NUTRITION SUPPORT AND CRITICAL CARE MODULE

Objectives Satisfactory Not

Completion Applicable
Review
1.The student will discuss with the rotation coordinator the role of nutrition
in the critical care and/or trauma patient. Include in the discussion, but
not limited to, all the following that are applicable
a. etiology and treatment
b. pathophysiology
c. metabolic/nutritional alterations
d. current medical treatments/trends

!. The student will discuss with the rotation coordinator the disease states
which necessitate nutritional support with enteral "#N$ or parenteral "%N
nutrition. Include in the discussion, but not limited to, all the following
that are applicable
a. Indications and contraindications for #N and %N
b. Complications of #N and %N
c. &oute of access for #N and %N
'. (iscuss the dietitian)s role as part of the health care team
Assess
*. +sing height/weight/labs and other pertinent information the student will
assess the appropriateness of
a. the #N and/or %N order
b. energy/protein/nutrient re,uirements
c. monitoring guidelines
-. The student will obtain diet histories.
./////// "0oal of ' or more$
N/A
1. The student will complete nutrition care plans.
.////// "0oal of ' or more$
Educate
2.The student will utili3e the diet history and care plan as well as any
other pertinent educational material to instruct patients and/or family
member on his/her specific dietary regimen.
. ////// "0oal of ' or more$
N/A
Document
4. +sing the format appropriate for the site, the student will document all
pertinent information in the medical record.
.////////"0oal of ' or more$
Observe/Optional
5. 6bser7e the placement of a central line and a feeding tube.
18.6bser7e the compounding of a %N solution in the pharmacy.
*/11
NUTRITION SUPPORT AND CRITICAL CARE WORKSHEET
1. Review and dc!"ent t#e $%%win& te'"s 'e%ated t ente'a% and (a'ente'a%
n!t'itin and c'itica% ca'e.
EN 9a:es it possible to pro7ide important substrate for those who cannot or will not meet daily
re,uirements 7ia oral inta:e but who ha7e an intact digesti7e system. #nteral feeding depends on the
anticipated length of time for feeding, degree of ris: for aspiration or tube displacement, patient)s clinical
status, presence or absence of normal digestion and absorption, patients anatomy, whether a surgical
inter7ention is planned.
) T!be 0astric Tube ;eeding. Common feeding practice for patients that can tolerate gastric
feedings. Critically ill patients may not tolerate these feedings in which they will e<perience
symptoms such as abdominal distention, discomfort, 7omiting, persistent high gastric residuals.
%atients recei7ing 0 Tube feedings are often considered higher ris: of aspiration pneumonia.
PE) %ercutaneous endoscopic 0astrostomy= nonsurgical techni,ue for placing a tube directly
into the stomach through the abdominal wall. +sually done for patients that need #N for ' to *
months.

N) Nasogastric tube= most common way to access the gastrointestinal tract. 0enerally used in
short term #N "'>* wee:s$. Tube is passed through nose and into the stomach and is used on
patients with normal 0I function. ;eedings administered by bolus, continuous, or intermittent
infusions.
ND Nasoduodenal tube= a tube that passes through the pylorus and into the duodenum. +sed in
patients that cannot tolerate gastric feedings.
N* Naso?e?unal tube= a tube passes through the pylorus and into the duodenum and into the
?e?unum. +sed in patients that cannot tolerate gastric feedings.
Resid!a%s A gastric residual is food from a pre7ious feeding left in the stomach at the start of
the ne<t feeding. The definition of what constitutes as gastric residual 7olumes "0&@$ as an
indicator of #N tolerance will 7ary. Nutrition and (iagnosis>&elated Care states, A#7erything 0&@
is an optional part of a monitoring plan to assess tolerance= #N should be held when 0&@ great
than or e,ual to !-8 ml is documented on two or more occasions. &eplace aspirate for the
electrolytes and gastric ?uices. (o not use blue dye added to the formula to test for aspiration.
