Intradialytic parenteral nutrition: a practical approach

Intradialytic parenteral nutrition (IDPN) therapy is becoming more prevalent in the malnourished patient undergoing maintenance hemodialysis. This is of particular concern to the nephrology nurse in that additional time is required to administer the solution, monitor the patient, and document the process. The IDPN monitoring flowsheet described in this article was developed to promote continuity of care from treatment to treatment, especially during initiation of IDPN, and to assist the nephrology nurse in administering and monitoring the therapy.

Nutritional support for the patient with renal failure

Renal failure presents patients and caregivers alike with numerous dilemmas in nutritional management. Too much protein, phosphate, or electrolytes, and the patient's renal failure becomes more symptomatic; too little of these nutrients and the patient is at great risk of developing fluid and electrolyte imbalances and of becoming protein-calorie malnourished. Dietary manipulation and often vigorous nutritional intervention (i.e., parenteral nutrition) are a must for these patients' survival. The nurse needs to understand the rationales behind nutritional care choices made by the physician and dietitian, and to be able to convey these rationales to the patient. The nurse also needs to be aware that the patient will use food, eating, and diet as a focus for acting out anxiety, fear, hopelessness, and anger. The nurse should also realize that these emotions are due, in part, to the metabolic derangements induced by the renal disease itself.

The immunologic role of the gastrointestinal tract

During the past few decades, researchers have shed new light on the role of nutritional support in the immunocompromised critically ill patient. "Nutritional pharmacology" has become the catch phrase of the 1990s due to the impact of selected nutrients on host immune defenses. When feasible, enteral nutrition is preferred to parenteral nutrition to preserve the integrity of the gut mucosal barrier, especially when administered jejunally in the early stages of hypermetabolism. Glutamine and fiber provide necessary fuels for the gastrointestinal tract, whereas arginine and omega-3 fatty acids exert beneficial effects on certain cells of the immune system. Daly et al demonstrated that "enteral nutrition with supplemental arginine, RNA nucleotides and omega-3 fatty acids (Impact, Sandoz Nutrition, Minneapolis, MN) compared with a standard enteral diet, significantly improved immune, metabolic and clinical outcomes (22% mean reduction in length of stay) in UGI cancer patients undergoing surgery." Although more research is needed in the area of nutritional pharmacology, newly available nutrient-specific enteral products (Table 1) provide promise for altering the clinical outcome of immunocompromised patients.

Nutritional support in the hypermetabolic patient

A patient who has experienced a major injury needs to undergo a careful assessment for hypermetabolism and malnutrition. Metabolic supportive therapy focuses on the support of the structural and functional integrity of organs and organ systems. The principles are derived from an understanding of the metabolic and physiologic responses to injury. When supportive therapy is applied in this manner, the chance of recovery can be significantly affected.

Diabetic ESRD patient supported with intradialytic parenteral nutrition

The patient did meet the expected outcomes. She was able to achieve a desired weight and continues to gain weight. Currently, consideration is being given to discontinuing IDPN therapy. The main concern is an exacerbation of her symptoms, which is often a problem with diabetic gastraparesis. BC's outlook on life is more positive. Hopefully, she will continue to be compliant with her diet, experience no increase in symptoms, and maintain this weight. As with all ESRD patients, her fluid status requires monitoring. Fluid gains are removed and she remains free of complications. BC is now able to participate in usual daily activities. She goes out to the hairdresser once a week and attends Sunday morning church service. Her sense of well-being is greatly improved. BC has expressed gratitude on numerous occasions for the treatment that she feels has saved her life. Her deteriorating physical state was severely affecting her emotional well-being. Her quality of life has been favorably altered by the intervention with IDPN therapy.

[An analysis of the nursing care given to the child on parenteral nutrition]

The purpose of this study was to collect information on nursing car of children receiving parenteral nutrition in order to gain knowledge to improve nursing care according to the resources available in the hospital. Our results showed that in the three hospitals studied there were no adequate physical space to prepare parenteral nutrition. There were no suitable accommodations for the children, the nursing care on P.N. were not standardized and the follow up was not well done.

Nurses and physicians on nutritional support: a comparison

During the last decade, several court cases have focused attention on the moral and legal aspects of withholding or withdrawing food and fluids from certain patients. The courts have not been unanimous in their judgements on these matters. In attempting to explore this issue, this article reviews both the nursing and medical literature on the withdrawing and withholding of food and fluids with particular attention to empirical studies. Several themes which emerge from the literature are used to explore the similarities and differences between the practices of nursing and medicine where nutritional support is concerned.

