NUTRITION

SUPPORT

NUTRITION
SUPPORT
BRENDA ODAY

MOMENTUM PRESS, LLC, NEW YORK

Nutrition Support
Copyright Momentum Press, LLC, 2016.
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First published by Momentum Press, LLC
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ISBN-13: 978-1-60650-761-2 (print)
ISBN-13: 978-1-60650-762-9 (e-book)
Momentum Press Nutrition and Dietetics Practice Collection
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Printed in the United States of America

Abstract
The study and practice of nutrition support has been evolving for
centuries. The last 50 years has brought this practice in nutrition therapy
to a very important place in medicine. As treatments have become more
sophisticated in fighting disease and saving lives, the role of nutrition
support has become recognized as vital to patient care. The most current
evidence based practice in the field and using the nutrition care process are
implemented to provide the best nutrition care to those in need. Selecting
patients whom most benefit from nutrition intervention is an important
responsibility of the healthcare team, which includes identification of
malnutrition. This area of practice demands an understanding of indications for the route of nutrition support, knowledge of access devices,
and components of ordering and monitoring nutrition support regimes.
Enteral nutrition has become the most utilized form of nutrition support,
while parenteral nutrition remains a life sustaining measure for those with
loss of gastrointestinal function. The variety of enteral formulas available
is vast, and understanding indications and use is an ongoing challenge.
Several ethical issues surrounding nutrition support, with end of life situations being a common dilemma. Application of evidence based practice in
certain disease states and conditions demands literature review, collaboration, and implementation of identified best practices. There are abundant
opportunities of topics to research and shape future direction of nutrition
support.

KEYWORDS
calculations for nutrition support, critical care nutrition, enteral nutrition, enteral nutrition formula, ethics in nutrition support, feeding tubes,
indications for nutrition support, malnutrition, nonfunctioning GI tract,
nutrition support, nutrition support dietitian, parenteral nutrition, short
bowel syndrome

Contents
List of Figures

ix

List of Tables

xi

About the Book

Acknowledgments
1Introduction to Nutrition Support

xiii
xv
1

1.1Introduction

1.2 Indications for Nutrition Support

1.3 Route of Nutrition Support

1.4 Estimated Nutrition Needs of Nutrition Support Patients

1.5 The Nutrition Care Process and Nutrition Support

1.6Summary

References9
2Enteral Nutrition

11

2.1 Access Devices

11

2.2 Enteral Feeding Equipment

13

2.3 Open and Closed Systems

13

2.4 Initiation and Delivery Schedules

14

2.5 Formula Selection for Enteral Nutrition

15

2.6 Enteral Formulary

23

2.7 Calculations for Enteral Nutrition

24

2.8 Monitoring and Evaluation

27

2.9Summary

35

References36

viii Contents

3Parenteral Nutrition

37

3.1 Access Devices

37

3.2 Parenteral Nutrition Solutions

38

3.3 Parenteral Nutrition Calculations

40

3.4Compounding

46

3.5 Premixed Parenteral Nutrition Versus Custom Solutions

46

3.6Additional Considerations for Parenteral Nutrition

Composition: Glutamine and Carnitine

47

3.7Medications

47

3.8 Initiation of PN

48

3.9 Schedules and Administration

48

3.10 Monitoring and Evaluation

49

3.11Summary

56

References57
4Nutrition Support in Disease States and Conditions

59

4.1Introduction

59

4.2 Liver Disease

59

4.3 Gastrointestinal Disease

62

4.4 Critical Care

67

4.5 Nutrition Support in Wounds

71

4.6 Renal Disease

76

4.7 Diabetes Mellitus

80

4.8Oncology

81

4.9Obesity

84

4.10Summary

89

References90
5Special Considerations in Nutrition Support

95

5.1 Transitional Feeding

95

5.2 Ethical Issues in Nutrition Support

97

5.3 Home Care

99

5.4 Future Directions of Nutrition Support

102

References105
Index

107

List of Figures
Figure 2.1. Enteral access devices.

12

Figure 2.2. Sample adult EN order form.

30

Figure 2.3. Management of diarrhea.

33

Figure 3.1. Sample adult PN order form.

52

Figure 4.1. Predictive energy equations in obesity.

85

List of Tables
Table 1.1. Identification of malnutrition

Table 1.2. Benefits of EN

Table 1.3. Examples of GI dysfunction as indication for PN

Table 1.4. Nutrition care process for EN and PN

Table 2.1. EN administration schedules

14

Table 2.2. Nutrient composition of enteral formulas

16

Table 2.3. Classification terms and definitions

17

Table 2.4. Enteral formulas and indications

19

Table 2.5. Liquid (15 mL) adult multivitamin with mineral

23

Table 2.6. Suggested EN monitoring

27

Table 3.1. Vascular access devices

38

Table 3.2. Macronutrient component of PN

39

Table 3.3.Adult parenteral multivitamin available in the

United States

43

Table 3.4. Commercial trace mineral solution: MTE-5

44

Table 3.5.Electrolyte requirements and commercially

available salts

44

Table 3.6. Suggested PN monitoring

50

Table 3.7. Steps to prevent CRBSI

54

Table 4.1. Summary of diet recommendations in SBS

66

Table 4.2. When are ICU patients ready for EN?