6ptimal patient positioning, use of pro:inetic agents to impro7e gastric emptying, continuous
infusion, and abdominal e<aminations to e7aluate for distension.
Brause ch.1*
PN+ &eser7ed for condition in which #N is contraindicated, unsuccessful, or inade,uate, and maintains
gut mucosal integrity. %ro7ides nutrients directly into the bloodstream intra7enously.
PICC %ine+ %eripherally Inserted Central Catheter= used in short>term or moderate>term infusion
at home or in the hospital. This catheter is inserted into a 7ein in the antecubital area of the arm
and threaded into the subcla7ian 7ein with the catheter tip placed in the superior 7ena ca7a. It is
a type of C@( "central 7enous catheter$ inserted into the arm rather than the nec:.
P't a cat#+ A small medical appliance that is installed beneath the s:in. A catheter connects the
port to a 7ein. +nder the s:in, the port has a septum through which drugs and infusions can be
in?ected and blood samples can be drawn many times without a Aneedle stic:C. Con7enient for the
patient as it in7ol7ed little daily care.
C,C+ Central @enous Catheter= also called central line= long, thin, fle<ible tube used to gi7e
medications, fluids, nutrients, or blood products o7er a long period of time. 6ften inserted into the
arm or chest through the s:in into a large 7ein. The catheter is threaded into the 7ein until it
reaches a large 7ein near the heart.
Hic-"an+ A central 7enous catheter most often used for administration of chemotherapy or other
medications. &emain in place for e<tended periods and are used when long>term intra7enous
access is re,uired. It is done under sedation. An incision is made at the ?ugular 7ein or nearby
7ein, and one on the chest wall. A tunnel is created through the two incisions and a catheter is
pushed through.
P!%"na'.+ In7ol7ing the lungs
,ent+ Supplying air
Int!batin+ The insertion of a cannula or tube into a hollow body organ. A nasogastric tube is
intubated into the patient.
A/)0s+ Arterial blood gas= a test that measures the arterial o<ygen tension "%a6!$, carbon
dio<ide tenion "%aC6!$, and acidity. In addition, arterial o<yhemoglobin saturation "Sa6!$ can be
determined. Abnormal A&0 may be subtle sign that a patient is declining.
Acid base ba%ance+ (ynamic e,uilibrium state of hydrogen ion concentration. Dlood pE le7el
should be 2.'- to 2.*-. A disruption in this balance occurs when acid or base losses or gains
e<ceed the body)s regulatory capabilities, or when normal regulatory mechanisms become
ineffecti7e. The lungs play a ma?or part in regulating this balance.
Res(i'at'. Acidsis+ low plasma pE, increased renal net acid e<cretion with resulting increase
in serum bicarbonate, caused by emphysema, C6%(, or other reparatory impairment.
Res(i'at'. A%-a%sis+ high plasma pE, decreased renal net acid e<cretion with resulting
decrease in serum bicarbonate. Aftermath of intense e<ercise, an<iety, early sepsis, e<cessi7e
e<piration of C6! and E!6.
1etab%ic Acidsis+ Fow plasma pE, decreased EC6'>, hyper7entilation with resulting low %co!=
diarrhea, uremia, :etoacidosis from uncontrolled diabetes mellitus= star7ation, high Gfat, low
carbohydrate diet, drugs
1etab%ic A%-a%sis+ Eigh plasma pE= increased EC6'>, hypo7entilation with resulting increase
in %co!= diuretics use, increased ingestion of al:ali, loss of chloride, 7omiting
ARDS+ Acute &espiratory (istress Syndrome= occurs when fluid builds up in the al7eoli in your
lungs causing less o<ygen in the bloodstream. #<treme shortness of breath is the primary
symptom. A&(S is typically seen in patients who are critically ill or who ha7e significant in?uries.
The ris: of death from A&(S increases with age and se7erity of the illness. A&(S can also result
from T%N feeding.
