Nutrition Options in Critical Care Unit Patients

Critically ill patients have increased metabolic requirements and must rely on the administration of nutritional therapy to meet those demands. Yet, according to research almost half of all hospitalized patients are not fed, are underfed, or are malnourished while in the hospital. This article demonstrates the importance of early feedings in critical care unit, and the available options open to nurses supporting initiation and management of early feedings. Enteral nutrition has proven to be an important therapeutic strategy for improving the outcomes of critically ill patients and the critical care nurse plays an integral role in their success.

Instrument validation and measurement of home healthcare nurses' knowledge of artificial nutrition and hydration at end of life

The purpose of this exploratory pilot study was two-fold: (a) to determine the reliability of the instrument to measure nurses' knowledge of artificial nutrition and hydration, and (b) to assess home healthcare nurses' knowledge of artificial nutrition and hydration. A cross-sectional design was used to administer the questionnaire to 91 home healthcare nurses in North Carolina; 33 questionnaires were returned. Results revealed an accurate answer rate of 73% and Cronbach's alpha was 0.71, indicating adequate internal consistency reliability.

Parenteral nutrition: considerations for practice

Malnutrition in the UK is estimated to affect 3 million people in the UK, costing the economy pound 13 billion a year. The effects can adversely affect an individual's wellbeing by exacerbating illness or reducing the prospect of a speedy recovery. The early identification of this actual or potential risk is recognised by using a validated nutritional screening tool as part of the patient assessment. Where risks are identified a structured plan should be put in place utilising oral and enteral techniques in nutritional support. However, for a number of patients these routes of feeding may not be an option, or may not fully meet the patient's nutritional requirements. It is in these circumstances that parenteral feeding may be considered under the supervision of a nutrition team. The careful selection of the parenteral solution alongside the most appropriate venous device to deliver the nutrition can assist in the effectiveness of this treatment and help in reducing the potential complications associated with this route.

The first case of catheter-related bloodstream infection caused by Nocardia farcinica

Nocardia farcinica is an emerging pathogen in immunocompromised hosts. Even though several species of Nocardia have been reported as causative pathogens of catheter-related blood stream infections (CRBSI), CRBSI caused by N. farcinica has not been reported. A 70-yr-old man with a tunneled central venous catheter (CVC) for home parenteral nutrition was admitted with fever for two days. Norcardia species was isolated from the blood through CVC and peripheral bloods and identified to N. farcinica by 16S rRNA and rpoB gene sequence analyses. This report emphasizes the rapid and correct identification of causative agents in infectious diseases in the selection of antimicrobial agents and the consideration of catheter removal.

[Nursing care in patients after thoracosurgical treatment especially esophageal tumor]

The main target of this study is to create a model of after-surgery nursing care system in patients after thoracic operations, especial patients with lungs and esophagus tumors. The main task of thoracosurgery is surgical treatment of lungs cancer which is the most common cancer in polish society. The main trigger of this cancer is smoking. In nursing the patients after the thoracosurgery operations the most important is to take care of efficient pleural drainage. This group of patients need special supervision in the early postoperative period. In the further postoperative days nursing care concentrate on mobilization and respiratory rehabilitation. Postoperative care in patient after esophagus operations simply means: continuous monitoring of vital signs, pharmacological treatment, parenteral feeding and daily nursing activities.

Management of intestinal failure and high-output stomas

Intestinal failure and a high faecal output from a stoma or fistula are rare gastrointestinal complications. Intestinal failure occurs when the intestine fails to absorb sufficient fluids and nutrients to maintain life, and can result from bowel resection or malabsorption. The management of these conditions raises many issues which nurses caring for affected patients need to consider. This article will discuss those relating to feeding, appliances and medication. Two methods of feeding that can be useful in patients with intestinal failure, namely parenteral nutrition (intravenous feeding) and fistuloclysis (feeding via an intestinal fistula), will be explored. Finally, a short case study will be presented to highlight the effects of some of these interventions and the problems that they can cause for patients.

[Clinical analysis of nosocomial infection in neonatal intensive care units]

OBJECTIVE

Nosocomial infections (NIs) have become a matter of major concern in neonatal intensive care units (NICU). The objectives of this study were to investigate the incidence of nosocomial infections of newborn infants in NICU and to explore the risk factors and strategies of infection control.

