![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png\")
\r\nTeam rounds are an opportunity to collaborate and communicate with the interdisciplinary team. You may update the team about your patient\u2019s care plan and gather important information on their diagnosis, prognosis, consults, current status, expected progression, next steps and disposition planning.<\/div>\r\n
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\r\n\r\n[caption id=\"attachment_1467\" align=\"aligncenter\" width=\"1024\"]![\"5](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/lt-jasmyne-avery-assigned-to-naval-hospital-camp-pendleton-performs-rounds-b3ff36.jpg\")
A doctor, nurse, and other medical staff are pictured conducting rounds in a hospital.
Photo by Madailein Abbott<\/a> is licensed under Public Domain<\/a>.[\/caption]\r\n\r\n<\/div>\r\n
A doctor, nurse, and other medical staff are pictured conducting rounds in a hospital.Photo by Madailein Abbott<\/a> is licensed under Public Domain<\/a>.[\/caption]\r\n\r\n<\/div>\r\n
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\r\n\r\nPoppy's PN Plan<\/h2>\r\n<\/header>\r\n
Poppy's PN Plan<\/h2>\r\n<\/header>\r\n\r\n\r\nWhen a dietitian is asked to assess a patient for PN, the first question should be \u201cIs PN appropriate for this patient?\u201d PN is an invasive, expensive and high-risk treatment compared to other methods of feeding.\r\n\r\nIn making your decision, consider the following about Poppy:\r\n\r\n \t- She is not tolerating EN.<\/li>\r\n \t
- She is critically ill (catabolic), with an acute kidney injury, and has lost a significant amount of weight preoperatively.<\/li>\r\n \t
- Her history of severe PVD may contribute to a prolonged period of poor tolerance to enteral nutrition.<\/li>\r\n<\/ul>\r\nThese factors coupled with inadequate nutrition support postoperatively may increase the chance of poor outcomes, morbidity and mortality.\r\n\r\nTherefore, Poppy is appropriate for parenteral nutrition support.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n
Timing of PN Initiation<\/h1>\r\nInitiation of parenteral nutrition may differ based on clinical indication and severity of malnutrition. It is common practice to initiate PN sooner for patients who are malnourished and are unable to meet their estimated nutrition requirements with oral intake or enteral nutrition.\u00a0 Other factors may also influence initiation of PN. However, general guidelines regarding initiation of PN are listed below.\r\n\r\n \t- For well-nourished, stable<\/strong> patients: Initiate parenteral nutrition after 5 to 7 days if unable to receive > 50% of estimated requirements orally or enterally.<\/li>\r\n \t
- Patients who are nutritionally-at-risk<\/strong> and unlikely to achieve adequate oral or enteral intake: Initiate parenteral nutrition within 3 to 5 days.<\/li>\r\n \t
- In patients with baseline<\/strong> moderate or severe malnutrition and insufficient or unattainable oral\u00a0 or enteral intake: Initiate parenteral nutrition as soon as possible.<\/li>\r\n \t
- For patients with severe metabolic instability<\/strong>: Delay initiation of parenteral nutrition until their condition has improved.<\/li>\r\n<\/ul>\r\n
Reminder of PN Formulations<\/h1>\r\nMacronutrients<\/h2>\r\nThe energy that is provided from macronutrients in PN is slightly different than the energy provided in other forms of nutrition (i.e. enteral formulas, food, beverages). Please note the differences below and ensure you use the correct values when determining your PN care plan.\r\n\r\nCaloric contributions of macronutrients:\r\n\r\n \t- Protein<\/strong>: 1 g amino acid = 4.0 kcals<\/li>\r\n \t
- Carbohydrate<\/strong>: 1 g dextrose = 3.4 kcals<\/li>\r\n \t
- Lipid<\/strong>: 1 g lipid = 10 kcals<\/li>\r\n<\/ul>\r\n
Lipids<\/h2>\r\nDepending on your hospital formulary, you may have access to various lipid emulsions. These emulsions vary in omega-3, 6 and 9 content. You should seek further readings regarding the use of various lipid emulsions and the associated advantages, disadvantages, and possible situations that they may be used in.\r\n\r\n \t- Intralipid<\/strong>: made of safflower or soybean oil + glycerol emulsifier + phospholipid (egg) and available as 10%, 20% & 30%<\/li>\r\n \t