DNR+ (o not resuscitate
DNI+ (o not intubate
C"$'t Ca'e+ %alliati7e and supporti7e treatment for patients who are suffering from a terminal illness or
who ha7e refused life>sustaining treatment. It is aimed at relie7ing symptoms, enhancing the ,uality of
remaining life, and easing the dying process.
Rena%+ In7ol7ing the :idneys
CRI+ Chronic &enal Insufficiency
CR2+ Chronic &enal ;ailure= gradual loss of :idney function, with progressi7ely more se7ere renal
insufficiency until the stage called chronic irre7ersible :idney failure or end>stage renal disease.
Symptoms include polyuria, anore<ia, nausea, dehydration, and neurologic symptoms.
AR2+ Acute &enal ;ailure= characteri3ed by a sudden reduction in 0;& "glomerular filtration rate$= causes
are categori3ed into ' categories= 1.$ inade,uate renal perfusion "prerenal$, !.$ disease with the renal
parenchyma "intrinsic$, and '.$ urinary tract obstruction "postrenal$
/UN+ Dlood +rea Nitrogen= waste product filtered out of the blood by the :idneys= conditions that affect
the :idney ha7e the potential to affect the amount of urea in the blood.

C'eatinine+ Haste product produced in the muscles= filtered out of the blood by the :idneys so blood
le7els are a good indication of how well the :idneys are wor:ing.
/we%s+
I%est".+ A surgical opening constructed by bringing the end or loop of the ileum out of the surface of
the s:in. Haste passes out of the ileosomy and is collected in an e<ternal pouching system stuc: to the
s:in. In this procedure the entire colon, rectum, and anus must be remo7ed.
C%st".+ A surgical procedure in which one end of the large intestines is brought out through the
abdominal wall. In this procedure only the rectum and anus are remo7ed.
I,0s+
D3W+ I- de<trose isotonic solution. A carbohydrate solution that uses glucose as the solute dissol7ed in
sterile water. ;i7e percent de<trose in water is pac:ed as an isotonic solution but becomes hypotonic
once in the body because the glucose "solute$ dissol7ed in steril water is metaboli3ed rapidly by the
body)s cells. &aises total fluid 7olume, helpful in rehydrating and e<cretory purposes. %ro7ides 128>!88
calories per 1,888 calories.
NS4145+ .*-I NaCF in Hater Cystalloid Solution. Eypotonic= raises total fluid 7olume. +sefully for daily
maintenance of body fluid but is of less 7alue for replacement of NaCl deficit. Eelpful for establishing
renal function. ;luid replacement for clients who don)t need e<tra glucose "diabetes$
NS+ Normal Saline= Sodium Chloride= An isotonic crystalloid solution that contains sodium chloride as the
solute dissol7ed in sterile water. The specific concentration for normal saline solution is .5I. It increases
circulated plasma 7olume when red cells are ade,uate
LR+ Factated &inger)s= normal saline with electrolytes and buffer. An isotonic crystalloid solution
contacting the solutes sodium chloride, potassium chloride, calcium chloride, and sodium lactate,
dissol7ed in steril water. Isotonic= replaces fluid and buffers pE.
Se(sis+ The presence of bacteria, other infectious organisms, or to<ins created by infectious organisms in the
bloodstream with spreading throughout the body.
1OS2+ 9ulti>6rgan System ;ailure= The syndrome generally begins with lung failure and is followed by failure of
li7er, intestines, and :idney in no particular order. %atients with 96S; are clinically hypermetabolic and e<hibit
high cardiac output, low o<ygen consumption, high 7enous o<ygen saturation, and lactic academia.
5. Knw t#e anat". $ t#e )ast'intestina% T'act. /e ab%e t $%%w $d $'" t#e
"!t# t t#e an!s.
