NUTRITIONAL SUPPORT FOR

NEUROSCIENCE PATIENTS

Introduction• For nurses providing holistic comprehensive

care for neuroscience patients, meeting nutritional needs is a critical component in the recovery process that requires an appropriate knowledge base.

• Injury, physiological dysfunction and stress often change the basic requirement and use of nutrients and water for energy, cellular function and repair of injured tissue.

• Additionally a patient with neurological condition may have deficits, such as an altered level of consciousness or paralysis of the muscles for chewing and swallowing which further complicates ingestion of nutrients.

BASIC NUTRITIONAL REQUIREMENTS

• The RDA describes target intake levels of essential nutrients for healthy people. • Nutrient requirement includes

macronutrients and micronutrients.• It is important to keep in mind that the

RDA cannot be relied onto precisely calculate the need of patients who are ill, especially if malabsorption is present.

NUTRITIONAL ASSESSMENT

• A nutritional assessment includes a thorough history, physical examination and laboratory studies.

• The RD assumes responsibility for conducting the nutritional assessment , estimating nutritional requirement and recommending a nutritional support plan of care.

• The nurse implements the nutritional plan of care provide education to patients and

familymonitors both response to therapy and

complication . implementation include safe

administration of nutrients by oral , enteral or o occasion , parenteral route.

COMPONENTS OF THREE NUTRITIONAL ASSESSMENT

• HISTORY Information about

Recent weight loss Anorexia , nausea , vomiting Diarrhoea Dietary changes

This can be collected from medical record, family member or the patient.

PHYSICAL EXAMINATION

Assessment of• Skin; turgor ,dryness, oedema, bruising ,

scaling , dermatitis , seborrhoea• Mucous membrane; dryness, colour,

bruising , especially gums.• Tongue; swelling , papillary atrophy• Eyes; pale or dry conjunctiva , sunken

eyeballs

• Hair; dull looking hair or hair loss. • Muscle; atrophy, wasting.• Height and weight • Anthropometric measurement such as

skin fold thickness and midarm muscle circumference are not useful in critically ill patients because of frequent presence of fluid retention and oedema. it is more useful in less severely ill patients.

BLOOD AND URINE CHEMISTRIES

• Serum albumin ; index of nutritional status , it has a long half life of approximately 18 days and is a poor marker of the effects of short term feeding in hospitalized patients. • Transferrin; half life of 8-10 days is

also frequently mentioned but is not very helpful with critically ill patients.

• Nitrogen; represents the end product of protein metabolism . nitrogen balance studies such as 24 hrs urinary urea nitrogen collection , compare nitrogen intake with nitrogen excretion to determine nitrogen balance. A negative balance reflects protein catabolism. • The goal of nutritional support is a

positive nitrogen balance

TESTS OF THE IMMUNE SYSTEM

TOTAL CIRCULATNG LYMPHOCYTE COUNT

• Most circulating lymphocytes are T cells . it’s a general indication for malnutrition. • Infection and immunosuppressant

drug alter the number of circulating lymphocytes and thus are not helpful in critically ill patients.

Delayed cutaneous hypersensitivity skin testing • This test is also not helpful in

critically ill, malnourished patients because of decreased cellular immunity response • When patient fails to react to any of

the several skin test antigens used and are described as ‘anergic’.

METABOLIC CHANGES FOLLOWING INJURY AND STARVATION

• The key difference is that in critical illness there is an increase in the basal metabolic rate , glucose use and gluconeogenesis. • Starved stressed patients do not

readily mobilize stored fats.

Difference in early metabolic responses to fasting and injury

Metabolic activity Simple starvation Starvation superimposed on to injury or stress

Basal metabolic rate decreased BMR Decreased or normal BMR initially

Glucose levels Low High

Glucose utilizations Limited glucose use Increased glucose use

Gluconeogenesis increase Gluconeogenesis initially ,Decrease after 5-7 days

Increased gluconeogenesis

Protein catabolism Low High

Fat catabolism High Low/ none

Ketone utilization Increased ketone use Decreased ketone use

Ketosis Present Absent

ketosuria Present Absent

ESTIMATING NUTRIENT REQUIREMENTS

• It is important because there are serious adverse effects from both overfeeding and underfeeding

• Overfeeding with high glucose infusion can lead to hyperglycemias, hypokalemia, oedema, a fatty liver degeneration and an increased risk of nosocomial infection. Overfeeding also increases the carbon dioxide production which may lead to difficulty weaning from ventilator.