69

Table 4.3. Specialty formula in ARDS

70

Table 4.4. Risk factors for impaired wound healing

72

Table 4.5. Summary of nutrition needs in wounds

76

Table 4.6. Nutrition complications in renal failure

77

xii List of Tables

Table 4.7. Nutrition content of renal formulas (per liter)

78

Table 4.8. Summary of nutrition needs in renal disease

79

Table 4.9. Glycemic levels for patients on nutrition support

80

Table 4.10. Diabetic formulas at a glance

82

Table 4.11. Formula at a glance: Impact 84

Table 4.12. Micronutrient considerations in bariatric surgery

86

Table 4.13. Bariatric formulas at a glance

87

Table 4.14. Summary of nutrition recommendations in HF, LVAD

88

Table 5.1. Suggested transitional feeding plans

96

Table 5.2. Oral supplements at a glance

96

Table 5.3.Possible symptoms of hydration and nutrition

provision at end of life

97

Table 5.4. Legal documents used in health care decisions

98

Table 5.5.Criteria to consider for discharge of patients on

nutrition support

100

Table 5.6. Examples of required documentation

101

About the Book

The study and practice of nutrition support has been evolving for centuries. The last 50 years has brought this practice in nutrition therapy to
a very important place in medicine. As treatments have become more
sophisticated in fighting disease and saving lives, nutrition interventions
have become just as savvy. This e-book brings a practical approach to
understanding the complex issues and concepts that nutrition support
practitioners may face with their patients. It also provides the most current
evidence based practice in the field while using the nutrition care process.
The entry level nutrition professional, interns, and students of medical
nutrition therapy may benefit from a review of both modalities of nutrition
support. Enteral nutrition (EN) has become the most utilized form of
nutrition support, while parenteral nutrition (PN) remains a life sustaining measure for those with loss of gastrointestinal function. The content
provides indications for the type of nutrition support used, reviewed access
devices, and crucial components of ordering nutrition support. For enteral
nutrition, there are examples of types of formulas used in certain disease
states and conditions. Practice opportunities in the form of scenarios and
case study calculations are provided for both EN and PN. The reader can
build confidence with a moderate level of exercises. Recommendations
for monitoring and evaluation of nutrition support are discussed, including anticipated complications and solutions. Many disease states and
conditions involve nutrition support, which is the sole focus of one of the
chapters. Other important topics covered are nutrition support in end of
life and ethical issues. Lastly, the future direction of nutrition support is
exciting and offers all levels of learner to explore the possibilities.

Acknowledgments
I will be forever grateful to Katie Ferraro for providing the opportunity
and encouragement to write this book. I wish to thank my colleagues,
dietetic interns, and students for the time spent reviewing early versions,
their comments and suggestions of how to best benefit the reader were
much appreciated. Tremendous support and understanding from my
family and friends was vital in this endeavor, and a wink to my late Father
for his ongoing inspiration.

CHAPTER 1

Introduction to
Nutrition Support
1.1INTRODUCTION
It has always been difficult to
What does CNSC stand for?
provide nutrition for those who
CNSC stands for Certified Nutriare unable to eat and swallow
tion Support Clinician. Practifood, so as the saying goes,
tioners with expertise in this area
necessity is the mother of
can take an examination and earn
invention. Nutrition support has
recognition as a nutrition support
been evolving for centuries, and
specialist through the National
especially over the past 50 years,
Board of Nutrition Support Certhis practice in nutrition therapy
tification. Recertification must be
has found a very important place
done every five years!
in medicine. As treatments have
become more sophisticated in fighting disease and saving lives, nutrition
interventions have become just as savvy. Nutrition support clinicians
may find themselves working in community hospitals, major teaching hospitals, home infusion, or private consulting. Practitioners who
choose this area of p ractice are highly respected members of the health
care team, and hold much responsibility in the nutrition care of patients.
Evidence-based practice has thwarted the investigation of when to feed,
what route to use, and how much nutrition support is provided to patients.
An important part of the decision to provide nutrition support is nutrition
assessment of patients. Enteral nutrition (EN) has become the most utilized form of nutrition support, while parenteral nutrition (PN) remains
a life-sustaining measure for those unable to utilize normal digestion.
Malnourished patients certainly deserve special attention. A major determinant for route of nutrition support is gastrointestinal (GI) function. How

2NUTRITION SUPPORT

much to feed nutrition support patients requires assessment of n utritional

needs, which is an important skill, and demands balancing several
factors. For nutrition support dietitians, the nutrition care process (NCP)
has become the standardized approach to articulate assessment, problems,
interventions, monitoring, and evaluation of nutrition support patients.

1.2INDICATIONS FOR NUTRITION SUPPORT

The most invasive interventions in medical nutrition therapy are EN and
PN. Consideration must be given to whether the benefit outweighs the
risks of providing nutrition support. Obtaining access to the GI tract or
circulatory system certainly may not be a benign procedure. Access device
complications and consequences of artificial nutrition provision can be
significant barriers to patients achieving positive outcomes. Thedecision
to initiate nutrition support always begins with the assessment of nutrition status. Well-nourished individuals can withstand longer periods
without nutrition support, specifically up to 7 to 14 days (Mueller 2012).
However, malnourished patients require much sooner intervention. The
more malnourished a patient may be, the more expedient a practitioner
should decide on providing nutrition support. In severe m
alnutrition,
nutrition support should be considered within a 1 to 3 day time frame.
Malnutrition contributes toward many outcomes, including morbidity,
mortality, functional status, quality of life, length of hospital stay, and
health care costs (White et al. 2012).
Table 1.1 is a summary of characteristics used to identify m
alnutrition.
These six characteristics are described in a collaborative effort of the
Academy of Nutrition and Dietetics (AND) and the American Society of
Parenteral and Enteral Nutrition (ASPEN). The incidence of m
alnutrition
Table 1.1. Identification of malnutrition
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation that may sometimes mask
weight loss
Diminished functional status as measured by hand grip strength
Source: White et al. (2012).

