Clinical Nutrition: Enteral and Tube Feeding PDF
Preview Clinical Nutrition: Enteral and Tube Feeding
ELSEVIER SAUNDERS TheCurtisCenter 170S.IndependenceMallW300E Philadelphia,Pennsylvania 19106 ENTERALANDTUBEFEEDING ISBN0-7216-0379-3 Copyright© 2005, ElsevierInc.(USA).Ailrights reserved. Nopartofthispublicationmaybereproducedortransmitted inanyformorbyanymeans,electronicor mechanical,includingphotocopying,recording, oranyinformationstorageand retrieval system,without permission inwritingfromthepublisher.Permissionsmaybesoughtdirectlyfrom Elsevier'sHealth SciencesRightsDepartment inPhiladelphia,PA,USA:phone: (+1) 2152387869,fax:(+1) 2152382239, e-mail:healthpermissions@elsevier.com.Youmayalsocompleteyourrequeston-lineviatheElsevier Sciencehomepage(http://www.elsevier.com).byselecting 'CustomerSupport' andthen 'Obtaining Permissions'. NOTICE Medicineisanever-changingfield. Standardsafetyprecautionsmustbefollowed,butasnew researchandclinicalexperiencebroadenourknowledge,changesintreatmentand drugtherapy maybecome necessaryorappropriate.Readersareadvisedtocheckthemostcurrentproduct informationprovidedbythemanufacturerofeachdrug tobeadministeredtoverify the recommendeddose,themethod anddurationofadministration,andcontraindications.Itisthe responsibilityofthelicensedprescriber, relying onexperienceand knowledgeofthepatient, to determinedosagesandthebesttreatment foreachindividualpatient. Neitherthepublishernorthe authorassumesanyliabilityforanyinjuryand/ordamagetopersonsorpropertyarising fromthis publication. ThePublisher Previouseditionscopyrighted 1997,1990,1984 Clinicalnutrition:enteralandtube feeding/editor-in-chief,RolandoH.Rolandelli; associateeditors,Robin Bankhead,Joseph1.Boullata, CharleneW.Compher.-4thed. p.;cm. Includesbibliographicalreferencesandindex. ISBN0-7216-0379-3 1.Enteralfeeding. 2.Tubefeeding. 1.Rolandelli,Rolando. [DNLM: 1.EnteralNutrition. 2.Food,Formulated. 3.Intubation,Gastrointestinal. 4.Nutrition. WB410C64152004) RM225.C5652005 615.8'55-dc22 2004049197 PrintedintheUnited StatesofAmerica Lastdigitistheprintnumber: 9 8 7 6 5 4 3 2 1 DEDICATION Thisbook isdedicated to mywife Mercedesand my children Patrick, Florencia, andVictoria fortheircontinued love andsupport. Contributors Satoshi Aiko. MD. PhD Stig Bengmark. MD. PhD ProfessorofSurgery Emeritus ProfessorofSurgery DepartmentofSurgeryII LundUniversity, Sweden National Defense Medical College HonoraryVisiting Professor Tokorozawa, Japan DepartmentsofHepatologyand Surgery UniversityCollege, London jorge Albina. MD LondonMedicalSchool ProfessorofSurgery, Brown Medical School London,England DirectorofSurgical Research DepartmentofSurgery, RhodeIslandHospital Mette M. Berger. MD. PhD DirectorofNutritionalSupportService Medecinadjoint(staffphysician) DepartmentofSurgery, RhodeIslandHospital Servicede SoinsIntensifsChirurgicaux&Centredes Providence, RhodeIsland Bniles Lausanne,France Abhinandana Anantharaju. MD Fellow inGastroenterology Carolyn D. Berdanier. PhD Loyola University ProfessorEmerita Maywood, Illinois Nutrition and CellBiology UniversityofGeorgia Olga Antonopoulos. MS. RD Athens, Georgia Clinical Dietitian Clinical Nutrition SupportService Michele Bishop. MD UniversityofPennsylvania Medical Center Assistant ProfessorofMedicine Philadelphia,Pennsylvania DirectorofPancreasInterestGroup Division ofGastroenterologyand Hepatology Vincent Arment], MD. PhD Mayo Clinic ProfessorofSurgery Jacksonville, Florida Department KidneyTransplantation Abdominal OrganTransplantSurgery joseph I. Boullata. PharmD. BCNSP TempleUniversityHospital ProfessorofPharmacyPractice Philadelphia,Pennsylvania Nutrition Supportand Critical Care juan Pablo Arnoletti. MD TempleUniversitySchoolofPharmacy AssistantProfessor Philadelphia,Pennsylvania Surgery Todd W. Canada. PharmD. BCNSP UniversityofAlabamaatBirmingham Critical Care/NutritionSupportPharmacist Birmingham, Alabama TheUniversityofTexasM.D. AndersonCancerCenter Robin Bankhead. CRNP.MS.CNSN Division ofPharmacy Coordinator, NutritionSupportService Houston,Texas Clinical NurseSpecialist ClinicalAssistant Professor TempleUniversity TheUniversityofTexasAtAustin CollegeofPharmacy