ESTIMATING TOTAL DAILY REQUIREMENTS (TDRs)

Factors necessary to calculate TDRs are;• Calculation of basal metabolic rate

( BMR)• Energy expenditure during activity

(EEA)• The thermogenic effect of food

intake (TER)

• The following formula is useful for calculation of TDR

TDR=BMR+EEA+TER

DIRECT METHOD OF CALCULATING BASAL METABOLIC RATE

• Harris- Benedict equation • BMR(men) = 66 + ( 13.7 × W ) + ( 5 × H )

( 6.8 × A )• BMR(women)= 665 + ( 9.6 × W ) + ( 1.8 × H )

( 4.7 × A ) • W= weight in kilograms• H= height in centimetres• A= age in years

CALCULATING EEA

• The EEA provides a correction factor based on the patients expenditure of energy. Each 1°C increase in body temperature increases the metabolic rate by approximately 5-10%.

EEA correction factor on account to fever

Clinical condition Correction factorOut of bed 1.3Confined to bed 1.2Fever 1+ 0.13 per degree ,C.Multiple fractures 1.2- 1.4Soft tissue trauma 1.14- 1.37Sepsis 1.4- 1.8Minor surgery 1.1.2Starvation in adult 0.70

CALCULATING TER OF FOOD INTAKE

• The increase in metabolic rate following eating is about 5-10%of the daily energy expenditure . the TER is difficult to assess in the hospitalized patients. Therefor using indirect calorimeter during or shortly after feeding infusion eliminates the need to estimate TER.

FORMULAS FOR ESTIMATING REE IN HOSPITALIZD PATIENTS

• Equation has been developed for both the ventilator dependent and spontaneously breathing patients.

• After the REE has been calculated a correction factor for activity is made.

• Hospitalized patients who are severly catabolic or malnourished or those with high fever or sepsis require an increases to the REE of 20% to 25%.

• Care should be taken to prevent overestimating total energy needs to prevent overfeeding syndrome.

• For ventilator dependent patients ,• REE = 1925 10(A) +5(W) +281 (S)

+292 (T) +851(B) • For spontaneously breathing patients • REE= 629 – 11 ( A ) + 25 ( W ) - 605

(O)

• A= age • W= body weight in kg• S= sex (male = 1 , female = 2 )• T = trauma ( present =1, absent = 0) • B= burns ( present =1, absent = 0)• O= obesity ( present =1, absent = 0)

INDIRECT METHOD OF CACULATING BMR

• Indirect calorimeter (metabolic cart) • This method measures oxygen uptake

(Vo2 ) and carbon dioxide uptake (Vco2 ) at the mouth .

• The equipment used include an open circuit method with a set of one way valves to direct expired air into a collection bag.

• At the end of the collection time both the volume and the composition of the expired air are measured and the rate of the oxygen consumption and the carbon dioxide production is calculated by the difference between the concentration of the inspired air and the gas collected.

• The data from indirect calorimetry include measurement of Vo2 and Vco2 for 15- 20 min .

• An estimate of REE and respiratory quotient (RQ) can be calculated and extrapolated to 24 hours.

• RQ= Vco2/ Vo2

• RQ reflects whole body substrate utilization and varies between 0.70 and 1.2 . an RQ grater than 1.0 is an indication of excessive carbohydrate calories resulting in fat synthesis which leads to high carbohydrate production , a situation to be avoided.

• Advantages are its accuracy and ability to be used with ventilated patients .

• Disadvantages include the need for special equipment , skilled personnel , increased cost, inaccuracy when the inspired FiO2 is > 0.40 .

PROVIDING NUTRIENTS

• Does the patient need nutritional support? • If so , what are the energy and protein

requirement for this patient ?• What route of administration should be

used ?• If enteral feeding is used , where should

the tube be placed? • When should the feeding begin ?• What feeding should be given ?

PATIENTS NEEDING NUTRITIONAL SUPPORT

• Those expected to receive nothing by mouth for more than 7- 10 days .

• Those with hypermetabolic states ) sepis , multitrauma)

• Those with pre-existing undernourishment

• In neuroscience population – comatose, multitrauma , septic patients

PROVIDING ADEQUATE ENERGY AND PROTEIN REQUIREMENT

• BMR for more hospitalized patients is 2,100 k cal if the patient do not exceed 200 Ib

• Even with correction factors for fever and sepsis ,patients total energy requirement are usually less than 3000 k cal/day.

• A general rule of thumb for caloric require ment for seriously ill patient is 25-35 kcla/kg/day of ideal body weight and 1.5 g/kg/day for protein

ROUTE OF ADMINISTRATION

• Enteral feeding rather than parenteral nutrition is clearly the prefferd route of administering nutritional support.