METHODS

The study enrolled 638 hospitalized newborn infants from Apr 2003 to Dec 2004. The clinical data, such as the clinical manifestation, the condition of colonized bacteria, were collected and analyzed by using SPSS software.

RESULT

There were 88 times of nosocomial infections in 74 newborn infants. The overall incidence of nosocomial infections was 11.6%. The mean duration from admission to first episode of NI was 7.98 +/- 4.58 days. The incidence density was 14.9 per 1000 NICU patient-days. Catheter-correlated hematogenous infection rate was 18 per 1000 umbilical or central line-days; the ventilator-associated nosocomial pneumonia rate was 63.3 per 1000 ventilator days. The smaller the gestational age and the lower the birth weight, the higher the incidences of nosocomial infection. The duration of hospitalization was longer in these infected infants than those non-infected infants. Univariate analysis indicated that gestational age < or = 32 W, the parenteral nutrition, birth weight < or = 1500 g and mechanical ventilation, apnea, small for gestational age infant, central venous catheter (P < 0.05) were risk factors for NIs. Multivariate analysis identified 3 independent risk factions: the parenteral nutrition ([OR] = 7.185 [95% CI, 3.399 - 15.188]), birth weight < or = 1500 g ([OR] = 3.310 [95% CI, 1.100 - 9.963]) and mechanical ventilation ([OR] = 2.527 [95% CI, 1.092 - 5.850]). The most common infection was pneumonia (45.4%). The mortality rate of nosocomial infections was 4.1%. Bacterial surveillance was examined by nasopharyngeal and rectal swab culture immediately on hospital admission and then once a week. The incidence rate of NIs was 24.8% in patients whose nasopharyngeal and rectal swab culture indicated bacterial colonization, and 1.9% in patients without bacterial colonization (chi(2) = 79.7, P < 0.001).

CONCLUSION

It is important to identify the high risk factors for nosocomial infections in newborn infants in NICU. Reducing the duration of the parenteral nutrition and the virulence manipulation as far as possible and getting the message of individual bacterial colonization in NICU may be conducive to decrease of the incidence of nosocomial infections and provide reference for rational clinical drug administration.

A patient with dementia and cancer: to feed via percutaneous endoscopic gastrostomy tube or not?

Despite the lack of clear benefits of feeding via gastrostomy tube in dementia patients, its use has been increasing. The views of health professionals, patients and their carers differ widely about the perceived benefits, which makes decision-making difficult and stressful. The palliative care approach of facilitating better communication and end-of life care planning can help avoid inappropriate gastrostomy tube placements. A case of an elderly male with dementia and two malignancies is described, and the place of the palliative care approach is explored.

Multiple dimensions of caring for a patient with acute necrotizing fasciitis

Critical care nurses within acute care settings are responsible for providing healthcare to a wide variety of patients and, consequently, knowledge regarding how to care for a patient with acute necrotizing fasciitis is imperative. A case study is presented to evidence the need for a multidisciplinary approach. Necrotizing fasciitis is defined and treatment options are presented. Caring for this patient is very challenging and demands a multidisciplinary team to coordinate all aspects of care to promote better patient outcomes.

Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU

AIM

To test whether a feeding algorithm could improve the nutritional support of intensive care patients.

BACKGROUND

Numerous factors may impede delivery of both enteral and parenteral nutrition to patients in the intensive care unit. Often there is a discrepancy between what is prescribed and actual delivery of nutrients. The purpose of this study was to test the effect of a nutritional support algorithm in an intensive care unit mainly by using the enteral route and if necessary by combining enteral and parenteral nutrition.

METHODS

In this prospective study, nutritional data were collected from routinely fed critically ill patients (controls, n=21) during the first three days following admission to the intensive care unit. A nutritional support algorithm was then implemented and nutritional data were collected from critically ill patients who participated in this intervention (intervention group, n=21). Data collected included the total amount of calories prescribed vs. received, onset of delivery of enteral nutrition, enteral vs. parenteral nutrition, and the use and size of enteral feeding tubes.