Philadelphia,Pennsylvania Austin,Texas Adrian Barbul. MD Pamela Charney. MS. RD/LD. CNSD Chairman, DepartmentofSurgery PhDStudent Sinai Hospital ofBaltimore SchoolofHealthRelatedProfessional Professor,Johns Hopkins Medical Institutions UniversityofMedicineand Dentistry Baltimore, Maryland Dayton, Ohio vii viii Contributors Connie Brewer, RPh, BCNSP Mark DeLegge, MD NutritionSupportPharmacist Associate ProfessorofMedicine Pharmacy Director, Section of Nutrition Mount Carmel Medical Center Digestive Disease Center Columbus, Ohio Medical University ofSouth Carolina Charleston, South Carolina Rene L. Chiolero, MD Head Surgical ICU& BurnCenter Clifford S. Deutschman, MS, MD, FCCM UniversityHospital (CHUV) ProfessorofAnesthesiaand Surgery Lausanne, Switzerland Hospital of the University of Pennsylvania Philadelphia, Pennsylvania David Ciccolella, MD Associate Professorof Medicine Rupinder Dhaliwal, RD Director, Asthma Center Nutrition Research Associate Medical Director, RespiratoryTherapy DepartentofMedicine Associate Director, AirwaysDisease Center QueensUniversity Pulmonaryand Critical Care Division Kingston, Canada TempleUniversitySchool ofMedicine Philadelphia, Pennsylvania Wilfred Druml, MD Greg van Citters, PhD Professorof Nephrology Research Fellow University ofVienna Gonda Diabetes Research Center ViennaGeneral Hospital DepartmentofGene Regulation& Vienna, Austria DrugDiscovery DivisionofMolecularMedicine Nancy Evans-Stoner, MSN, RN CityofHope National Medical Center/Beckman Clinical Nurse Specialist Research Institute Clinical Nutrition SupportService Duarte, California University of Pennsylvania Medical Center Melanie Berg, MS, RD Philadelphia, Pennsylvania Directory ofNutritional Services Hazelwood Center Ivone M. Ferreira, MD, MSc, PhD Louisville,Kentucky International Specialist Physician University ofTorontoand University Sheila Clohessy, RD, LD, CNSD ofWestern Ontario Clinical Dietitian Ontario, Canada LoyolaUniversityMedical Center Maywood, Illinois Lisa Freeman, PhD, DVM Associate Professor, Department Charlene Compher, PhD, RD, CNSD ofClinical Sciences Assistant Professorin Nutrition Science TuftsUniversitySchool of Veterinary Universityof PennsylvaniaSchool of Nursing Medicine Philadelphia, Pennsylvania North Grafton, Massachusetts Tracy Crane, RD Jan Willem M. Greve, MD, PhD Research SpecialistSenior ProfessorofSurgery UniversityofArizona University Hospital Maastricht Department of Nutritional Sciences Maastricht, The Netherlands Tucson, Arizona Edwin Deitch, MD Peggi Guenter, PhD, RN, CNSN Chairman and ProfessorofSurgery Managing Editor forSpecial Projects DepartmentofSurgery AmericanSocietyforParenteral and Universityof Medicineand Dentistry of Enteral Nutrition NewJersey Havertown, Pennsylvania Newark, NewJersey Dipin Gupta, MD Cornelis H.C. Dejong, MD, PhD Research Fellow ConsultantSurgeon Cardiac andThoracicSurgery Academic Hospital Maastricht Temple UniversitySchool ofMedicine Maastricht, The Netherlands Philadelphia, Pennsylvania Contributors ix Myeongsik Han, MD, PhD Debra S. Kovacevich, RN, MPH Associate Professor CoordinatorofNursing, Nutrition & PatientCare DepartmentofSurgery Services UniversityofUlsan College ofMedicine HomeMed Seoul,Korea UniversityofMichigan Hospitalsand HealthCenters Theresa Han-Markey, MS, RD ClinicalAssistantProfessor, Collegeof Didactic ProgramDirector, AdjunctLecturer Pharmacy UniversityofMichiganSchoolofPublicHealth UniversityofMichigan Program inHumanNutrition AnnArbor, Michigan AnnArbor, Michigan Lori Kowalski, MS, RD, CNSD jeanette Hasse, PhD, RD Clinical Dietitian TransplantNutrition Specialist Clinical Nutrition/Nutrition Support BaylorRegionalTransplantInstitute Children'sHospitalofPittsburgh BaylorUniversityMedical Center Pittsburgh, Pennsylvania Dallas,Texas Polly Lenssen, MS, RD, CD, FADA jimmi Hatton, PharmD, BCNSP Manager Associate Professor Clinical Nutrition Pharmacyand Neurosurgery Children'sHospitaland Regional UniversityofKentuckyCollege ofPharmacy MedicalCenter Lexington, Kentucky Dietitian SeattleCancerCareAlliance Daren Keith Heyland, MD, FRCPC, MSC Seattle,Washington Associate Professor DepartmentofMedicine Henry Lin, MD