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home - Nutrition - Nutrition Therapy - Choose Route and Type of Feed Written by Dr Sebastian Zeki
Knowledge

Describes the body composition, energy homeostasis, requirements
and sources of macro and micronutrients and consequences of
deficiency or excess

Outlines the different methods available to assess nutritional status
Skills
Is able to use and interpret a valid nutrition screening tool (e.g.
MUST)

Can assess the nutritional status of individual patients using
appropriate methodology

Behaviours
Liaises appropriately with other members of a nutrition support team
Also....
Knowledge

Describes the GI and non-GI causes of weight loss and clinical
consequences of undernutrition

Lists the features suggestive of an eating disorder
Outlines the risks of feeding someone with significant weight loss
secondary to poor nutritional intake and how to minimise such risks

Skills
Can take a relevant history and perform an appropriate examination
in order to be able to identify the likely cause for anorexia/weight loss
(including psychiatric conditions).

Arranges relevant investigations, interprets results and organises
appropriate management plan

Behaviours
Explains and discusses potential causes with patient, especially those
with non-organic conditions

Also....
Knowledge


Knows the appropriate indications and contraindications for the use of
enteral and parenteral nutrition.

Outlines the different types of enteral and parenteral feeding lines and
indications for use of each

Describes the principles of perioperative nutritional and fluid
management

Lists the risks and complications of all types of artificial nutrition
support and describe how to minimise these.

Describes the re-feeding syndrome and associated risks and
management

Describes the role of different members of the nutrition support team
(NST)

Outlines the ethical and legal implications of provision, withdrawal
and withholding artificial nutrition support

Skills
Chooses an appropriate bedside, endoscopic or radiological method
and route for nutritional support, including different parenteral lines
and gastric vs. post-pyloric tube placement options.

Demonstrates competence in insertion of a naso-jejunal tube and
verification of position

Supervises the use and management of feeding lines and prescribe
appropriate intravenous and enteral feeding regimes in conjunction
with dietetic, nursing and pharmacy colleagues in the NST

Monitors patients on artificial nutrition support to avoid the re-feeding
syndrome.

Understands the principles of perioperative nutritional and fluid
management

Determines patient capacity and make appropriate decisions for
artificial nutritional support

Behaviours
Assesses the different options for nutritional support, explains and
then discusses these with the patient and/ or carers/patient advocate,
as appropriate

Also...

Knowledge
Assessment
Methods GMP
Knows the prevalence of undernutrition in the community, care
settings and hospitals
AA, SCE 1
Appreciates the costs to the NHS of undernourished patients SCE 1
Understands the consequences of undernutrition (at organ and
molecular levels
SCE 1
Knows how to perform nutritional screening and assessment (BMI,
%WL, likely oral intake over next 5 days, mid arm circumference and
muscle mass, grip dynometry etc). Know that albumin is not a
nutritional marker
SCE 1
Estimates a patient’s nutritional requirements (energy, protein, water,
electrolytes, trace elements and vitamins) in health and in different
circumstances (e.g. perioperatively, critical care etc) and with different
illnesses
SCE 1
Knows the causes for dysphagia (e.g. cerebro-vascular disease) and
be able to asses swallowing
SCE 1
Understands how the catering system operates in a hospital SCE 1
Knows how food can be fortified and know the types of oral nutritional
supplements available
SCE 1
Understands how to assess a patient for the risks of developing
refeeding problems
SCE 1,2
Knows the benefits and risks of EN and PN SCE 1
Knows the different roles of each member of a NST (clinician, nurse,
dietician and pharmacist)
SCE 1,2,3
Skills
Performs a nutritional assessment DOPS 1
Is able to select appropriate fluids and nutrition in the early postoperative phase
CbD, mini-CEX 1
Can identify and treat patients at risk of refeeding problems CbD, mini-CEX 1,2 Gastroenterology 2009 Page 114 of 155
Recognises vitamin and mineral deficiencies and conditions in which
they are likely to occur (e.g. vit A deficiency with severe steatorrhoea)
and be able to give appropriate treatment
CbD, mini-CEX 1,2
Selects method and route of feeding CbD, mini-CEX 1,2
Inserts enteral feeding tubes NG and PEG DOPS 1,2
Selects appropriateness for a PEG or RIG CbD 1,2
Enters patient on BANS TO 1,3
Behaviours
Works within and lead a multidisciplinary NST MSF 1,2,3,4
Has the expertise to be able to chair a nutrition steering committee MSF, TO 1,2,3,4
Is able to balance the benefits and risks of the methods of giving
artificial nutritional support

Also...

