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Transcript of 1) Morton PG, Fontaine DK (eds). Critical Care Nursing: A Holistic Approach. 9 th edition....
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1) Morton PG, Fontaine DK (eds). Critical Care Nursing: A Holistic
Approach. 9th edition. Philadelphia: Lippincott; 2009. PP: 1017-1033.
2) Kururilla J (eds). Essentials of Critical Care Nursing: A Holistic
Approach. 9th edition. New Delhi: Jaypee Brothers; 2007. PP: 334-342.
. مترجم: پوران سامی، چاپ اول، انتشارات ICU( مارینو پ. کتاب کامل 3
.459- 481، صفحات 1387بشری، تهران،
4) Singer P, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive
care. Clinical Nutrition 2009: 1-14.
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اختالل در عملکرد سیستم
ایمنی.
اختالل در ترمیم زخم.
تحلیل عضالت بدن.
افزایش وابستگی به ونتیالتور.
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( محاسبه انرژی با روشی ساده Kururilla:(
30 انرژی )کیلوکالری(= وزن )کیلوگرم( *
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- انرژی مورد نیاز برای فعالیت های فیزیکی فرد:2
.BEE درصد 50 تا 10 در افراد عادی:
.BEE درصد 20 تا 10 در فرد بستری
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- انرژی مورد نیاز در شرایط استرس زای مختلف:3
%10 جراحی های الکتیو:
%10-30 تروما:
%50-80 سپتی سمی:
%100-200 سوختگی ها )بر اساس وسعت(:
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جراحی الکتیو، عفونت خفیف
استرس خفیف25
شکستگی، عفونت شدید
استرس متوسط35
سوختگی شدید، نارسایی کلیه
استرس شدید45
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.استفاده از آندوسکوپی فیبر اپتیک
. لوله های مجهز به مغناطیس خارجی
.تزریق متوکلوپرامید
.تزریق هوا
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For nutrition where patient cannot consume
sufficient calories to meet metabolic needs
Impaired swallowing (neurologic, neuro-
muscular, obstructive neoplasms)
NG tube associated aspiration
Gastric decompression
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Inability to bring the anterior gastric wall
in apposition to the anterior abdominal
wall (prior subtotal gastrectomy, ascites,
marked hepatomegaly)
Severe obesity
Small bowel fistula
Incorrectable coagulopathy
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.تراکم کالری
.اسمواللیته
( پروتئین و پپتید Peptamen و Vital HN.)
چربی ها Pulmocare.
( گلوتامین Alitraq یا Impact glutamine)
فیبر: قابل تخمیر )سلولز، پکتین، صمغ(- غیر قابل تخمیر
)لیگنین ها(
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انسداد لوله.
رفالکس.
اسهال )سوربیتول- محلول های هیپرتونیک-
آنتروکولیت(.
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23
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اختالل عملکرد دستگاه
گوارش.
بدخیمی ها.
وضعیت هایپرمتابولیک.
استراحت روده.
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Peripheral Parenteral Nutrition تغذیه از طریق ورید محیطی
(PPN)
Total Parenteral Nutrition (TPN) تغذیه کامل وریدی
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%20 دکستروز
%3 آمینواسید
%20 اینترالیپید
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Protein………………...Amino Acids 10% 500 ml
Carbohydrates…….Dextrose 50% 500 ml
Fat……………………….Lipid Emulsion 20% 500 ml
Vitamins………………Multivitamin Infusion
Minerals……………….Electrolytes and Trace Elements
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میلی لیتر در ساعت(60 لیتر روزانه )TPN 1/5محلول : 1مرحله
mmol 30 لیتر دکستروز سالین روزانه حاوی 1/5انفوزیون جانبی:
KCL/L.
میلی لیتر در ساعت(80 لیتر روزانه )TPN 2محلول : 2مرحله
میلی لیتر در 40 لیتر دکستروز سالین روزانه )1انفوزیون جانبی:
ساعت(
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میلی لیتر در 100 لیتر روزانه )TPN 2/5محلول : 3مرحله
ساعت(
میلی لیتر در 20 لیتر دکستروز سالین روزانه )0/5انفوزیون جانبی:
ساعت(
میلی لیتر در ساعت(120 لیتر روزانه )TPN 3محلول : 4مرحله
میلی لیتر در 20 لیتر دکستروز سالین روزانه )0/5انفوزیون جانبی:
ساعت(
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Macronutrient Concentrations in PN Solutions
Macronutrient concentrations (%) = the
grams of solute/100 ml of fluid
D70 has 70 grams of dextrose per 100 ml.
