. On the Report drop down list select
Nutrition Assessment and then click
refresh.
How to make the Nutrition Assessment a
Hotlink:
1. In either the Doc view or Flow sheet
modules, click the Edit tab on the
module header to open the Personalize
Module page.
2. Select “Nutrition Assessment 2 ” from
the drop down list next to one of three
hotlinks.
3. Click Save at the bottom of the page.
How to Access Nutrition Assessment in
Horizon Clinical:
1. Log in and select patient
2. Go to the menu bar
3. Select Review and select “Nutrition
Assessment 2 ”
5
St. Luke's University Health Network
APPROVED DIETS
(Approved through the Nutrition care Committee)
Nutrition prescriptions: When ordering a diet the entire
diet order must be reordered each time you revise a single
component of the diet prescription. Patients are able to
select their food choices on most diets. A hostess will
visit the patients or the patient may call the call center to
place their meal order. Diets that are not selective are
denoted with an asterisk*.
Regular (House) Diet
Provides approximately 90g
protein and 2000 calories
with no restrictions.
Finger Food Diet
Regular diet allowing
patient to eat without
utensils.
Pediatric Diet (Only @ SLB) Age appropriate diet for
ages ~2-17.
Toddler Diet (Only @ SLB) Age appropriate diet for ~14 year olds.
NPO
Nothing by mouth
TRANSITIONAL/LIQUID DIETS
Clear Liquid
Includes fluids with
minimal residue; no milk
products. Limit 24-48 hrs,
provides approximately 800
calories and 200 gm.
carbohydrate. Is appropriate
for patients with diabetes.
Includes wide variety of
liquids; liberal use of milk
Full Liquid
6
products. Not for extended
time use.
Surgical Soft (GI)
Foods may be easier to
digest. Inadequate in
calories and protein recommended for use only
1-2 days. Limits most raw,
highly seasoned, fried or
fatty foods. If “soft to
chew” diet desired, see
dysphagia diets.
T & A*
Used post-operatively for
tonsillectomy and
adenoidectomy on the
pediatrics unit.
TEXTURE MODIFIED (Need to order liquid
consistency separately)
Level 1 Dysphagia
(Pureed)
Regular diet pureed
(pudding-like) consistency.
Mechanically non-irritating.
Should be used for those
who have difficulty
swallowing or chewing
Level 2 Dysphagia
(Mechanically Altered)
Transition diet between the
pureed and dental soft.
Meats are minced and most
other foods are chopped.
There are no particulates
such as rice or corn. Bread
and crackers are not served
with this diet.
7
Level 3 Dysphagia
(Dental Soft)
Regular diet modified to
include only foods that are
easy to chew. Tougher
meats are diced or thinly
sliced.
Liquid Consistency
Thin, nectar thick, honey
thick and pudding thick
consistencies are available.
Consult speech therapist to
determine appropriate liquid
consistency.
CARBOHYDRATE / CALORIE
CONTROLLED / WEIGHT MANAGEMENT
These diets are used for those who those patients that
have blood glucoses.
Patients who are receiving
medication that may elevate blood glucose such as
steroids, or s/p cardiac surgery and may benefit by a carb
controlled diet.
1 Carbohydrate (CHO) Serving = 15 grams of Carbohydrate (CHO)
Consistent Carbohydrate
Level 1
(1500 – 1800 Kcals)
Carbohydrates are
consistent at each meal.
Level 1 provides 4 CHO
servings (60 gms) each
meal. Protein and fat is
added to fill the calorie
needs. An evening snack is
not routinely provided but
will be provided if ordered.
8
Consistent Carbohydrate
Level 2
(1900 – 2100 Kcals)
Level 2 provides 5 CHO
servings (75 gms) at each
meal. An evening snack is
not routinely provided but
will be provided if ordered
Consistent Carbohydrate
Level 3
(2200 – 2400 Kcals)
Level 3 there are 6 CHO
servings (90 gms) at each
per meal. An evening snack
is not routinely provided but
will be provided if ordered
DIABETES AND PREGNANCY
Diabetes can occur during pregnancy due to increased
insulin resistance. The goal is to attain glycemic control
and prevent the body from spilling ketones in the urine.
Gestational Diabetes
1800 Kcals
Provides 3 CHO servings at
each meal and 1 CHO
serving at AM and PM
snacks, and 2 CHO servings
at HS snack. 5 oz. protein
is divided between 3 meals,
and 1 oz. protein at each
snack.
Gestational Diabetes
2000 Kcals
Provides 3 CHO servings at
breakfast and 4 CHO
servings at lunch and
dinner. Between meal
snacks contain 1-2 CHO
servings and 1 oz. protein.