Knowledge
Assessment
Methods GMP
Knows the anatomy and physiology of the gut and thus the
consequences of the loss of all or part of the stomach, jejunum, ileum
and colon and associated organs (e.g. pancreas and gallbladder)
SCE 1
Understands gastrointestinal fluid losses in the fasting state and after
food
SCE 1
Knows where different macro/micronutrients, water, electrolytes,
vitamins and trace elements are absorbed
SCE 1
Can define, classify and grade the severity of intestinal failure.
Knows the appropriate investigations required to fully assess a
patient with IF
CbD, mini-CEX, SCE 1,2
Knows the current criteria for referral for consideration of a small
intestinal (+/-and liver) transplant and know the current chances of
patient survival, graft survival and the patient being able to completely
stop PN
mini-CEX, SCE 1,2
Has knowledge of congenital gut disorders that may necessitate
nutritional support (e.g. volvulus).
CbD 1
Skills
Can take a relevant history from patients with IF and perform a
relevant clinical examination - including inspection of abdominal
wounds, fistulas and at the stoma/fistula outputs, and inspecting any
tubes/catheters and appliances
DOPS 1,2
Understands the underlying disease process and its appropriate
management.
CbD, mini-CEX 1,2,3,4
Understand the surgical procedures and the remaining
gastrointestinal anatomy (be able to draw a diagram of the remaining
gastrointestinal anatomy)
CbD 1,2
Can predict the outcome in terms of the nutritional and fluid support
needed and predict the duration for which this support is needed
CbD, mini-CEX 1,2
Can select and administer the most appropriate fluid and nutritional
support
CbD, mini-CEX 1,2,3 Gastroenterology 2009 Page 115 of 155
Can help to plan the time for any corrective surgery CbD, mini-CEX 1,2,3,4
Understands and works with psychological medicine to address the
psychological/emotional needs of a patient
MSF, TO 1,2
Can discuss possible referral for intestinal transplantation when
appropriate.
CbD, mini-CEX 1,2,3,4
Behaviours
Has a structured approach to managing a patient who presents with
intestinal failure
CbD, mini-CEX 1,2
Works with the multidisciplinary NST and other specialties (e.g. pain
team, stoma care, tissue viability, psychological medicine)
MSF, TO 1,2,3,4
Gives care appropriate to the patient’s needs and anxieties, and can
liaise with the patient, carers, friends and family

Also...
Knowledge


Has knowledge of stomas includes understanding how why and
where a stoma is formed

Appreciates the difference between a jejunostomy ileostomy and
colostomy and the problems that can result from each

Understands the role of a stoma care nurse and the problems with
which she/he can help (leakage poor stoma etc)

Understands the underlying diseases that result in a jejunostomy
being fashioned

Has a systematic approach to investigating the causes of a high
output stoma

Understands the principles of treatment including restricting oral
hypotonic fluid drinking a glucose-saline solution and the use of
drugs (antidiarrhoeal and antisecretory)

Knows when parenteral support is needed including subcutaneous
saline and magnesium

Able to predict patient outcome in terms of fluid and nutritional needs
from knowledge of how much functional bowel remains

Knows the long term problems of having a jejunostomy
(dehydration/renal failure gallstones liver fibrosis and osteoporosis)

Is aware of other surgical options in short bowel (reverse segment
intestinal lengthening etc)

Understands the principles of feeding into bowel that is not in
continuity (fistuloclysis)
DOPS

Knows how remaining bowel length can be measured (at surgery or
radiologically)
TO
Skills
Can use/apply the different types of stoma bag / drainage bag and
how they are used
TO
Can explain to a patient why drinking hypotonic fluid is detrimental
Can investigate the causes of a high output stoma (other than a short
bowel)

Can choose the most appropriate fluid nutrition and drug treatments
and route by which they are given

Behaviours
Is able to explain the principles of management to patients carers
friends and family and be able to manage long-term problems
(osteoporosis gallstones renal stones and poor venous access)

Works closely within the multidisciplinary NST especially with the
dieticians

Also

Knowledge


Knows the advantages of having a colon in situ in terms of fluid and
nutritional requirements and appreciates desirability of restoring
intestinal continuity where possible

Appreciates these patients mainly have problems from becoming
slowly undernourished and that they rarely have fluid balance
problems

Knows the principles behind a high polysaccharide low oxalate diet
(but one in which the fat content is not increased)

Understands the mechanisms of intestinal adaptation and the time
over which it occurs

Appreciates the problems which are specific to this type of patient
with a short bowel namely calcium-oxalate renal stones and d- lactic
acidosis

Skills
Recognises when dietary measures are inappropriate and PN is
needed

Can recognise when intestinal adaptation has occurred and PN can
be stopped

Gives appropriate dietary advice and prescribe drugs to reduce
diarrhoea (including bile sequestering agents

Behaviours
Can explain to the patient carers friends and family the relevance of
the preserved colon and thus advise about what the patient should
eat

Works closely within the multidisciplinary NST especially with
dieticians

Also...
Knowledge


Indications:
• Knows when parenteral nutrition should be given in
preference to enteral nutrition

Catheter care:
• Appreciates strict aseptic technique needed to insert and care
for parenteral feeding catheters

• Knows about the different catheter types (including ports)
Prescription:
• Knows how a parenteral feeding bag is made up including its
limitations

