Tanta University

Faculty of Nursing.
Critical care and emergency department
1st Semester , 3 rd. Year 2023
Group : 6

NUTRITION
IN CRITICALLY
ILL PATIENTS
UNDER SUPERVISION OF :

DR / Asmaa Yusri
Prepared by :

• Alaa Antar Magdy

• Omnia Nasr Khalil
• ALShaimaa Majdi
• Elham Shahin
• Ahmed Mohammed elsharkawy
• Ahmed Abu Abiya
• Ahmed Abdullah AlKhouli
• Ahmed Mohamed Jabr
• Ahmed Mohamed Rushdi
• Ahmed Mitwalli AlSharqawi

outlines

1. Introduction

2. Causes of poor nutrition in critically ill patient

3. Goals of nutrition in critically ill patient

4. What is the role of nutrition in critically ill patient

5. Methods of feeding (Internal, Parenteral )

6. Assessment of nutrition in critical ill patients

7. Common nursing diagnosis

8. Nursing care and monitoring

 INTRODUCTION

Nutrition support is an important aspect of care for critically ill patients. It

refers to the provision of calories, protein, electrolytes, vitamins, minerals,
trace elements, and fluids through enteral or parenteral means The primary
goal of nutrition support is to alter the course and outcome of the critical
illness. The nutritional needs of critically ill patients are poorly understood
and vary with the phase of critical illness. The fundamentals of nutrition
support for critically ill patients include the goals, outcomes, indications,
contraindications, and daily nutritional requirements

Some points to put into consideration when providing nutrition support to

critically ill patients:

1. Acute critical illness is traditionally thought to be characterized by

catabolism exceeding anabolism
2. Carbohydrates are believed to be the preferred energy source during
this period because fat mobilization is impaired
3. The basis of protein prescriptions is the hope for mitigation of the
breakdown of muscle proteins into amino acids, which then serve as
the substrate for gluconeogenesis, as reflected in a favorable nitrogen
balance
CAUSES OF POOR NUTRITION IN CRITICALLY ILL PATIENTS

1. Increased metabolic demands - Critical illness creates a

hypermetabolic stress response that increases nutrient requirements.
Patients can quickly become malnourished if intake is not increased to
match.
2. Anorexia and impaired appetite - Many medications, pain, anxiety,
gastroparesis, and more can suppress appetite in these patients. This
reduces nutritional intake.
3. Malabsorption - Critically ill patients may have gastrointestinal issues
like diarrhea, short bowel syndrome, pancreatitis, etc. that impair
nutrient absorption.
4. Delayed gastric emptying - About 50% of critically ill patients
experience delayed gastric emptying which limits tolerance of enteral
feeding.
5. Reduced gastrointestinal motility - Medications, electrolyte
imbalances, and neurological issues can slow GI function and nutrient
delivery.
6. Hyperglycemia - Uncontrolled high blood glucose increases calorie
and protein needs. Stress hyperglycemia is common in critical illness.
GOALS OF NUTRITION IN CRITICALLY ILL PATIENTS

A. Preserve lean body mass and muscle - Prevent excessive loss of

protein and muscle through adequate protein/calorie delivery and
physical therapy. Helps maintain strength and function.
B. Support metabolic demands - Provide adequate macronutrients
(protein, carbs, fat) and micronutrients to meet elevated nutritional
needs induced by critical illness.
C. Maintain gut integrity - Use enteral nutrition when possible to supply
nutrients and stimulate the gastrointestinal tract. Help prevent atrophy
and translocation.
D. Modulate the immune response - Specific nutrients like arginine and
omega-3 fatty acids may help improve immune cell function and
wound healing.
E. Achieve glycemic control - Provide appropriate calories and adjust
insulin to maintain blood glucose in a safe, normal range. Avoid wild
swings.
F. Correct micronutrient deficiencies - Replete important vitamins and
minerals (zinc, selenium, iron, etc.) that may be depleted.
G. Avoid overfeeding - Prevent provision of excess calories which can
increase metabolic demands and cause complications.
H. Minimize risk of refeeding syndrome - Cautiously increase nutrition
to avoid electrolyte shifts in severely malnourished patients.
I. Reduce complications and mortality - Adequate nutrition can help
reduce risk of infections, weakness, pressure injuries, and potentially
improve survival.
 ROLE OF NUTRITION IN CRITICALLY ILL
PATIENTS

The importance of nutrition in critically ill patients includes :

A. Improving wound healing

B. Reducing infection risk
C. Fighting infection and having a strong immune system
D. Avoiding further weight loss
E. Helping the patient get stronger
F. Helping the patient's body recover
G. Reducing the length of hospital stay
H. Protecting against severe catabolism and preventing
significant deconditioning2
I. Improving outcomes in hospitalized patients3
J. Attempting to improve patient outcomes by improving
immunologic function and reducing morbidity and mortality
 Methods of feeding (Internal, Parenteral )

1- ENTERAL FEEDING

Enteral feeding refers to the delivery of nutritional formula directly

into the gastrointestinal tract through a feeding tube. It is the
preferred method of feeding for critically ill patients when the gut
is functional.