6 oz. of protein servings at
meals are divided as 1 oz. at
breakfast, 2 oz. at lunch and
9
3 oz. at dinner. 1 serving of
fat per meal is permitted.
Gestational Diabetes
2200 Kcals
Gestational Diabetes
2400 Kcals
Provides 3 CHO servings
at breakfast and 4 CHO at
lunch and dinner. 2 CHO
servings and 1 protein
serving is provided as 3
snacks. 7 oz. of protein is
divided between the meals:
1 oz. at breakfast, 3 oz. at
lunch, and 3 oz. at dinner.
1 fat serving per meal is
also permitted.
Provides 3 CHO servings
at breakfast and 4 CHO
servings at lunch and
dinner. 2-3 CHO servings
and 1 protein serving is
provided in 3 snacks.
Protein servings at meals
are divided as 2 oz. at
breakfast, 3 oz. at lunch,
and 3 oz. at dinner. 1-2 fat
servings per meal are
permitted.
CARDIAC
Low Cholesterol
Limits cholesterol in the
diet to < 300 mg/day. .
Limits saturated fat. High
fiber foods promoted.
Low Fat
Limits all types of fat to 40
to 50 gm/day.
10
2 gm. Sodium
Most restricted sodium
level offered.
4 gm. Sodium (NAS)
Least restrictive of the
sodium diets. Salt packet
and high Na foods are not
permitted.
Step 1 Cardiac
Less than 30% of total
calories from fat with less
than 10% from saturated
fat. Contains about 3 gms.
Na, 300 mg cholesterol, 25
to 30 gms of fiber and is
approximately 1800
calories.
TLC 2.3gm Na
< 25% total calories from
fat w/ < 7% from sat fat.
< 200 mg cholesterol, 2gm
plant sterols, 10-25gm
soluble fiber. Meat portion
2 to 3 oz. @ meals. A
stand-alone lifestyle diet.
Should not be used in
combination with other
diets.
Open Heart
For use up to 48 hrs. s/p
surgery to aid with BG
control.
Cardiac Cath
Cardiac step 1 finger food
diet used for 1-2 meals after
procedure.
11
Low Phosphorus
RENAL
Provides 1000 mg
phosphorus.
2 gm. Potassium
2 or 3 gm. restriction per
renal function. Often
restricted when urine output
is less than 1 liter/day and if
the patient is on dialysis.
Renal (Dialysis)
Diet provides ~ 2000 kcal,
80 gm. protein, 2.5 gm. K+
and Na, 1000 mg phos.
Fluid restriction per
physician order.
GASTROINTESTINAL
Gluten Free
Eliminates all wheat,
barley, rye and oat products
(ie, breads, pastas). Gluten
free substitutes are
available.
High Fiber
Soluble and insoluble fiber
is gradually added to the
diet as needed.
Lactose Restricted
Lactose is limited to
tolerance level. Lactaid or
soy milk is provided.
Low Fiber/Residue
Diet limits dietary fiber to
< 10g.
12
Non-Ulcerogenic
Avoids alcohol, caffeine,
and pepper and pepper
seasoned foods.
Post-Gasterectomy
Provides 5-6 small meals.
High fat foods, sweets,
sugars, and carbonated
beverages are avoided.
Milk is provided as
tolerated.
WEIGHT MANAGEMENT
These diets restrict calories and assist weight management therapies.
(not available at SLB)
Weight Management level 1
1500-1800 calories
Weight Management level 2
1900-2100 calories
Weight Management level 3
2200-2400 calories
BARIATRIC DIETS
Bariatric
Clear Liquid*
Sugar-free beverages, no
carbonation, small portions
(1 oz.) every 15 min. No
Straw
Bariatric
Full Liquid
Low-fat, sugar free liquids,
includes milk products.
Lactaid and soy products
13
are available. small portions
(1 oz.) No straw
Bariatric Pureed
Transition diet s/p tolerating
bariatric clear/full liquid.
Recommended 3-5 days
post-op bariatric surgery. ½
portions of food. Non-fat
milk. No high sugar.
Bariatric Soft
Transition diet s/p tolerating
bariatric pureed diet.
Recommended for patients
who are 6 days post op. ½
portions of moist foods.
Soft fruits and vegetables
allowed. No high sugar
foods or carbonated
beverages. No straw.
Bariatric Maintenance
Limits calories and
concentrated sugar foods.
Non-carbonated, low sugar
beverages permitted.
Appropriate for gastric
bypass patients who are at
least 6 months post-op.