INTRODUCTION TO NUTRITION SUPPORT3

has been difficult to define with standardized evidence-based criteria;

therefore, the literature-reported incidence ranges from 15 to 60percent.
The characteristics chosen were the most evidence-based, change with
nutrition status, and can be trended over time. Two of the outlined c riteria
should be present and described when making a m
alnutrition d iagnosis.
Poor nutrition intake and involuntary weight loss have long been
identified as nutritional risk factors. These characteristics can increase
the severity of malnutrition over time. For example, severe malnutrition may be defined as oral diet intake <75 percent of estimated energy
needs and >5 percent weight loss over 1 month. Body composition
changes such as lean body mass, fat stores, and fluid accumulation can be
visualized. Improved techniques to assess and monitor changes are
being developed, and hopefully can be practical for the health care
environment. Functional status, defined here as hand grip strength,
can be m
easured and trended as well. In addition to the characteristics
listed, the inflammatory process in both acute and chronic disease can
also increase nutrition risk for malnutrition. It is important to identify
those candidates who may benefit from nutrition intervention early in the
course of i llness to m
inimize adverse consequences and potential delayed
recovery. Although patient care is interdisciplinary, dietitians are vital in
the process of assessment of nutrition status and advocating for meeting
the nutrition needs of patients. For those patients unable to attain adequate nutrition through conventional oral intake, nutrition support with
either EN or PN should be considered.

1.3 ROUTE OF NUTRITION SUPPORT

The first point to determine when patients have been identified as
candidates for nutrition support is the route of administration. The primary
consideration is the functionality of the GI tract. It has been well established
that when gut function is adequate and access is available, EN is the
preferred method of feeding patients. Several meta-analysis, guidelines,
and systematic reviews evaluate the evidence supporting the use of EN. For
critical care patients, professional guidelines strongly recommend early
intervention with EN. If patients are unable to tolerate adequate EN, PN
should be considered (AND 2015; Heyland 2015; Martindale et al. 2009;
Singer et al. 2009). In these meta-analysis and guidelines, many patient
care outcomes were reviewed. These outcomes included cost, length of
hospital stay, feeding adequacy, complications, gut mucosal integrity, and
mortality. EN has been shown to be advantageous over parenteral support

4NUTRITION SUPPORT

in maintaining normal GI physiology and function. The benefits of EN are

shown in Table 1.2. As may be expected, the most p hysiologically similar
route is to use the GI tract. This allows for a normal digestive process that
promotes integrity of the mucosal cells and tissues. There is less l ikelihood
of ulcerations and dysfunction of the gallbladder. Normal digestion and
absorption of nutrients in turn promote normal liver processes. Finally,
one of the most important aspects to GI health and perhaps overall health
is the microbiome. Disruption in feeding the microflora can have devastating consequences, so enteral feeds help preserve a suitable environment
for these organisms (McClave and Heyland 2009; Mueller 2012).
For patients with a nonIs PN appropriate? Questions to
functioning GI tract, PN may
ask!
be indicated. There are at
Is the GI tract functioning? If yes,
least three issues to consider
useit!
when deciding to utilize PN:
Is the patient malnourished? If yes,
(1) the nutritional status of the
preference is for feeding with EN first,
patient, (2) expected duration
then consider PN if EN is unavailable
of GI tract dysfunction, and
or unsuccessful.
(3) the anticipated length of
Do you anticipate a prolonged GI
PN
treatment course. For
dysfunction with PN >7 to 10 days? If
malnourished or critical care
yes, you may want to start PN!
patients with tentative GI
function, it may be important to initiate PN until enteral route access
and tolerance of EN provision is established (Heyland 2015). Examples
of severe GI dysfunction that may require PN intervention are shown in
Table 1.3. Bowel obstructions are usually due to tumors of the GI tract. In
severe shock, sepsis, cardiac infarction, or major blood losses, there may
not be an adequate amount of blood flowing to the GI tract. The result
can be limited motility and digestive capability that may not allow for
Table 1.2. Benefits of EN
Maintain of normal gut function and integrity of mucosal tissue and
intestinal villi
Less risk of the gut forming an abscess or ulceration
Prevents gallbladder dysfunction
First-pass digestion allows nutrients to be absorbed in a timely manner
for the body to utilize
Promotes the health of the microbiome, and therefore decrease the risk
of infectious diarrhea
Source: McClave and Heyland (2009); Mueller (2012).