Modes of enteral feeding

• Nasogastric tube (NGT): inserted through a nostril and

into the stomach.
• Orogastric tube (OGT): inserted through the mouth and
into the stomach.
• Nasoenteric tube: inserted through a nostril and into the
intestines.
• Prepyloric tubes: end in the stomach above the pyloric
sphincter.
• Postpyloric tubes: end beyond the pyloric sphincter in the
jejunum.
INDICATIONS OF ENYERAL FEEDING

1. Traumatic brain injury, which may impair the level of

consciousness or require a coma

2. Stroke, which may impair the ability to swallow

3. Dementia, which may affect the appetite or cognition

4. Cancer, which may cause fatigue, nausea, and vomiting

5. Gastric dysfunction with malnutrition, which may prevent

normal digestion or absorption

Contraindications of enteral feeding

• Hemodynamic instability
• Impending need for intubation
• Significant gastrointestinal pathology
• Persistent bowel obstruction or ileus
• High-output fistula or severe malabsorption
• High risk for nonocclusive bowel necrosis
• Aspiration or refeeding syndrome
COMPLICATIONS OF ENTERAL FEEDING

Hemodynamic instability

Impending need for intubation

Significant gastrointestinal pathology

Persistent bowel obstruction or ileus

High-output fistula or severe malabsorption

High risk for nonocclusive bowel necrosis

Aspiration or refeeding syndrome

2- Parenteral feeding

refers to the administration of nutritional formulas directly into

a patient's vein. It bypasses the gastrointestinal tract and allows

providing nutrition when normal eating and digestion is not

possible.

Indications of parenteral feeding :

1- Cancer. Cancer of the digestive tract may cause an obstruction of the

bowels, preventing adequate food intake. Cancer treatment, such as

chemotherapy, may cause your body to poorly absorb nutrients.

2- Crohn's disease. Crohn's disease is an inflammatory disease of the

bowel that may cause pain, bowel narrowing and other symptoms that

affect food intake and its digestion and absorption.

3- Short bowel syndrome. In this condition, which can be present at birth

or occur as the result of surgery that has removed a significant amount

of small intestine, you don't have enough bowel to absorb enough of

the nutrients you eat.

4-Ischemic bowel disease. This may cause difficulties resulting from

reduced blood flow to the bowel.

5-Abnormal bowel function. This causes food you eat to have trouble

moving through your intestines, resulting in a variety of symptoms that

prevent enough food intake. Abnormal bowel function can occur due to

surgical adhesions or abnormalities in bowel motility. These may be

caused by radiation enteritis, neurological disorders and many other

conditions.

Contraindications of parenteral feeding

• Blockage of the gut (obstruction) or the gut failing to work (ileus)

• Perforations of the gut where feeding will result in worsening

infections

• Where a large part of the gut has been removed and the patient

cannot absorb enough food (short bowel syndrome)

• Where parts of the bowel are diseased and not able to absorb

properly (functional short bowel)

• If gastrointestinal tract is fully functional with adequate absorption

of macro and micronutrients

• When administration of PN is anticipated for less than 5 days in

patients without severe malnutrition

Complications of parenteral feeding

1- Infection - Central IV catheters used for parenteral nutrition are

at risk of infection. Catheter-related bloodstream infections or

sepsis can occur. Strict sterile techniques must be used.

2- Blood clots - Thrombosis related to the IV catheter can occur,

especially with peripheral IVs. Clots can lead to catheter

occlusion or emboli.

3- Metabolic complications - These include hyperglycemia,

electrolyte imbalances like low phosphate or high CO2, and

vitamin/mineral deficiencies or toxicities. Abnormal lab values

require adjustments in the nutrition formula.

4- Liver dysfunction - Parenteral nutrition is associated with liver

complications like cholestasis, fatty liver disease, and cirrhosis

from liver toxicity. Risk is higher with prolonged use.

5- Bone disease - Osteopenia and osteoporosis can occur due to

bone mineral deficiencies like calcium and vitamin D. Weight-

bearing activity should be encouraged.