14
MISCELLANEOUS
Fluid Restriction
Physician Ordered 24 Hour
Fluid Allowance
<800 ml
800-999 ml
1000-1199 ml
1200-1499 ml
1500-1799 ml
1800-1999 ml
2000-2200 ml
Ordered as a modifier.
Specify restriction ml. See
food service allotment
below.
Fluid Allotment Provided
by Food and Nutrition
Services for Each Meal
No fluid provided by Food
and Nutrition
120 ml per meal
180 ml per meal
180 ml per meal
240 ml per meal
240 ml per meal
360 ml per meal
Kosher
Diet per patient needs to
follow their kosher dietary
laws. Frozen meals
provided for patients
following strict kosher law.
Low Purine
Foods restricted of animal
origin, fatty foods and
alcohol. Patients are
encouraged to drink plenty
of fluids.
Low Tyramine
Indicated when MAOI
drugs are administered.
Diet avoids aged or
fermented products.
15
Low Iodine
Pre-renal
Vegetarian
Wired Jaw Diet
Diet includes approx 50
mcg of iodine. Used with
thyroid disorders. Should
be started 2 weeks prior to
treatment.
Diet is 200 mg K+, 1500 mg
Phos,70 gms Protein, 3000
mg Na
This diet is a lacto-ovo
vegetarian diet.
Individualized per patient’s
needs / requests.
Consists of a fortified full
liquid diet w/ liquid
supplements & pureed
items which pass easily
through a large straw. It is
approx 2000 calories per
day.
Diets will be modified to accommodate food allergies.
The food allergy should be entered in HEO in the allergy
screen. The allergy should be entered in the instruction
field also when diet is ordered.
TUBE FEEDING DIET ORDERS
Tube feeding diet can be ordered two ways: “Tube
Feeding” or “Tube Feeding with Oral Diet.” If a patient
is able to eat and have a tube feeding, “Tube Feeding with
Oral Diet” must be selected. If only “Tube Feeding” is
selected, the subsequent diet order will not be accepted as
diets are non-compliant with “Tube Feeding” only
selection. (consult a dietitian or see enteral formulary for
enteral product selections)
16
RD to Adjust Diet Order Nutrition
Protocol
This protocol can be approved when a diet is ordered in HEO.
To approve the protocol, the physician responds “yes” when
asked if they desire to “Notify Nutrition, RD to adjust Diet
Order” per protocol.
The purpose of the protocol is to permit the RD to adjust the
diet per the patients’ needs. Protocol will be employed when
the nutrition assessment indicates the patients’ energy, fluid,
protein or nutrient intake is inadequate to meet estimated needs
or when a patient condition requires an another therapeutic diet
modification.
Changes that may be made by the RD:
Texture modification
Addition of supplements to assist in meeting patient’s
nutritional needs
Calorie level/Carbohydrate level adjustment in
coordination with patient’s estimated needs
Adjustments of diets for intolerances/allergies
Dysphagia diet changes made congruent with speech
recommendations for patients who are currently
receiving PO intake
Mineral adjustments
Correction of diet order if incorrectly ordered in
computer
Adjustment in diet per patient preferences or past diet
restriction
Increase / Decrease enteral kcal.
The dietitian will chart the assessment findings and rationale
for any changes made in the Validate Protocol section of the
nutrition note. The physician will be able to view the alteration
via HEO. When critical alteration is being considered, the RD
will discuss with the MD.
17
Nutrition Assessment of Adult Patients
ANTHROPOMETRICS
Estimating IBW
Women: Allow 45.4 kg for first 5 ft. of height plus
2.3 kg. for each additional inch above 5 ft.
Men:
Allow 48.1 kg for first 5 ft. of height plus
2.7 kg for each additional inch.
ABW: Adjusted Body Wt.
Should be used if pt. is ≥ 125% of IBW
ABW= [(Actual Wt. – IBW) x 0.25] +
IBW
BMI
Wt. (kg)
Ht (m)²
BMI result:
<18.5
18.6-25
25.1-29.9
30-34.9
35-39.9
≥40
or
Wt. (lbs.) x 703
Ht (in)²
Indication
Underweight
Normal Weight
Overweight
Obesity Grade I
Moderate Obesity (Grade II)
Morbid Obesity (Grade III)
18
IBW Weight adjustment for amputation*
Type of amputation
% Total Body Weight
Foot
1.5
BKA
5.9
AKA
15
Entire Lower Extremity 16 - 18
Hand
0.7
Forearm and Hand
2.3
Entire Arm
5
*Double if bilateral
Disability Adjustment
Paraplegia: subtract 5-10% from IBW
Quadriplegia: subtract 5-15% from IBW
ADULT NUTRITION REQUIREMENTS
Calorie, protein and fluid needs are calculated during
an in-depth nutritional assessment. An accurate height
and weight are integral in determining the patient’s needs.