INTRODUCTION TO NUTRITION SUPPORT5

Table 1.3. Examples of GI dysfunction as indication for PN

Bowel obstruction
Ischemia or lack of blood flow to the gut
Failed EN due to poor motility despite prokinetic medication and
postpyloric tube
Severe ulcerations or fistula leaking bowel content to peritoneum or
subcutaneous
Short bowel syndrome in which there is inadequate bowel to absorb
life-sustaining nutrition
adequate enteral provision. Loss of bowel continuity due to ulcerations,
fistulas, or traumatic injury not yet surgically repaired may require PN as
well. If a significant portion of the bowel is removed, individuals will be
unable to absorb adequate nutrients and will require long-term nutrition
support for survival.
To positively affect outcomes, the course of PN should be expected to
be at least 7 to 10 days. Short-term PN courses of fewer than 5 to 7days
may have no effect on outcome or nutrition status (ASPEN Board of
2009). Furthermore, the benefit of PN must outweigh the risk of incurring
complications associated with its use. Complications associated with PN
are hyperglycemia and infections related to the access devices required for
administration. These complications can be both costly and detrimental to
patient outcome (Mueller 2012). Peripheral parenteral nutrition (PPN) is
limited by the inability to provide significant nutrition. It is reserved for
patients without central access options. The benefit of PPN use has not
been shown in the literature in terms of outcome data. Therefore, it is not
widely used in the practice of nutrition support (AND 2015; ASPEN 2009;
Mueller 2012; Singer et al. 2009).

1.4ESTIMATED NUTRITION NEEDS OF

NUTRITION SUPPORT PATIENTS
The nutrition requirements of nutrition support patients are dynamic and
evolving as individuals improve or decline in health. There are many
predictive equations for resting energy Expenditure (REE), most have
been developed to predict energy needs for healthy individuals. Also,
the estimated energy requirement (EER) predicts energy intake required
to m
aintain balance in healthy individuals (Mahan, Escott-Stump, and
Raymond 2012). For illness, there are a couple hundred equations including

6NUTRITION SUPPORT

Weir equation
REE (kcal/day) = [(VO2 3.94) + (VCO2 1.11)] 1,440 min/day
Ireton-Jones, Penn State, and Swinamer. These equations include factors
such as body weight, height, age, gender, and adjustments that account for
activity and metabolic conditions. The limitations of these equations are
that they do not account for body composition, nutrition status, ethnicity,
or often metabolic stress. Also, accuracy of these equations to determine
REE has been low in comparison with using indirect calorimetry. Indirect
calorimetry measures actual REE, so it may be considered a more objective
measure as it reflects all variables that may be present. Indirect calorimetry
involves the use of a metabolic cart or a hand-held device to measure
oxygen consumption (VO2) and carbon dioxide production (CO2). These
measurements are then used to calculate the REE using the Weir equation.
Patients may be intubated in the intensive care unit or ambulatory in
clinics, and it takes less than 30 minutes to complete the test. Because
it measures REE, the best time of measurement is immediately after
sleeping during the night. Any nutrition support patient may benefit from
using indirect calorimetry to prevent underfeeding or overfeeding. Special
attention should be paid in patients who are malnourished, significantly
under- or overweight, have had limb amputations, spinal cord injuries,
and long hospital courses on nutrition support where predictive equations
are less accurate. Although indirect calorimetry remains the most reliable
in assessing energy needs, it is deemed less practical as it requires trained
personnel and specialized pulmonary function test equipment. In addition, it is not a reimbursable service in the in-patient settings (Mahan,
Escott-Stump, and Raymond 2012; Wooley 2011). A more convenient and
widely used method for predicting energy needs is weight-based calculations, or kcal per kilogram (kg). Energy needs of most patients range from
20 to 35 kcal/kg, with literature supporting the use of 25 kcal/kg in critical
care patients (Mueller 2012). Protein needs for nutrition support patients
range from the recommended daily allowance (RDA) of 0.8 g/kg/day up
to 2.5 g/kg/day (www.nap.edu; Martindale et al. 2009). Disease state,
organ function, and severity of condition dictate exact protein needs. The
RDA for micronutrients provides guidance to nutrition support patients
needs, with exceptions in certain conditions and GI losses (www.nap.edu).
Practitioners should be aware of the micronutrient provision in both EN
and PN. For EN products, the minimum volume of formula required to
meet the RDAs are provided by the manufacturers to assist practitioners in
determining the need for supplementation. For PN patients, it is important

INTRODUCTION TO NUTRITION SUPPORT7

to monitor solution administration to ensure micronutrients are supplied

in adequate amounts.

1.5THE NUTRITION CARE PROCESS AND

NUTRITION SUPPORT
In 2003, AND developed a process that uses common language to promote
consistency of practice and documentation within the profession. The NCP
involves the steps of (1) nutrition assessment and r eassessment, (2)nutrition diagnosis, (3) nutrition intervention, and (4) nutrition monitoring and
evaluation. As reviewed, determining the candidates for nutrition support
first involves assessment of nutrition status, followed by a specific nutrition diagnosis. Nutrition diagnosis is unique to the dietetics professional.
An online manual has been implemented by AND to define codes and
provide diagnostic terms for intake, clinical, and behavioral domains.
The International Dietetics and Nutrition Terminology codes: Enteral
Nutrition (ND-2.1) Parenteral or IV Fluids (ND-2.2), have been designed
specifically for use in nutrition support. There are terms dedicated to
define the two routes of nutrition support, terminology for the diagnostic
statement, and the appropriate information to include in the intervention
section of documentation shown in Table 1.4 (AND 2013). The nutrition
diagnosis is described by the PES statement, which defines the problem,
etiology, and signs and symptoms. The detailed explanation of the nutrition support is provided in the intervention section of the NCP. For EN,
the type of formula, rate of delivery, schedule, additional water flushes,
and access device, and where formula is being a dministered, are documented. In PN, macronutrients, micronutrients, osmolarity of the solution,
rate of delivery, and type of access device can be listed. Both EN and
PN intervention sections of documentation may outline any instructions
on care of the access site. One of the intentions of the NCP is to link
problems and interventions to outcomes, which helps illustrate the efficacy of medical nutrition therapy. Therefore, monitoring and evaluation
of objective goals and parameters is important. Monitoring and evaluation
should measure the progress or resolution of signs and symptoms of the
PES statement. A simple example: a malnourished (underweight) patient
undergoing EN therapy would likely have a goal of weight gain. Weight
of the patient is measured and monitored, with progress toward the weight
gain goal evaluated by the clinician. If adequate data collection of these
types of patients shows EN increases weight in malnourished patients and