- SMOFlipid<\/strong>: soybean oil, medium chain triglycerides (MCT), olive oil, and fish oil (6%\/6%\/5%\/3% w\/v)<\/li>\r\n \t
- Omegavan<\/strong>: purely fish oils, DHA, EPA<\/li>\r\n \t
- ClinOleic<\/strong>: olive oil<\/li>\r\n<\/ul>\r\n
Lipid emulsion concentrations<\/caption>\r\n \r\n\r\nLipid Emulsions<\/th>\r\n Omega-3<\/th>\r\n Omega-6<\/th>\r\n Omega-9<\/th>\r\n Saturated<\/th>\r\n MCT<\/th>\r\n<\/tr>\r\n \r\nSoybean oil emulsion<\/th>\r\n 5%<\/td>\r\n 60%<\/td>\r\n 20%<\/td>\r\n 15%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\nOlive-soybean oil mixture<\/th>\r\n 3%<\/td>\r\n 20%<\/td>\r\n 60%<\/td>\r\n 17%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\nFish oil emulsion<\/th>\r\n 60%<\/td>\r\n 10%<\/td>\r\n 10%<\/td>\r\n 20%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\nSMOF emulsion<\/th>\r\n 10%<\/td>\r\n 20%<\/td>\r\n 30%<\/td>\r\n 10%<\/td>\r\n 30%<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nMicronutrients<\/h2>\r\nVitamins, minerals, and trace elements should be included in parenteral nutrition solutions as depletion of a compromised patient\u2019s micronutrient reserves could impair the patient\u2019s ability to absorb and utilize nutrients.\r\n\r\nElectrolytes are also added to PN solutions. Unlike vitamins, minerals and trace elements, electrolytes must be adjusted daily in a patient who is starting PN to account for losses, disease effects and organ function.\r\n\r\nThere are guidelines which govern how much calcium and phosphorus can be given to avoid precipitates. <\/span>Acetate is added to buffer acid from amino acids as bicarbonate cannot be added.\u00a0 Large electrolyte deficiencies must be corrected by IV boluses (ordered by the MD\/NP) prior to initiating PN or advancing solutions.\u00a0 <\/span>Institutional formularies will determine which micronutrients are available and training should be provided to ensure safe delivery to patients.\u00a0<\/span>\r\n\r\nHere is a sample electrolyte regimen for a stable patient receiving PN:\r\n
- \r\n \t
- She is not tolerating EN.<\/li>\r\n \t
- She is critically ill (catabolic), with an acute kidney injury, and has lost a significant amount of weight preoperatively.<\/li>\r\n \t
- Her history of severe PVD may contribute to a prolonged period of poor tolerance to enteral nutrition.<\/li>\r\n<\/ul>\r\nThese factors coupled with inadequate nutrition support postoperatively may increase the chance of poor outcomes, morbidity and mortality.\r\n\r\nTherefore, Poppy is appropriate for parenteral nutrition support.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n
Timing of PN Initiation<\/h1>\r\nInitiation of parenteral nutrition may differ based on clinical indication and severity of malnutrition. It is common practice to initiate PN sooner for patients who are malnourished and are unable to meet their estimated nutrition requirements with oral intake or enteral nutrition.\u00a0 Other factors may also influence initiation of PN. However, general guidelines regarding initiation of PN are listed below.\r\n
- \r\n \t
- For well-nourished, stable<\/strong> patients: Initiate parenteral nutrition after 5 to 7 days if unable to receive > 50% of estimated requirements orally or enterally.<\/li>\r\n \t
- Patients who are nutritionally-at-risk<\/strong> and unlikely to achieve adequate oral or enteral intake: Initiate parenteral nutrition within 3 to 5 days.<\/li>\r\n \t
- In patients with baseline<\/strong> moderate or severe malnutrition and insufficient or unattainable oral\u00a0 or enteral intake: Initiate parenteral nutrition as soon as possible.<\/li>\r\n \t
- For patients with severe metabolic instability<\/strong>: Delay initiation of parenteral nutrition until their condition has improved.<\/li>\r\n<\/ul>\r\n
Reminder of PN Formulations<\/h1>\r\n