6- Immune suppression - Long term use of parenteral nutrition may

lead to lowered immunity due to lack of intestinal stimulation.

Risk of infection is increased.

 7- Fat overload syndrome - This results from excess lipids in the

nutrition formula and can cause liver enlargement, coagulopathy,

respiratory distress.

8- Hypertriglyceridemia - High triglyceride levels from excess fat

content in the nutrition. Can lead to pancreatitis.

Assessment of nutrition in critical ill patients

• Weight and body mass index (BMI) - Document current weight and

BMI compared to usual baseline. Significant unintended weight loss

may indicate malnutrition.

• Medical history - Gauge nutritional intake and absorption prior to

hospitalization. Chronic conditions, medications, surgeries affecting

nutrition status.

• Physical exam - Assess muscle/fat stores, fluid status, signs of

vitamin/mineral deficiencies. Oral cavity exam if considering enteral

feeding.

• Biochemical data - Albumin, prealbumin, transferrin can indicate

protein status. Electrolytes, glucose, liver function tests give

metabolic information.

• Nutrient intake and needs - Calculate current oral/enteral/parenteral

intake. Estimate protein and caloric needs based on stress, injury,

comorbidities.

• Gastrointestinal function - Evaluate gastrointestinal motility, ability

to tolerate enteral feeds or absorb nutrients. Risk of aspiration?

• Functional status - Level of consciousness, ability to ingest

orally/enterally. Assess for deficits in swallowing, feeding oneself.

• Risk factors - Multiple comorbidities, elderly, trauma/burns increase

nutritional needs. Prior malnutrition is a major risk.

• Duration of critical illness - Prolonged ICU stays increase risk of

malnutrition. Aggressive nutrition therapy warranted.

• Response to interventions - Monitor intake, weight, lab values to see

if nutritional goals are being met and adjust accordingly.

Common nursing diagnosis

• Imbalanced nutrition: less than body requirements - Related to

increased metabolic demands, catabolic stress, inability to
absorb/consume nutrients.
• Risk for unstable blood glucose level - Due to critical illness,
medications, nutritional status.
• Risk for electrolyte imbalance - Common electrolytes like
potassium, magnesium, phosphate may shift rapidly.
• Risk for aspiration - Due to altered level of consciousness,
intubation, mechanical ventilation. Requires positioning, suctioning.
• Impaired gas exchange - Ventilator settings may need adjustment to
improve oxygenation and ventilation.
• Risk for infection - Related to invasive devices like central lines,
endotracheal tubes, Foley catheters. Require aseptic care.
• Risk for bleeding - Due to coagulopathy, thrombocytopenia,
anticoagulant medications. Requires close monitoring.
• Impaired skin integrity - Pressure ulcers, moisture-associated skin
damage from immobility, edema.
• Acute pain - From recent trauma, surgery, underlying condition.
Requires analgesic management.
• Risk for falls - With altered mental status, unsteady gait once
mobilizing, attached lines/tubes.
• Anxiety/Fear - Being in an unfamiliar ICU setting with alarming
monitors and equipment.

Nursing care and monitoring

• Assess nutritional status - Obtain weight, BMI, intake history,

labs. Examine for muscle/fat wasting, fluid status.
• Determine nutrient needs - Estimate protein, caloric
requirements based on metabolic stress. More is needed for
wounds, burns, trauma.
• Choose nutrition route - Oral, enteral, or parenteral feeding
based on GI function. May start TPN if unable to tolerate
enteral.
• Manage enteral feeds - Select formula type. Monitor
placement of NG tube. Check residuals and tolerance. Titrate
rate slowly.
• Manage parenteral nutrition - Ensure proper venous access.
Monitor lab values and replace nutrients like electrolytes,
vitamins.
• Position properly - Keep head of bed elevated at least 30
degrees to prevent aspiration if receiving enteral or oral fluids.
• Monitor intake and output - Record ins/outs meticulously.
Weigh patient daily at same time. Assess net fluid balance.
• Observe for refeeding syndrome - Can occur when starting
feeds after prolonged malnutrition. Monitor and correct
electrolytes.
• Watch for gastrointestinal issues - Distension, diarrhea or
constipation, high gastric residuals. May require rate
adjustment or holding feeds.
• Prevent contamination - Use sterile technique for tube feeds,
TPN. Change giving sets appropriately.
• Skin/mouth care - Keep lips moist. Assess skin turgor and
mucous membranes. Turn patient to prevent breakdown.
• Blood glucose monitoring - Monitor blood sugars and manage
hyper/hypoglycemia. Adjust insulin as needed.