8NUTRITION SUPPORT

Table 1.4. Nutrition care process for EN and PN

Definition

Terminology
in PES
Nutrition
diagnosis

Etiology

Signs and
symptoms

Enteral nutrition
(ND-2.1)
Nutrition provided
through the GI tract via
tube, catheter, or stoma
distal to the oral cavity

Parenteral or IV fluids
(ND-2.2)
Administration of
nutrients and fluids
intravenously, centrally
or peripherally

Swallow difficulties
(NC-1.1)
Altered GI function
(NC-1.4)
Inadequate oral intake
(NI-2.1)
Inadequate EN infusion
(NI-2.3)
Inability to absorb
nutrients
Inability to chew or
swallow
Physical assessment:
Significant weight loss
BMI <18.5
Muscle wasting
Skin turgor
Growth or weight gain
failure
Diet history:
Intake <75% of
requirements
Prolonged inadequate
intake expected to be
>7to 10 days
Client history:
Aspiration
Coma
Intubation

Altered GI function
(NC-1.4)
Inadequate PN infusion
(NI-2.7)
Impaired nutrient
utilization (NC-2.1)

Inability to absorb
nutrients
Decreased length of GI
tract
Physical assessment:
Significant weight loss
BMI <18.5
Muscle wasting
Skin turgor
Growth or weight gain
failure
Diet history:
Intake <75% of
requirements
Prolonged inadequate
intake expected to be
>7to 14 days
Client history:
Malabsorption
Intractable emesis or
diarrhea
Severe peritonitis
Intestinal obstruction
Paralytic ileus
Bowel ischemia
Short bowel syndrome

INTRODUCTION TO NUTRITION SUPPORT9

Intervention

Name of formula
Concentration (kcal/mL)
Rate (mL/h)
Volume (mL/day)
Schedule (hours
administered)
Route (type of tube)
Site care
Water flush (mL)

PN solution:
Carbohydrate, Protein,
Lipids (g)
Osmolarity (mOsmo)
Micronutrients
Additional fluid or IV fluid
Rate (mL/h)
Schedule (hours
administered)
Route (type of catheter)
Site care

Source: AND (2013).

therefore improves outcomes, the practice may be validated. Furthermore,

reimbursement of services may be easier to obtain and more patients may
benefit from the practice of using EN in malnourished patients.

1.6SUMMARY
Nutrition support has undergone many positive changes in the past few
decades. The ability to more accurately define which patients may benefit
from nutrition support intervention has been researched and d ocumented
in many professional organization guidelines and publications. Nutrition
support clinicians are becoming increasingly important to the health care
team. Their expertise in assessment of nutrition status and nutritional
needs is invaluable for appropriate patient selection and accurate
provision of nutrition support. In the future, the dietitians scope of care
in nutrition support needs further clarification, as there is wide variation
among institutions. Standardization of practice and documentation is also
becoming more refined with the NCP, as it has now been in use for over
a decade. The NCP has important application to the nutrition support
area of practice. Implementing evidenced-based nutrition interventions is
most important, as research and investigation are eliminating ineffective
practices and bringing us new approaches to providing nutrition support.

REFERENCES
AND (Academy of Nutrition and Dietetics). 2013. Nutrition Terminology
Reference Manual (eNCPT): Dietetics Language for Nutrition Care. http://
ncpt.webauthor.com (accessed November 30, 2015).

