Clinical Nutrition I

Instructor : Jumana Abuqwider

The nutrition care process (NCP)
HEALTH STATUS
(1) being totally healthy and resistant to disease, to
(2) having an acute illness, to
(3) living with a chronic disease or condition that significantly
alters one’s capacity to function well, and finally to
(4) having a terminal illness.
Improving Health and Nutritional
Status through Nutrition Care
• Health status
• In addition to understanding the goal of nutrition care as it
relates to a person’s health status, it is also important to
evaluate and determine a person’s nutritional status.
• Assessing a person’s nutritional status involves not only
comparing the amounts and types of nutrients that a person
consumes to nutrient requirements at various stages
throughout the continuum of growth, health, and illness
but also examining the wide variety of factors that influence
both nutrient intake and nutrient requirements.
• The balance between nutrient intake and nutrient
requirements is considered to be “good.”
• An inadequate or excessive intake of nutrients, or the form
of nutrients is not well utilized by the body, a nutrient
“imbalance” is present.
• Nutrient imbalance can result in significant health
consequences.
• An excess of kilocalories (kcal) and undesirable eating
patterns are associated with the progression of a number of
chronic diseases such as obesity, diabetes mellitus, coronary
artery disease, and hypertension.
• Inadequate intake of kcal and certain nutrients such as
protein, on the other hand, can contribute to a
compromised immune system and poor wound healing.
Improving Health and Nutritional
Status through Nutrition Care
• Nutrition Status
Nutrition is important to promote health and prevent and
treat disease statuses
Adequacy of nutrient intake is important but does not
completely describe nutritional status
 Determination of a person’s nutritional status is also
dependent on a wide variety of factors (biological,
pathological, behavioral, cognitive, and environmental and
systems)
Improving Health and Nutritional
Status through Nutrition Care
Purpose of Providing Nutrition Care
• Providing nutrition care can influence and change the
factors that contribute to an imbalance in nutritional status
and thus restore an improved state of nutritional health.
ADA’s Standardized Nutrition
Care Process (NCP)
• nutrition care process (NCP) : a systematic problem-solving
method developed by the ADA that dietetics professionals
use to think critically, make decisions addressing nutrition
related problems, and provide safe, effective, high-quality
nutrition care.
• NCP consists of four distinct but interrelated and connected
steps: (1) nutrition assessment, (2) nutrition diagnosis, (3)
nutrition intervention, and (4) nutrition monitoring and
evaluation.
Use of the NCP to Improve Quality of Care
• The NCP is a standardized process—not standardized care.
• A standardized process refers to a consistent structure and
framework used to provide nutrition care, whereas standardized
care implies that all clients receive the same care.
• A combination of both the process of care (the steps of the
nutrition care process in a systematic and consistent manner)
and the content of care (incorporation of evidence-based
practice guides) to produce improved quality of care and
improved nutritional status.
Critical Thinking
Supportive Systems: Screening
and Referral System and Outcomes
Management System

• A screening and referral system identifies those individuals

or groups who would benefit from nutrition care provided
by dietetics practitioners.
• the outcomes management system: An outcomes
management system is used to evaluate the effectiveness
and efficiency of the entire NCP process (assessment,
diagnosis, interventions, outcomes, costs, and other factors)
when nutrition care is provided to a number of patients.
Steps of the NCP
Step 1: Nutrition Assessment
• very systematic process of obtaining, verifying, and
interpreting data in order to make decisions about the
nature and cause of nutrition-related problems
• The first step of the NCP provides important information
that helps determine a person’s health and nutritional
status.
Nutrition assessment

• Nutrition care assessment should ensure that appropriate

and reliable data that are collected for use in determining
the existence of specific nutrition problems.
• Organizing and categorizing data utilizing the five domains
of the assessment standardized terms improves the
efficiency and effectiveness of nutrition assessment and
nutrition diagnosis.
Food- and Nutrition-Related History
• food and nutrition information is assessed either by
collecting data retrospectively or by summarizing data
gathered prospectively.
• Information gathered will include both dietary information
and physical activity patterns.
• The ultimate goal of collecting dietary information is to
determine the nutrient content of food that is consumed
and to then assess the appropriateness of the nutritional
intake for that particular individual.
• Food- and Nutrition-Related History
1. Twenty-Four-Hour Recall
2. Food Record/Food Diary
3. Food Frequency
4. Observation of Food Intake/“Calorie Count”
Twenty-Four-Hour Recall
• recall of all food and drink that has been consumed in the
previous 24-hour period.
• The clinician questions the client about activities during the
period in order to stimulate the client’s memory.
• At the end of the recall, the clinician reviews the
information to verify serving sizes and preparation
methods, and to clarify any other uncertainties.
Advantages and disadvantages
1. short administration time
2. very little cost
3. negligible risk for the client
-----------------------------------------------
1. does not always show typical eating patterns, since day-to-day
dietary intake may vary considerably.
2. clients may report information they feel the clinician wants to
hear
3. Clients may over- or underreport their intake.
4. this method requires dependence on the client’s memory.
Food Record/Food Diary
• Th is method has the client document his or her dietary
intake as it occurs over a specified period of time. Typically,
the record is kept over a three- or five-day period and should
include a sampling of both weekdays and weekends.
• Clients estimate or weigh their food intake.
 Advantages and disadvantages

Advantages disadvantages
not totally reliant on the Problems with validity because of
client’s memory underreporting
much more the client may change food habits
representative of the client’s actual for the recording period
intake.
heavier burden on the client
Food Frequency
• The food frequency procedure is a retrospective review of
specific food intake.
• Foods are organized into groups, and the client identifies
how often and in what quantities he or she consumes a
specific food or food group.
• self-administered.
Advantages and disadvantages
Advantages disadvantages
inexpensive response rates tend to be lower
since the instrument is self
administered.
quick to administer foods on the pre-prepared list may
be inappropriate for the individual
who is participating in the food
frequency
may not include ethnic or child
appropriate foods or quantities that
are realistic for those eating
larger amounts, such as athletes.
Observation of Food Intake/“Calorie Count”
• In an acute care or long-term care setting.
• In most institutions, nursing or nutrition staff document
what the patient eats from meal trays. then calculates
nutritional information.
• This method also allows the RD or DTR to establish rapport
and determine food preferences and tolerances.
Evaluation and Interpretation
of Dietary Analysis Information
1. Evaluation and Interpretation Using the U.S. Dietary
Guidelines.
2. Evaluation and Interpretation Using USDA’s MyPyramid.
3. Evaluation and Interpretation Using the Diabetic
Exchanges/Carbohydrate Counting.
4. Evaluation and Interpretation Using Individual Nutrient
Analysis.
5. Evaluation and Interpretation Using Daily Values/ Dietary
Reference Intakes.
Anthropometric/Body
Composition Measurements
• “Anthropometry is the measurement of body size, weight,
and proportions.” Body composition refers to the
distribution of body compartments (e.g., muscle mass and
body fat) as part of the total body weight. Evaluating both
anthropometric and body composition data allows the
clinician to fully assess these compartments.
• Results of anthropometric assessment can be used to both
identify goals for nutrition intervention and monitor
changes that occur as a result of either those interventions
or continued effects of disease and stress.
Clinical assessment
• Clinical assessment of nutritional status involves a detailed
history, a thorough physical examination, and the
interpretation of the signs and symptoms associated with
malnutrition.
• It can be an efficient and effective way for an experienced
and astute clinician to evaluate a patient’s nutritional status
without having to depend entirely on laboratory and
diagnostic tests that may delay initiation of nutritional
support and increase the time and cost of hospitalization.
Biochemical measures
• Protein status
• Iron status
• Calcium status
• Zinc status
• Iodine status
• Vitamin ( A, D, C, B, Folate)
• Blood chemistry tests ( enzymes, BUN, bilirubin, lipid
profile
• Biochemical tests can potentially provide more objective
and quantitative data on nutritional status.
• Biochemical tests, also known as biomarkers
• can detect nutrient deficits before changes in the
anthropometric or give signs of deficiency
• Some of these tests are useful indicators of recent nutrient
intake and can be used in conjunction with dietary methods
to assess food and nutrient consumption
Step 2: Nutrition Diagnosis
• nutrition diagnosis—the identification and descriptive labeling of an actual
occurrence of a nutrition problem that dietetics practitioners are responsible
for treating independently
• Nutrition diagnosis is not the same a medical diagnosis. It describes a
problem for which nutrition related activities provide the primary
intervention.
• A nutrition diagnosis should not be confused with a medical diagnosis; the
distinction between the two is extremely important. A medical diagnosis is
the art of distinguishing one disease from another and describes the nature
of that disease.
• The desired format for writing a nutrition diagnosis is PES (problem,
etiology, and signs and systems).
• Critical thinking skills such as finding patterns and relationships, stating
problems clearly and singularly, and ruling in/ruling out certain diagnoses
are essential to making accurate nutrition diagnosis.
• Accurate nutrition diagnoses set the stage for quality nutrition intervention
and nutrition monitoring and evaluating.
Step 2: Nutrition Diagnosis
• PES Statements Nutrition diagnoses are written in a PES
(problem, etiology, signs/symptoms) format that lists the
problem, its cause, and appropriate defining characteristics.
• The problem (P) is also referred to as the diagnostic label. It
describes in a general way an alteration in the client’s nutritional
status. Words like excessive, inadequate, and inappropriate are
frequently found in these labels.
• The etiology (E) or related factors are those factors that
contribute to the cause or existence of a particular problem.
• Finally, the signs and symptoms (S) are the defining
characteristics obtained from the subjective and objective
nutrition assessment data.
• the nutrition diagnostic statement, it is generally stated in the
following way: the problem (P) related to the etiology (E) as
evidenced by the signs and symptoms (S).
Nutrition Diagnosis- PES Statement
For example
• “Inadequate energy intake (P) related to changes in taste
and appetite (E) as evidenced by average daily kcal intake
50% less than estimated recommendations (S)”
• “Involuntary weight loss (P) related to inadequate energy
intake (E) as evidenced by eight pounds weight loss within
four weeks (S)
Step 3: Nutrition Intervention
• Nutrition interventions are the actions taken to treat
nutrition problems.
• Nutrition intervention involves two steps: planning and
implementation.
• the nutrition intervention should target the etiology
identified during the assessment step of NCP.
• if the nutrition diagnosis is Excessive Carbohydrate and the
etiology is lack of knowledge about high carbohydrate
foods, then the appropriate intervention would be
education on which foods are high in carbohydrate.
• When the RDN cannot treat the etiology of the nutrition
diagnosis directly, the treatment should focus on
ameliorating the signs and symptoms of the diagnosis.
• For example, a frequent etiology of malnutrition in
hospitalized adult patients is inflammation. The RDN may
not be able to intervene directly in the inflammatory
process; however, inflammation can increase the patient’s
nutritional needs. Therefore, although the RDN may not be
able to reduce the inflammation, the RDN can increase the
amount of nutrients provided to the patient through high-
calorie foods, nutritional supplements, or other nutrition
support therapies.
• During the planning phase of the nutrition intervention, the
RDN, patient or client, and others as needed, collaborate to
identify goals and objectives that will signify success of the
intervention.
• Whether in an inpatient or outpatient clinical setting,a
significant component of the plan is the patient prescription.
• Interventions may include food and nutrition therapies,
nutrition education, counseling, or coordination of care.
• Because the care process is continuous, the initial plan may
change as the condition of the patient changes, as new needs are
identified, or if the interventions prove to be unsuccessful.
• Interventions should be specific; they are the “what, where,
when, and how” of the care plan.
• For example, in a patient with "inadequate oral food or
beverage intake,” an objective may be to increase portion
sizes at two meals per day.
• Four categories of interventions are within the Nutrition
Care Process Terminology (eNCPT): (1) food and nutrient
delivery, (2) nutrition education, (3) nutrition counseling,
and (4) coordination of nutrition care by a nutrition
professional.
Step 4 :Monitoring and Evaluation of Nutrition
Care
• The fourth step in the NCP involves monitoring and
evaluation of the effect of nutrition interventions.
• the RDN first determines indicators that should be
monitored.
• These indicators should match the signs and symptoms
identified during the assessment process.
• For example, if excessive sodium intake was identified
during the assessment, then an evaluation of sodium intake
is needed at a designated time for follow-up.
• In the clinical setting the goal of nutrition care is to meet
the nutritional needs of the patient or client; thus
interventions must be monitored and progress toward goals
must be evaluated frequently.
• This ensures that unmet objectives are addressed and care is
evaluated and modified in a timely manner.
• Evaluation of the monitored indicators provides objective
data to demonstrate effectiveness of nutrition interventions,
regardless of the setting or focus
• If objectives are written in measurable terms, evaluation is
relatively easy because a change in the indicator is compared
with the status of the indicator before implementation of
the nutrition intervention.
• When evaluation reveals that objectives are not being met
or that new needs have arisen, the process begins again with
reassessment, identification of new nutrition diagnoses,
and formulation of a new NCP.
DOCUMENTATION IN THE NUTRITION CARE
RECORD
• MNT and other nutrition care provided must be documented in
the health or medical record. The medical record is a legal
document; if interventions are not recorded, it is assumed that
they have not occurred. Documentation affords the following
advantages:
1. It ensures that nutrition care will be relevant, thorough, and
effective by providing a record that identifies the problems and
sets criteria for evaluating the care.
2. It allows the entire health care team to understand the
rationale for nutrition care, the means by which it will be
provided, and the role each team member must play to
reinforce the plan and ensure its success.
 Anthropometric
measurement and body
composition
O Anthropometry is the measurement of body
size, weight, and proportions.
O Measures obtained from anthropometry
can be sensitive indicators of health,
development, and growth in infants and
children.
O Anthropometric measures can be used to
evaluate nutritional status, whether it be obesity
caused by over nutrition or emaciation resulting
from protein-energy malnutrition.
O They are valuable in monitoring the effects of
nutritional intervention for disease, trauma,
surgery, or malnutrition.
O Anthropometry also is considered the method of
choice for estimating body composition in a
clinical setting.
 Length and stature
O In measurements of length and stature,
reference will be made to positioning the
head in the Frankfort horizontal plane.