6. De$ine and e7(%ain t#e 'e$eedin& s.nd'"e.
"All information from https//www.youtube.com/watchJ7KwHTwAcl3n&w$
&efeeding syndrome is triggered by aggressi7e oral, enteral, or parenteral carbohydrate feeding following
a period of nutrition depri7ation "i.e., star7ation, anore<ia, cache<ia$. The dri7ing force for the metabolic
process of refeeding syndrome is the sudden influ< of glucose into cells adapted to low glucose
metabolism. The ?ump in glucose metabolism strains intracellular and e<tracellular reser7es of
phosphorus, magnesium, and potassium because regulatory processes ha7en)t caught up with the new
demands. %articularly, the shift of these minerals from the e<tracellular to the intracellular compartment
can abruptly lower blood concentrations of the minerals. The se7ere mineral and fluid imbalances
"hypophosphatemia, hypo:alemai, hypomagnesemia$ that occur with refeeding can lead to cardiac arrest,
neuromuscular complications, and respiratory dysfunction.
Patients at 'is- $' 'e$eedin& s.nd'"e a'e t#se w# a'e ada(ted t "a%n!t'itin and %w &%!cse
!ti%i8atin+
o
Cancer cache<ia
o
Anore<ia ner7osa
o
#lderly patients
o
9alnutrition due to hunger, stress, fasting, or malabrosption
o
9arasmus or :washior:or
o
Chronic alcoholism
o
N%6 status for o7er 2 days
o
(iabetic :etoacidosis
o
%ost>operati7e patients
o
Chronic antacid users
o
Chronic diuretic users
o
&apid weight loss, such as following bariatric surgery
o
Infectious disease such as TD or AI(S
T#e c'ite'ia $' identi$.in& (atients at 'is- $' 'e$eedin& s.nd'"e a'e as $%%ws+
One ' "'e $ t#e $%%win&+
o
D9I L11 :g/m
!
o
+nintentional loss of more than 1-I of body weight in less than 1 months 6& more than 2.-I in
' months 6& more than -I in one month
o
Nutritional Inta:e Fittle to non in 2>18 days
o
Faboratory Indices Fow potassium, magnesium, phosphate pre>feeding= low serum prealbumin
Tw ' "'e $ t#e $%%win&+
o
D9I L14.- :g/m
!
o
+nintentional loss of more than 18I of body weight in less than 1 months
o
Nutritional Inta:e Fittle to none in more than - days
o
Eistory #<cessi7e use of alcohol, diuretics, antacids= chemotherapy
P'eventin& Re$eedin& S.nd'"e+
1.$ A7oid o7erfeeding "start low and go slow$ Degin repletion slowly, no more than !8I abo7e basal
energy e<penditure calculated by using actual weight. As a guideline, use 1->!8 :cal/:g/day or
M1888 :cal/day. 0radually increase o7er one wee:.
!.$ A7oid e<cess glucose %ro7ide glucose at no more than ! mg/:g/minute to begin with= no more than
1-8>!88 g/day. #7en a -I de<trose solution can cause refeeding syndrome.
'.$ %ro7ide phosphate, magnesium, and potassium Correct abnormalities before initiation of nutrition
support. 9onitor electrolyte le7els se7eral times per day for the first '>2 days of treatment.
*.$ &estrict fluid inta:e= initiate sodium>containing fluids slowly Fimit initial fluid inta:e to 488>1888
ml/day. A7oid e<cess sodium inta:e "e.g., L1mmol/:g/day$. Height gain N 1 :g/w: indicates fluid
retention
-.$ %ro7ide a thiamin supplement %atients at ris: for refeeding should recei7e thiamin supplementation
"-8>188 mg/d I@ or 188 mg %6 ->2 days.$
Indicatins $' Ente'a% 2eedin& 9T2:+ I$ t#e ;)UT WORKS< USE IT=.

1. 9alnourished patient e<pected to be unable to eat N ->2 days
!. Normally nourished patient e<pected to be unable to eat N2>5 days
'. %atients with mental status changes.
*. @entilator patients with an intact gut.