Indirect calorimeter is the Gold standard to determine
calorie and protein needs.
 Kcal Requirements
 Kcal needs based on calories/kg body wt:
Most commonly used method providing
kcal/kg body weight depending on weight and
severity of illness. For patients >125% of IBW,
ABW should be used with a 25% correction
factor. Grossly underweight or malnourished
19
individuals should have needs estimated using
their actual weight.
Patient Status
Kcal Needs (Kcal/kg)
Maintenance Wt.
No/Mild Stress
Weight Loss
Weight Gain/Anabolism
Stressed
Refeeding Risk
Morbid Obesity
BMI>30, Critically Ill
25-30
20-25
30-35
20 initially
15-25
11-14kcal/kg
Actual wt., or
22-25kcal/kg IBW
 Other predictive equations validated to be
useful in critical care are the Penn State 2003b and
the Penn State 2010 equations in ventilated
patients. Mifflin St, Jeor is validated outside of
critical care.
 Indirect Calorimetry to determine REE
(Resting Energy Expenditure)
ORDER AS: “Metabolic Cart Study”
Indications
• Clinical conditions and diagnoses that
significantly alter REE.
• Failure of a patient to respond to
nutrition
support
per
predictive
equations.
• Individualization of nutrition support in a
critical patient to avoid complications of
over or under-feeding.
20
•
Failure to wean from mechanical
ventilation without known cause.
Recommended in patients with:
• Extended ventilation > 1 week
• Sepsis
• ARDS
• Multisystem organ failure
• Large, or open, multiple wounds
• Morbid obesity, critically ill
Consider for patients with:
• Extended use of paralytic agents
• Obesity
• Extended nutrition support
• Multiple or neurological trauma
• Amputations
• Cachexia / underweight
Interpretation of Respiratory Quotient (RQ)
Energy Source/Measurement Condition
RQ_
Fat Oxidation
0.7
Protein Oxidation
0.8
Carbohydrate Oxidation
0.95-1
Mixed Substrate Oxidation (goal)* 0.83 -0.85
Lipogenesis (overfeeding)
>1.01
Hyperventilation
>1.01
Ketosis
<0.6
* ACCEPTABLE GOAL RANGE: 0.8 to 0.95
NOTE:
1. Pt. must be intubated for the test to be
performed, FIO2 ≤ 60%, no air leak or chest
21
tube leak.
2. The validity of the test should be questioned
if the patient fails to achieve a steady state or
if the overall RQ is <0.67 or >1.3.
3. The energy of critically ill ICU patients can
range from 10% below to 23% above a
“steady state REE”.
4. The test should be held until:
--90 minutes after a change in vent setting
--3 to 4 hours after hemodialysis treatment
--12 hours after a TF / TPN change
 Refeeding Syndrome Risk
REFEEDING SYNDROME
Refeeding syndrome is defined as the metabolic
and physiologic consequences of depletion,
repletion, compartmental shifts, and interrelationships
of phosphorus, potassium, magnesium, glucose
metabolism, vitamin deficiency, and fluid
resuscitation.
Individuals at risk for refeeding syndrome:
Those with anorexia, malnutrition, chronic
alcoholism, morbid obesity, prolonged fasting,
prolonged IV hydration, significant stress and
depletion, those with large electrolyte imbalances,
NPO ≥ 7 days.
Recommendations to reduce the risk of
refeeding syndrome:
•
Be informed about refeeding syndrome
and the individuals at risk
22
•
Correct electrolyte abnormalities before
initiating nutrition support
•
Administer nutrition volume and fluid
slowly (800-1000ml for first day)
•
Estimate Kcal needs at 20 Kcal/kg for
first 2-3 days. If TPN to be initiated use
“Standard TPN”, recommended for Day
#1.
•
Monitor pulse rate and I/O’s closely
•
Provide appropriate vitamin supplements
•
Carefully monitor electrolytes over the
first week including:
o Phosphorus
o Potassium
o Magnesium
Refeeding Syndrome Manifestations
• Hypophosphatemia
• Increased intravascular volume
• Hypokalemia
• Hypomagnesemia
• Less common, Wernicke’s
encephalitis
Can occur up to 72 hours
post start of feeding.
23
 Protein Requirements – Protein is provided
.8 to 2 gm./kg.