O (feet/inches, centimeter/ millimeter,

O Stature, or standing height, can be
measured for subject 2 to 3 years of age
and older who are cooperative and able
to stand without assistance.
O Using the moveable rod on a platform scale
is not recommended because it often lacks
rigidity, the headboard is not always
correctly aligned, there is no rigid surface
against which to position the body, and the
platform height will vary depending on the
subject’s weight

O use a stadiometer,
O Nonambulatory Persons
In nonambulatory persons (those unable to
walk) or those who have such severe spinal
curvature that measurement of height would
be inaccurate, stature can be estimated
from knee height.
Knee height
Knee height caliper
Estimate height from demi span
 Head Circumference
O Head circumference measurement is an important
screening procedure to detect abnormalities of head
and brain growth, especially in the first year of life.

O A flexible, nonstretchable measuring tape is required.

O Objects such as pins should be removed from the hair.

O Head circumference is most easily
measured when the infant or child is sitting
on the lap of the caregiver,
O although older children can be measured
when they are standing.

O lower edge of the tape should be positioned

just above the eyebrows, above (not over)
the ears, and around the back of the head,
 Measuring Weight
O One of the most important measurements in
nutritional assessment is body weight.
O Weight is an important variable in equations
predicting caloric expenditure and in indices
of body composition.

O Body weights should be obtained using an

electronic scale,
 Pediatric
O Infants should be weighed on a pan-type
pediatric electronic scale that is accurate to
within at least 10 g
O either a towel or diaper) used in the pan
should be in place when the zero
adjustments are made on the scale or its
weight should be subtracted from the
infant’s weight.
 Children and adults
O Children and adults who can stand without
assistance are weighed on a platform
electronic scale that is accurate to 100 g
(0.1 kg).
Non ambulatory Persons
O Body weight also can be computed from
knee height, calf circumference, midarm
circumference, and subscapular skinfold
thickness.
 BMI
O WHO categories

O Consider the body frame

O Consider the body composition

O Consider the age

 BMI and morbidity
O There is overwhelming scientific evidence
that overweight and obese individuals, as a
group, tend to die at a younger age
compared to persons who are not
overweight or obese.

O Excess body fat is an important risk factor

for type 2 diabetes, hypertension, coronary
heart disease, certain types of cancer,
osteoarthritis, and other health conditions.
 BMI and mortality
O A recent study that pooled data from 57 different
prospective studies with nearly 900,000
participants mostly from western Europe and
North America showed that risk of death was
lowest when BMI was approximately 22.5 kg/m 2
to 25.0 kg/m 2
O Every additional 5 kg/m 2 of BMI greater than 25. was
associated with a 30% greater risk of death from all
causes, 40% greater risk of death from cardiovascular
60% to 120% greater risk of death from diabetic, renal,
and hepatic diseases, 10% increased risk of death from
neoplastic diseases.
 Height weight tables

Method to asses the optimum body weight

 Measuring Frame Size
Formula
O The following formula can be used to
determine frame size from the ratio of body
height to wrist circumference,
 Factors affect the BMI
O Discussion
 WHO growth charts
O Growth charts are a fundamental tool for evaluating
physical growth and development and for assessing
the nutritional status and general well-being of
infants, children, and adolescents.

O Used to follow up nutritional management in sick

child ( enteral or parenteral feeding)
O Traditionally, they have primarily been used
for detecting malnutrition,
O prevalence of overweight and obesity among
children and adolescents have led to the
increased use of growth charts to screen for
unhealthy weight gain, overweight, and
obesity in the pediatric population
 CDC growth chart
O Age 0-24 months ( birth to 2 years)
O 2- 20 years

O Developed by the CDC using growth

standard data collected by the World Health
Organization (WHO) in its Multicentre Growth
Reference Study (MGRS)
O Age 0-2 years

O The study was conducted between 1997 and 2003

in six sites: Pelotas, Brazil; Accra, Ghana;
O Delhi, India; Oslo, Norway; Muscat, Oman; and Davis,
California.

O Mothers, infants, and young children participating in

the study had to meet strict inclusion and exclusion
criteria.

(exclude babies for smoker mothers, low income >37

getational age or < 42 weeks,
All breast fed for 12 months
 Using the charts
O select the chart that correctly matches the
child’s age and sex.
O Measurements for length, head circumference,
and weight must be carefully taken following the
standardized methods
O Age should be calculated to the nearest month
O Then locate the subject’s length, weight, or head
circumference on the vertical axis.
O Draw a small circle on the chart where the lines
representing these two values intersect.
O nine percentile curves: 2, 5, 10, 25, 50, 75, 90,
95, and 98.
O it is on or near the 50th percentile curve. In
other words, the 50th percentile is considered the
average, or median,
O If a child’s height for age were at the 10th
percentile, only 10% of children of the same age
and sex would be shorter.
O If the plotted length for age were on the 75th
percentile curve, 75% of girls her age would be
shorter than she is.
O The charts for the age interval birth to 24
months give percentile curves for
1- length-for-age
2- weight-for-age
3- weight-for length,
4- head circumference-for-age.
 Charts from 2-20
O The charts recommended for assessing
growth in children and adolescents from age
2 up to 20 years were published in 2000
and developed by the CDC using growth
reference data because high-quality growth
standard data
O For age 2-20 years
O These charts are based primarily on
anthropometric measurements performed on
nationally representative samples of infants,
children, and adolescents during a series of
national health examination surveys conducted
by the CDC between 1963 and 1994
O For the age interval 2 to 20 years, the charts
give percentile curves for
1- stature (height)-for-age
2- weight-for-age
3- body mass index for age
4- weight-for-stature.
 Differences
O Head circumference, a variable included in
the birth-to- 24-months age charts, is omitted in
the charts for those 2 to 20 years old.

O Stature (or standing height) is used instead of

length

O The tables for recording this subject’s

anthropometric data and, when appropriate, the
mother’s and father’s stature, are located in the
upper left-hand corner of the charts.
O Another difference is in the number of
percentile curves.
O In the stature-for-age and weight-for-age
charts for both sexes, there are seven
percentile curves: 5, 10, 25, 50, 75, 90, and
95
 Circumferences
O MUAC
O WC
O HC
O CC

O Land marks
MUAC
Waist circumference
O Waist circumference (distance around the waist)
is a common measure used to check for fat held
around the stomach.
O Having extra body fat around the stomach-more
than 88 cm (35 in.) for women and more
than 102 cm (40 in.) for men-increases your risk
of heart disease and diabetes.
O Place a tape measure around the body at the
top of the hip bone. This is usually at the level of
the belly button
Hip circumference
W/H ratio
O Two ways to assessing total abdominal fat that
are relatively easy to perform in the clinical
setting are the
1- waist-to-hip ratio and waist circumference. The
waist to- hip ratio (WHR) is calculated by dividing
the waist circumference by the hip (or gluteal)
circumference

O excessive fat in the visceral compartment is

most strongly correlated with increased risk for
morbidity and mortality;
O < 0.9 and < 0.8 for adult males and females,
O The cutoffs points (Caucasian) of WHR used
(>1 in men and >0.85 in women)

O cutoffs points for Asians used (0.95 in men

and 0.80 in women)
Calf circumference
Knee height
Circumferences and muscle
wasting
O The cut off points affected by:

O Age
O Gender
O Ethnicity
O Health status
 Body fat distribution
O Body fat distribution can be classified into two
types:
O (1) upper body, android, or male type, and
O (2) lower body, gynoid, or female type

O Obese persons with most of their fat

within the hips and thighs have gynoid obesity.

O Android obesity is generally (but not always)

seen in obese males
O Total abdominal fat has been described as
the sum of the fat, or adipose tissue,
present in three compartments of the body’s
1- subcutaneous (just under the skin),
2- visceral (surrounding the organs within the
peritoneal cavity), and
3- retroperitoneal (outside of and posterior to
the peritoneal cavity).
 Body composition
O Good indicators for nutritional status (
depletion of the body fat )
O Body composition can be an important
factor in certain athletic events (can help
these athletes maintain body fat at levels
that are neither too high nor too low.

Athlete female triad (read)

Body compartment model
 Measuring the body
composition
O Direct method ( Cadaveric studies )

O Indirect method
- Skin fold
- Densitometry
- Total Body Water and biochemical
- Electrical conductance
 Direct method
O The most comprehensive direct study of
body composition was the Brussels Cadaver
Analysis Study (CAS)
O more than 30 cadavers were studied from
1979 to 1983.
O The CAS helped validate various in vivo
methods for estimating body composition
and collected data for developing new
anthropometric models for determining body
composition
 Indirect methods

O Skin fold
O Densitometry
O Electrical conduction
O Rays ( dual x ray, infrared, ultrasound)
 Skinfold measurements
O The most widely used method of indirectly estimating
percent body fat in clinical settings is to measure
skinfolds— the thickness of a double fold of skin and
compressed subcutaneous adipose tissue
O Tool: caliper ( many models)
 Advantages
O The equipment needed is inexpensive and
requires little space;
O measurements are easily and quickly
obtained; and, when correctly done,
O skinfold measurement provides estimates
of body composition that correlate well with
those derived from hydrostatic weighing, the
most widely used laboratory method for
determining body composition.
 Fat control
Slim Guide

Holtain
Lange

Harpenden
Assumptions for skin fold
O overall subcutaneous adipose tissue is best
assessed by measuring multiple skinfold sites.
A minimum of three is recommended. Proper
site selection is critical because
subcutaneous fat layer thickness can vary
significantly within a 2- to 3-cm proximity of
certain sites.
O Adipose tissue can be divided into external,
or subcutaneous (what lies directly under
the skin), and internal portions (that within
and around muscles and surrounding
organs).
O The only direct data on the relationship of
external-to-internal adipose tissue comes from
the CAS.
Measurement Technique
O Page 189
1- right side measurement ( except indicated
other wise)
2- allocate the land marks
3- The skinfold should be firmly grasped by the
thumb and index finger of the left hand about
1 cm. proximal to the skinfold site and pulled
away from the body. ( difficult in obese)
4- The caliper is held in the right hand,
perpendicular to the long axis of the skinfold
and with the caliper’s dial facing up and easily
readable.

O 5- The caliper should not be placed too

deeply into the skinfold or too close to the
tip of the skinfold.
6- The dial is read approximately 4 seconds
after the pressure from the measurer’s hand
has been released on the lever arm of the
caliper.
O If caliper tips exert force for longer than 4
seconds, the reading will gradually become
smaller as fluids are forced from the
compressed tissues.
7- minimum two measurements should ne
taken for each site ( 15 second apart)

8- The measurer should maintain pressure

with the thumb and index finger throughout
each measurement.
9- When measuring the obese, it may be impossible
to elevate a skinfold with parallel sides,
particularly over the abdomen. In this situation,
the measurer should use both hands to pull
the skinfold away while a partner attempts to
measure the width.
10- Measurements should not be taken
immediately after exercise or when the person
being measured is overheated because the
shift in body fluid to the skin will inflate normal
skinfold size.

11- Practice and practice to be professional

 Site selection
O According to the Anthropometric
Standardization Reference Manual.

8 site are commonly used

 Triceps
O Because of its accessibility, the triceps is the
most commonly measured site.
O The triceps skinfold site is on the posterior
aspect of the right arm, over the triceps
muscle, midway between the lateral
projection of the acromion process of the
scapula and the inferior margin of the
olecranon process of the ulna.
Measurement of the triceps
skinfold.
 Chest or pectoral
O The chest, or pectoral skinfold site, is measured using
a skinfold with its long axis running from the top of
the anterior axillary fold to the nipple.
 Subscapular
O The subscapular site is 1 cm below the lowest, or
inferior, angle of the scapula,
 Midaxillary
O this site is at the right midaxillary line (a vertical line
extending from the middle of the axilla) level with the
xiphisternal junction (at the bottom of the sternum
where the xiphoid process begins).
Midaxillary
 Suprailliac
O This skinfold is measured just above the
iliac crest at the midaxillary line

O The measurer should grasp the skinfold

about 1 cm posterior to the midaxillary line
and measure the skinfold at the midaxillary
line
 Abdomin
O The subject stands erectly with the body
weight evenly distributed on both feet,
abdominal muscles relaxed, and breathing
quietly.
O A horizontal skinfold 3 cm to the right
of and 1 cm below the midpoint of the
umbilicus is measured
 Thigh
O This site is a vertical skinfold along the
midline of the anterior aspect of the thigh
midway between the junction of the midline
and the inguinal crease and the proximal
(upper) border of the patella, or knee cap
 Medial calf
O With the subject sitting, the right leg is
flexed about 90 degrees at the knee with
the sole of the foot flat on the floor.