• Understands the components of a feeding beg
• Understands the issues of compatibility (cracking and
creaming etc)
TO
Assessment/monitoring:
• Knows how to assess the nutritional / fluid requirements and
prescribe appropriate amounts
DOPS EX
Complications: Gastroenterology 009 Page of 55
• Knows how to diagnose and manage catheter related sepsis
exit site and tunnel infections central vein thrombosis
abnormal liver function tests (LFT) and blocked catheters

• Knows that most LFT abnormalities have causes other than
the PN

• Knows that a proximal catheter tip is the most common
reason for central vein thrombosis

Outcome:
• Appreciates the difficulties of managing parenteral nutrition at
home

• Knows about the long term problems including venous
access recurrent catheter related sepsis and osteoporosis

Training:
• Appreciates the training programme for establishing a patient
on HPN (including funding connection disconnection
dressing care)
TO
• Be aware of where patients can obtain more information (e g
PINNT)
TO
Funding:
• Understands how to arrange funding for long-term HPN TO
Skills
Can write PN prescriptions according to a patients needs
Appreciates when PN is necessary and be able to implement it
Can safely insert parenteral feeding lines (PICC and Tunnelled
central lines) using the jugular subclavian and femoral central routes

Institutes appropriate investigations and treatments for all catheterrelated complications This includes venography thrombolysis and
venous stenting for central vein thrombosis

Can access a parenteral feeding line using aseptic technique (to take
blood and blood cultures)

Can treat catheter related sepsis with an anti-biotic lock technique
Can remove a cuffed feeding line
Can recognise PN associated liver disease and know when to
consider a liver (+/- small bowel) transplant

Coordinates the process for discharging a patient on HPN
Behaviours
Selects the appropriate route for a PN feeding catheter and manage
the feeding and any complications in a competent and caring manner

Works within a multidisciplinary NST liaising with the surgeons
radiologists psychiatrists and home care providers as necessary

Discusses the various and often complex issues openly and honestly
with the patient carers friends and family

Choose Route and Type of Feed

Nutritional support Assessment (1) Subjective assessment (HX, examination) - Well nourished- Moderately malnourished-Severely malnourished (2) BMI plus hage weight loss (more than 10% weight loss in one month equals needs nutritional support) (3) Specific nutritional deficiencies (ADEK) (4) Albumin as marker of surgical outcomes Indications for feeding: Inadequate intake 5 to 7 days. No oral intake 3 to 5 days. Enteral Parenteral - NG intolerable - Prolonged -High output enterocutaneous fistula - Home parenteral feeding needed for severe short gut syndrome and severe chronic pseudo obstruction Enteral nutrition — Start if anticipating no oral for >5 days Infusion rate Initiate at 15-30 mL/hr and incrementally increase. Discontinue if gastric residual volume > 150 to 250 mL Can keep for 6 mnths Gastrost/enterostomies Parenteral nutrition — Start if failed/ CI to enteral feeding. Gradually increase rate Peripheral catheters If enteral feed due to start in 7 to 10 days Central lines if feed more than two weeks Monitoring for re-feeding: Daily weight. Daily blood glucose. Temperature chart. U&Es daily.MJ/CA/Phos/ZN weekly. - Obese more than 30 - Normal 18.5 to 24.9 - Life threatening less than 14 Thrombophlebitis reduced by - Pressure technique - Asepsis - GTN patch - Heparin plus or minus Cortisol - Long line - Non reactive material eg Silicone - Decrease osmolality of food Significant Weight Loss Measurements:≥2 % decrease of baseline body weight in one month ≥5 % decrease in three months, or ≥10 % in six months Dietary Assessment:(BMI).BMI = body weight (in kg) ÷ stature (height, in meters) squared.Fasting lipid profile/blood glucose, HbA1C, CRP, hematocrit, albumin, U&E’s.A Full History:.-24-hour dietary recall.-Food frequency questionnaire.-Food diary.-Consider lifestyle that will stop change of diet. Adjunct Therapies — To prevent emesis, aspiration, and nosocomial pneumonia associated with enteral feeds can consider:Promotility agents —Doesn’t reduce the risk of aspirationSmall bowel feeding — Doesn’t reduce mortalityHead elevation — To 45 degrees does reduce incidence of pneumonia (1)Fluid balance calculation (2) Trace/vitamins calculations (3) Energy requirements calculations - Calculate BMI - Add 10% per degree centigrade - Add 600 kilocalories if weight gain needed - Adjust for mobility (4) Protein (nitrogen) calculations - 1 to 2g/protein/kg/24 hours - Depending on level of catabolism (5) Electrolytes calculations Na = weight in kilograms K = weight in kilograms Ca = 5 to 10mmol/day Mg = 5 to 10mmol/day PO4= 10 to 30mmol/day Choosing the feed Enteral vs parenteral feeding Techniques for delivery Choosing the feed (increased Na/decreased K/decreased PO4) Written by Dr Sebastian Zeki

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