Macronutrients<\/h2>\r\nThe energy that is provided from macronutrients in PN is slightly different than the energy provided in other forms of nutrition (i.e. enteral formulas, food, beverages). Please note the differences below and ensure you use the correct values when determining your PN care plan.\r\n\r\nCaloric contributions of macronutrients:\r\n
- \r\n \t
- Protein<\/strong>: 1 g amino acid = 4.0 kcals<\/li>\r\n \t
- Carbohydrate<\/strong>: 1 g dextrose = 3.4 kcals<\/li>\r\n \t
- Lipid<\/strong>: 1 g lipid = 10 kcals<\/li>\r\n<\/ul>\r\n
Lipids<\/h2>\r\nDepending on your hospital formulary, you may have access to various lipid emulsions. These emulsions vary in omega-3, 6 and 9 content. You should seek further readings regarding the use of various lipid emulsions and the associated advantages, disadvantages, and possible situations that they may be used in.\r\n
- \r\n \t
- Intralipid<\/strong>: made of safflower or soybean oil + glycerol emulsifier + phospholipid (egg) and available as 10%, 20% & 30%<\/li>\r\n \t
- SMOFlipid<\/strong>: soybean oil, medium chain triglycerides (MCT), olive oil, and fish oil (6%\/6%\/5%\/3% w\/v)<\/li>\r\n \t
- Omegavan<\/strong>: purely fish oils, DHA, EPA<\/li>\r\n \t
- ClinOleic<\/strong>: olive oil<\/li>\r\n<\/ul>\r\n
Lipid emulsion concentrations<\/caption>\r\n \r\n\r\n Lipid Emulsions<\/th>\r\n Omega-3<\/th>\r\n Omega-6<\/th>\r\n Omega-9<\/th>\r\n Saturated<\/th>\r\n MCT<\/th>\r\n<\/tr>\r\n \r\n Soybean oil emulsion<\/th>\r\n 5%<\/td>\r\n 60%<\/td>\r\n 20%<\/td>\r\n 15%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\n Olive-soybean oil mixture<\/th>\r\n 3%<\/td>\r\n 20%<\/td>\r\n 60%<\/td>\r\n 17%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\n Fish oil emulsion<\/th>\r\n 60%<\/td>\r\n 10%<\/td>\r\n 10%<\/td>\r\n 20%<\/td>\r\n -<\/td>\r\n<\/tr>\r\n \r\n SMOF emulsion<\/th>\r\n 10%<\/td>\r\n 20%<\/td>\r\n 30%<\/td>\r\n 10%<\/td>\r\n 30%<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n Micronutrients<\/h2>\r\nVitamins, minerals, and trace elements should be included in parenteral nutrition solutions as depletion of a compromised patient\u2019s micronutrient reserves could impair the patient\u2019s ability to absorb and utilize nutrients.\r\n\r\nElectrolytes are also added to PN solutions. Unlike vitamins, minerals and trace elements, electrolytes must be adjusted daily in a patient who is starting PN to account for losses, disease effects and organ function.\r\n\r\nThere are guidelines which govern how much calcium and phosphorus can be given to avoid precipitates. <\/span>Acetate is added to buffer acid from amino acids as bicarbonate cannot be added.\u00a0 Large electrolyte deficiencies must be corrected by IV boluses (ordered by the MD\/NP) prior to initiating PN or advancing solutions.\u00a0 <\/span>Institutional formularies will determine which micronutrients are available and training should be provided to ensure safe delivery to patients.\u00a0<\/span>\r\n\r\nHere is a sample electrolyte regimen for a stable patient receiving PN:\r\n
- SMOFlipid<\/strong>: soybean oil, medium chain triglycerides (MCT), olive oil, and fish oil (6%\/6%\/5%\/3% w\/v)<\/li>\r\n \t
- Carbohydrate<\/strong>: 1 g dextrose = 3.4 kcals<\/li>\r\n \t
- Patients who are nutritionally-at-risk<\/strong> and unlikely to achieve adequate oral or enteral intake: Initiate parenteral nutrition within 3 to 5 days.<\/li>\r\n \t
- For well-nourished, stable<\/strong> patients: Initiate parenteral nutrition after 5 to 7 days if unable to receive > 50% of estimated requirements orally or enterally.<\/li>\r\n \t
![\"Illustration](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/PN-Procurement-300x300.png\")
Illustration of a 2-in-1 PN procurement. A double lumen catheter has a y-connector leading to two bags: 1. amino acids, dextrose, electrolytes, vitamins and minerals; 2. Lipid.[\/caption]\r\n\r\nSome hospitals have a pre-determined standardized formulary<\/strong> for ease of ordering and preparing PN. The pre-determined formulas are all named and vary in macronutrient volumes. Additives are individualized based on patients\u2019 needs. The RD chooses the solution which closely matches the patient\u2019s requirements. Here is an example of a standardized bag order form: