Nutrition Advisory Committee

University of Washington Medical Center and Clinical Nutrition Committee, Harborview Medical Center

Acknowledgements

Special thanks to the following individuals for their contributions to this manual:

Susan Bussell, R.D., Kim Donnelly, R.Ph., Scott Helton, M.D., Susan Kracke, R.Ph., Robert Labbe, Ph.D., Edward Lipkin, M.D., Ph.D., Jill McCormick, M.S.,R.D., Patricia Riley, R.D., Megan Veldee, M.S., R.D., Sarah Washburn M.S., R.D., and thanks to Jana Huddleston, for her computer and word processing support.

Table of Contents

I. Introduction ............................................................ 1

II. Nutritional Assessment .......................................... 2-3

1. Risk Factors
2. Diet History
3. Medical History
4. Physical Examination
5. Subjective Global Assessment
6. Laboratory Tests

III. Estimating Nutritional Requirements ....................... 4-8

1. Determine Ideal or "Adjusted" Body Weight
2. Energy Requirements
3. Protein Requirements
4. Fluid Requirements
5. Electrolyte Requirements
6. Fat Requirements
7. Micronutrient Requirements

IV. Nutritional Therapy Options .................................. 9-10

1. Nutrition Modalities
   1. Oral Diet
      
   2. Enteral Nutrition
      
   3. Parenteral Nutrition
      

V. Enteral Nutrition .................................................. 11-23

1. Tube Placement Options
   1. Nasoenteric Feeding Tubes
   2. Tube Enterostomy
2. Formula Selection
3. Administration Guidelines
   1. Initiation and Progression
   2. Calculate Additional Fluid Requirements
   3. Transition to Cyclic or Bolus Feedings
   4. Vitamin and Mineral Requirements
   5. Monitoring
4. Writing Enteral Nutrition Orders
5. Medications and Enteral Nutrition
6. Complications of Enteral Nutrition Therapy

VI. Parenteral Nutrition ........................................... 24-36

1. Access Routes and Catheter Placement
   1. Access Routes
   2. Catheter Placement Requests
2. Initiating Parenteral Nutrition
   1. Formula Determination
   2. Writing Parenteral Nutrition Orders
3. Administration Guidelines
4. Medications and Parenteral Nutrition Therapy
5. Complications of Parenteral Nutrition Therapy

VII. Monitoring Nutritional Therapy .................................. 37

1. Physical Examination
2. Functional Assessment
3. Laboratory Tests
   1. Basic Test Schedule
   2. Nitrogen Balance
   3. Protein-energy Balance Markers
   4. Evaluating Acid/Base Balance
   5. Vitamins and Minerals
   6. Liver Dysfunction
4. Short Gut Syndrome
5. Refeeding Syndrome

VIII. Appendices........................................................ 45

1. Common Drug and Nutrient Interactions
2. Physical Signs Suggestive of Nutrient Deficiencies
3. Nutrition Assessment Protocal
4. Nutrition-Related Lab Tests
5. Metropolitan Life Insurance Ideal Body Weights
6. Estimating Energy Requirements
7. Essential Nutrients in Human Metabolism
8. Diagnosis of Nutritional Anemias

XI. Recommended Readings............................................... 65