RESULTS

Patients in the intervention group were both prescribed and actually received significantly larger amounts of nutrients than patients in the control group. They also received a larger proportion of their nutrients in the form of enteral nutrition. In addition, the nutritional support algorithm led to greater consistency in nursing practices with respect to aspiration of gastric content and rate of increment in enteral feeding.

CONCLUSION

The study confirms that a nutritional support algorithm improved the delivery of nutrients to critically ill patients. The algorithm was most effective with respect to the delivery of enteral nutrition. The effect was primarily because of early and more rapid increment in the delivery of enteral nutrition administered by nurses based on improved physician orders. The combination of enteral and parenteral nutrition may contribute to meeting adequate nutritional requirements.

RELEVANCE TO CLINICAL PRACTICE

By using a nutritional algorithm focused on enteral nutrition, but including parenteral nutrition as a supplement, it is possible to improve the delivery of clinical nutrition in the intensive care unit patients.

Promoting adequate nutrition: using artificial feeding

An earlier article in this series (Holman et al 2005a) identified that in some circumstances the decision is made to administer artificial feeding. Here, Cheryl Holman, Sally Roberts and Maggie Nicol describe the reasons why artificial feeding may be necessary in older people and how it can be administered.

Management and effects of parenteral nutrition

Despite nutrition being a basic human need, malnutrition in hospitals remains surprisingly common, with the effects clearly documented (Taylor and Goodison-McLaren, 1992). Malnourished patients are more likely to suffer from complications; are at increased risk of developing infections; have poor or delayed wound healing, increased mortality rates and longer hospital stays. This article focuses on the basics of parenteral nutrition in the adult, addressing a small selection of potential complications.

[Nurse experiencing care of patient under parenteral nutrition]

It is about a research with the objective of understanding the experience of the nurse in the process of taking care being the caregiver of the patient under parenteral nutrition. We have utilized the Symbolic Interactionism and the Theory Grounded in Data for the theoretical-methodological referral. Ten nurses who have experienced this praxis in a public hospital in the city of Fortaleza, Ceará, have taken part of the study. The data collection was performed through participant observation and semi-structured interview. We have identified the phenomenon that expresses the nurse experiencing the care by showing attitudes, feelings and meanings regarding care.

Living wills, duty of care and the right to treatment

CASE STUDY

Agnes Simon, a district nurse with 20 years' experience, has been caring for a man with motor neurone disease for the last 5 years. During this time the patient has shown remarkable tenacity but the disease has now progressed to the stage where artificial nutrition and hydration (ANH) is required. A percutaneous endoscopic gastrostomy tube has been inserted through which the patient receives food, water and medication. On her most recent visit the patient gave Agnes a signed and witnessed living will. Unusually, the living will did not indicate the patient's wishes regarding the limitation of treatment. Instead it made clear that the patient wished to continue to receive ANH up to the time of his death. He did not want the care team to withdraw this treatment without his permission, as he feared he would suffer from the indignity of slowly dying from thirst and starvation. Agnes has never seen a living will where a patient demands a right to treatment and wonders whether such a document is lawful and binding on her.

Reducing the risks of parenteral nutrition

Parenteral nutrition is a vital method of delivering essential nutrients to some patients. But if used inappropriately it can increase the risk of catheter-related infection and incur unnecessary expense. Mary Bird explains how a nutritional support team's involvement transformed the quality of care for patients receiving the therapy at one trust.

A enfermeira avaliando o cuidar do paciente em nutrição parenteral

O presente estudo teve como objetivo compreender a vivência da enfermeira avaliando o processo de cuidar do paciente em nutrição parenteral. Utilizamos o Interacionismo Simbólico e a Teoria Fundamentada nos Dados para o referencial teórico - metodológico. Fizeram parte do estudo dez enfermeiras que vivenciaram esta prática em hospital público da cidade de Fortaleza, Ceará. A coleta de dados foi realizada no período de 01 de abril a 30 de dezembro de 2001 através da observação participante e entrevista semi - estruturada. Identificamos o fenômeno - Avaliando o processo de cuidar do paciente em nutrição parenteral- que expressa a enfermeira vivenciando o cuidado mostrando atitudes, sentimentos e significados para o cuidar.

Current practice in administration of parenteral nutrition: venous access

Today, there are many alternative feeding options for patients unable to eat and drink and nutrition support has become part of everyday clinical practice. Although feeding via the enteral route used to be considered optional, recent experts have re-examined the role of parenteral nutrition, and found it to be as beneficial. This article will review current practice surrounding parental nutrition, its indications and the associated complications. Successful feeding via the intravenous route relies on the selection of the appropriate intravenous access, optimum nursing care and close patient monitoring. The range of venous access options will be discussed and advantages and disadvantages identified.

Pediatric Parenteral Nutrition

Pediatric and adult parenteral nutrition have more similarities than differences. The differences between the two practices become apparent in the time frame for starting support, a few pediatric-specific products, and growth monitoring. The biggest challenge facing the practitioner is to familiarize him- or herself with the wide range of requirements for macro- and micronutrients.

The nursing care of a patient with enterocutaneous faecal fistulae

This article discusses the nursing care given to a patient with a large abdominal, enterocutaneous faecal fistula. It highlights classification, signs, symptoms and some causal factors related to fistulas. Fistulas are rare and there is minimal evidence-based knowledge on the subject. However, incorporating knowledge from other specialties, such as tissue viability, can assist in caring for this client group. Diagrams illustrate the extent of the problems and assist with understanding the appliance techniques. There are many problems that may be encountered in the care of fistulas that are not encountered with planned stomas. Difficulties may include containment of the faecal matter within a wound, problems associated with skin care, leakage and dietary issues. The author's methods of confronting and coping with these problems in this case study are discussed, with the aim of assisting other nurses in similar situations.

Parenteral hydration and nutrition in the geriatric patient: clinical and ethical issues

A common ethical and legal issue in elder care involves the decision to withhold or withdraw parenteral hydration and nutrition (PHN) at the end of life and in the terminal stage of dementia. The aging of the population will impact the frequency with which nurses face this situation in their practices and with their families. The ethical, legal, and clinical issues involving PHN discussed in this article will assist the nurse in his or her practice.

Nutrition strategies in neurotrauma

A basic understanding of metabolic alterations that occur following neurotrauma is essential for addressing nutritional requirements. Interventions must be research based and must focus on the support of metabolic alterations, minimizing the effect of catabolism and optimizing caloric delivery to meet metabolic demand. The goal of accuracy in the delivery of nutritional support is to ensure a reduction in patient morbidity. Nutritional support requires an ongoing, daily assessment of caloric goals, protein requirements, patient responses, and assessment of nutritional laboratory values. Using this strategy, neurotrauma patients will have the greatest opportunity for a positive outcome.

Parenteral nutrition for the acutely ill

Parenteral nutrition (PN) is one of the most sophisticated forms of intravenous therapy in use today. Intravenous feeding is a life-saving technology for patients unable to maintain their nutritional status using the gastrointestinal tract. Although PN has become an integral component of patient care, the risks associated with this therapy must be weighed against the potential benefits. Comprehensive clinical management includes selection of candidates, implementation and monitoring of therapy, and ensuring a seamless transition when PN is no longer required. Optimal parenteral nutrition demands expertise in caring for vascular access devices. A collaborative approach to care minimizes the risks associated with PN and ensures positive patient outcomes.

The effect of a 1-hour training program on the incidence of bacteremia in pediatric patients receiving parenteral nutrition

The effect of a 1-hour nurse training program on the frequency of bacteremia in patients receiving parenteral nutrition was evaluated in a pediatric tertiary center. All of the nurses had previous instruction on aseptic techniques in nursing school. The current program focused on aseptic management of intravenous catheters and implanted subcutaneous ports in patients receiving parenteral nutrition (PN). One hundred eighty-four nurses had a 1-hour training session in groups of three to five. The frequency of bacteremia in children receiving PN was not reduced (9.2% versus 8.9%), and there was no significant difference in time from the start of PN to the diagnosis of bacteremia (P = 0.31). The authors conclude that a 1-hour training session for the nursing staff was not sufficient. It is suggested that staff training for prevention of bloodstream infections associated with intravascular devices should cover a wider range of topics and take place over a longer period of time.

If the gut works use it

Using education and increased monitoring, a nutritional support team lowered parenteral nutrition days from 84 to 5 per quarter, increased the proportion of patients meeting their nutritional requirements from 75% to 97%, and saved money.