-. Any patient unable to eat enough to sustain weight
T ca%c!%ate T2 < an Ente'a% $'"!%a'. is needed t -nw
ca%'ies4"%< ('tein4"% and wate'4%ite'.
T!be 2eedin& Ca%c!%atins+
Nutritional 0oals 1488:cals 28gms/pro !888mls/water
Eow to calculate calorie, protein and fluid
6rder Oe7ity 28mls/hr with 1!8mls water flush , */hrs
Oe7ity has 1.81 :cal/ml, .8**gms/pro/ml, 4'-mls water/F formula.
1. ;ind total 7olume
&ate < !*/hrsK 1148 total 7olume
!. Calories See ;ormulary for :cals/ml
1148 < 1.81 :cals/mlK 1248.4 calories in formula
'. %rotein See ;ormulary for gms/pro/ml
1148 < .** gms/pro/mlK 2'.5 gms of protein in formula
*. ;luid See ;ormulary for mls per Fiter of total 7olume
1148 di7ided by 1888K 1.14 liters < 4'- mls water/liter K 1*8!.4
-. ;igure Hater ;lushes
;luid goals G water in T;K 2!8 mls
Can gi7e water flushes e7ery */hrs "1 times/d$ or PI( "* times/day$.
QNote water flushes from meds and /or I@;.
If protein/:cal ratio does not match patient)s goals, or if labs/diagnosis are a consideration, another formula may
be needed.
T!be 2eedin& Ca%c!%atins
Nutritional 0oals 1488:cals 28gms/pro !888mls/water
Eow to calculate calorie, protein and fluid needs from specific goals.
QCan start from calories or protein to figure an appro<imate rate.
1. To obtain appro<imate rate using protein goal
(i7ide gms/pro needed by ////gms/pro/formulaK ///mls/hr
&ound to the nearest -mls.
QThis assures ade,uate protein will be pro7ided at that rate.
28/.8**K1,-58/!*K 11mls/hr
!. To obtain appro<imate rate using calorie goal
(i7ide :cals needed by ////:cals/ml/formulaK ///mls/hr
&ound to the nearest -mls.
QThis assures ade,uate calories will be pro7ided at that rate.
1488/1.81K1154/!*K28
6. Cntin!e .!' ca%c!%atins and dc!"ent t#e" be%w to figure the nutrients in T; as in the first e<ample.
Pa'ente'a% N!t'itin 9PN: )!ide%ines > All %N solutions must infuse 7ia central 7enous access with the
catheter ending in the Superior @ena Ca7a
PN is !s!a%%. indicated in t#e $%%win& sit!atins+
Inability to absorb ade,uate nutrition 7ia the 0I tract
Acute abdominal obstruction, prolonged ileus, abdominal trauma
Anticipated N%6 status N - days in a patient at ris: for malnutrition
Anticipated inability to pro7ide sufficient nutrients 7ia enteral route
PN "a. be cnt'aindicated in t#e $%%win& sit!atins+
Anticipated length of therapy less than - days
A prognosis that does not warrant aggressi7e nutrition therapy "end stage disease$
Inability to obtain 7enous access
Bnow the following
Hhat is the caloric 7alue of 1 gram of de<troseJ
'.* :cals/g
Hhat is the caloric 7alue of 1 gram of amino acid/proteinJ
* :cals/g
;at emulsions are a7ailable in 18I, !8I, and '8I concentrations. Hhat is the caloric 7alue of each "per
mF$J
18I K 1.1 :cal/cc
!8I K !.8 :cal/cc
'8I K '.8 :cal/cc
TPN ca%c!%atins based n &'a"s (e' da. $ "ac'n!t'ients.
N!t'itina% )a%s+ 1?@@-ca%s A@&"s4(' 5@@@"%s4wate'
1. Sta't wit# n!t'itin &a%s $'" .!' assess"ent $ t#e (atient.
5. Divide t#e tta% v%!"e desi'ed b. 5B #!'s t btain t#e 'ate (e' #!'.
!888 / !* hrs K 4-mls/hour. &ound up to nearest - mls. This is your rate.
