NUTRITION FOR SPECIFIC DISEASE STATES
PRESSURE ULCERS
Patients who are at the greatest risk of developing pressure ulcers are those who are nonambulatory and have a compromised nutritional status.
Disease states, such as cancer, diabetes, renal disease, and heart disease, may predispose patients to pressure ulcers secondary to the decrease in oxygen supplied to at-risk areas (eg, coccyx, elbows, and heels).
Assessment of serum albumin is key in this high-risk population, since hypoalbuminemia, if not corrected, has been associated with the development and progression of pressure ulcers.
Nutritional intervention needs to include adequate protein and adequate calories to spare protein from wound healing. The goal is a serum albumin of greater than 3.5 g/dL. The amount of protein and number of calories need to increase as the stage of the ulcer increases.
Supplementation with vitamin C should not exceed 200% of the US recommended daily allowance (RDA). Supplementation with zinc is consistent at 30 mg/day for men and 24 mg/day for women.
NEUROLOGIC DISEASES
Not all patients with neurologic conditions have the same feeding problems; however, a common problem throughout this population is dysphagia, or difficulty swallowing.
Observable symptoms that dysphagia may be present include drooling, choking, coughing (during or after meals), an absent gag reflex, and a gurgly voice quality. If undiagnosed, dysphagia can lead to malnutrition as a result of inadequate intake.
Early detection and intervention are paramount. Nutritional intervention is performed with a team approach that centers primarily on the dietitian and the speech therapist. The speech therapist identifies treatment options; the dietitian adjusts diet consistency (liquids vs solids) to meet a patient's needs and ensures that palatability is not jeopardized in the process.
Another common issue is a patient's limited ability to eat independently, as a result of problems such as hemiparesis, tremors, apraxia, and weakness. The associated medical concern is an increased risk of aspiration. To prevent aspiration, the best position for the patient is sitting upright as erect as possible, with both feet resting on the floor.
Independence in self-feeding can be achieved with the use of a scoop plate if the patient has the strength to push food to the side of the plate. The plate is designed to allow food then to fall on the spoon.
Enteral nutrition is a treatment option for this population when oral nutrition has been deemed unsafe due to aspiration risk or when the patient can no longer meet nutritional needs with an oral diet.
TRAUMATIC BRAIN INJURY
Most patients with traumatic brain injuries (TBIs) are well nourished prior to their injury; however, they become hypermetabolic and catabolic following injury. Therefore, aggressive nutritional intervention needs to be addressed very early. Patients who are not treated aggressively are likely to undergo rapid loss of lean body mass and immunosuppression.
Energy requirements for patients who have sustained TBI generally are 40% greater than those estimated by the Harris-Benedict equation. Therefore, indirect calorimetry is recommended.
Providing adequate protein is essential, but note that patients following TBI are likely to be in a negative nitrogen balance for the first 2-3 weeks postinjury, despite aggressive intervention.
In general, a large percent of this population experience dysphagia impaired gastric emptying, and alterations in normal eating patterns. Some patients are distracted easily, and meal times need to be extended. Some eat very rapidly and tend to consume excess quantities at meal times.
Close monitoring during meals is essential. Parenteral and/or enteral support often is a necessary intervention during the early stages of treatment and during the transition period back to oral nutrition.
BURNS
Nutritional support in this population is a challenge. These patients are at extraordinary risk of infection and intestinal ileus. Patients with burns are hypermetabolic and catabolic. Energy needs can increase by 100%, related to hypermetabolism. Protein needs are huge owing to the catabolic condition and because of protein losses through the wound itself.
Patients with burns over less than 20% of their total body surface area (TBSA) usually are able to meet nutritional needs with a high protein/calorie diet.
Patients with burns over greater than 20% of their TBSA require a more aggressive approach, such as TPN and/or tube feeding. If an ileus is present or the patient is unable to tolerate 100% of his or her nutritional needs enterally, TPN is the intervention of choice.
SPINAL CORD INJURY
Nutrition in acute SCI is a very complex issue. The following complications are associated with SCI and can affect the patient's ability to consume adequate nutrition:
Paralysis
Glucose intolerance
Anemia
Paralytic ileus
Gastrointestinal ulcers
Neurogenic bowel and bladder
Depression
Skin/wound breakdown
Pneumonia
Nutritional needs change frequently with this population because of stress response, sepsis, fever, infection, and surgery. Nutritional assessments need to be frequent, with ongoing diet alterations made to keep up with the patients' changing needs.
PULMONARY DISEASE
The major function of the respiratory system is to provide adequate oxygen to the body and to eliminate the carbon dioxide this process produces.
The 3 macronutrients (ie, carbohydrate, fat, protein) all affect this ratio. The respiratory quotient (RQ) is a volume ratio between the oxygen consumed and carbon dioxide produced.
The following are the RQs associated with each macronutrient substrate:
Substrate RQ
Carbohydrate 1.0
Lipid 0.7
Protein 0.8
Overfeeding >1.0
Overall energy needs and protein needs are based on the patient's goal to maintain lean body mass versus depleting lean body mass. In the situation of maintenance, energy needs are estimated at 25-35 kcal/kg, and protein needs are estimated at 1.2-1.9 g protein/kg.
In the situation of repletion, energy needs are estimated at 35-45 kcal/kg and protein needs are estimated at 1.6-2.5 g protein/kg.