O The point of maximum calf circumference is

marked at the medial (inner) aspect of
the calf.
 The biceps skinfold
O It is a vertical fold on the anterior aspect of
the arm, over the belly of the biceps muscle,
directly opposite the triceps skinfold site
 Two site skinfold
measurement
O The most commonly used approach to
assessing body composition for young
people age 6 years through the mid-20s
O uses the sum of the triceps and subscapular
sites.
These sites have the following advantages:
they are highly correlated with other measures
of body fatness;
 Multiple-Site Skinfold
Measurements
O Predicting body density and then percent of body fat from
skinfold measurements requires regression equations.

O These formulas have been developed by comparing

a variety of skinfold and other anthropometric measures
with measurements of body density (usually by hydrostatic
weighing) to see which anthropometric measures
are best at predicting body density
 Densitometry
O Densitometry is assessing body composition
by measuring the density of the entire body.
O Density is expressed as mass per unit
volume and usually is obtained through
hydrostatic, or underwater, weighing, other
method : air displacement
Underwater Weighing
 Assumption
O The approach also assumes a constant fat
mass density of 0.90 g/cm 3 and a density
of the fat-free mass of 1.10 g/cm

O Use of formula

O Procedures : not required

 Weakness
O Underwater weighing has several weaknesses.
O 1- It is not practical for testing large numbers of
people.
O 2- Subjects must be willing and able to remain
submerged and motionless long enough for an
accurate measurement of weight to be made.
O 3- The technique requires some special
equipment, experience, and financial investment
O 4- based on assumption ( many sources of error)
O 5- cavity inside the body ( GUT)
 Total Body Water
O water labeled with (isotope) either tritium ( 3
H 2 O), deuterium ( 2 H 2 O= D2O), or the
stable
isotope of oxygen (H 2 18 O).
Trace for the labeled water distribution during
the equilibrium period
 Air Displacement
Plethysmography
O alternative to underwater weighing, body
volume (and, consequently, body density
and percent body fat)
O can be measured using a technique known
as air displacement plethysmography.

O commercially available air displacement

plethysmograph (what the manufacturer
calls the “Bod Pod ®
 Others
O Total body potassium
More than 90% of all the body’s potassium is
located within fat-free tissues

O Neutron activation analysis

allows measurement of the body’s content of
calcium, iodine, hydrogen, sodium, chloride,
phosphorus, carbon, and nitrogen.
Indicators for muscle, bone minerals
O Creatinine Excretion
The amount of creatinine excreted in the urine
over a 24-hour period can be used in
estimating body muscle mass.

O 3-Methylhistidine is an amino acid found in

actin and myosin, the contractile proteins of
muscle.
 Electrical Conductance
O The use of electrical conductance to assess
body composition is based on the marked
difference in electrolyte content between fat
and fat-free tissue.

O electrolytes in body water are capable

of conducting electricity
O the body’s fat-free mass has a greater
electrical conductivity than its fat mass.
Bioelectrical impedance (BIA)
O Very popular
O Safe
O User friendly
O Portable
O Rapid
O Non invasive
O Accuracy depends on the model and the brand
O Need to be validated in hospitalized patients
O Can not be used in subjects with edema
O Affected by the hydration status of the subjects
 Others
O Infrared Interactance

O safe
O noninvasive,
O Rapid
O convenient to use.
O hospitals, health clubs, and weight loss
clinics.
O Ultrasound
O It is noninvasive,
O Nonradioactive
O Safe
O relatively portable
O Expensive and
O Need training
Computed tomography (CT)
O an imaging technique producing highly detailed
cross-sectional images of the
body resulting from differences in the transmission
of an X-ray beam through body tissues of differing
density.
Advantage
1- Used to assess the subcutaneous and
intrabdominal fat
2- used to differentiate among various types of
lean tissue, such as skeletal muscle, visceral
mass, or organ mass;
O Limited use : due to safety issues
Magnetic Resonance Imaging
O that allows both imaging of the body and in
vivo chemical analysis without hazard to the
subject.
O The advantages of MRI are several:
1- It is totally noninvasive,
2- use no ionizing radiation (thus, it is safe for
children, females of childbearing age, and multiple
studies on the same subject)
3- produces high-quality images of the body,
allows the amount and distribution of body fat to
be studied,
4- and can be used to study the metabolic
activity of tissues or organs.
 Dual -Energy X-R ay
Absorptiometry(DXA)
O Dual-energy X-ray absorptiometry (DXA) was
originally developed as a means of
assessing bone mineral density
for the diagnosis of osteoporosis,
O Recent years it has become one of the most
widely used approaches for determining fat
mass and fat-free mass.
O advantage of being fast and safe. A
whole-body scan takes about 3 minutes, and
the radiation exposure is 0.01 to 0.04
millirem, an extremely low dose compared to
the exposure from a conventional chest X
Ray

Affected by the hydration of the subjects

Biochemical Assessment of
Nutritional Status
Biochemical measures
• Protein status
• Iron status
• Calcium status
• Zinc status
• Iodine status
• Vitamin ( A, D, C, B, Folate)
• Blood chemistry tests ( enzymes, BUN, bilirubin, lipid profile
Introduction
• Biochemical tests can potentially provide more objective and
quantitative data on nutritional status.
• Biochemical tests, also known as biomarkers
• can detect nutrient deficits before changes in the
anthropometric or give signs of deficiency
• Some of these tests are useful indicators of recent nutrient
intake and can be used in conjunction with dietary methods to
assess food and nutrient consumption
Use of Biochemical Measures
• Can be grouped into two general categories: static tests and
functional tests.
• These are sometimes referred to as direct and indirect tests

• Static tests are based on measurement of a nutrient or

its metabolite in the blood, urine, or body tissue—for example,
serum measurements of folate, retinol, vitamin B 12 ,
vitamin D.
Functional tests of nutritional status are based on the
ultimate outcome of a nutrient deficiency which is the failure
of the physiologic processes that rely on that nutrient for
optimal performance.
Included among these functional test are measurement of dark
adaptation (assesses vitamin A status) and urinary excretion of
xanthurenic acid in response to consumption of tryptophan

• many functional tests remain in the

experimental stage,
• Biochemical tests can also be used to examine the
validity of various methods of measuring dietary intake
or to determine if respondents are underreporting or over
reporting

( 24 hour urine Nitrogen excretion, 24 hour diet recall)

• Biochemical tests must be used in conjunction with measures
of dietary intake, anthropometric measures, and clinical
methods
Protein status
• Method to assess protein status
1- anthropometric and body composition

2- Diet

3- Clinical

4- Biochemical
types of protein in human body
• Somatic protein
The body’s somatic protein is found within skeletal muscle.
• Visceral protein can be
regarded as consisting of protein within the organs or viscera
of the body (liver, kidneys, pancreas, heart, and so on), the
erythrocytes (red blood cells), serum protein
(exchangeable)
Together they form 30%- 50% of total protein .
• The remaining body protein is found primarily in the skin and
connective tissue (bone matrix, cartilage, tendons, and
ligaments) and is not readily exchangeable with the somatic and
visceral protein pools.
important term
• PEM
• relationship to mortality and poor clinical outcome

• Primary : insufficient intake

• Secondary: in adequate absorption, increase requirement and
increase loss).
Creatinine Excretion
and Creatinine-Height Index
• A biochemical test sometimes used for estimating body muscle
mass is 24-hour urinary creatinine excretion.

• Creatinine, a product of skeletal muscle, is excreted in a relatively

constant proportion to the mass of muscle in the body.

• It is readily measured by any clinical laboratory.

How to use creatinine value to evaluate the protein status:
1- Lean body mass can be estimated by comparing 24-hour urine
creatinine excretion with a standard based on stature
2- cut off points
• Female : 18mg/kg
• Male : 23mg/kg
• 3- creatinine- height index (CHI),
creatinine- height index (CHI),
• a ratio of a patient’s measured 24-hour urinary creatinine
excretion and the expected excretion of a reference adult of the
same sex and stature.
limitation
• 1- The value of protein status measurements based on urinary
creatinine measurements can also be compromised by the
effect of diet on urine creatinine levels
• 2- variability in creatinine excretion,
• 3- height-weight tables for determining expected creatinine
excretion based on sex and stature
nitrogen balance
• A person is said to be in nitrogen balance when the amount
of nitrogen (consumed as protein) equals the amount excreted by the
body.
Nitrogen excreted through: urine, feces, blood loss.

• Positive nitrogen balance occurs when nitrogen intake exceeds nitrogen

loss and is seen in periods of anabolism, such as childhood or recovery
from trauma, surgery, or illness.

• Negative nitrogen balance occurs when nitrogen losses exceed nitrogen

intake and can result from insufficient protein intake, catabolic
states (for example, sepsis, trauma, surgery, and cancer),
or during periods of excessive protein loss (as a result of
burns or certain gastrointestinal and renal diseases characterized
by unusual protein loss)
• Nutritional support can help return a patient to positive nitrogen
balance or at least prevent severe losses of energy stores and
body protein.

• Nitrogen balance studies involve 24-hour measurement of

protein intake and an estimate of nitrogen losses from the body.
The following formula is used:
• Protein intake, measured by dietary assessment methods, is
divided by 6.25 to arrive at an estimate of nitrogen intake.

• Nitrogen loss is generally estimated by measuring urine urea

nitrogen (which accounts for 85% to 90% of nitrogen in the
urine)

• Limitation
- Underestimate the nitrogen loss through stool, wound drainage,
burns , diarrhea and vomiting
- Presence of nonurea nitrogen in the urine
Serum protein
• Serum protein concentrations can be useful in assessing
protein status, in determining whether a patient is at risk
of experiencing medical complications, and for evaluating
a patient’s response to nutritional support.
Albumin
• Serum albumin level has been shown to be an indicator
of depleted protein status and decreased dietary protein intake.

• Low concentrations of serum albumin are associated with

increased morbidity and mortality in hospitalized patients.

• Its relatively long half-life (14 to 20 days) and large body pool (4
to 5 g/kg of body weight) cause serum levels to respond very
slowly to nutritional change

• 60% of the albumin located out of the blood stream ( the

extravascular albumin move to the blood when the albumin
decrease)
• Factors affect the albumin level
1- rate of synthesis
2- distribution in the body
3- the rate of catabolism
4- abnormal loss ( burns , drainage)
5- altered fluid status

During stress : the acute phase reactants ( c reactive protein and

oothers, decrease the albumin synthesis )
transferrin
• Serum transferrin is a b -globulin synthesized in the liver that
binds and transports iron in the plasma.

• Because of its smaller body pool and shorter half-life, it has been
considered a better index of changes in protein status compared
with albumin.

• transferrin levels decrease in chronic infections, protein-losing

enteropathy, chronically draining wounds, nephropathy, acute
catabolic state

• Serum levels can be increased during pregnancy, estrogen

therapy, and acute hepatitis.
prealbumin
• Prealbumin, also known as transthyretin and thyroxinebinding
prealbumin,

• is synthesized in the liver and serves as a transport protein for

thyroxine (T 4 ) and as a carrier protein for retinol-binding
protein

• Short half life, and small body pool ( sensitive indicator of protein
status and malnutrition)
• Reduced by liver disease, sepsis, protein losing enteropathies ,
hyperthyroidism, surgery , trauma
• Can be increases in patients with chronic renal failure
Retinol-Binding Protein
• Retinol-binding protein, a liver protein, acts as a carrier
for retinol

• It circulates in the blood as a [Link] trimolecular complex with

retinol and prealbumin.

• Short half life ( 12 hours)

• serum levels are increased in renal disease

• Serum levels can be decreased in vitamin A deficiency, acute
catabolic states, and hyperthyroidism
Iron status
• Iron deficiency is the most common single nutrient deficiency
and the most common cause of anemia.
Preschool children and women of childbearing age are at highest
risk of iron deficiency.

Causes of iron deficiency:

• 1- ingestion or absorption of dietary iron is inadequate to meet
iron losses
• 2- iron requirements increased by growth or pregnancy.
• 3- heavy menstruation,
• 4- frequent blood donations
• 5- early feeding of cow’s milk to infants (microscopic bleeding in
GI)
• 6- frequent aspirin use,
• 7- disorders characterized by gastrointestinal bleeding.
• Risk of iron deficiency
Period of rapid growth ( infancy, adolescence and pregnancy)
Anemia is a hemoglobin level below the normal reference range
for individuals of the same sex and age.

• Microcytic refers to abnormally small red blood cells

defined by a mean corpuscular volume (MCV) < 80
• macrocytic describes unusually large red blood cells defined as
an MCV > 100 .
Hypochromic cells are those with abnormally low levels of
hemoglobin as defined by a mean corpuscular hemoglobin
concentration < 320 g of hemoglobin/L or by a mean corpuscular
hemoglobin < 27
• Causes of anemia
1- iron deficiency
2- inflammation
3- infection
4- tissue injury
5- cancer
Stages of Iron Depletion
• The risk of iron deficiency increases as the body’s iron stores are
depleted.
• Iron depletion can be divided into three stages.
Serum Ferritin
• When the protein apoferritin combines with iron, ferritin
is formed.
Ferritin, the primary storage form for iron in the body, is found
primarily in the liver, spleen, and bone marrow.

• In healthy persons, approximately 30% of all iron in the body is in

the storage form, most of this as ferritin but some as
hemosiderin.