10NUTRITION SUPPORT
AND. 2015. Nutrition Care Manual. http://www.nutritoncaremanual.org
(accessed June 15, 2015).
Heyland, D. 2015. Canadian Clinical Practice Guidelines. Retrieved May 25,
2015 from www.criticalcarenutrition.org
IOM. Food and Nutrition Board, Institute of Medicine, and National Academies.
2010. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Vitamins. Retrieved May 20, 2015 from www.nap.edu
Mahan, K., S. Escott-Stump, and J. Raymond. 2012. Krauses Food and the
Nutrition Care Process, 1931, 25373. Pennsylvania, PA: Elsevier.
Martindale, R.G., S.A. McClave, V.W. Vanek, M. McCarthy, P. Roberts, B. Taylor,
J.B. Ochoa, L. Napolitano, and G. Cresci. 2009. Guidelines for the Provision
and Assessment of Nutrition Support Therapy in the Adult Critically Ill
Patient: Society of Critical Care Medicine (SCCM) and American Society of
Parenteral and Enteral nutrition (ASPEN). Journal of Parenteral and Enteral
Nutrition 33, no. 3, pp. 277316. doi:10.1177/0148607109335234
McClave, S., and D. Heyland. 2009. The Physiologic Response and Associated
Benefits from Provision of Early Enteral Nutrition. Nutrition in Clinical
Practice 24, no. 3, pp. 30515. doi:10.1177/0884533609335176
Mueller, C. 2012. ASPEN Adult Nutrition Support Core Curriculum, 171243,
25393. 2nd ed. Silver Spring, MD: American Society for Parenteral and
Enteral Nutrition.
Singer, P., M.M. Berger, G. Van den Berghe, G. Biolo, P. Calder, A. Forbes,
R.Griffiths, G. Kreyman, X. Leverve, C. Pichard, and Espen. 2009. ESPEN
Guidelines on Parenteral Nutrition: Intensive Care. Clinical Nutrition 28,
no.4, pp. 387400. doi:10.1016/j.clnu.2009.04.024
White, J.V., P. Guenter, G. Jensen, A. Malone, and M. Schofield. 2012. Consensus
Statement of the Academy of Nutrition and Dietetics/American Society
of Parenteral and Enteral Nutrition: Characteristics Recommended for
Identification and Documentation of Adult Malnutrition (Undernutrition).
Journal of the Academy of Nutrition and Dietetics 112, no. 5, pp. 73038.
doi:10.1016/j.jand.2012.03.012
Wooley, J. 2016. Indirect Calorimetry: Applications in Practice. R
espiratory
Care Clinics of North America 12. no. 4, pp. 61933. doi:10.1015/
j.rcc.2006.09.005.

Index
A
Abdominal compartment
syndrome, 75
Academy of Nutrition and
Dietetics (AND), 102
Acute kidney injury (AKI), 77
Acute respiratory distress
syndrome (ARDS), 70
Advance Directive, 98
Aluminium, 79
American Society of Parenteral
and Enteral Nutrition
(ASPEN), 102
Anti-inflammatory nutrient
supplement, 17
Arginine, 71
Ascorbic acid, 43
Aspiration pneumonia, 3031
B
Bariatric formulas, 8687
Bariatric surgery. See also Obesity,
nutrition support for
bariatric formulas, 8687
micronutrient considerations, 86
Bifidobacterium bifidum, 104
Bifidobacterium lactis, 104
Biotin, 23, 43
Blood serum osmolarity
calculation, 45
Blood sugar control, 34, 8081
Blood urea nitrogen (BUN), 45,
49, 55
Bowel obstruction, 5

Branched-chain amino acid

(BCAA)-containing
formulations, 62
C
Cachexia, 104
Calcium, 79
Calorimetry, 6
Cancer patients, nutrition support
of, 8184. See also Diseases
and conditions, nutrition
support in
energy expenditure and, 83
PN and EN, 8384
surgical resection and, 8384
Carbohydrate intake, 31
Cardiac cachexia, 88
Carnitine, 47
Catheter-related blood stream
infections (CRBSIs), 5354
Certified Nutrition Support
Clinician (CNSC), 1
Cholecystitis, 56
Cholestasis, 56
Chromium, 23, 44
Chronic kidney disease(CKD), 77
Clogging of feeding tubes, 32
Clostridium difficile, 32
Coagulopathy, 61
Compounding PN, 46
Continuous feeding schedules, 34
Continuous renal replacement
therapy (CRRT), 77
Conversation Ready process, 98

108Index

Copper, 44, 79, 86

Critical care nutrition, nutritional
provision for, 7071
Critical illness, nutrition support
therapy for, 6771
acute-phase stress response, 68
enteral feeding, 6869
fluid resuscitation and electrolyte
balance, 69
formula selection, 70
full feeding vs trophic feeding,
69
metabolic support, 70
nutritional needs of, 7071
patients in ventilation, 68
predictive energy requirement,
70
supplementation of glutamine
and arginine, 71
Crohns disease, 64
Cyanocobalamin, 43, 79
Cyclic feedings, 15
Cyclic schedules of PN, 4849
Cytokines, 68
D
Dexapanthenol, 43
Dehydration of enteral-fed
patients, 34
Dementia patients, nutrition
support for, 9899. See also
Diseases and conditions,
nutrition support in
Dextrose, 48
Diabetes mellitus, 8081
nutrition support for, 8081
Diabetic formulas, 8182
Diarrhea, associated with enteral
feeding, 3233
Discharge considerations of
patients on nutrition support,
100. See also Ethical issues in
nutrition support
Diseases and conditions, nutrition
support in

critical illness, 6771

diabetes mellitus, 8081
GI dysfunction and disorders,
6267
liver disease, 5962
obesity, 8489
oncology, 8184
renal disease, 7680
in wound healing, 7176
Diuretic medication therapy, 22
dl-alpha tocopheryl acetate, 43
Domperidone, 31
Durable Power of Attorney for
Health Care (DPAHC), 98
Dysmotility, 31
E
Early enteral feeding, 14
End-of-life nutrition support,
9798
symptoms of hydration and
nutrition provision, 97
Enteral access devices, 1113. See
also Enteral nutrition (EN)
enteral feeding equipment, 13
feeding tube characteristics,
1213
feeding tube pumps, 13
for gastric access, 12
long-term, 12
nasogastric tubes, 1112
open and closed systems, 13
short-term, 11
for small bowel access, 12
Enteral feeding complications. See
also Enteral nutrition (EN)
access site infection, 28
aspiration pneumonia, 3031
clogging of feeding tubes, 32
dehydration, 34
diarrhea, 3233
dysmotility, 31
enteral misconnection, 32
fluid and electrolyte balance,
impact on, 28