• Nutrients to the intestinal lumen protect the iintefrity of the GI tract. They preserve optimal gut function , maintain the gut barrier from translocation of microorganism and support gut associated immune system IgA secretion.

• Enteral nutrition is safer , more convenient and less expensive than parenteral nutrition.

FEEDING TUBES AND SITE OF PLACEMENTS

• When there is an intact intestinal tract 3 POSSIBILITIES EXIST FOR delivering food into the alimentary tract.

• Oral feeding is always the preferred method of nutritional support . however in many hospitalized neurological patients this is not possible for a number of reasons , for coma , high risk for aspiration and multitrauma. In that case temporary oral – gastric or nasogastric tube into the stomach or naso duodenal tube into the duodenum are available. For neuroscience patients with a basal skull fracture, facial fracture or leakage of CSF-insertion of a tube nasally is contraindicated.

• Enteral feeding should not be delayed to establish small bowel access.most patients are able to tolerate some gastric feeding early in the course of illness. The need for prolonged tube feeding is an indication for a simple surgical procedure whereby a gastrotomy or jejunostomy tube is sutured into position on the abdominal wall.

• Another enteral tube placement option for long term feeding is percutaneous endoscopic gastrostomy (PEG) it involves a placement of a 16-18 gauge latex or silicon catheter through the abdominal wall directly into the stomach using an endoscopic approach.

BEGINNING FEEDING

• Early nutritional support within 12-48 hours blunts the hypercatabolic state and sepsis related to serious illness. • After insertion of a nasogastric or

nasoduodenal tube feedings are not begun until an x-ray film of the abdomen confirms appropriate GI placements.

• Feeding should be started at 25-30 ml/hr and increased by 10-25ml/hr every 1-4 hrs as tolerated until the caloric (25 kcal/kg/day)goal is achieved.

• Tolerance is evaluated by measurement of gastric residuals (less than 200 ml) and presence of abdominal distension, vomiting, diarrhoea. If the gastric residual is grater than 220ml , the feeding is held for 2 hrs and then resumed.

• Feeding can be increased at a slower rate ,but this is often not necessary and delays achievement of the caloric intake goal.• The goal rate should be achieved by

the 3rd day of the therapy,if not earlier. Feeding can be administered intermittently a few times a day or continuously with a food pump.

SELETION OF FEEDING FORMULAType of formula

description Brand names and examples

Standard Complete formulas that provide macronutrients and micronutrients RDA.Lactose free Provide 1.0 1.2 kcal /mlFirst choice for most patients.

Ensure, isocal, magical, osmolite

High protein Have a higher protein /nitrogen and a ratio of nonprotein calories to nitrogen of <130:1, but >110:1For those patients who are severely catabolic and protein deficient , such as severe trauma or patients with large or poorly healing wounds .

Isocal HCN and isocal HN

Very high protein

Similarto high protein , but with a lower ratio of nonprotein calories to nitrogen of <110:1.

Sustacal

Disease specific Intact protein designed specifically to meet the protein , electrolyte and glucose limitation of specific disease.

Glucerna;travasorbrenal

With fiber Thee formulas produce more fecal residue that increases stool bulk .For patients with constipation and diarrhoea.

Jevity

Elemental Calories aare supplied primarily as free amino acids and oligosaccharides .For patients with decreased ability to digest and absorb standard formulas.

Criticare HN ,stresstein and vivonex TEN

Volume restricted

Caloric density >1.2kcal/ml Useful when fluid overload is a problem such as ascites, renal failure, congestive heart failure.

Ensure plus, ensure plus HN and protain XL

Very high protein

Similarto high protein , but with a lower ratio of nonprotein calories to nitrogen of <110:1.

Sustacal

Disease specific Intact protein designed specifically to meet the protein , electrolyte and glucose limitation of specific disease.

Glucerna;travasorbrenal

With fiber Thee formulas produce more fecal residue that increases stool bulk .For patients with constipation and diarrhoea.

Jevity

Elemental Calories aare supplied primarily as free amino acids and oligosaccharides .For patients with decreased ability to digest and absorb standard formulas.

Criticare HN ,stresstein and vivonex TEN

Volume restricted

Caloric density >1.2kcal/ml Useful when fluid overload is a problem such as ascites, renal failure, congestive heart failure.

Ensure plus, ensure plus HN and protain XL

PROBLEMS ASSOCIATED WITH TUBE FEEDING

The major problems are;• Underfeeding • Overfeeding

Underfeeding ; • related to starvation , depletion of protein

stores delayed wound healing high risk for skin breakdown , high risk for nosocomial infection , respiratory muscle weakness and ventilator dependency, increased mortality and morbidity.