Parenteral nutrition: an overview of current practice

Nutritional support should always be provided via the gastrointestinal tract if possible, but parenteral nutrition, i.e. infusion of nutrients directly into the venous circulation, can be a safe and effective method of nutritional support when used in carefully selected patients and monitored appropriately. A multidisciplinary team approach to patient selection, assessment and monitoring is recommended. Access for parenteral feeding is traditionally via a central vein, but the peripheral route can be used for short-term feeding and should be considered for the majority of patients. Nutritional requirements should be assessed on an individual basis and a feeding regimen designed using standard formulations where possible. The transition back onto oral or enteral nutrition should be closely supervised by a dietitian. Parenteral feeding can be provided to the community if appropriate, but thorough training, monitoring and support are essential.

Parenteral nutrition

Patients with a non-functioning gastrointestinal tract, those who require bowel rest or cannot receive enteral nutrition will be considered for parenteral feeding. This Update looks at indications, venous access, administration and complications.

Intradialytic parenteral nutrition therapy for the malnourished hemodialysis patient

Intradialytic parenteral nutrition (IDPN) is a type of parenteral nutrition therapy designed to meet the unique needs of the malnourished patient with end-stage renal disease (ESRD) on chronic hemodialysis (HD). It is given during the HD treatment three times a week through the HD machine blood lines. Because of renal failure, the patient with ESRD must receive a kidney transplant (cadaver or living related donor) to preserve his/her life, or choose one of two forms of renal replacement therapy: HD or peritoneal dialysis (PD). This article will focus on the hemodialysis patient and IDPN therapy.

The value of IDPN as a supplemental therapy when elderly patients fail to thrive--two case studies

On the last day of his life, H.J. came into the dialysis unit smiling and joking. He spent the time watching a movie and visiting with visitors and staff. He reported feeling better than he had in a long time. His predicted 3-day death watch had become nearly 5 months of improved quality of life and precious time spent with his large extended family. He frequently expressed gratitude for the chance to prolong those few days into such an unexpected extension. He and his family attributed this gift to the nursing care and encouragement he received in the dialysis unit. Everyone was aware that the IDPN therapy, along with improvement in his own daily nutritional intake, was a critical element. Later that night, H.J. had a cardiac arrest, and he died peacefully at home with his family. There is no doubt that without the financial resources available to him to pay for his IDPN, the outcome would not have been the same. As it was, all the intended patient outcomes were achieved.

Meeting the special nutritional needs of sick infants with a percutaneous central venous catheter quality assurance program

Adequate nutrition is important in infancy because it can affect brain growth. A critical period for brain growth is the end of the fetal growth period and the first 2 years of life. Delivery of nutrition to infants in the neonatal intensive care unit is challenging because illness and prematurity increase nutritional need and create access difficulties. One technique, percutaneous central venous catheter (PCVC) placement, eliminates access difficulties. Nevertheless, safe delivery of parenteral nutrition through PCVCs is dependent on minimizing infectious and mechanical complications. With the implementation of a PCVC quality assurance program, problems can be identified early, and appropriate, timely interventions can be initiated.

[The meaning of parenteral nutrition for the hospitalized patient]

The need to understand the meaning of parenteral nutrition to the client in hospital context has come from my personal questioning on nursing care. Participative observations have been made as well as interviews and diligences with seven clients in hospital, who have been having parental nutrition. These information have been analysed through interactive approach, showing the situation faced by patients who have hospital assistance; how they say parental nutrition within this context; and what meaning has been given to it. This study revealed feelings, behaviours and attitudes related to the biological, emotional and social cultural aspects of the patient. All of them have been linked to parental nutrition. The limits faced by parental nutrition and its obstacles in the nursing assistance were finally understood.

Systemic inflammatory response syndrome, sepsis, and nutritional support

This article reviews the metabolic alterations that occur in SIRS and sepsis and the management of these patients nutritionally. Practical clinical assessment parameters that can be used by the critical care nurse to determine the nutritional and metabolic needs of the patient are presented. Issues related to enteral and parenteral routes of delivery are presented, and a discussion of disease-specific nutritional formulas is included. An understanding of the determination of metabolic and nutrition needs and the provision of adequate support to meet those needs are vital to the care of the hypermetabolic septic patient.