• As iron stores become depleted, tissue ferritin levels decrease.

• low serum ferritin concentration is a sensitive indicator of early

iron deficiency, but it didn’t reflect the severity of the depletion
Hemoglobin
• Hemoglobin is an iron-containing molecule found in red blood
cells that is capable of carrying oxygen and carbon dioxide.

• It is used as an index of the blood’s oxygen carrying

capacity.
Hematocrit
• is defined as the percentage of red blood cells making up the
entire volume of whole blood.

• It can be measured manually by comparing the height of whole

blood in a capillary tube with the height of the RBC column after
the tube is centrifuged.
Mean Corpuscular Hemoglobin
• The mean corpuscular hemoglobin (MCH) is the amount
of hemoglobin in red blood cells.

• It is calculated by dividing hemoglobin level by the red blood cell

count.
Mean Corpuscular Volume
• Mean corpuscular volume (MCV) is the average volume
of red blood cells.

• Values for MCV are normally in the range of 80 to 100 fL for both
males and females.

• Macrocytosis ( macrocytic anemia) caused by: vitamin B 12 and

folate deficiency , chronic liver diseases, alcoholism,
chemotherapy.
• Microcytosis ( microcytic anemia ) iron deficiency, chronic
diseases, lead poisoning
Assessing iron status
Iron Overload
• A second disorder of iron metabolism is iron overload,
which is the accumulation of excess iron in body tissues.

• Iron overload is most often the result of hemochromatosis,

• a group of genetic diseases characterized by excessive intestinal
iron absorption and deposition of excessive amounts of iron in
parenchymal cells with eventual tissue damage.

• Iron overload cause: liver, heart and pancreas damage

Calcium status
• Calcium is essential for bone and tooth formation,
muscle contraction, blood clotting, and cell membrane integrity.

• Of the 1200 g of calcium in the adult body, approximately 99% is

contained in the bones.

• The remaining 1% is found in extracellular fluids, intracellular

structures, and cell membranes.
• there are no appropriate biochemical indicators for assessing
calcium status.
• This is due to :
1- large part to the biological mechanisms that tightly control
serum calcium levels despite wide variations in dietary intake
2- the fact that the skeleton serves as a calcium reserve so large
that calcium deficiency at the cellular or tissue level is essentially
never encountered, at least for nutritional reasons.
• assessing calcium status can be categorized in three areas:
1- bone mineral content measurement,
2- biochemical markers and
3- measures of calcium metabolism.
Serum calcium fractions
• Serum calcium exists in three fractions: protein-bound,
ionized, and complexed.
• Hypocalcemia ( low calcium in plasma) < 2.3
Hypoparathyroidism ( hungry bone)
Renal disease
Acute pancreatitis

Hypercalcemia:> 2.75

Bone resorption,
Renal tubular reabsorption
Hyperthyroidism
Hypervitaminosis of vitamin D
Urinary Calcium
• Urinary calcium levels are more responsive to changes in
dietary calcium intake than are serum levels.

Dietary factors : high protein diet and low in phosphate

High serum calcium leads to high urine calcium

• diurnal variation in urinary calcium: ca concentrations higher

during the day and lower in the evening.
urinary calcium loss occurs when the kideny ability to reabsorb
calcium is impaired
Zinc status
• Zinc’s most important physiologic function is as a component
of numerous enzymes.

• zinc is involved in many metabolic processes, including protein

synthesis, wound healing, immune function, and tissue
growth and maintenance.

Severe zinc deficiency characterized by hypogonadism and

dwarfism has been observed in the Middle East

Low Zinc intake is prevalent among women

• Decreased levels can result from stress, infection or
inflammation, and use of estrogens, oral contraceptives, and
corticosteroids.

• Plasma zinc can fall by 15% to 20% following a meal.

Increased plasma zinc concentrations can result from
fasting and red blood cell hemolysis.
plasma zinc concentration
• Static measurements of plasma zinc are available, but their use is
complicated by the body’s homeostatic control of zinc levels and
by factors influencing serum zinc levels that are unrelated to
nutritional status.
Metallothionen and Zinc Status
• Metallothionen is a protein found in most tissues but
primarily in the liver, pancreas, kidney, and intestinal
mucosa.

• Metallothionen holds promise as a potential indicator

of zinc status.

In case of : low zinc and high metallothionin  stress, infection,

inflammation.

In case of zinc is low and metallothionin is low  Zinc deficiency

Hair Zinc
• Several researchers have investigated the use of zinc in
hair as an indicator of body zinc status.

• Decreased concentration of zinc in hair has been reported in zinc

deficiency

• Because hair grows slowly (about 1 cm per month), levels of zinc

and other trace elements in hair reflect nutritional status over
many months and thus are not affected by diurnal variations or
short-term fluctuations in nutritional status.

• Easy sampling, no risk as blood, easily stored

• Consider hair color may affect the zinc status.

Urinary Zinc
• Lower than expected concentrations of zinc have been reported
in the urine of zinc-depleted persons.

• Other factors affect the urinary zinc

Liver cirrhosis, hepatits, sickle cell anemia, TPN.

Not convenient : 24 hour urine collection

Iodine Status
• Iodine is a trace element essential for the synthesis of
thyroid hormones that regulate metabolic processes
related to normal growth and development in humans
and animals.

• Inadequate intake of iodine leads to insufficient production of

thyroid hormones, resulting in a variety of adverse effects
collectively referred to as iodine deficiency disorders.
assessing Iodine status
• Because more than 90% of dietary iodine is eventually
excreted in the urine, urinary iodine (UI) is the most
widely used indicator of recent iodine intake and nutrition
status.

• For individuals, a 24-hour urine collection is necessary to

estimate iodine intake using UI concentration.

• Limitation: day to day variation, hydration status.

• TSH is a sensitive indicator of iodine status during the neonatal

period.
• Thyroid hormone concentrations are considered unreliable
indicators of iodine status.
Vitamin A Status
• Vitamin A status can be grouped into five categories:
deficient, marginal, adequate, excessive, and toxic.

• Biochemical assessment of vitamin A status generally

involves measurements of plasma concentrations of retinol
or the vitamin A carrier protein, retinol binding protein
(RBP), retinol isotope dilution, and dose-response tests.

Less common: epithelial cell of the conjunctiva, liver biopsy and

dark adaptation
plasma levels
• Measurement of plasma concentration of retinol is the
most common biochemical measure of vitamin A in a population
group.

• Under normal conditions, about 95% of plasma vitamin A is in

the form of retinol and bound to retinol-binding protein, and
about 5% is unbound and in the form of retinyl esters.

• Serum measurements are predictive of vitamin A status only

when the body’s reserves are either critically depleted or
overfilled.
cut off points
• Plasma concentrations <10 m g/dL (0.35 m mol/L) are considered
severely deficient
• and values < 20 m g/dL (0.70 m mol/L) are considered deficient.
• 20 Serum values > 20 m g/ dL (> 0.70 m mol/L) are indicative of
adequate status,
• serum levels > 300 m g/dL are diagnostic of chronic
hypervitaminosis A.
relative dose response
• The relative dose-response test (RDR) and modified relative
dose-response test (MRDR) are based on the principle
That:

when stores of retinol are high, plasma retinol

concentration is little affected by oral administration of
vitamin A. But when reserves are low, the plasma retinol
concentration increases markedly, reaching a peak 5 h
after an oral dose.
Conjunctival Impression Cytology
• Vitamin A deficiency can result in morphologic changes
in epithelial cells covering the body and lining its cavities.

• It can result in a decline in the number of mucus-producing

goblet cells in the epithelium of the conjunctiva of the
eye.
Dark Adaptation
• The best-defined function of vitamin A is its role in the
visual process.
• The visual pigment rhodopsin is generated when the protein
opsin in the rods of the retina combines with a cis -isomer of
retinol

• Under normal conditions,

sufficient retinol is present, and rhodopsin is readily
formed.
When vitamin A is in short supply, less rhodopsin is formed, and
the eye fails to adapt as readily to low light levels after exposure to
bright light levels.
Direct Measurement of Liver Stores
• Direct measurement of hepatic vitamin A stores in liver
tissue is considered the “gold standard” of vitamin A status,
but its invasive nature limits its usefulness.

• The assay can be done on a very small amount of

liver tissue obtained by inserting a biopsy needle through
the abdominal wall.
Retinol Isotope Dilution
• The procedure involves administering to a subject a known
amount of vitamin A that is labeled with a nonradioactive
isotope

• A sample of blood is then removed from the subject and

the plasma concentrations of the labeled and unlabeled
vitamin A are measured. Using a mathematical formula,
the ratio of the labeled vitamin A to the unlabeled vitamin
A is calculated. This ratio is used to estimate the size of the
subject’s total vitamin A pool.
Vitamin D status
• The major physiological function of vitamin D in vertebrates,
including humans, is to maintain serum calcium
and phosphorus concentrations in a range that supports
bone mineralization, neuromuscular function, and various
cellular processes.

• Vitamin D (calciferol) is a fat-soluble sterol found in

a limited number of foods, including fish-liver oils, fatty
fishes, mushrooms, egg yolks, and liver.

• The two major forms of vitamin D are cholecalciferol (D 3 ) and

ergocalciferol (D 2 ).
Assessing vitamin D status
• Vitamin D status is best assessed by measuring the serum
concentration of 25-hydroxyvitamin D [25(OH)D],

Deficiency : < 30 nmol/l

In adequacy : 30-50
Sufficient: 50-75

Direct measure using several techniques:

HPLC
ELISA
Mass spectrophotometer
vitamin C status
• Vitamin C is a generic term for compounds exhibiting
the biological activity of ascorbic acid, the reduced form
of vitamin C.
• The oxidized form of vitamin C is known as dehydroascorbic acid.

• The sum of ascorbic acid and dehydroascorbic acid constitutes all

the naturally occurring biologically active vitamin C.
• Vitamin C status is assessed by measuring total ascorbic acid in
serum (or plasma) and in leucocytes (white blood cells).

• The serum concentration of ascorbic acid is considered an index

of the circulating vitamin available to the tissues.
• The leucocyte concentration is considered an index of tissue
stores.

• Vitamin C deficiency is generally defined as a serum (or plasma)

concentration < 11.4 micromoles per liter ( m mol/L) or the level
at which signs and symptoms of scurvy begin to appear.
• A low serum (or plasma) concentration is 11.4 to 23.0 m mol/L.
Serum and Leukocyte Vitamin C
• in recent years, there has been increasing interest in using the
level of vitamin C in polymorphonuclear leukocytes (the granular
leukocytes:
• neutrophils, eosinophils, and basophils) and the mononuclear
leukocytes (the agranular leukocytes: lymphocytes
and monocytes)

as indicators of vitamin C status

• Serum levels of ascorbic acid have been shown to correlate

with dietary vitamin C intake and with vitamin C levels in
leukocytes (white blood cells).
• Factors affect vitamin C level :
• Smoking
• Gender ( females show higher vitamin C level than males)
Vitamin B status
• Vitamin B 6 status can be assessed by several methods.

• Static measurements can be made of vitamin B 6

concentrations in blood or urine
and functional tests can measure the activity of several enzymes
dependent on vitamin B 6

The direct measurement is plasma PLP: plasma pyridoxal

phosphate

• Fasting measurements of plasma PLP are considered the single

most informative indicator of vitamin B 6 status for healthy
persons.
• In certain cases :
Astham
Pregnancy
Coronary heart diseases.
Abnormal low concentration of PLP is not reflective
Folate status
• Folate, or folacin, is a group of water-soluble compounds
with properties and chemical structures similar to those
of folic acid,

• The recommended measurements for assessing

folate status are serum folate concentration and red blood
cell (RBC) folate concentration.

Factors elevate the serum folate level:

Renal failure, liver diseases, hemolysis of red blood cells, alcohol,
smoking, oral contraceptive pills.
• Serum folate : fluctuating ( in day, day- day)

• a low serum folate concentration is considered < 2 ng/mL.

• low RBC folate concentration is considered < 95 ng/mL.

vitamin B 12 status
• Vitamin B 12 , or cobalamin, include a group of cobalt containing
molecules that can be converted to methylcobalamin
or 5 9 -deoxyadenosylcobalamin, the two coenzyme forms of
vitamin B 12 that are active in human metabolism.

• Biochemical Indicators of B 12 Status

biomarkers for assessing vitamin B 12 status are those that:
1- directly measure vitamin B 12 in the blood and
2- functional biomarkers measuring metabolites that accumulate
when vitamin B 12 status is inadequate.
• Direct measures
• of circulating vitamin B 12 are serum or plasma total cobalamin
and serum holo-transcobalamin,
• the transport protein of absorbed vitamin B 12 .

• These measures reflect the broad range of vitamin B 12 status

from severe deficiency to adequacy
• A functional biomarker specific to vitamin B 12status :

1- urinary or serum methylmalonic acid (MMA),

which is increased when vitamin B 12 status is inadequate.

2- plasma concentration of total homocysteine (tHcy), which

increases when vitamin B 12 status is inadequate,

but is also increased during folate and vitamin B 6

deficiency
Blood Chemistry Tests
• They include :
• Electrolytes
• enzymes
• metabolites and
• other miscellaneous substances

chemistry profile, chemistry panel, chem profile,

Alanine aminotransferase
• Alanine aminotransferase (ALT), also known as serum glutamic
pyruvic transaminase (SGPT)
• is an enzyme found in large concentrations in the liver and to a
lesser extent in the kidneys, skeletal muscles, and myocardium
(heart muscle).

