Nutritional Supplements
• Nutrients: dietary products that undergo chemical changes when ingested (and metabolized)
that cause tissue to be enhanced and energy to be liberated
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o Required for cell growth and division; enzyme activity; synthesis of carbs, fats, proteins
o Secrete hormones, wound healing, immune, gut integrity, ETC.
• Nutritional support may be required
• Malnutrition: The body’s nutritional needs are not met by nutrient intake.
• Enteral nutrition: administration of food or nutrients through the gastrointestinal (GI) tract
• Parenteral nutrition: administration of nutrients directly into the circulation by means of an
intravenous (IV) solution
Enteral Nutrition
• Pts may benefit from the delivery of nutritional supplements by feeding tube include those with
abnormal esophageal or stomach peristalsis, altered anatomy secondary to surgery,
depressed consciousness, or impaired digestive capacity
• enteral route is the preferred route of administration of nutritional supplements
• six routes of enteral delivery routes (see picture below- table 55.1)
• 100+ different enteral supplements
• Contraindications: allergy; inability to metabolize nutrients
• AE: GI intolerance; diarrhea; aspiration PNA; dumping syndrome
• Many interactions may occur with meds such as ABX (d/t delayed gastric emptying and
amount of acid interfering with med absorption)
o Can reduce absorption of Phenytoin PO... which can lead to seizures
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• Minimal digestion needed; residual is minimal
• Used for malabsorption, partial bowel obstruction, irritable bowel disease, other conditions
• Hyperosmolarity of formulas may cause GI problem
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• Complete, Ensure, Ensure Plus, Isocal, Osmolite, Portagen, Jevity, Sustacal
• Preferred over elemental formulations for patients with fully functional GI tracts and few
specialized nutrient requirements; cause fewer GI problems
• Most closely resemble normal dietary intake
• contain complex nutrients derived from proteins, carbohydrates, and fat
• among the most used enteral formulations because they most closely resemble normal dietary
intake
• preferred over elemental formulations in patients who have fully functional gastrointestinal
tracts and have no specialized nutrient needs
• less hyperosmolar than elemental formulations and therefore cause fewer gastrointestinal
problems
• contraindicated in patients with a known hypersensitivity to them
• They are available without a prescription
• The most common product: Ensure40
• Complete, Ensure, Ensure Plus, Isocal, Osmolite, Portagen, Jevity, Sustacal
• Preferred over elemental formulations for patients with fully functional GI tracts and few
specialized nutrient requirements; cause fewer GI problems
• Most closely resemble normal dietary intake
• contain complex nutrients derived from proteins, carbohydrates, and fat
• among the most used enteral formulations because they most closely resemble normal dietary
intake
• preferred over elemental formulations in patients who have fully functional gastrointestinal
tracts and have no specialized nutrient needs
• less hyperosmolar than elemental formulations and therefore cause fewer gastrointestinal
problems
• contraindicated in patients with a known hypersensitivity to them
• They are available without a prescription
• The most common product: Ensure
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• lactose-free and is also available in a higher-calorie formula called Ensure Plus
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• Three types
• Carbohydrate: Moducal, Polycose
• intended to be used in addition to monomeric or polymeric formulations to provide a
more individual specialized nutrient mix
• They are available in liquid formulations only
• Fat: MCT Oil, Microlipid
• Microlipid is a fat supplement supplying only fats
• concentrated source of calories and contains 4.5 kcal/mL
• given to help individualize nutrient formulations
• may be used in patients with malabsorption and other gastrointestinal disorders and in
those with pancreatitis
• available in liquid formulations only
• Protein: Casec, ProMod, Propac, Stresstein
• used to increase patients’ protein intake and provide additional protein
• derived from a variety of sources such as whey, casein, egg whites, and amino acids
• All available products are dried powders that must be reconstituted with water
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• Single nutrient formulas
• Intended for use with monomeric or polymeric formulations
• Amin-Aid, Hepatic-Aid, Travasorb Renal, Traum-Aid HBC
• Contain varying amounts of specific amino acids
• Used for patients with diseases associated with altered metabolism capabilities
• Many are listed as modular formation
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Parenteral Nutrition
• Totally digested nutrients are given intravenously, directly into the circulatory system
o The entire GI system is bypassed, eliminating the need for absorption, metabolism, or
bowel elimination
• Total parenteral nutrition (TPN)
• Used in pts who are unable to tolerate nutrition via GI route/have poor absorption of nutrients
• IV vitamins, minerals, amino acids, dextrose, and lipids, calories, carbs
• Can be administered peripheral IV or central line
o ******* PPN= peripheral parenteral nutrition is NOT THE SAME FORMULA as TPN
▪ Specially made so not as harsh on veins
▪ Temporary route
▪ Better for pts with lower nutritional supplement needs; may still have PO intake
o TPN MUST GO THROUGH CENTRAL LINE
▪ Intrajugular, PICC, port....