Index 109

hyperglycemia, 29, 3334

metabolic complications, 29
nausea, 3031
refeeding syndrome, 29, 31
vomiting, 3031
Enteral formulary, 2324
Enteral misconnection, 32
Enteral nutrition (EN), 1, 31, 60,
64, 66, 73, 75, 9596. See also
Enteral access devices; Enteral
feeding complications; Formula
selection, for enteral nutrition
(EN); Parenteral nutrition (PN)
administration schedules, 14
benefits of, 34
calculations for, 2427
for critical illness patients, 6869
fluid calculation in, 35
formula selection for, 1523
monitoring and evaluation of,
2735
nutrition care process for, 89
order form, 30
promoting tolerance and
adequacy of, 103104
Ergocalciferol, 43
Erythromycin, 31
Esophageal varices, 61
Estimated energy requirement
(EER), 5
Ethical issues in nutrition support,
9799
end-of-life, 9798
legal documents, 98
Exogenous insulin, 80
F
Feeding tube pumps, 13
Fiber modular products, 33
Fistulas, 67
Folic acid, 23, 43, 79
Formula selection, for enteral
nutrition (EN), 1523. See also
Enteral nutrition (EN)
classification, 17
concentrated formulas, 17

diabetes mellitus and, 8182

GI disorders and, 64
immune-enhancing or
-modulating formulas, 1718
modular nutrient supplement,
17, 20
obesity and, 86
osmolality formulas, 17, 2122
semielemental formulas, 1718
specialty- and disease-specific
formulas, 1720
standard formulas, 17
terms and definitions, 17
vitamin and mineral
preparations, 2223
Formula selection for ICU
patients, 70
G
Gastric banding, 84
Gastric emptying, 31, 103
Gastrointestinal (GI) function
dysfunction as indicator, 5
nutritional support for, 1
Gastrointestinal (GI) tract
dysfunction and disorders, 37,
59, 6267, 84
anemias, 63
catheter-related infections and
hepatobiliary disorders, 67
complications, 5556
dumping syndrome, 63
fat intolerance or steatorrhea, 63
fistulas, 67
gastrointestinal (GI) anastomosis
perforation, 75
hypertriglyceridemia, 63
inflammatory bowel disease
(IBD), 6465, 67
lactose intolerance, 63
motility, 31
osmotic diarrhea and, 32
pancreatitis, 6364
short bowel syndrome (SBS),
6566
upper GI resections, 6263

110Index

Glutamine, 47, 71
Glycemic control, 33
Guar gum, 33
H
Heart failure patients
malnutrition in, 8688
nutrition status in, 88
nutrition support in mechanical
cardiac support and transplant,
8889
Hemodialysis (HD), 77
Hepatic encephalopathy, 6162
Home care, effective and safe
nutrition support in, 99101
nutrition care plan, 100
Hyperglycemia, 5, 29, 3334, 54,
8081
long-term effects of, 33
Hyperlipidemia, 34
Hypoglycemia, 54
I
Immune-enhancing or -modulating
formulas, 1718, 8384
Implanted ports and tunneledcuffed catheters, 38
Inflammation and nutrients, 105
Inflammatory bowel disease
(IBD), 6465, 67
Initiation and delivery schedules,
1415
EN administration schedules, 14
Insoluble fibers, 16
International Dietetics and
Nutrition Terminology codes, 7
Intradialytic PN (IDPN), 78
Iodine, 23
Iron, 23, 86
Iron dextran, 44
Ischemia, 5
L
Lactase, 66
Lactobacillis acidophilus, 104

Lactobacillis planetarium, 104

Left ventricular assist devices
(LVAD), 8889
Lipids, 40, 48, 54
Liver disease, 5962. See also
Diseases and conditions,
nutrition support in
causes of, 60
complications, 61
enteral formula selection, 6162
micronutrients in, 62
nutrient needs of, 61
prevalence of malnutrition in, 60
route of nutrition support, 6061
type of feeding tube used in, 61
M
Macronutrients, 3840, 77
for renal disease, 7880
as stock solutions, 3839
Magnesium, 79
Malnutrition, 11, 37, 59, 84
in cancer patients, 81
characteristics, 3
from complications of surgery,
83
effect of, 2
in heart failure patients, 8688
identification and treatment of,
23, 104
in liver disease, 60
nutrition risk for, 3
in renal dysfunction, 76
wound healing and, 74
Maltodextrin, 16
Manganese, 44
Medium-chain triglycerides
(MCTs), 16
Medroxyprogesterone acetate, 89
Megesterol acetate, 89
Metoclopraminde (Reglan), 31
Micronutrients, 22, 38, 4344
considerations in bariatric
surgery, 86
in liver disease, 62