Elevated after liver injury ( hepatitis , liver toxicity

May be elevated after MI, muscle diseases.

Decreased level : chronic renal dialysis

Range adult : 4-36 IU/L

albumin and total protein
• Albumin is a serum protein produced in the liver.

• Refer to the previous slides

Alkaline Phosphatase (ALP)
• Alkaline phosphatase (ALP) is an enzyme found in the
liver, bone, placenta, and intestine and is useful in detecting
diseases in these organs.

Expected values are higher (physiological)

• in children
• during skeletal growth in adolescents, and
• during pregnancy

Pathological increase :
Hyperparathyroidism
Certain bone tumor
Liver disease
Low level of ALP: (not clinically significant )
Normal level: 30-120U/L
Aspartate aminotransferase (AST)
• also known as serum glutamic oxaloacetic transaminase (SGOT),

• is an enzyme found in large concentrations in the myocardium, liver,

skeletal muscles, kidneys, and pancreas. Within 8 to 12
hours following injury to these organs.
• Serum levels peak in 24 to 36 hours and then return to normal in about
4 to 6 days following injury

• Elevated :
MI
Liver diseases
Pancreatitis
Muscle skeletal injury
Toxin s ( liver toxicity )
Range :0-35 U/L
Bilirubin
• Bilirubin, the major pigment of bile, is produced by the
spleen, liver, and bone marrow from the breakdown of the
heme portion of hemoglobin and is released into the blood.

• Most of the bilirubin combines with albumin to form

what is called free, or unconjugated, bilirubin.

• Free bilirubin then is absorbed by the liver, where it is conjugated

(joined) to other molecules to form what is called conjugated
bilirubin and is then excreted into the bile.
• Serum bilirubin levels can be reported as direct bilirubin, indirect
bilirubin, or total bilirubin.

• Direct bilirubin is a measure of conjugated bilirubin in serum.

Indirect bilirubin is a measure of free, or unconjugated, bilirubin
in serum.

• Serum bilirubin rises when the liver is unable to either

conjugate or excrete bilirubin.

• Elevated conjugated (direct) bilirubin suggests obstruction of bile

passages within or near the liver. Elevated free, or unconjugated
(indirect), bilirubin is indicative of excessive hemolysis
(destruction) of RBC
• Elevated indirect bilirubin also is seen in neonates whose
immature livers are unable to adequately conjugate bilirubin.

• A serum bilirubin concentration greater than about 2 mg/dL

results in jaundice.
• The adult reference ranges for adults are 0.3 to 1.0 mg/dL or
for total bilirubin,

• 0.1 to 0.3 mg/dL for direct (conjugated),

• and 0.2 to 0.8 mg/dL for indirect (unconjugated) bilirubin
BUN
• Urea, the end product of protein metabolism and the primary
method of nitrogen excretion, is formed in the liver and excreted
by the kidneys in urine.
Elevated BUN is referred to as azotemia.
• An increased blood urea level:
• indicates renal failure,
• dehydration,
• gastrointestinal bleeding,
• congestive heart failure,
• high protein intake,
• insufficient
• renal blood supply, or blockage of the urinary tract
• Decreased BUN occurs in
• Liver diseases
• Over hydration
• malnutrition,
• or anabolic steroid use.

• The adult reference range is 10 to 20 mg/dL

calcium
• Serum levels of calcium, an important cation (positively
charged ion), are helpful in detecting disorders of the
bones and parathyroid glands, kidney failure, and certain
cancers.

• The adult reference range

• calcium is 9.0 to 10.5 mg/dL,
• and for ionized calcium it is 4.5 to 5.6 mg/dL
Carbon dioxide CO2
• Measurement of carbon dioxide (CO 2 ) in serum helps
assess the body’s acid-base balance.
Elevated CO 2 is seen in metabolic alkalosis, and decreased levels
reflect metabolic acidosis.

The adult reference range in serum or plasma is 23 to 30 mEq/L.

chloride
• Chloride, an electrolyte, is the primary anion (negatively
charged ion) within the extracellular fluid.

• It works in conjunction with sodium to help regulate acid-base

balance, osmotic pressure, and fluid distribution within the body.

• Low serum chloride levels (hypochloremia) are associated with

alkalosis and low serum potassium levels (hypokalemia).

• Hyperchloremia (elevated serum chloride) may be seen in kidney

disease, overactive thyroid, anemia, or heart disease.
• The adult reference range is 100 to 106 mEq/L
Cholesterol
• Correlated with coronary hear diseases
• <200 mg/dl
Creatinine
• Measurement of serum creatinine, like measurement of
blood urea nitrogen, is used for evaluating renal function.

Elevated serum levels are seen when 50% or more of the

kidney’s nephrons are destroyed.
The reference range fo adult males is 0.6 to 1.2 mg/dL, and for
adult females it is 0.6 to 1.2 mg/dL
glucose
• Used to diagnose DM, hypoglycemia,

• HBA1C: Glycosylated hemoglobin , index of long term sugar

control
• OGTT: oral glucose tolerance test
lactate dehydrogenase LDH
• Lactic dehydrogenase (LDH), an enzyme found in the
cells of many organs (skeletal muscles, myocardium,
liver, pancreas, spleen, and brain),

• Serum levels of LDH rise 12 to 24 hours following a myocardial

infarction and are often measured to determine whether an infarction
has occurred. (AST)

• Increased :
• Hepatitis
• Cancer
• Kidney
• Burns
• Trauma
• Adult reference : 100-190 U/L
Phosphorus
• The serum level of phosphorus (also known as inorganic
phosphorus) is closely correlated with serum calcium level.

Elevated:
Renal failure
Hypothyroidism
Hyper thyroidism
Increase intake ( laxative)

Decreased:
Hyperthyroidism
Rickets
osteomalacia
Chronic use of anti acid

Range : 3-4.5 mg/dl

Potassium
• Potassium, the major intracellular cation, is involved in
the maintenance of acid-base balance, the body’s fluid
balance, and nerve impulse transmission.
Elevated serum potassium (hyperkalemia) is most often due to:
• renal failure
• inadequate adrenal gland function (Addison’s disease),
• severe burns,
• or crushing injuries.
Low serum potassium (hypokalemia) can result from :
• diuretics
• intravenous fluid administration without adequate potassium
• vomiting
• diarrhea, and
• Eating disorders.
Normal range : 3.5- 5 meq/L
sodium
• Sodium, the major extracellular cation, is primarily
involved in the maintenance of fluid balance and acid-base
balance.

Elevated sodium level (hypernatreia)

1- dehydration
2- excessive water output ( diarrhea , vomiting, sweating , burns)

Hyponatremia :
Excessive sodium loss, ( diuretics, gastric suctioning)
Fluid retention
Water intoxication
Normal range : 135-145 meq/L
Triglyceride
• Triglyceride (TG) is a useful indicator of lipid tolerance
in patients receiving total parenteral nutrition.

• Fasting serum TG provides a good estimate of very low-density

lipoprotein levels

• Elevated serum TG is now considered a risk factor for coronary

heart disease and an indicator of persons needing coronary heart
disease risk-reduction intervention.
Factors contributing to increased fasting serum TG include
• genetic factors,
• Obesity
• physical inactivity,
• cigarette smoking,
• excess alcohol intake,
• very-high carbohydrate diets,
• type 2 diabetes,
• chronic renal failure, and nephrotic syndrome,
• use of such drugs as corticosteroids, protease inhibitors, beta-
adrenergic blocking agents, and estrogen.

• Normal range: TG<150mg/dl

Liver function test
• ALT
• ALP
• Total protein
• Albumin
• AST
• Bilirubin
• GGT
• PT ( prothrombin time) This test measures how long it takes
your blood to clot. If it takes a long time, that could be a sign of
liver dama
kidney function test
• GFR
• Creatinine
• BUN
Lipid profile
• Total cholestrol
• LDL
• HDL
• Total cholestrol : HDL ratio
• TG
Blood gases
Acidosis and alkalosis – acid
base disorders
Respiratory acidosis
Reduced CO2 elimination
• Decreased breathing rate (respiratory drive) due to drugs
or central nervous system disorders
• Impaired breathing and lung movement (respiratory
mechanics) due, for example, to trauma or abnormal presence
of air between the lung and the wall of the chest
(pneumothorax)
• Respiratory muscle/nerve disease (myasthenia gravis,
botulism, amyotrophic lateral sclerosis (ALS), Guillain-Barre
syndrome)
• Airway obstruction (food or foreign object)
• Lung disease
• Respiratory alkalosis
Increased CO2 elimination
• Hyperventilation due to anxiety, pain, shock
• Drugs, such as early in a overdose of aspirin (salicylates)
• Pneumonia, pulmonary (lung) congestion (due to heart
failure), or embolism
• Exercise
• Fever
• Central nervous system tumor, trauma, infection (meningitis,
encephalitis)
• Liver failure
• Metabolic acidosis
Decreased HCO3-, due to increased acid or loss of bicarbonate
• Alcoholic ketoacidosis
• Diabetic ketoacidosis
• Kidney failure
• Lactic acidosis
• Toxins – late in an overdose of salicylates (aspirin), methanol,
ethylene glycol
• Gastrointestinal bicarbonate loss, such as from
prolonged diarrhea
• Renal bicarbonate loss
• Metabolic alkalosis
Increased HCO3-, due to loss of acid or gain of bicarbonate
• Diuretics
• Prolonged vomiting
• Severe dehydration
• Diseases that cause loss of potassium
• Administration of bicarbonate, ingestion of alkali
• Mild acidosis may not cause any symptoms or it may be
associated with nonspecific symptoms such as fatigue, nausea,
and vomiting. Acute metabolic acidosis may also cause an
increased rate and depth of breathing, confusion, and
headaches, and it can lead to seizures, coma, and in some
cases death.
• Symptoms of alkalosis are often due to associated potassium
(K+) loss and may include irritability, weakness, and muscle
cramping.
Treatment

• Treatment of acidosis and alkalosis involves identifying and

treating the underlying cause(s) of the imbalance and
providing whatever support is necessary to the affected
person.

• In some cases, health practitioners may

give intravenous HCO3- to people with dangerously low
blood pH levels.
Clinical assessment of the
nutritional status
• Clinical assessment of nutritional status involves a detailed
history, a thorough physical examination, and the
interpretation of the signs and symptoms associated with
malnutrition.
• It can be an efficient and effective way for an experienced
and astute clinician to evaluate a patient’s nutritional status
without having to depend entirely on laboratory and
diagnostic tests that may delay initiation of nutritional
support and increase the time and cost of hospitalization.
• Signs are defined as observations, made by a qualified
examiner, of which the patient is usually unaware.
• Symptoms are clinical manifestations reported by the
patient.

• Clinical assessment is done by:

• Medical history
• Dietary history
• SGA
Medical history
• Obtaining a patient’s history is the first step in the clinical
assessment of nutritional status. A good way to begin is by
reviewing the patient’s medical record, giving careful
attention to the patient’s medical history.
• A variety of diseases can affect nutritional status.
• Among these are diabetes, kidney disease, various cancers,
coronary heart disease, stroke, liver disease (e.g., hepatitis
and cirrhosis), gallbladder disease, AIDS, ulcers, and colitis,
as well as recent or past surgical procedures
• Other conditions affecting nutritional status the ability to
chew and swallow; appetite; and the presence of vomiting,
diarrhea, constipation, flatulence, belching, or indigestion.
Component of medical history
Medications
• Information on the use of medications will provide clues
about the patient’s actual or perceived medical condition.
• This will include prescription and over- the-counter
medications, vitamin and mineral supplements, and
nontraditional medications, such as herbal and folk
remedies.
• This information can also be helpful in identifying drug
nutrient interactions potentially having an adverse effect on
the patient’s nutritional status.
Psychosocial factors
• include the patient’s age; occupation; educational level;
marital status; income; living arrangements; number of
dependents; use of alcohol, tobacco, and illicit drugs; degree
of social and emotional support; and access to and ability to
pay for health care.
• The necessary detail of the history will vary depending on
circumstances and will be influenced by the patient’s ability
to respond to questioning.
Dietary History
• This includes a wide range of information about :
• 1- usual eating patterns (timing and location of meals and
snacks)
• 2- food preferences and aversions,
• 3- intolerances and allergies
• 4- amount of money available for purchasing food,
• 5- ability to obtain and prepare food
• 6- eligibility for and access to food assistance programs,
• 7- using supplement
Subjective global assessment (SGA) -
Diagnosing Malnutrition
• Patients identified to be at nutrition risk require a diagnosis
to confirm malnutrition. Subjective global assessment
(SGA) is the gold standard for diagnosing malnutrition.
SGA is a simple bedside method used to diagnose
malnutrition and identify those who would benefit from
nutrition care.
Subjective Global Assessment
• Subjective Global Assessment (SGA) is a clinical technique for
assessing the nutritional status of a patient based on features of
the patient’s history and physical examination.
• SGA is based on four elements of the patient’s history :
1. Recent loss of body weight
2. changes in usual diet
3. presence of significant gastrointestinal symptoms
4. and the patient’s functional capacity)
• and three elements of the physical examination (loss of
subcutaneous fat, muscle wasting, and presence of edema or
ascites).
Cachexia
Fat loss upper arm
Fat loss shoulder
Fat loss shoulder
Ascites
Subjective global assessment
 Specialized Nutrition
Support:
Enteral & Parenteral Nutrition
Chapter 16

Nutrition & Diet Therapy (7th Edition)

 Need for Nutrition Support
• Nutrition support: delivery
• Nutrition support may be of formulated nutrients by
required to meet patient’s feeding tube or
nutritional needs intravenous infusion
– Patients often too ill to • Enteral nutrition:
obtain energy & nutrients supplying nutrients using
by consuming foods
GI tract, including tube
– Or illness may interfere feedings & oral diets
with eating, digestion or
absorption • Parenteral nutrition:
intravenous provision of
nutrients, bypassing the GI
tract

Nutrition & Diet Therapy (7th Edition)

Enteral Nutrition
• If GI function is normal and a poor
appetite is the primary nutrition
problem, patients may be able to
improve their diets by using oral
supplements.
• If patients are unable to meet their
nutrient needs by oral intakes alone,
tube feedings can be used to deliver
the required nutrients.
Nutrition & Diet Therapy (7th Edition)
 Selecting a Feeding Route

Nutrition & Diet Therapy (7th Edition)

Oral Supplements
• Patients who are weak or debilitated
may find it easier to consume oral
supplements than to consume meals.
• A patient who can improve nutrition
status with supplements may be able
to avoid the stress, complications,
and expense associated with tube
feedings.