Patient Status
Protein Needs (gm./kg)
No stress
0.8 to 1
Surgery
1.2-1.5
Mild Infection
1.2
Skeletal Trauma
1.5-2
Sepsis
1.5-2
Critically ill pts. with
1.2-2gm/kg
BMI < 30
Actual wt²
Critically ill pts. with
BMI 30-40
≥2g/kg IBW²
Critically ill pts. with
BMI ≥40
≥2.0g/kg IBW²
**Pts. on CRRT
1.5-2.5²
** (Grade C evidence)²
 Fluid Requirements – Fluid intake ranges from
25 to 40 ml/kg but varies greatly
dependent of illness.
Factors affecting fluid requirements:
Increased fluid needs:
Excessive diarrhea
Large ostomy
Fistula
Polyuria
Excessive vomiting
Fever
Incr Kcal and Pro intake
Rapid or prolonged
High gastric o/p
hemorrhage
Physical activity
Large open wounds
24
Certain medications
Decreased fluid needs:
CHF
Respiratory failure
Multi-system organ failure Renal failure
Head trauma
Hepatic failure
Estimating fluid requirements
Note: Use Actual Body Weight unless otherwise
indicated.
Age
Fluid needs (ml/kg)
16-25 yrs.
40
25-55 yrs.
35
55-65 yrs.
30
>65 yrs.
25-30
or, 1ml/Kcal energy expenditure
BIOCHEMICAL DATA
Albumin (Half-life: 14-20 days) Not a reliable indicator
of protein status in hospitalized patients due to long halflife and sensitivity to hydration status and inflammatory
metabolism.
Factors resulting in increased values:
Dehydration, IV albumin, blood
transfusions
Factors resulting in decreased values:
Liver disease, ascites, infection, nephrotic
syndrome, post-op edema, over-hydration,
25
malabsorption,
poor
intake,
acute
malnutrition, pregnancy
Prealbumin (Half-life: 2-3 days). Not a reliable
indicator of protein status in acute care/critical care,
hospitalized patients due to its sensitivity to inflammatory
metabolism. Provision of additional protein in the face of
critical illness will not improve PAB lab value.
Factors resulting in increased value:
Renal disease, corticosteroids
Factors resulting in decreased value:
Trauma, infection, stress, liver disease, ~5 day’s s/p
surgery
The appropriate use of hepatic proteins in the
nutritional assessment process is as indicators of
morbidity, mortality, or severity of illness. The sickest of
patients are those who are the most likely to require
nutritional intervention.
24 hr. UUN/Calculating Nitrogen Balance
(NB)
NB = Protein intake (g/24hrs) - [Nitrogen o/p (gm./24hrs) +
4]
6.25
Values should be interpreted in context of the patient’s
clinical status. Factors limiting validity include: adequacy
of urine collection, nitrogen losses from large open
wounds, severe burns, diarrhea, renal failure, liver failure.
26
CRITERIA FOR IDENTIFICATION
OF NUTRITIONAL DEFICIENCIES
Identification of Malnutrition, morbid obesity
and underweight status.
*The form: “Malnutrition/BMI Documentation Form”
(Form no. 15889NP ) will be placed in the Progress Notes
by the dietitian if a patient exhibits at least two
characteristics of malnutrition per the Academy of
Nutrition and Dietetics and the American Society for
Parenteral and Enteral Nutrition. The form also can
indicate a BMI that is ≤ 18.5 or ≥ 40. The form is used to
alert the physician and other health care providers of an
added risk, malnutrition or excessive/inadequate body
weight.
A dietitian will initiate the Malnutrition form, initiate an
intervention, and place the form in the progress notes for
physician review and signature. A signed form by a
physician signifies agreement with the findings.
ENTERAL NUTRITION (EN)
Enteral nutrition should begin if inadequate nutrition
is expected > 7 days. If the patient has a pre-exsisting
malnutrition and not consuming adequate nutrition,
enteral nutrition should begin immediately.
Indications for Enteral Nutrition Support in the face
of inadequate oral intake unless contraindicated:
27
• Anorexia
• Head and neck surgery
• Neoplasms
• Trauma
• Dysphagia
• Mandibular fractures
• Coma
• CVA
• Demyelinating diseases
Markedly Increased Nutritional Requirements:
•
•
•
Sepsis
Trauma
Closed head injury
Limited Nutrient Absorption:
•
•
•
•
•
•
Malabsorption
GI Fistulas (enteral access placed distal
to fistula, or volume of o/p < 200ml)
Chronic Pancreatitis
Inflammatory bowel disease
Short bowel syndrome
Pancreatic insufficiency
Contraindications for Enteral Nutrition
Support:
• High o/p GI fistula
• Paralytic ileus
• Mesenteric ischemia
• Total Small bowel obstruction
• Inability to gain access
• Intractable vomiting or diarrhea
• Lower GI Bleed
28
•
Aggressive therapy not warranted
“Specialized nutrition therapy is not
obligatory in cases of futile care or end-oflife situations. The decision to provide
nutrition therapy should be based on
effective patient/family communication,
realistic goals, and respect for patient
autonomy.” (Grade E evidence).