10% amino acid solution has 10 grams amino
acids/100 ml of solution
20% lipids has 20 grams of lipid/100 ml of
solution
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Protein Content Calculations
To calculate the grams
of protein supplied by a
TPN solution, multiply
the total volume of
amino acid solution (in
ml*) supplied in a day
by the amino acid
concentration.
Example Protein
Calculation
1000 ml of 8% amino
acids:
1000 ml x 8 g/100 ml
= 80g
Or 1000 x .08 = 80 g
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Dextrose Calculation
1000 ml of D50W (50% dextrose)
1000 ml x 50g / 100 ml = 500g dextrose
OR 1000 ml x .50 = 500g dextrose
500g dextrose x 3.4 kcal/g = 1700 kcal
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Calculation of Lipid Content
To determine kcalories supplied by lipid*, multiply the volume of 10% lipid (in ml) by 1.1; multiply the volume of 20% lipid (in ml) by 2.0.
If lipids are not given daily, divide total kcalories supplied by fat in one week by 7 to get an estimate of the average fat kcalories per day.
*|Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.
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Example Lipid Calculation for 2-in-1
500 ml of 10% lipid
500 ml x 1.1 kcal/ml = 550 kcal
500 ml 20% lipid
500 ml x 2.0 kcal/ml = 1000 kcal
Or, alternatively, 500 ml of 10% lipid = 50
grams lipid x 10 kcal/g or 500 kcal
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Calculation of Dextrose/AA with Piggyback Lipids (2-in-1)
Determine patient's kcalorie, protein, and fluid needs.
Determine lipid volume and rate for "piggy back" administration. Determine kcals to be supplied from lipid.
(Usually 30% of total kcals). Divide lipid kcals by 1.1 kcal/cc if you are using
10% lipids; divide lipid kcals by 2 kcal/cc if you are using 20% lipids. This is the total volume.
Divide total volume of lipid by 24 hr to determine rate in cc/hr.
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Example Calculation
Nutrient Needs:
Kcals: 1800. Protein: 88 g. Fluid: 2000 cc
1800 kcal x 30% = 540 kcal from lipid
Lipid (10%):
540 kcal/1.1 (kcal/cc) = 491 cc/24 hr =
20 cc/hr 10% lipid (round to 480 ml)
Remaining fluid needs: 2000cc - 480cc = 1520cc
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Determine protein concentration
Subtract volume of lipid from total fluid
requirement to determine remaining fluid needs.
Divide protein requirement (in grams) by
remaining fluid requirement and multiply by 100.
This gives you the amino acid concentration in %.
Multiply protein requirement in grams x 4 to
determine calories from protein
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Protein Calculations
Protein: 88 g / 1520 cc x 100 =
5.8% amino acid solution
88 g. x 4 kcal/gm =352 kcals from
proteinRemaining kcal needs: 1800 – (528 + 352) =
920 kcal
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Determine dextrose concentration
Subtract kcals of lipid + calories from protein from total kcals to determine remaining kcal needs.
Divide "remaining kcals" by 3.4 kcal/g to determine grams of dextrose.
Divide dextrose grams by remaining fluid needs (in protein calculations) and multiply by 100 to determine dextrose concentration.
Determine rate of AA/dex solution by dividing "remaining fluid needs” by 24 hr.
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Dextrose Concentration
920 kcal/3.4 kcal/g = 270 g dextrose
270 g / 1520 cc x 100 = 17.7% dextrose solution
Rate of Amino Acid / Dextrose: 1520 cc / 24hr = 63 cc/hr
TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr
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بار در روز.4 کنترل عالئم حیاتی حداقل
.ثبت جذب و دفع روزانه
.کنترل وزن روزانه
ساعت.6 کنترل قند ادرار هر
کنترل روزانه قند خون، اوره، الکترولیت های سرم تا زمان
ثابت شدن آن و سپس دو بار در هفته.
.کنترل کلسیم و فسفر سرم دو بار در هفته
،کنترل هموگلوبین، زمان پروترمبین LFT و TIBC هفته ای یک
بار.
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Osmolarity in PPNWhen a hypertonic
solution is introduced into a small vein with a low blood flow, fluid from the surrounding tissue moves into the vein due to osmosis. The area can become inflamed, and thrombosis can occur.
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IV-Related Phlebitis
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عوارض مربوط به کاتتر.
عوارض متابولیک.
عوارض گوارشی.
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