6. Ca%c!%ate t#e ('tein ca%'ies ne7t. Dont forget that the calorie goals are 1800.
So, 28 g of protein Q *:cals/g will pro7ide !48 :cals
.
B. Ne7t add in t#e %i(id ca%'ies.
If we choose !-8mls of !8I lipids, we will pro7ide -88 calories per day from lipids.
Add these together. Rou will pro7ide 248 calories from protein :cals and lipid :cals.
3. T#e 'e"ainin& CCCCC ca%'ies can be ('vided wit# de7t'se.
Calculate 18!8 :cals / '.* ":cals/gram in de<trose$ K '88 grams.
D. D!b%e c#ec- .!' answe'. T#is wi%% be .!' TPN 'de'+
T%N S 4- mls/hour
28 g protein per day
'88 grams of de<trose per day
!-8mls !8I lipids daily
TPN Ca%c!%atins $'" E
(This method is being phased out of most hospitals as the preferred method is to order TPN based on
grams per day. However, percents are still used on the RD eam so it is best to !now how to
calculate TPN using both methods".
N!t'itina% )a%s+ 1?@@-ca%s A@&"s4(' 5@@@"%s4wate'
Ca%c!%ate tta% ca%'ies and ('tein $'" a TPN 'de'+
O'de'+ TPN ?@"%s4#' B.53EAA 5@EDe7 w4 5@E 53@"%s %i(ids dai%.
1. 2ind tta% v%!"e+
&ate < !*hrsK 15!8 mls "T@ or total 7olume$
5. P'tein+
Total 7olume < *.!-I AAK 41.1 gms/pro
0ms/pro < *:cals/gmK '!1.* :cals from pro
6. De7t'se+ 9Use /W $ 3B.3-&:
Total 7olume < !8I (e<K '4* gms/de<
0ms/de< < '.*:cals/gmK 1'8-.1 :cals from de<
(e<trose Foad L*.8mg/:g/minute
0ms/de< di7ided by DH/:g di7ided by 1**8". of minutes in day$ < 1888K *.45 de< load
B. Add t#e ca%'ies $'" ('tein and de7t'se+
Subtract from caloric goals. Hhat is left is for lipid K 114 :cal
3. Li(id+
18I -88mls K1.1:cals/ml !8I !-8mls K!.8:cals/ml
'8I used for fluid restriction and ' in 1 solutions
Fipid may be gi7en daily, e7ery other day or !>' times/wee:
QFipids contraindicated w/ egg allergy.
Ca%c!%ate E $ CHO< P'tein and Li(id. T'. $' a ba%anced ('$i%e !n%ess (ts. T) ' cnditin wa''ant
t#e'wise.
Ca%c!%ate ca%'ie< ('tein and $%!id needs $'" &a%s.
FCan sta't $'" ca%'ies ' ('tein t $i&!'e an a(('7i"ate 'ate.
1. T btain a(('7i"ate 'ate !sin& ('tein &a%s+
(i7ide gms/pro needed by ////IAA "*.!-I>2I$K //////mls appro<imate rate.
(i7ide appro<imate rate by !*/hrsK ///// &ate "&ound to nearest -mls$
0ms/pro < *:cals/gmK/////:cals from pro
28/*.!-IK11*2/!*K28 rate
28<*K!48:cals pro
5. De7t'se+
&ate < ////I de< "18>'8I$K ///// gms/de<
0ms de<trose < '.*:cals/gmK ///// :cals from de<trose
11*2 < !8I K '!5
'!5 < '.* K 1114 :cals/de<
1114T!48K1'54
1488>1'54K*8! for lipid

6. Cntin!e .!' ca%c!%atins and dc!"ent t#e" be%w to figure the nutrients in T%N as in the first e<ample.