Enteral Formula Selection Guidelines
See Enteral Formulary Card for product
descriptions. Available from any dietitian or
call #4166.
• “Immune-modulating enteral
formulations should be used for the
appropriate patient population (major
elective surgery, trauma, burns, head and
neck cancer, and critically ill patients on
mechanical ventilation). (Grade A
evidence for surgical ICU pts.; Grade B
evidence for medical ICU pts.).² - Pivot
1.5
• “Patients with ARDS and severe acute
lung injury (ALI) should be placed on an
enteral formulation characterized by an
anti-inflammatory lipid profile (i.e., ω-3
fish oils, borage oil) and antioxidants.
(Grade A evidence).² - Oxepa
• “ICU patients with acute renal failure
(ARF) or acute kidney injury (AKI)
should be placed on standard enteral
formulation, and standard ICU
recommendations for protein and calorie
provision should be followed. If
significant electrolyte abnormalities exist
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•
or develop, a specialty formulation
designed for renal failure (with
appropriate electrolyte profile) may be
considered. (Grade E evidence).² - jevity
“Standard enteral formulations should be
used in ICU patients with acute and
chronic liver disease. – jevity. Branched
chain amino acid formulations (BCAA)
should be reserved for the rare
encephalopathic patient who is refractory
to standard treatment with luminal acting
antibiotics and lactulose.” (Grade C
evidence).² - NutraHep
Initiation of Enteral Nutrition Support
• “In the ICU patient population, neither
the presence nor absence of bowel
sounds, nor evidence of passage of flatus
and stool is required for the initiation of
enteral feeding.” (Grade B evidence).²
• “In the ICU setting, evidence of bowel
motility (resolution of clinical ileus) is
not required in order to initiate EN”
(Grade E evidence).²
• Start tube feeding full strength at 20-30
ml/hr. based on pt. status (lower if
critical or on significant pressors; higher
if was recently eating and status is
stable).
• Advance by 10-20 ml every 4-8 hours as
tolerated to goal rate. See aspiration
precautions below.
• “Efforts to provide > 50-65% of goal
calories should be made in order to
achieve the clinical benefit of EN over
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the first week of hospitalization.” (Grade
C evidence). Studies suggest that this
improve outcomes to promote faster
return of cognitive function in head
injury patients and to improve outcome
from immune-modulating enteral
formulations in critically ill patients.²
Monitoring of Enteral Nutrition Support
• Assessment of GI tolerance
o Abdominal discomfort, pain
o Nausea/Vomiting
o Abdominal distention
• Aspiration Precautions
o HOB should be elevated ≥ 30°
“In all intubated ICU patients
receiving EN, the HOB should be
elevated 30° to 45°. (Grade C
evidence).²
o EN residuals ≥ 250 ml residual
x2
o “Holding EN for gastric residual
volumes <500 ml in the absence
of other signs of intolerance
should be avoided. (Grade B
evidence).²
o “Agents to promote motility such
as prokinetic drugs,
metoclopramide or erythromycin
should be initiated where
clinically feasible. (Grade C
evidence.²
o “Withholding of EN for repeated
high gastric residual volumes
alone may be sufficient reason to
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switch to small bowel feeding.”
(Grade E evidence).²
•
•
•
Aspiration Detection
o Clinical signs and symptoms
(dyspnea, tachypnea, wheezing,
rales, tachycardia, cyanosis,
decreased oxygenation,
anxiety/agitation, fever/aspiration
pneumonia)
Hydration Status
o Assess over hydration (edema,
high urine output, dilute urine
specific gravity, hypertension,
respiratory insufficiency, CHF,
rapid weight gain)
o Assess dehydration (decreased
urine output, concentrated urine,
elevated urine specific gravity,
dry lips and mucous membranes,
poor skin turgor, sunken eyes, flat
neck veins, lethargy,
hypotension, tachycardia,
elevated BUN, constipation, rapid
weight loss)
o Fluid intake should approximate
fluid output
o 1 kg of weight change is
equivalent to 1 liter of fluid
Assessment of Nutrient Intake
o Assess actual nutrient intake to
determine the need for change in
nutrition support. (Review RD
FU note) Holding EN for
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•
multiple or prolonged time
periods should be avoided. Every
effort should be made to infuse
the missed EN.