Nutrition & Diet Therapy (7th Edition)

 • Hospitals usually stock a variety
of nutrient-dense formulas,
milkshakes, fruit drinks, and
snack bars to provide to patients
at risk of becoming malnourished.
• In pharmacies too.
• examples of popular liquid
supplements include Ensure,
Boost, and Carnation Breakfast
essential.

Nutrition & Diet Therapy (7th Edition)

• These types of products can add
energy and protein to the diets of
patients and be a reliable source of
nutrients.

Nutrition & Diet Therapy (7th Edition)

• When a patient uses an oral
supplement, taste becomes an
important consideration. Allowing
patients to sample different products
and select the ones they prefer helps
to promote acceptance.

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
Candidates for Tube Feedings
• Tube feedings are typically
recommended for patients at risk of
developing protein-energy
malnutrition who are unable to
consume adequate food and/or oral
supplements to maintain their
health.

Nutrition & Diet Therapy (7th Edition)

• The following medical conditions or
treatments may indicate the need for
tube feedings

Nutrition & Diet Therapy (7th Edition)

• Severe swallowing disorders
• Impaired motility in the upper GI tract
• GI obstructions and fistulas that can be bypassed
with a feeding tube
• Certain types of intestinal surgeries
• Little or no appetite for extended periods, especially
if the patient is malnourished
• Extremely high nutrient requirements
• Mechanical ventilation
• Mental incapacitation due to confusion, neurological
disorders, or coma

Nutrition & Diet Therapy (7th Edition)

• Contraindications for tube feedings
include severe GI bleeding, high-
output fistulas, intractable vomiting or
diarrhea, and severe malabsorption.
• The procedure may also be
contraindicated if the expected need
for nutrition support is less than 5 to 7
days in a malnourished patient or less
than 7 to 9 days in an adequately
nourished patient.

Nutrition & Diet Therapy (7th Edition)

Tube Feeding Routes
• The feeding route chosen depends on
the patient’s medical condition, the
expected duration of tube feeding,
and the potential complications of a
particular route.

Nutrition & Diet Therapy (7th Edition)

[Link] Access
• When a patient is expected to be
tube fed for less than four weeks,
the feeding tube is generally routed
into the GI tract via the nose
(nasogastric or nasoenteric routes).
• The patient is frequently awake
during transnasal (through-the-nose)
placement of a feeding tube

Nutrition & Diet Therapy (7th Edition)

• While the patient is in a slightly
upright position with head tilted, the
tube is inserted into a nostril and
passed into the stomach (nasogastric
route), duodenum (nasoduodenal
route), or jejunum (nasojejunal
route).
• The final position of the feeding tube
tip is verified by abdominal X-ray or
other means.

Nutrition & Diet Therapy (7th Edition)

• In infants, orogastric placement, in
which the feeding tube is passed into
the stomach via the mouth, is
sometimes preferred over transnasal
routes; this placement allows the
infant to breathe more normally
during feedings.

Nutrition & Diet Therapy (7th Edition)

• When a patient will be tube fed for longer
than four weeks, or if the nasoenteric
route is inaccessible due to an obstruction
or other medical reasons, a direct route to
the stomach or intestine may be created
by passing the tube through an
enterostomy, an opening in the abdominal
wall that leads to the stomach
(gastrostomy) or jejunum (jejunostomy).
An enterostomy can be made by either
surgical incision or needle puncture.

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
Nutrition & Diet Therapy (7th Edition)
Nutrition & Diet Therapy (7th Edition)
[Link]
Selecting a Feeding Route
• Gastric feedings (nasogastric and
gastrostomy routes) are preferred
whenever possible. These feedings
are more easily tolerated and less
complicated to deliver than intestinal
feedings because the stomach
controls the rate at which nutrients
enter the intestine.

Nutrition & Diet Therapy (7th Edition)

 • Gastric feedings are not possible, if
patients have gastric obstructions or
motility disorders that interfere with
the stomach’s ability to empty.
• Gastric feedings are also avoided in
patients at high risk of aspiration, a
common complication in which
substances from the GI tract (either
GI secretions or refluxed stomach
contents) are drawn into the lungs,
potentially leading to pneumonia
Nutrition & Diet Therapy (7th Edition)
• Table 16-1 summarizes the
advantages and disadvantages of the
various tube feeding routes.

Nutrition & Diet Therapy (7th Edition)

Feeding Tubes
• Feeding tubes are made from soft,
flexible materials (such as silicone or
polyurethane) and come in a variety
of lengths and diameters.

Nutrition & Diet Therapy (7th Edition)

 • The tube selected largely depends
on the patient’s age and size, the
feeding route, and the formula
viscosity.
• The outer diameter of a feeding
tube is measured in French units, in
which each unit equals 1/3
millimeter; thus, a “12 French”
feeding tube has a 4-millimeter
diameter.
• The inner diameter depends on the
thickness of the tubing material.
Nutrition & Diet Therapy (7th Edition)
• Double-lumen tubes are also
available; these allow a single tube
to be used for both intestinal
feedings and gastric decompression,
a procedure in which the stomach
contents of patients with motility
problems or obstructions are
removed by suction.

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition Support
• Wide selection of enteral formulas, designed to
meet variety of medical & nutritional needs
• May be used alone or in conjunction with other
foods
• Many formulas can provide all of nutrient
requirements if consumed in sufficient volume
• Classified according to macronutrient composition
• Preferred over intravenous feedings
Enteral nutrition
requires intact &
normal GI function

Nutrition & Diet Therapy (7th Edition)

 Types of Enteral Formulas
• Standard formula: for patients who can digest &
absorb nutrients without difficulty; contains
protein & carbohydrate sources
• Hydrolyzed formulas: used for patients with
compromised digestive or absorptive functions—
macronutrients are partially or fully broken down
& require little, if any, digestion before absorption
• Disease-specific formulas: designed to meet
nutrient needs of patients with particular
disorders: liver, kidney, lung diseases, glucose
intolerance, metabolic stress
• Modular formulas: contain only one or two
macronutrients; used to enhance other formulas
Nutrition & Diet Therapy (7th Edition)
Macronutrient Composition
• The amounts of protein, carbohydrate, and fat in
enteral formulas vary substantially.
• The protein content of most standard formulas
ranges from 12 to 20 percent of total kcalories.
• note that protein needs are high in patients with
severe metabolic stress, whereas protein
restrictions are necessary for patients with
chronic kidney disease.
• Carbohydrate and fat provide most of the energy
in enteral formulas; standard formulas generally
provide 30 to 60 percent of kcalories from
carbohydrate and 15 to 30 percent of kcalories
from fat.
Nutrition & Diet Therapy (7th Edition)
Energy Density
• The energy density of most enteral
formulas ranges from 1.0 to 2.0 kcalories
per milliliter of fluid.
• The formulas that have higher energy
densities can meet energy and nutrient
needs in a smaller volume of fluid
• benefit patients who have high nutrient
needs or fluid restrictions

Nutrition & Diet Therapy (7th Edition)

Fiber Content
• Fiber-containing formulas may be helpful
for improving fecal bulk and colonic
function, treating diarrhea or constipation,
and maintaining blood glucose control.
• Conversely, fiber-containing formulas are
avoided in patients with acute intestinal
conditions or pancreatitis and before or
after some intestinal examinations and
surgeries.

Nutrition & Diet Therapy (7th Edition)

Osmolality
• Osmolality refers to the moles of
osmotically active solutes per kilogram of
solvent.
• An enteral formula with an osmolality
similar to that of blood serum (about 300
milliosmoles per kilogram) is an isotonic
formula, whereas a hypertonic formula
has an osmolality greater than that of
blood serum.

Nutrition & Diet Therapy (7th Edition)

• Most enteral formulas have osmolalities between
300 and 700 milliosmoles per kilogram.
• elemental formulas and nutrient-dense formulas
have higher osmolalities than standard formulas.
• Most people are able to tolerate both
isotonic and hypertonic feedings without
difficulty.
• When medications are infused along with
enteral feedings, the osmotic load
increases substantially and may contribute
to the diarrhea experienced by many
tube-fed patients.

Nutrition & Diet Therapy (7th Edition)

Formula Selection

Nutrition & Diet Therapy (7th Edition)

The main factors that influence formula
selection include:

1. GI function.
2. Nutrient and energy needs
3. Fiber modifications.
4. Individual tolerances (food allergies and
sensitivities)-lactose free and gluten free.
patients with food allergies, ingredient
lists should be checked before providing
a formula.

Nutrition & Diet Therapy (7th Edition)

Safe Handling
• Individuals who are ill or malnourished often
have suppressed immune systems, making them
vulnerable to infection from foodborne illness.
• the personnel involved with preparing or
delivering formula should be aware of the specific
protocols at their facility that prevent formula
contamination.
• Hazard Analysis and Critical Control Points
[HACCP] system
• Hazard Analysis and Critical Control Points (HACCP) system: a management system
to identify and correct potential microbial hazards in the preparation, storage,
handling, and administration of food products

Nutrition & Diet Therapy (7th Edition)

• Formulas may be delivered using an open feeding
system or a closed feeding system.
• With an open system, the formula needs to be
transferred from its original packaging to a
feeding container (cans or bottles, concentrates
that need to be diluted, and powders).
• In a closed system, the sterile formula is
prepackaged in a container that can be contected
directly to a feeding tube.
• Closed systems are less likely to become
contaminated, require less nursing time, and can
hang for longer periods of time than open
systems.
• closed systems cost but less expensive in the
long run because they prevent bacterial
contamination and thus avoid the costs of
treating infections.
Nutrition & Diet Therapy (7th Edition)
Formula Safety Guidelines
• the nursing staff assumes
responsibility for its safe handling.
• Clinicians should carefully wash
hands and put on disposable gloves
before handling formulas and feeding
containers.

Nutrition & Diet Therapy (7th Edition)

The following steps can reduce the risk of
formula contamination when using open
feeding systems
1. Before opening a can of formula, clean the lid with a disposable
alcohol wipe and wash the can opener (if needed) with detergent
and hot water. label the can with the date and time it was
opened.
2. Store opened cans or mixed formulas in clean, closed containers.
Refrigerate the unused portion of formula promptly. Discard
unlabelled or improperly labelled containers and all open
containers.
3. No more than an 8-hour supply of formula (or a 4-hour supply
for newborn infants) when using liquid formula from a can.
Formulas prepared from powders or modules should hang no
longer than 4 hours. Discard any formula that remains, rinse the
feeding bag and tubing, and add fresh formula to the feeding
bag. A new feeding container and tubing (except for the feeding
tube itself) is necessary every 24 hours.
• For closed systems, the hang time should be no longer than 24 to
48 hours.
Nutrition & Diet Therapy (7th Edition)
Administration of Tube
Feedings
• Preparing for Tube Feedings Before
starting a tube feeding, health
practitioners can ease fears by fully
discussing the procedure with the
patient and family members, who
may feel anxious about the use of a
feeding tube.

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
• Serious complications can develop if a transnasal
tube is accidentally inserted into the respiratory
tract or if formula or GI secretions are aspirated
into the lungs.
• To minimize the risk of incorrect tube placement,
clinicians use X-rays to verify the positon of the
feeding tube before a feeding is initiated.
• Tube placement can also be monitored by testing
the pH of a sample of body fluid drawn into the
feeding tube, as the pH in the stomach (5 or
lower) is lower than the pH in the small intestine
or respiratory tract (6 or higher).

Nutrition & Diet Therapy (7th Edition)

• To reduce the risk of aspiration, the patient’s
upper body is elevated to a 30- to 45-degree
angle during the feeding and for 30 to 60
minutes after the feeding whenever possible.
• The addition of blue food coloring to formula was
formerly suggested as a means of identifying
aspirated formula in lung secretions.

Nutrition & Diet Therapy (7th Edition)

Formula Delivery Methods
• Nutrient needs may be met by
delivering relatively large amounts of
formula several times per day
(intermittent feedings) or smaller
amounts continuously (continuous
feedings).