Index 111

for renal disease, 7880

in wound care and healing, 72
Mifflin-St Joer equation, 85
Modular nutrient supplement, 17,
20
Molybdenum, 23
Monitoring for EN, 2728
blood glucose levels, 28
enteral feeding tube access site,
28
magnesium and phosphorus
levels, 28
suggested, 27
Monitoring for PN, 4956
nitrogen balance, 5051
order sets and protocols, 5152
suggested, 50
N
Necrotizing fasciitis, 74
Negative nitrogen balance, 2829,
51
Niacinamine, 43
Nitrogen balance, calculation of,
2728
Nontunneled central catheter, 38
Nutrient composition of enteral
formulas, 16
Nutrition care process (NCP), 2
nutrition support and, 79
steps, 7
Nutrition diagnosis, 7
Nutrition support. See also
Diseases and conditions,
nutrition support in; Ethical
issues in nutrition support;
Vitamin and mineral
preparations
energy and protein provision,
102103
estimated nutrition needs of, 57
future directions, 102105
indications for, 23
measurement using calorimetry,
6

nutrition care process and, 79

recommended daily allowance
(RDA), 6
route of, 35
Nutrition therapy education, 101
O
Obesity, nutrition support for,
8489. See also Diseases and
conditions, nutrition support in
enteral formula selection in, 86
predictive energy equations in,
85
protein recommendations, 86
provision of energy, 8586
vitamin and mineral needs, 86
Omega-3 fatty acids, 16, 74, 86,
105
Oral nutrition supplements, 64,
76, 96
Order sets
and protocols for EN, 29
and protocols for PN, 5152
Osmolality formulas, 17, 2122
in PN, 4546
Osmotic diarrhea, 32
P
Pancreatic enzyme replacement
therapy, 83
Pancreaticoduodenectomy, 64
Pancrelipase (Creon), 8384
Parenteral nutrition complications,
5256. See also Diseases and
conditions, nutrition support in
coagulopathy, 53
gastrointestinal, 5556
infectious, 5354
mechanical, 53
metabolic, 5455
osteopenia and osteoporosis, 55
Parenteral nutrition (PN), 1, 5, 66,
74, 9596. See also Enteral
nutrition (EN)
access devices, 3738

112Index

acid-base balance in, 45

calculations, 4043
carnitine, 47
complications associated with, 5
compounding, 46
fluid and electrolyte
requirements, 44
GI dysfunction as indication for,
45
glutamine, 47
initiation of, 48
issues to consider deciding, 4
long-term, 37
medications added with, 4748
micronutrients, 4344
monitoring and evaluation,
4956
multivitamin preparations, 43
nutrition care process for, 89
nutrition prescription for, 40
osmolarity of solutions, 4546
peripheral (PPN), 5, 38
premixed vs custom solutions,
4647
schedules and administration,
4849
short-term, 5, 37
total parenteral nutrition (TPN)
solution, 37
trace minerals, 44
Penn State University equation, 85
Peripheral catheters, 38
Peripherally inserted central
catheter (PICC), 38
Peripheral parenteral nutrition
(PPN), 5
Peritoneal dialysis (PD), 77
Persistent vegetative state (PVS),
nutrition support for, 99. See
also Diseases and conditions,
nutrition support in
Phosphorus, 79
Phyllopquinone, 43
Physician Orders for LifeSustaining Treatment (POLST),
98

PN-associated liver disease

(PNALD), 49, 56
Potassium, 79
Prebiotics, 33
Probiotics, 103
Prokinetic medication therapy, 31
Prucalopride, 31
Pyridoxine, 43, 79
R
Refeeding syndrome, 29, 31
Reimbursement and medical
necessity, 100101
Renal disease, nutritional support
in, 7680. See also Diseases
and conditions, nutrition
support in
consideration of macronutrients
and micronutrients, 7880
goals of, 7778
intradialytic PN (IDPN) for, 78
nutritional needs, 76
nutrition complications in renal
failure, 77
nutrition content of renal
formulas, 78
Renal replacement therapy (RRT),
77
Resting energy expenditure (REE),
56
Retinol, 43
Riboflavin, 2223, 43
Roux-en-Y gastric bypass, 84
S
Selenium, 44, 79, 86, 88
Semi-elemental formulas, 1516
Short bowel syndrome (SBS), 5,
6566
Sleeve gastrectomy, 84
Small bowel access, 12
Small bowel bacterial overgrowth
(SBBO), 66
Small intestine bacterial
overgrowth (SIBO), 66
Soluble fibers, 16, 33

Index 113

Specialty- and disease-specific

formulas, 1720
Stress response and nutrients, 102
System inflammatory response
syndrome (SIRS), 73
T
Teduglutide (GATTEX), 103
Thiamin, 22, 43, 79
Total parenteral nutrition (TPN)
solution, 37
Transitional feeding, 9597
plans, 96
U
Ulcerations, 5
Ulcerative colitis, 64
Urine urea nitrogen (UUN), 28
V
Vascular access devices, 38
Vitamin and mineral preparations,
2223, 72. See also Nutrition
support
liquid preparations, 2223
recommended daily intakes
(RDIs), 22
vitamin A, 2223, 79
vitamin B, 79
vitamin B6, 23

vitamin B12, 23
vitamin C, 23, 43, 7980
vitamin D, 23, 43, 55, 79, 86, 88
vitamin D3, 80
vitamin E, 2223
vitamin K, 61
Vomiting, 3031
W
Water flushes, 29
Weir equation, 6
Whipple procedure, 64
Wound care and healing, nutrition
support in, 7176. See also
Diseases and conditions,
nutrition support in
burn patients, 7374
chronic wounds, 7273
malnourished patients, 74
micronutrients, 72
open abdomen, 7576
pressure ulcers, 7273
risk factors for impaired, 72
surgical wounds, 7475
trauma, 7374
Z
Zinc, 23, 44, 79, 86
Zorbitive, 103