Body Weight
o Same scale, minimal clothing
o Frequency: daily if critically ill,
or unstable fluid status; weekly
when stable
•
Biochemical and Hematological Indices
o Baseline: CMP, Mg, Phosphorus
(others per pt. morbidities)
o Follow-up based on patient’s
clinical status.
• Maintaining Feeding Tube Patency
o Irrigate tube before and after each
intermittent feeding or
medication administration.
o Medications should be given
separately, with 5-10 ml of water
given between each one.
o For continuous feedings, flush
with at least 20-30ml of water
every 4 hours.
“Tolerance to EN in patients with severe
acute pancreatitis may be enhanced by the
following measures:
• Minimizing the period of ileus after
admission by early initiation of EN.
(Grade D evidence)
•
Displacing the level of infusion of
EN more distally in the GI tract.
(Grade C evidence).
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NOTE: The underlying medical condition/s should
be reassessed on an ongoing basis to evaluate
transitional feeding and/or initiation of increasing
oral intake. Review RD assessment. Consult
dietitian for initial/reassessment.
PARENTERAL NUTRITION (PN)
PN should be used only if the gut is not
functional/available and PN use is anticipated > 7 days
in a well-nourished person. When the gut is not
useable and the patient is malnourished, PN should
begin immediately
Indications for PN
• Failure of EN trial with proper tube
placement.
• EN is contraindicated (see above) due to
non-functioning intestinal tract.
• “If there is evidence of protein-calorie
malnutrition on admission and EN is
not feasible, it is appropriate to initiate
PN as soon as possible following
admission and adequate resuscitation.”
(Grade C evidence).²
Contraindications for PN
•
•
•
•
Functioning GI tract
Inability to obtain venous access
A prognosis that does not warrant
aggressive nutrition support
When the risks of PN are judged to
exceed the potential benefits
What to do prior to PN initiation?
• Consult dietitian
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•
Obtain patient’s actual height and
weight. Use adjusted weight if patient is
>125% of IBW
• Obtain labs: Phos, K+, Mg and replete
prior to TPN initiation. TG
Macronutrient Calculation in PN
1. Carbohydrate (CHO)
CHO is given as dextrose monohydrate
which contains 3.4 kcal/gm.
CHO Load:
mg CHO/kg/min = gm. CHO x 1000
Kg x 1440
=
gm. CHO
Kg x 1.44
GOAL for Maximum Carbohydrate load:
3 – 5mg/kg/min
< 4mg/kg/min for diabetics and critically ill
2. Protein
Amino Acids provide 4 Kcal/gm.
3. Fat
Lipids contain 10 Kcal/gm.
Minimum required to prevent EFAD
(essential fatty acid deficiency): 2-4% of
the Kcal requirement should come from
linoleic acid. (This is met with minimum
of 500 ml of 20% lipids/week).
Maximum recommended: <30% of total
Kcal, or < 1gm/kg/day to minimize effect
of IV lipids on impaired immune response.
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CALCULATING a PN FORMULATION:
Step 1: Determine dosing weight
•
•
Use actual body weight.
For patients who are overweight at > 125%
of their Ideal Body Weight (IBW) use
Adjusted Body Weight (ABW) for Kcal
and Pro requirements.
ABW: Adjusted Body Wt.
ABW= [(Actual Wt. – IBW) x 0.25] +
IBW
IBW Women: Allow 45.4 kg for first 5 ft. of height
plus 2.3 kg. for each additional inch.
IBW Men: Allow 48.1 kg for first 5 ft. of height
plus 2.7 kg for each additional inch.
Step 2 (Day 1): Determine initial total Kcal
requirements per day.
Kcal: 20 Kcal/kg dosing weight
Pro: 1gm/kg dosing weight
See dietitian to determine Kcal/nutrient goals for
succeeding days.
Standard base solution is available for day #1.
Step 3: Break down calorie requirement into
macronutrients
____ (Total Kcal/day) x 0.5 = _______Dextrose Kcal
(maximum 3-7gm/kg/day)
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____ (Total Kcal/day) x 0.3 = _______Lipid Kcal
(limit to 1gm/kg/day)
____ (Total Kcal/day) x 0.2 = _______Protein Kcal
(.8-2gm/kg/day)
Breakdown of macronutrients may change based on
patient condition and lab values.