Technology-dependent children in New York State

A survey in New York State revealed 210 medically stable technology-dependent children retained inappropriately in acute-care hospitals. They remained in hospitals primarily because of a shortage of skilled home nursing services in the communities where they lived, family problems that prevented their care at home, and a shortage of beds in appropriate skilled nursing facilities. Most of the children were younger than one year of age, most had disorders of the central nervous system or respiratory system, and most needed respiratory support. The average child needed more than 13 hours of skilled nursing care per day. With adequate nursing services, many of these children could be cared for in their homes. For some, family care was not feasible because of social, psychological, and economic problems. To make it possible to care for medically stable technology-dependent children most effectively, we must develop additional community-based resources. Home nursing services of the highly skilled kind needed to care for them are in short supply today in New York State. There is a shortage of beds in extended care nursing facilities capable of caring for them, especially for infants and very young children. There is a shortage of the other supportive social services needed by families who attempt to care for them at home. Until we address these needs and develop these services, technology-dependent children medically appropriate for care outside acute-care hospitals will be forced to remain hospitalized, to the detriment of the children and their families.

Risks and benefits of home parenteral nutrition in the acquired immunodeficiency syndrome

The gastrointestinal tract is a major target of the human immunodeficiency virus. Many AIDS patients have weight loss and/or diarrhea. Parenteral nutrition can be used to treat malnutrition associated with malabsorption. We reviewed retrospectively the clinical course of 22 patients with AIDS and weight loss greater than 10% who received home parenteral nutrition (HPN) for 56.2 patient-months. Mean weight loss was 21.4%, mean duration of HPN 2.55 months, mean age 37.4 years. Fifteen patients gained weight, six stabilized and two continued to lose weight. Nine patients returned to previous activity. Five died. The rates of catheter-related sepsis, complications, and metabolic disturbances were 0.12, 0.25, and 0.12/100 catheter days, respectively, results identical to those reported in other patient populations where HPN is commonly applied. We found that HPN induced weight gain and clinical improvement in most patients without higher risks of sepsis than in patients with malignancies.

Methods of nutritional support in the home

Recent advances in nutrition support methods now offer home patients the possibility of maintaining nutritional adequacy when intake is compromised. Using either enteral or parenteral feeding when appropriate allows patients to achieve an improved quality of life at home. Options for management offer a wide variety of choices in feeding methods, formulations, delivery systems, rates and scheduling as well as services provided for a given need. Team management of these patients is necessary to assure proper medical care and support.

Nutritional support of pulmonary patients: a multidisciplinary approach

Pulmonary disease affects and is affected by the nutritional status of the patient. The relationships between nutrition, medications, complications, and the course of pulmonary disease itself are multifaceted and are the focus of concern for the nutritional support team. Nutritional support of patients with pulmonary disease demands the expertise of a multidisciplinary team in monitoring the nutritional status of patients, appropriately selecting feeding solutions and routines, selecting and administering medications, and planning and implementing nursing interventions. Recognition of the importance of the nutritional component of care for patients with pulmonary disease is the focus of this article.

[Peripheral parenteral nutrition: contribution of nursing to the development, preparation and control protocols]

In the present work the role of nursing in peripheric parenteral nutrition (PPN) is described. The main role is framed within the Unit of Nutritional Support along with the design of the corresponding protocols. The outstanding difference in the composition of our PPN vs those manufactured by the pharmaceutical industry, is the inclusion of glucose as the sole source of carbohydrates. These protocols secure similar nursing care in all patients. With respect to the local venous tolerance to our PPN, it was significantly better than that found in the group infused with a commercial PPN. By contrast, no differences in glycosuria were observed. The economical savings were of 1,980 pesetas per nutrition/day.

[Parenteral nutrition protocol: information for nursing care]

For a correct application of PN (parenteral nutrition) protocols, not only is it essential to centralize follow-up, but also to make this known among the nursing staff. With this purpose in mind, the PN Unit organized in-depth seminars on the different hospitalization areas, after previously preparing a questionnaire indicating the extent to which the protocol was known among the staff. A study of the results obtained with the questionnaire enabled us to evaluate the following: the technical difficulties involved in basic understanding of the PN field, an analysis of priorities and the establishing of reference points for later evaluations.

Adequate intake to allow optimum development. Feeding and elimination in SCBU

There are a number of options available for babies who cannot feed orally, but all babies receiving critical care must be carefully monitored for both feeding and elimination.

[Parenteral feeding in severe states in infants]

Parenteral nutritional of babies that cannot provide for their necessities by the oral pathway is only temporary, exceptional method, indicated in very severe cases. Presently this method is considered as adequate in the frame of complex measures intended for intensive care. Following a review of objectives of parenteral feeding programs, and their staging the authors describe in detailed manner the experience acquired by their group in this field.