• Causes are multifactorial and delay in initiating feeding is common.

• Diarrhoea, vomiting, GI tract dysfunction and electrolyte imbalance are problems which interfere with adequate nutritional support in patient receiving enteral feeding.

Overfeeding;

• Related to complication such as hyperglycemia, azotemia, hypertonic dehydration, electrolyte imbalance, edema, metabolic acidosis, hypercapnia, hyperlipidemia , hepatic stenosis , refeeding syndrome and an increased risk of nosocomial infection

• Causes are overestimating daily caloric needs

• The potential problems are diarrhoea, vomiting, gastric distension, dehydration, aspiration, hyperglycemia, electrolyte imbalance, other disease related intolerance, migrating feeding tube, refeeding syndrome, catheter occlusion.

MEDICATION

• The size and location of feeding tube , as well as the specific drug must be considered.

Tube• The diameter of the tube is

important . the smaller the diameter tube the more likely is to become clogged .

Drug administration guidelines

• Use liquid preparation of a drug, if available. Crushing or dissolving of tablets is discouraged, if absolutely necessary , dissolve in at least 10 – 15 ml of water.

• Hard gelatinous casule should be oened and dissolved in at least 10 – 15 ml of water

• Drugs irritating to the gi tract should be dissolved in large amount of water before administration.

• Do not add drugs to the enteral feeding

• Stop the feeding before administering the medication.

• Flush the feeding tube with water to remove residual formula before administering the drug.

• Flush the feeding tube with 10-30 ml of water after administering the drug.

• For patients on an intermittent gastric feeding schedule , adjust the timing of medication of the feeding schedule according to the need for drug delivery on a full or empty stomach.

Drug with special administration requirements with enteral feeding

• Patients receiving phenytoin and receiving continuous feeding require increased doses of phenytoin to maintain therapeutic level because it binds to protein resulting in decreased absorption of the drug.

• carbamazepine suspension is another commonly prescribed anticonvulsant drug .dilute the suspensions so that it will not adhere to the walls of the feeding tube .

• Flush well after the administration.

Monitoring patients receiving enteral feeding

• Electrolytes• Renal function• Liver function • Other chemistries; glucose• Other laboratory data; calcium,

phosphorus , magnesium, albumin, prealbumin triglycerides , cholesterol baseline and as indicated .

• The nurses role ; meeting the nutritional needs of a patients;• The nurse begins with conducting a

nutritional assessment to establish a baseline and plan of care.

• Based on a nutritional assessment, various collaborative problems and nursing diagnosis can be made.

• Because of the complexity of neurological illness that impacts on the nutritional goal, several potential collaborative problems must be kept in mind, they include starvation, paralytic ileus, hypoglycaemia, hyperglycemias, negative nitrogen balance, electrolyte imbalance, sepsis , aspiration I pneumonia,.

• Other problems may be added, such as renal or hepatic failure based on complication that occur as a result of neurological insult.

The following nursing diagnosis are often identified for the patient with problems related to nutritional needs

• impaired nutrition more than body requirement

• impaired nutrition less than body requirement• risk for deficit fluid volume• risk for excess fluid volume• impaired swallowing• risk for aspiration

ONGOING NURSING ASSESSMENT

• The nurse can monitor the patients nutritional status with the following parameters

• Once stabilized , weigh the patients twice a week on designated days and note trends in stability of weight.

• Observe skin turgor, the condition of the tongue and mucous membranes, muscle tone and muscle bulk daily for evidence of dehydration.

• Record and monitor intake and output and daily balance .

• Maintain a calorie count with the help of the clinical dietician.

• Monitor tolerance to oral or enteral feeding , use as base for process of feeding to caloric goal.

• Monitor appropriate laboratory data , electrolyte , glucose, prealbumin, createnine, BUN.

ADMINISTERING ENTERAL FEEDING

• Enteral feeding may be administered in one of two ways; continuously with the use of a food um or intermittently with the use of a gavage bag.

• Check the position of the tube to be sure it has not migrated

• If the patient has a tracheotomy tube in lace deflate the cough; keep it deflated for one hr after completion of the feeding. The purpose of this action is to prevent aspiration

• Addition of a few drops of blue food colouring into the feeding is often recommended as a way to assess pulmonary aspiration of enteral formula in incubated patients . • Follow hospital recommendation.• If used, observe the tracheal

secretion to note blue discolouration a an indication of aspiration .

CONCLUSION

• New studies have been undertaken to fill the multiple gaping knowledge and to clarify areas of controversy. For nurses providing holistic comprehensive care for neuroscience patients, meeting nutritional needs is a critical component in the recovery process that requires an appropriate knowledge base.

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