Step 4: Convert calories to grams
______Dextrose Kcal ÷ 3.4 Kcal/gm. = _____gm.
Dextrose
______Lipid Kcal ÷ 10 Kcal/gm. =
_____gm.
Lipid
______Protein Kcal ÷ 4 Kcal/gm. = _____gm. Protein
Step 5: Convert Grams to Milliliters
_____ gm. Dextrose/day x 100 ml ÷ _____ Dextrose %
= _____ ml Dextrose
_____ gm. Lipid/day x 100 ml ÷
20 Lipid %
= _____ ml Lipid
_____ gm Protein/day x 100 ml ÷ _____ Amino Acid %
= _____ml Amino Acid
Step 6: Consult dietitian for further assessment
and recommendations. If in doubt, order:
Standard PN solution for first day and
await recommendations from dietitian.
NOTES:
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•
Initial PN should NOT meet GOAL kcal
level unless pt. has been well nourished
within the previous 48 hours.
• Fluid needs are usually not met 100% by
the PN. This allows for flexibility with
fluid adjustments via IV’s at bedside.
• NOTE: Propofol provides 1.1 Kcal of fat
per ml, and MUST be calculated into the
total fat provisions and total kcals.
• When ordering PN, use form no. 14708,
Adult Total Parenteral Nutrition (TPN)
Order Sheet. On the back of the form is
a calculation worksheet.
• “A combination of antioxidant vitamins
and trace minerals (specifically including
selenium) should be provided to all
critically ill patients receiving
specialized nutrition therapy.” (Grade B
evidence).² Renal function needs to be
considered.
Monitoring of Parenteral Nutrition Support
•
Fluid
o PN volume may be concentrated
for patients at risk for volume
overload.
o Accurate I/O’s should be kept.
•
Biochemical and Hematological Indices
o Glucose Control
 See “Insulin Infusion
Protocol” sheet.
o Electrolyte and Acid-Base
Imbalances
 Phos, Mg, K+ should be
monitored daily x at least 72
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hrs. TG monitored initially
and then weekly.
• Body Weight
o Frequency: Daily if critically ill
or fluid status unstable; bi-weekly
when stable.
NOTE: The underlying medical conditions should
be reassessed on an ongoing basis to evaluate the
possibility of complimentary or sole transition from
PN to an enteral feeding or PO initiation. Consult a
dietitian for reassessment when enteral feeding is a
consideration.
“In patients stabilized on PN, periodically repeated
efforts should be made to initiate EN. As tolerance
improves and the volume of EN calories delivered
increases, the amount of PN calories supplied
should be reduced. PN should not be terminated
until ≥ 60% of target energy requirements are being
delivered by the enteral route.”
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References:
1. Gottschlich, MM, editor-in-chief. Nutrition Support
Core Curriculum: A Case-Based Approach – The Adult
Patient. American Society for Parenteral and Enteral
Nutrition. Silver Spring, MD: 2012.
2. McClave, SA, Martindale, RG, Vanek, VW,
MCCarthy, M, Roberts, P, Taylor, B, Ochoa, JB,
Napolitano, L, and G Cresci. Guidelines for the Provision
and Assessment of Nutrition Support Therapy in the
Adult Critically Ill Patient: Society of Critical Care
Medicine and American Society for Parenteral and
Enteral Nutrition. Journal of Parenteral and Enteral
Nutrition. 2009; 33: 277-316.
3. McClave, SA, and HL Snyder. Use of Indirect
Calorimetry in Clinical Nutrition. Nutrition in Clinical
Practice. 1992; 7: 207-221.
4. Merritt, Russell editor-in-chief. The A.S.P.E.N.
Nutrition Support Practice Manual, 2nd Edition.
American Society for Parenteral and Enteral Nutrition.
Silver Spring, MD:2005.
5. Pronsky, ZM. Food Medication Interactions, 17th Ed.
Food-Medication Interactions. Birchrunville, PA: 2012.
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6. Robinson, Malcolm K, et al. Improving Nutritional
Screening of Hospitalized Patients: The Role of
Prealbumin. Journal of Parenteral and Enteral Nutrition.
2003; 27: 389-395.
7. Wooley, JA, and HC. Sax. Indirect Calorimetry:
Applications to Practice. Nutrition in Clinical Practice.
2003; 18: 434-439.
To contact a dietitian, call:
Bethlehem 484-526-4166
Allentown 610-628-8798
Quakertown 215-538-4621
Miners 570-645-8107
Anderson 484-503-1029
Warren 908-859-2207
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Updated 5/2014
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