Nutrition & Diet Therapy (7th Edition)

• Intermittent feedings are best tolerated when
they are delivered into the stomach (not the
intestine). Generally, a total of about 250 to 400
milliliters of formula is delivered over 30 to 45
minutes using a gravity drip method or an
infusion pump
• The exact amount is determined by dividing the
required volume of formula into several daily
feedings

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
 [Link]
=I2_OtaPwRbQ&t=682s

Nutrition & Diet Therapy (7th Edition)

• Due to the relatively high volume of
formula delivered at one time, intermittent
feedings may be difficult for some patients
to tolerate, and the risk of aspiration may
be higher than with continuous feedings.
An advantage of intermittent feedings is
that they are similar to the usual pattern
of eating and allow the patient freedom of
movement between meals.

Nutrition & Diet Therapy (7th Edition)

• Rapid delivery of a large volume of
formula into the stomach (250 to
500 milliliters over 5 to 15 minutes)
is called a bolus feeding. This type of
feeding may be given every 3 to 4
hours using a syringe.

Nutrition & Diet Therapy (7th Edition)

• Bolus feedings are convenient for patients and
staff because they are rapidly administered, do
not require an infusion pump, and allow greater
independence for patients.
• However, bolus feedings can cause abdominal
discomfort, nausea, and cramping in some
patients, and the risk of aspiration is greater than
with other methods of feeding.
• For these reasons, bolus feedings are used only
in patients who are not critically ill.

Nutrition & Diet Therapy (7th Edition)

• Continuous feedings are delivered slowly
and at a constant rate over a period of
8 to 24 hours, and are most often used for
intestinal feedings. The slower delivery
rate is easier to tolerate, so continuous
feedings are generally recommended for
critically ill patients or patients who cannot
tolerate intermittent feedings.

Nutrition & Diet Therapy (7th Edition)

• An infusion pump is usually used to
ensure accurate and steady flow rates;
consequently, the feedings can limit the
patient’s freedom of movement and are
also more costly. Continuous feedings
conducted for shorter periods (8 to 16
hours; called cyclic feedings) allow greater
patient mobility and GI rest and may be
used to help patients transition to
intermittent feedings or an oral diet.

Nutrition & Diet Therapy (7th Edition)

Initiating and Advancing
Tube Feedings
• Formula administration techniques
vary widely among institutions, so
protocols should be reviewed
carefully before working with
patients.
• In addition, patient tolerance must
be considered when adjusting
formula delivery rates.

Nutrition & Diet Therapy (7th Edition)

Some general guidelines
include the following
• Formulas are typically provided full-strength;
diluting them is not recommended because this
reduces the nutrients provided and increases
contamination risk.
• Intermittent feedings can start with 60 to 120
milliliters at the initial feeding and be increased
by 60 to 120 milliliters every 8 to 12 hours until
the goal volume is reached.
• Continuous feedings may start at rates of about
10 to 40 milliliters per hour and be increased by
10 to 20 milliliters per hour every 8 to 12 hours
until the goal rate is reached.
Nutrition & Diet Therapy (7th Edition)
• If the patient cannot tolerate an
increased rate of delivery, the
feeding rate is slowed until the
person adapts.

Nutrition & Diet Therapy (7th Edition)

• Goal rates can usually be achieved over
24 to 48 hours, although in some patients,
formula delivery can be started at the goal
rate immediately.
• Slower rates of delivery may be better
tolerated by critically ill patients, when
concentrated formulas are used, or in
patients who have undergone an extended
period of bowel rest due to surgery,
intestinal disease, or the use of parenteral
nutrition.
Nutrition & Diet Therapy (7th Edition)
Checking the Gastric Residual
Volume
• To ensure that the stomach is
emptying properly, the nurse may
measure the gastric residual volume,
the volume of formula and GI
secretions remaining in the stomach
after feeding.

Nutrition & Diet Therapy (7th Edition)

• In this procedure, the gastric
contents are gently withdrawn
through the feeding tube using a
syringe, usually before intermittent
feedings and every 4 to 8 hours
during continuous feedings in
critically ill patients.

Nutrition & Diet Therapy (7th Edition)

• Although the practice is
controversial,some experts
recommend that feedings be
withheld and an evaluation be
conducted if the gastric residual
volume exceeds 500 milliliters.
• If the tendency to accumulate fluids
persists, the physician may
recommend intestinal feedings or
begin drug therapy to stimulate
gastric emptying.
Nutrition & Diet Therapy (7th Edition)
 Meeting Water Needs
• Although water needs vary, many patients
require about 30 to 40 milliliters of water per
kilogram body weight daily.
• Additional water is required in patients with
severe vomiting, diarrhea, fever, excessive
sweating, high urine output, high-output
ostomies, blood loss, or open wounds. Fluids may
be restricted in persons with kidney, liver, or
heart disease.

Nutrition & Diet Therapy (7th Edition)

• The water in formulas meets a
substantial portion of water needs:
most enteral formulas contain about
70 to 85 percent water, or about 700
to 850 milliliters of water per liter of
formula. In addition to the water in
formulas, water can be provided by
flushing water separately through
the feeding tube

Nutrition & Diet Therapy (7th Edition)

• Water flushes are also conducted to
prevent feeding tubes from clogging;
the water used for flushes (20 to 30
milliliters before and after
intermittent feedings and about
every 4 hours during continuous
feeding) should be included when
estimating fluid intakes.

Nutrition & Diet Therapy (7th Edition)

 Medication Delivery during
Tube Feedings
• diet-drug interactions must be
considered.
• Medications can also cause feeding
tubes to clog.

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
 Medications and Continuous
Feeding
• Continuous feedings are ordinarily stopped before
and after medication administration to prevent
interactions that may clog the feeding tube or
interfere with the medication’s absorption.
• Some medications may require a prolonged
formula-free interval; for example, feedings need
to be stopped for at least one hour before and
after administering phenytoin, a medication that
controls seizures
• In such cases, the formula’s delivery rate needs
to be increased so that the correct amount of
formula can be delivered.
Nutrition & Diet Therapy (7th Edition)
 Diarrhea
• Medications are a major cause of the
diarrhea that frequently accompanies tube
feedings. Diarrhea is especially associated
with the administration of sorbitol
containing medications, laxatives, and
some types of antibiotics. The high
osmolality of many liquid medications can
also cause diarrhea, so dilution of
hypertonic medications may be helpful.

Nutrition & Diet Therapy (7th Edition)

 Tube Feeding Complications
• Table 16-2 , page 451

Nutrition & Diet Therapy (7th Edition)

 Transition to Table Foods
• After the patient’s condition improves, the
volume of formula can be tapered off as the
patient gradually shifts to an oral diet.
• Individuals receiving continuous feedings are
often switched to intermittent feedings initially.
• Patients using elemental formulas may begin the
transition by using a standard formula, either
orally or via tube feeding.
• Oral intake should supply about two-thirds of
estimated nutrient needs before the tube feeding
is discontinued completely.

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care
• Oral use • Patients can drink enteral
– Supplement diet when formulas when they are
food consumption does unable to consume enough
not meet need food from a conventional diet
– Reliable source of
nutrients & energy
– Taste important
consideration
• Tube feedings
– Used when patient
cannot consume
enough food or formula
orally
– Feeding delivered
directly to stomach or
intestine
Nutrition & Diet Therapy (7th Edition)
 Enteral Nutrition in Medical
Care (con’t)
• Candidates for tube feedings:
– Severe swallowing difficulties
– Little or no appetite for extended periods, especially if
malnourished
– GI obstructions, impaired motility of the upper GI tract
– After intestinal resection, beginning enteral feedings
– Mentally incapacitated due to confusion, dementia,
neurological disorders
– Individuals in coma
– Individuals with extremely high nutrient requirements
– Individuals on mechanical ventilators

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Feeding routes
– Selected on basis of medical condition,
expected duration, potential complications of a
particular route
– Main routes:
• Transnasal (temporary)
– Nasogastric
– Nasoduodenal
– Nasojejunal
• Gastrostomy
• Jejunostomy

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Formula selected after assessment of the
diagnosis, patient’s age, medical
problems, nutritional status, ability to
digest & absorb nutrients
• Nutrition-related factors influencing
formula selection
– Energy, protein & fluid requirements
– Need for fiber modifications
– Individual tolerances (food allergies &
sensitivities)

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Administration of tube • Open feeding system:
feedings requires formula to be
transferred from original
– Safe handling packaging to feeding
• Open feeding system container
• Closed feeding system • Closed feeding system:
• Safety guidelines formula prepackaged in
– Review of procedure ready-to-use containers
with patient & family • Intermittent feeding: delivery
of prescribed volume over 20-
– Verification of tube 40 minutes
placement (Xray) • Continuous feeding: slow
– Formula delivery delivery at constant rate over
• Intermittent feedings 8-24 hour period
(bulk over 20-40 min) • Bolus feeding: delivery of
• Continuous feedings prescribed volume in less
(pump) than 15 minutes
• Bolus feeding (one or
several “shots”)

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Formula volume & strength
– Procedures vary by institution
– Almost all patients can receive undiluted isotonic or hypertonic
formulas
– Generally started slowly and volume gradually increased
• Rate & amount of increase depend on patient’s tolerance
• Continuous feedings may be better tolerated than
intermittent feedings
• Checking gastric residual volume (vol. of formula in stomach after fdg.)
– Volume of formula remaining in stomach from previous feeding
– Evaluate if gastric residual >200 mL
– If tendency to retain persists, physician may consider intestinal
feedings or drug therapy to stimulate gastric emptying

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
Meeting water needs
• Adults require about 2000 mL of
water daily
– Fluid intake may be restricted for Estimating fluid
patients with kidney, liver or requirements
heart disease
– Fluid intake may be increased Adults: 30-40 mL/kg;
with fever, high urine output, 30 mL/kg for older
diarrhea, excessive sweating,
adults
severe vomiting, fistula drainage,
high-output ostomies, blood loss, Children: 50-60 mL/kg
open wounds Infants: 150 mL/kg
• Standard formulas contain about
85% water (about 850 mL/liter);
nutrient-dense formulas contain
about 69-72% water
• Meet fluid needs with additional
water flushes

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Transition to table foods
– Volume of formula is tapered off as
condition improves
– Gradual shift to oral diet
• Begin drinking same formula that is
delivered by tube
• Oral intake should supply about 2/3 of
nutrient needs before tube feedings
discontinued

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Giving Medication through feeding tubes
– Potential for diet-drug interactions must be
considered before administration
– Continuous feeding halted for approximately
15 minutes before & 15 minutes following
medication delivery (longer for some
medications)
– Type of medication may make tube
administration impossible—require change to
alternate route
• Generally best to administer medications by
mouth whenever possible

Nutrition & Diet Therapy (7th Edition)

 Enteral Nutrition in Medical
Care (con’t)
• Complications of tube feedings
– Gastrointestinal problems: nausea, diarrhea
– Mechanical problems related to tube feeding process
– Metabolic problems: biochemical alterations & nutrient
deficiencies
• Many complications preventable with appropriate
feeding route, formula & delivery method
• Close attention to patient’s medical condition &
medication use is important (follow up/reassessment)
– Monitor weight, hydration status
– Verify lab test results

Nutrition & Diet Therapy (7th Edition)

 Parenteral Nutrition Support
• Indicated for patients who do not have functioning GI
tract & who are malnourished (or likely to become so)
• Used when enteral formulas cannot be used or
intestinal function is inadequate
• Life-saving option for critically-ill persons
• Costly and combined with many complications
• Two main access sites: central or peripheral vein

Nutrition & Diet Therapy (7th Edition)

Candidates for Parenteral
Nutrition
• Intractable vomiting or diarrhea
• Severe GI bleeding
• Intestinal obstructions or fistulas
• Paralytic ileus (intestinal paralysis)
• Short bowel syndrome (a substantial
portion of the small intestine has been
• removed)
• Bone marrow transplants
• Severe malnutrition and intolerance to
enteral nutrition
 Venous Access
• The access sites for parenteral
nutrition fall into two main
categories: the peripheral veins
located in the hand or forearm, and
the large-diameter central veins
located near the heart

Nutrition & Diet Therapy (7th Edition)

 Venous Access
• Peripheral parenteral nutrition (PPN)
– Can only provide limited amounts of energy &
protein
– Peripheral veins can be damaged by overly
concentrated solutions
– phlebitis may develop - characterized by
redness, swelling, and tenderness at the
infusion site.
– To prevent phlebitis, the osmolarity of
parenteral solutions used for PPN is generally
kept below 900 milliosmoles per liter
Peripheral parenteral nutrition
(PPN)
– Limited to patients who do not have high
nutrient needs or fluid restrictions
– Used most often for short-term nutrition
support less than 2 weeks (7-10 days).
– The use of PPN is not possible if the peripheral
veins are too weak to tolerate the procedure
– Rotation of vein sites may be necessary

Nutrition & Diet Therapy (7th Edition)

 Venous Access (con’t)
• Total Parenteral Nutrition
-Most patients meet their nutrient
needs using the larger central veins,
where blood volume is greater and
nutrient concentrations do not need to
be limited.

Nutrition & Diet Therapy (7th Edition)

• Because the central veins carry a
large volume of blood, the parenteral
solutions are rapidly diluted; thus,
patients with high nutrient needs or
fluid restrictions can receive the
nutrient-dense solutions they
require.