▪ Major concern for CLABSI!
▪ Can be more long-term
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PPN TPN
• Peripheral IV
• provides the basic nutrient building
blocks for anabolism
• Indications: supplement to PO
intake; temporary inability for oral
ingestion, anorexia
• Temporary use (<2 weeks)
• AE: phlebitis, fluid overload
• Fluids for PPN limited to lower
dextrose concentrations
• Cannot provide adequate caloric
intake only through PPN
• Used in hospital/facility
• Large central vein access (CVAD)
• Indications: prs who require
prolonged (>10 days) of nutritional
supplements and unable to obtain
through GI route
• Can be used at home
• High risk for CLABSI, metabolic
alterations
Nursing implications
• Ensure that a complete nutritional assessment is taken, including a dietary history, weekly and
daily food intakes, and weight and height measurements
• Consult with a registered dietitian
• Assess baseline laboratory studies, such as total protein, albumin, blood urea nitrogen, red
blood cell count, white blood cell count, and cholesterol
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• Collect anthropometric data
• Assess for allergies to components of enteral nutritional supplements (e.g., whey, egg whites).
• Assess for lactose intolerance
• If administering enteral nutrition by tube feedings, follow facility policy for ensuring proper tube
placement and for checking residual volumes before administering a feeding
• Follow procedures for flushing tubing to prevent clogging the feeding tube with formula
• Carefully monitor how the patient is tolerating enteral feedings
• Keep in mind that most enteral feedings are started slowly, and the rate is increased gradually
• Follow facility policies and procedures for care and maintenance of TPN IV lines, including
tubing and dressing changes
• Monitor patient’s temperature; report any increase immediately
• Monitor blood glucose levels and for hyperglycemia, hypoglycemia
• While on TPN, the pancreas provides increased amounts of insulin to cover the increased
glucose levels
• If TPN is discontinued abruptly, rebound hypoglycemia may occur until the pancreas has time to
adjust to changing glucose levels
• If TPN must be discontinued abruptly, then infuse 5% to 10% glucose to prevent hypoglycemia,
according to facility policy
• Monitor for fluid overload while on TPN
• Monitor daily weights and intake and output volumes
Key points (from pharm book)
• A thorough nutritional assessment and possible consultation with a registered dietitian or
nutritionist are essential for adequate intervention for the malnourished patient.
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• Various enteral feeding formulations with different nutritional content are available, including
some that are lactose free.
• Enteral feedings may result in complications such as hyperglycemia, dumping syndrome, and
aspiration of the nutritional supplement.
• Parenteral nutrition (PN) supplementation (intravenously administered) is TPN or
hyperalimentation. PN or TPN may be administered through a central vein or through a
peripheral vein (PPN).
• TPN is administered through a central venous catheter because of the hyperosmolarity of the
substances used and the need for dilution provided by a larger-diameter vein to prevent damage
to the vein. Parenteral nutrition given through a peripherally inserted central catheter (PPN) line
is another option but uses a solution with a lower concentration of dextrose and other
ingredients.
• Parenteral feedings may result in air embolism, fever, infection, fluid volume overload,
hyperglycemia, or hypoglycemia. If they are discontinued abruptly, rebound hypoglycemia may
result.
• Cautious and skillful nursing care may prevent or decrease the occurrence of complications
associated with enteral or parenteral nutritional supplementation