Nutrition on a Patient with Acute and Recurrent Pancreatitis - Essay Example

Case Study - Patient with Acute and Recurrent Pancreatitis Using the five-step nutrition care process, discuss how you would work with the registered dietitian (RD) to create a Nutrition Care Plan for this patient. Nutritional assessment is the first step in the care process and should include measurement of anthropometric data, laboratory values, medical history, and other associated information. Appropriate nutrition diagnosis for this patient would be “Altered GI function RT pancreatic pathology as evidenced by medical history”.

Planning for this patient care should uphold the returning to normal of nutritional status. Interventions should be collaborated by the physician, nurse, RD, and laboratory technician. The calorie and protein needs of the patient are calculated by the RD and appropriate method of feeding will be ordered by the physician. The nurse is responsible in coordinating the orders by the health team. Evaluation should focus on the patient’s tolerance of the interventions implemented and reassessment of the overall nutritional status. 2. How you would use anthropometric data to assess his nutritional status?

Anthropometric measurement is part of every nutrition status assessment. In the patient’s case, it provides a notable impression of weight loss (approx. 20 lbs.)in the past two months based on the difference between the UBW as reported by the patient and his current weight. His present BMI is 20.7 (within the normal range). On the other hand, weight itself cannot be regarded as reliable since various factors may affect its accuracy, such as third spacing usually associated with pancreatitis (Lugli, Carli & Wykes, 2007).

Thus, other tests should be considered to obtain the most accurate data on his nutritional status. 3. What are the options for providing nutritional support?Patient remained at NPO status 24 hours after admission. To maintain/ improve nutritional status, options for this patient include Total Parenteral Nutrition (TPN) or Enteral nutrition (EN). Both options are based on the “pancreatic rest” theory, in which the pancreas should be allowed to rest to regain functionality (Ioannidis, Lavrentieva & Botsios, 2008).

TPN was considered as the gold standard of management in acute pancreatitis, but the risks of complications associated with this therapy lead to the change of intervention to the use of Enteral nutrition (McClave et al., 2006).4. When would you initiate feeding and how? When the patient’s condition does not improve, tube feedings might be ordered by the physician. According to Ioannidis, Lavrentieva and Botsios (2008), initial amount of nutritive solution administered should be 25 mL/h. This should gradually increase until the desired quantity (25 kcal/kg/day) is achieved in 24-48 hours. 5. If tube feedings are warranted, how will you determine the type of formula to use?

The formula for feeding should minimize the pancreatic secretion of digestive enzymes as much as possible. Thus, a fat- free elemental diet or oligopeptide diet (in which 70% of the contained fat is in the form of moderate chain triglycerides) may be used to minimize pancreatic stimulation. Some studies support the addition of glutamine, selenium, antioxidants, and immunomodulatory components to formula to improve lymphocyte proliferation, increase T-cell DNA synthesis and decrease release of the proinflammatory cytokine IL-8 (Ioannidis, Lavrentieva & Botsios, 2008).

In contrast, probiotics are not recommended in the formula because these components are known to cause local mucosal inflammation in the small intestine. In fact, the risk for infection is not reduced with probiotics. Generally, protein should be supplied between 1.2 to 1.5 g/kg body weight/day, while fat can be safely administered up to 2 g/kg body weight/day (Ioannidis, Lavrentieva & Botsios, 2008).6. Why are enteral feedings important for a patient with severe acute pancreatitis? Enteral nutrition (EN), like TPN, minimizes pancreatic stimulation.

But unlike TPN, EN minimizes the risk of infection and sepsis, maintains intestinal health, supports splanchnic protein synthesis, and prevents the progression of multiple organ failure (Ioannidis, Lavrentieva & Botsios, 2008). Its effectiveness is comparable with TPN but is less expensive (Lugli, Carli & Wykes, 2007). Actually, the major disadvantage of using TPN is the failure to use the gastrointestinal tract which could exacerbate the stress response and aggravate the condition (McClave et al., 2006).7.

What would you do to minimize potential complications from enteral tube feeds? The complications of enteral feeding includes possible pancreatic stimulation, paralytic ileus, damage to the tissue integrity due to insertion, diarrhea (Lugli, Carli & Wykes, 2007) and metabolic imbalances like hyperglycemia (Farver, 1993). These complications can be prevented and minimized by constant monitoring of the patient. 8. Where would you place the tube? Researchers practically agree on the placement of the enteral feeding in the mid- distal jejunum.

According to Ioannidis, Lavrentieva and Botsios (2008), early infusion of oligopeptide solutions for enteral nutrition ensures pancreatic rest. There is also lesser stimulation when the nutrients directly come in contact with the distal part of the intestine. In fact, several inhibitory factors (inhibitory polypeptide, polypeptide YY, somatostatin, various intra- luminal proteases, and biliary salt) are secreted when the administration of nutrients is distal to the first jejunal helix even if the feeding is continuous.

Precisely, the end of the tube should be 25- 30 cm after the Treitz ligament. 9. Discuss the transition from the tube to oral feeding. At what point would you discontinue the tube feedings? Although mild paralytic ileus usually occurs as a consequence of enteral feeding, this should not stop the intervention. Usually, oral consumption of food commences at 3- 4 days after the patient last complained of pain and the levels of serum amylase and lipase have returned within the normal range. At the onset of oral refeeding, particular attention should be considered on the clinical signs of the condition since pancreatitis may be manifested again when the pancreas is not fully adjusted yet (Ioannidis, Lavrentieva & Botsios, 2008).

High carbohydrate and moderate amounts of protein is recommended in the first feedings. This amount is increased continuously to cope up with the body’ increased demand of energy related to the hypermetabolic state.10. How would you evaluate progress toward meeting his nutritional needs? Early convalescence is expected when less than one- third of the pancreas is damaged, or the duration of pain is less than 6 days, and the maximum pancreatic lipase level is less than triple the normal. This is evaluated by laboratory analysis and a thorough assessment such as weight taking and functional capability (Ioannidis, Lavrentieva & Botsios, 2008).

Each plasma micronutrients is measured by biomarkers specific to each substance (Lugli, Carli & Wykes, 2007).ReferencesFarver, K. (2003). Enteral Feeding Complications. Perspectives on Nutrition, 1(4). Grodner, M., Anderson, S. L., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed.). St. Louis, MI: Mosby, Inc.Ioannidis, O, Lavrentieva, A, & Botsio, D. (2008). Nutrition Support in Acute Pancreatitis. JOP. Journal of the Pancreas, 9(4), 375-390.

Available from http://www.joplink.net/prev/200807/20.htmlLugli, A. K. , Carli, F., & Wykes, L. (2007). The importance of nutrition status assessment: The case of severe acute pancreatitis. Nutrition Reviews, 65(7), 329-334.McClave, S. A., Chang, W-K., Dhaliwal, R., & Heyland, D. K. (2006). Nutrition support in acute pancreatitis: A systematic review of the literature. JPEN, Journal of Parenteral and Enteral Nutrition, 30(2), 143-56.