Nutrition & Diet Therapy (7th Edition)

 Venous Access (con’t)
• Total parenteral nutrition (TPN)
– Can reliably meet complete nutrient
requirements because of that called TPN
– Provides nutrient-dense solutions for
patients with high nutrient needs or fluid
restrictions
– Preferred for long-term intravenous
feedings
– Inserted directly into a large central vein

Nutrition & Diet Therapy (7th Edition)

• To access central veins, the tip of a
central venous catheter can either be
placed directly into a large-diameter
central vein or threaded into a central vein
through a peripheral vein

Nutrition & Diet Therapy (7th Edition)

• catheter: a thin tube placed within a
narrow lumen (such as a blood
vessel) or body cavity; can be used
to infuse or withdraw fluids or keep a
passage open

Nutrition & Diet Therapy (7th Edition)

 Parenteral Solutions
• pharmacies are often responsible for
preparing parenteral solutions; this
because the pharmacist can
customize the solutions to meet
patients’ nutrient needs and because
the solutions have a limited shelf life.
•

Nutrition & Diet Therapy (7th Edition)

 Parenteral Solutions
• Customized formulations to meet patients’
nutrient needs
• Prescriptions for parenteral solutions
Highly individualized; often recalculated
on daily basis until patient’s condition
stabilizes
• Contents:
– Amino acids (both essential and non-essential for protein)
– Carbohydrates (dextrose)
– Lipid emulsions
– Fluid & electrolytes
– Vitamins & trace minerals
Nutrition & Diet Therapy (7th Edition)
 Amino Acids
• Parenteral solutions contain all of the essential
amino acids and various combinations of the
nonessential amino acids.
• The amino acid concentrations in commercial
solutions range from 3 to 20 percent
• Disease-specific products are available for
patients with liver disease, kidney disease, and
metabolic stress, but lack of evidence of their
benefit

Nutrition & Diet Therapy (7th Edition)

 Carbohydrate
• Glucose is the main source of energy in
parenteral solutions.
• It is provided in the form dextrose monohydrate,
in which each glucose molecule is associated with
a single water molecule.
• Dextrose monohydrate provides 3.4 kcalories per
gram, slightly less than pure glucose, which
provides 4 kcalories per gram.
• Commercial dextrose solutions are available in
concentrations between 2.5 and 70 percent;
concentrations greater than 10 percent are
usually used only in TPN solutions.
Nutrition & Diet Therapy (7th Edition)
 Lipids
• Lipid emulsions supply essential fatty acids and
are a significant source of energy.
• The emulsions available in the United States
contain triglycerides from either soybean oil or a
mixture of olive oil and soybean oil, egg
phospholipids to serve as emulsifying agents, and
glycerol to make the solutions isotonic.

Nutrition & Diet Therapy (7th Edition)

• Lipid emulsions are available in 10, 20, and 30
percent solutions, containing 1.1, 2.0, and 3.0
kcalories per milliliter, respectively. Therefore, a
500-milliliter container of 10 percent lipid
emulsion would provide 550 kcalories; the same
volume of a 20 percent lipid emulsion would
provide 1000 kcalories
• the 30 percent lipid emulsion can be used for
preparing mixed parenteral solutions but is not
approved for direct infusion into patients

Nutrition & Diet Therapy (7th Edition)

• Lipid emulsions are often provided daily and may
supply 20 to 30 percent of total kcalories.
• Including lipids as an energy source reduces the
need for energy from dextrose and thereby
lowers the risk of hyperglycemia in glucose-
intolerant patients.
• Lipid infusions must be restricted in patients with
hypertriglyceridemia

Nutrition & Diet Therapy (7th Edition)

 Fluids and Electrolytes
• Daily fluid needs range from 30 to 40 milliliters
per kilogram body weight in stable patients.
• The amount of fluid provided is adjusted
according to daily fluid losses and the results of
hydration assessment
• The electrolytes added to parenteral solutions
include sodium, potassium, chloride, calcium
magnesium, and phosphate.
• The amounts infused differ from DRI values
because they are not influenced by absorption, as
they are when consumed orally.

Nutrition & Diet Therapy (7th Edition)

• In the parenteral nutrition order, most electrolyte
concentrations are expressed in milliequivalents
(mEq), which are units that indicate the number
of ionic charges provided by the electrolyte.
• The body’s fluids and parenteral solutions are
neutral solutions that contain equal numbers of
positive and negative charges.

Nutrition & Diet Therapy (7th Edition)

• Because electrolyte imbalances can
be lethal, Blood tests are
administered daily to monitor
electrolyte levels until patients have
stabilized

Nutrition & Diet Therapy (7th Edition)

 Vitamins and Trace Minerals
• All vitamins are usually included in parenteral
solutions, although a preparation without vitamin
K is available for patients using warfarin therapy.
• The trace minerals typically added to parenteral
solutions include chromium, copper, manganese,
selenium, and zinc.
• Iron is often excluded because it can destabilize
parenteral solutions that contain lipid emulsions;
therefore, special forms of iron may need to be
injected separately

Nutrition & Diet Therapy (7th Edition)

Nutrition & Diet Therapy (7th Edition)
 Medications
• To avoid the need for a separate
infusion site, medications are
occasionally added directly to
parenteral solutions or infused
through a separate port in the
catheter.

Nutrition & Diet Therapy (7th Edition)

 Parenteral Formulations
• When a parenteral solution contains dextrose,
amino acids, and lipids, it is called a total nutrient
admixture (TNA), a 3-in-1 solution, or an all-in-
one solution.
• A 2-in-1 solution excludes lipids, and the lipid
emulsion is administered separately, often using
a second port in the catheter. Although the
administration of TNA solutions is simpler
because only one infusion pump is required, the
addition of lipid emulsion to solutions may reduce
their stability.
• s, lipids are often administered separately when
they are not a major energy source and are used
only to provide essential fatty acids
Nutrition & Diet Therapy (7th Edition)
Nutrition & Diet Therapy (7th Edition)
 Osmolarity
• The osmolarity of PPN solutions is limited to 900
milliosmoles per liter because peripheral veins
are sensitive to high nutrient concentrations.
• TPN solutions may be as nutrient dense as
necessary.
• Amino acids, dextrose, and electrolytes
contribute the most to a solution’s osmolarity.
Because lipids contribute little to osmolarity, lipid
emulsions can be used to increase the energy
provided in PPN solutions

Nutrition & Diet Therapy (7th Edition)

 Administering Parenteral
Nutrition
• Many hospitals organize nutrition
support teams, consisting of
physicians, nurses, dietitians, and
pharmacists, that specialize in the
provision of both enteral and
parenteral nutrition.
• The nurse, who performs direct
patient care, plays a central role in
administering and monitoring
parenteral infusions.
 Care of Intravenous
Catheters
• Catheter-related problems frequently cause
complications
• Catheters may be improperly positioned or may
dislodge
after placement.
• Air can leak into catheters and escape into the
bloodstream, obstructing blood flow.
• Catheters in peripheral veins may cause phlebitis,
necessitating reinsertion at an alternate site.
• A catheter may become clogged from blood
clotting or from a buildup of scar tissue around
the catheter tip.
• Catheters are also a leading cause of infection:
contamination may be introduced during insertion or
may develop at the placement site.
• To reduce the risk of complications, nurses use aseptic
techniques when inserting catheters, changing tubing, or
changing a dressing that covers the catheter site.
• Unusual bleeding or a wet dressing suggests a problem
with catheter placement.
• A change in infusion rate may indicate a clogged
catheter.
• Infection may be indicated by redness or swelling around
the catheter site or by an unexplained fever. Routine
inspections of equipment and frequent monitoring of
patients’ symptoms help to minimize the problems
associated with catheter use.
Administration of Parenteral
Solutions
• Infusion protocols vary among institutions.
• One approach is to start the infusion at a slow
rate (with a solution that is either full strength or
nutrient dilute) and increase the rate gradually
over a 2- to 3-day period.
• Another method is to give the full volume of a
nutrient-dilute solution on the first day and
advance nutrient concentrations as tolerated.
• risk of fluid overload, hyperglycemia, or other
complications.
• Parenteral solutions are usually infused
continuously over 24 hours (continuous
parenteral nutrition) in acutely ill patients.
• Patients who require long-term parenteral
nutrition often receive infusions for 10- to 14-
hour periods only (cyclic parenteral nutrition),
more freedom of movement during the day.
• Regular monitoring can help to prevent
complications.
• The parenteral solution and tubing are checked
frequently for signs of contamination.
• Routine testing of glucose, lipid, and electrolyte
levels helps to determine tolerance to
solutions.
• Frequent reassessment of nutrition status may
be necessary until a patient has stabilized.
 Discontinuing Parenteral
Nutrition
• Parenteral infusions are usually tapered
off at the same time that tube feedings or
oral feedings are begun, such that the two
methods can together supply the needed
nutrients.
• Transitioning to an oral diet is sometimes
difficult because a person’s appetite
remains suppressed for several weeks
after parenteral nutrition is terminated.
 Managing Metabolic
Complications
1- Hyperglycemia (blood glucose levels that exceed
about 180 mg/ dL during parenteral infusions) most
often occurs in patients who are glucose intolerant,
receiving excessive energy or dextrose, undergoing
severe metabolic stress, or receiving corticosteroid
medications.
• It can be prevented by providing insulin along with
parenteral solutions, avoiding overfeeding or overly
rapid infusion rates, and restricting the amount of
dextrose in the solution.
• Dextrose infusions are generally limited to less than 5
milligrams per kilogram of body weight per minute in
critically ill adult patients so that the carbohydrate
intake does not exceed the maximum glucose
oxidation rate.
2- Hypoglycemia :uncommon
• occurs when parenteral nutrition is
interrupted or discontinued or if
excessive insulin is given.
• infuse a dextrose solution at the
same time that parenteral nutrition
is interrupted or stopped.
3- Hypertriglyceridemia :may result
from dextrose overfeeding or overly
rapid infusions of lipid emulsion.
• If blood triglyceride levels exceed
400 milligrams per deciliter, lipid
infusions should be reduced or
stopped.
• 4- Refeeding Syndrome:
• Severely malnourished patients who are aggressively
fed (parenterally or otherwise) may develop refeeding
syndrome, characterized by electrolyte and fluid
imbalances and hyperglycemia.
• These effects occur because dextrose infusions raise
levels of circulating insulin, which promotes anabolic
processes that quickly remove potassium, phosphate,
and magnesium from the blood.
• The altered electrolyte levels can lead to fluid
retention and life-threatening changes in various
organ systems.
• To prevent refeeding syndrome, start parenteral
infusions slowly and carefully monitor electrolyte and
glucose levels when malnourished patients begin
receiving nutrition support.
5- Liver Disease : Fatty liver often results
from parenteral nutrition, but it is usually
corrected after the parenteral infusions
are discontinued.
• Long-term parenteral nutrition=
progressive liver disease.
• To minimize the risk, avoid giving the
patient excess energy, dextrose, or
lipids (which promote fat deposition in
the liver) and monitor liver enzyme
levels weekly.
• Cyclic infusions may be less problematic
than continuous infusions.
6- Gallbladder Disease
• When parenteral nutrition
continues for more than a few
weeks, sludge (thickened bile) may
build up in the gallbladder and
eventually lead to gallstone
formation.
• Patients requiring long-term
parenteral nutrition may be given
medications to stimulate
gallbladder contractions or improve
bile flow or may have their
gallbladders removed surgically.
7- Metabolic Bone Disease Long-term
parenteral nutrition is associated
with lower bone mineralization and
bone density, which may be related
to altered intakes or metabolism of
calcium, phosphorus, magnesium,
and vitamin D.
• Interventions may include
adjustments in parenteral
nutrients, medications, and weight-
bearing physical activity.
 Administering Parenteral
Nutrition
• Multidisciplinary nutrition support
team of health care professionals
– Physicians
– Nurses
– Dietitians
– Pharmacist
• Potential complications related to
venous line & metabolic problems

Nutrition & Diet Therapy (7th Edition)

 Administering Parenteral
Nutrition (con’t)
• Administration procedures
– Insertion & care of intravenous catheters
– Administration of parenteral solutions
• Continuous administration -24 hours/day
• Cyclic administration – 10 to 16 hour periods
– Monitoring patient condition, nutritional status,
complications
– Discontinuing of feedings-when GI function
returns

Nutrition & Diet Therapy (7th Edition)

 Nutrition Support at Home
• Continuation of nutritional support (tube feedings
or parenteral nutrition) after medical condition
has stabilized
• Candidates for home nutrition support
– Long-term nutrition care required for chronic conditions
– Users intellectually capable of learning procedures,
monitoring treatment & managing complications
• Planning for home nutrition
– Involvement of users in decision making to ensure long-
term compliance & satisfaction
– Assessment & evaluation of type of feeding, equipment,
resources, ability to perform procedures

Nutrition & Diet Therapy (7th Edition)

 Nutrition Support at Home
(con’t)
• Quality of life issues • Portable pumps & convenient
– Lifestyle adjustments carrying cases allow people
may cause struggle for who require home nutrition
patients & families support to move about freely
– Economic impact
– Time & other demands
associated with
treatment
– Physical difficulties,
including disrupted
sleep
– Social issues
– Life-sustaining therapy
associated with serious
complications
Nutrition & Diet Therapy (7th Edition)