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Section 4 - Home Nutritional Support

Introduction

Nutritional support in the home is a logical extension of support provided to hospitalized patients. It has allowed successful management of patients with diseases that would otherwise have resulted in repeated or prolonged hospitalization. Nutritional therapy in the home can save health care dollars and improve clinical outcome. However, these services require careful assessment, planning, monitoring, and follow-up in order to be successful. Please support this web site

An interdisciplinary team of health professionals must assess, implement, monitor, and maintain home nutrition therapy. The treatment team should include:

  • A physician
  • A nurse
  • A dietician
  • A pharmacist
  • A home care company


Indications

Indications for long term nutritional support are the same as those for hospitalized patients, with the additional consideration of the capabilities of the patient and family members as well as the safety of the home environment.

Home enteral nutrition is indicated when there is disease or impairment of digestion or absoprtion of nutrients resulting in the need for tube feedings to provide sufficient nourishment to maintain appropriate weight or growth and to support life.
Home parenteral nutrition is indicated when the GI tract does not allow adequate absorption or transport of sufficient nutrients to maintain appropriate weight or growth and to support life.


Considerations

Several medical and social factors must be considered when selecting a patient for home nutritional support.

Stable medical condition

The patient's medical condition must be stabilized for safe discharge to home.

Acceptance by patient and caregivers

The patient and caregivers must understand and accept the risks and responsibilities for home nutrition therapy. It must be emphasized that compliance with therapy is essential in order for it to be successful.

Capabilities of patient and caregivers

The patient and caregivers must have the dexterity and cognitive ability to perform required care. They must be able to troubleshoot minor problems or call for assistance.

Adequacy of support system

The support system includes the health professionals involved in caring for and monitoring the patient; other individuals such as family, friends, clergy, or others who may be of assistance to the patient; and the provider of nutrition and medical products.

  1. There is an adequately trained support network of family members, friends, and caregivers.
  2. There is a reliable provider, with 24-hour availability, for nutrition and medical products, services, and other necessary supplies.
  3. Adequate insurance coverage and eligibility for reimbursement must be considered.

Adequacy of home environment

The home must be a clean, safe environment for storage, preparation, and administration of nutritional support.

  1. Hot and cold running water.
  2. Dependable refrigeration.
  3. Appropriate and adequate dry storage space.
  4. Adequate lighting and electricity.
  5. Phone service and access to emergency medical service.


Nutrition support care plan

Once it is decided that a patient is a candidate for home nutrition support, the specifics of care should be established through a nutrition plan of care. Factors that should be included in this plan are:

  1. Define the individual's nutritional goals.
  2. Create a patient-specific nutrient prescription.
  3. Select the appropriate route for providing nutrients.
  4. Select the appropriate access device.
  5. Establish schedule for infusion of enteral or parenteral nutrition therapy.
  6. Establish appropriate preparation and administration techniques for the patient caregivers.
  7. Determine a plan for safe storage and preparation of formulas, for management of equipment, and for site care.
  8. Establish and document a plan for monitoring nutrition therapy.


Long term complications

In addition to the complications mentioned in previous sections of this tutorial, the home patient is susceptible to metabolic complications from long-term nutritional support, particularly PN.

Metabolic bone disease

Metabolic bone disease is particularly pertinent to parenteral nutrition patients. It has been suggested that 40 to 100% of patients on long term PN have decreased bone density or evidence of metabolic bone disease. Bone pain and spontaneous fractures are hallmarks of this disorder. Although aluminum contamination was once suspected as the cause, little is actually known about the pathogenesis and treatment of this disorder. The mineral and vitamin D status of long term PN patients should be evaluated. The patient should be encouraged to be mobile, get exposure to the sun, and exercise.

Essential fatty acid deficiency

Essential fatty acid deficiency, like MBD, is particularly pertinent to PN patients. It may be prevented by giving a minimum of 1g/kg/week of IV fat emulsion.

Vitamin K deficiency

Because Vitamin K is not included in the adult multivitamin injection, PN patients are at risk of developing a deficiency. There are various methods of administering Vitamin K to prevent deficiency:

  • 10mg subcutaneously once weekly
  • 10mg added to PN once weekly
  • 0.25 to 1mg added to PN daily

Folic acid and Vitamin B-12 deficiency

Macrocytic anemias are common in long-term PN patients. Folic acid and B-12 deficiencies must be ruled out in any patient with a macrocytic anemia. Patients with malabsorption disorders are always considered to be of high risk of FA and B-12 deficiency. Therapeutic doses of these vitamins are required for several weeks until the anemia is corrected. Patients with short-bowel syndrome will need B-12 injections if they lack the terminal ileum.

Iron deficiency

Eventually, a long-term PN patient who cannot eat or absorb nutrients will become iron deficient. Because it may crack the emulsion, iron is never added to TNAs. There are several approaches to treatment of iron deficiency. One is to administer the iron as a short, separate infusion while the PN solution is not hanging. Another is to add 25mg to 100mg of iron three times a week to a PN solution with the lipid omitted. The lipids are then administered the other four days of the week.

Liver and gallbladder disease

Other complications of long-term PN includes steatosis, cholestasis, and cholelithiasis. Steatosis is a benign and reversible condition resulting from excess administration of dextrose calories. Cholestasis results from the lack of enteric stimulation that occurs with long-term PN therapy. Biliary sludge has been reported to occur in 100% of patients receiving long-term PN. The billiary sludge may eventually form gallstones. Cholestasis is a chronic condition which may progress to irreversible liver disease. Measures to prevent or treat this complication include:

  • Avoid excess caloric load
  • Decrease glucose intake
  • Remove copper from PN
  • Initiate some oral intake if possible


Monitoring

Because a variety of complications may develop in long-term nutritional support, diligent patient monitoring is necessary. The following table is only a guideline, the frequency of monitoring should be individualized to the patient's condition and potential for complications.

Schedule for monitoring long-term nutritional support

Parenteral Enteral
Blood chemistry Monthly Every 6 months
Lytes, BUN, creatinine Monthly Every 6 months
Triglycerides Monthly Every 6 months
Glucose Monthly Every 6 months
Serum proteins Monthly Every 6 months
Weight Weekly Weekly
I & O Weekly Weekly
Nitrogen balance PRN PRN


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Section 4 - Home Nutritional Support

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