QueensUniversity AssociateProfessorofMedicine Kingston, Canada Division ofGastrointestinal and LiverDiseases Mary Hise, PhD, RD KeckSchoolofMedicine Assistant Professor, Dieteticsand Nutrition UniversityofSouthernCalifornia UniversityofKansas Medical Center LosAngeles, California Kansas City, Kansas Linda Lord, NP, MSN Daniel L. Hurley, MD, FACE Nurse Practitioner Assistant ProfessorofMedicine Nutrition SupportService Mayo MedicalSchool UniversityofRochesterMedicalCenter Consultant Rochester,NewYork Division ofEndocrinology, Diabetes, Metabolism, Nutrition, and InternalMedicine Louis j. Magnotti, MD Mayo Clinic and Mayo Foundation Assistant ProfessorofSurgery Rochester, Minnesota DepartmentofTrauma UniversityofMedicineand Dentistryof Gabriel lonescu, MD NewJersey FirstYearFellow Newark, NewJersey St. Luke's-Roosevelt Hospital Center NewYork, NewYork Ainsley Malone, MS, RD NutritionSupportDietitian Gordon jensen, MD, PhD Pharmacy DirectorofVanderbiltCenterfor MountCarmelWestHospital HumanNutrition Columbus,Ohio Vanderbilt Medical Center Nashville,Tennessee Paul E. Marik, MD, FCCM, FCCP ProfessorCritical CareMedicine Donald Kotler, MD DepartmentofCritical CareMedicine Chief, Division ofGastroenterology UniversityofPittsburgh St. Luke's-Roosevelt Hospital Center Pittsburgh, Pennsylvania ProfessorofMedicine ColumbiaUniversityCollege ofPhysiciansand Karen McDoniel, RD, LD, CNSD Surgeons NutritionSupportSpecialist New York, NewYork Barnes-Jewish Hospital, St.Louis, MO x Contributors M. Molly McMahon, MD, FACE Kathy Prelack, PhD, RD Associate ProfessorofMedicine Clinical Nutrition Manager MayoMedical School Nutrition Support Service Consultant Shriners Hospital forChildren DivisionofEndocrinology, Diabetes, Metabolism, Boston, Massachusetts Nutrition, and Internal Medicine Massimo Raimondo, MD MayoClinicand MayoFoundation Rochester, Minnesota Assistant ProfessorofMedicine DivisionofGastroenterology& Hepatology Margaret M. McQuiggan, MS, RD, CNSD MayoClinic Clinical Dietitian Specialist Jacksonville, Florida Herman Hospital jorge Reyes, MD Houston,Texas ProfessorofSurgery University of Pittsburgh Kathryn Michel, DVM, MS, DACVN Children'sHospital ofPittsburgh AssistantProfessorof Nutrition Pittsburgh, Pennsylvania School ofVeterinary Medicine Universityof Pennsylvania Carol Rollins, MS,RD, CNSD,PharmD, BCNSP Philadelphia, Pennsylvania Clinical Associate Professor PharmacyPractice andScience William E. Mitch, M.D. College of Pharmacy,The University President, American Society of Nephrology ofArizona Edward Randall ProfessorofMedicine Tucson, Arizona Chairman, Department ofMedicine Clinical Specialist, Nutrition Support UniversityofTexas Medical Branch Pharmacy Galveston, Texas UniversityMedical Center Tucson, Arizona Sohrab Mobarhan, MD Professor ofMedicine john Rombeau, MD LoyolaUniversity ProfessorofSurgery Maywood, Illinois Universityof Pennsylvania Philadelphia, Pennsylvania Frederick A. Moore, MD M. Bonnie Rosbolt, PharmD Medical Director, TraumaServices Professor and ViceChairman Clinical Assistant Professor UniversityofTexas Medical School College ofPharmacy Department ofSurgery Universityof Kentucky Houston, Texas Lexington, Kentucky Trish Fuhrman, MS, RD, FADA, CNSD Patrick Neligan, MA, MB, BcH,FCARCSI Area Clinical Nutrition Marketing Manager AssistantProfessor ofAnesthesia Coram Healthcare Hospital ofthe UniversityofPennsylvania St.Louis, Missouri Philadelphia, Pennsylvania julie L. Roth, MD Anita Nucci, PhD, RD Assistant ProfessorofMedicine Manager, Clinical Nutrition/Nutrition Support& FeinbergSchool ofMedicine Intestinal Care Center Northwestern Memorial Hospital Clinical Nutrition Wellness Institute Children's Hospital ofPittsburgh Chicago, Illinois Pittsburgh, Pennsylvania Heather Rowe, RD, CNSD Mark Nunnally, MD Clinical Dietitian Assistant Professor HomeMed Department ofAnesthesiaand University of Michigan Hospitals and CriticalCare Health Centers UniversityofChicago Ann Arbor, Michigan Chicago, Illinois Cesar Ruiz, MA, CCC/SLP julie E. Park, MD Assistant ProfessorinSpeech, Language, and Hearing Resident, Department ofSurgery Science Program Johns Hopkins Medical Institutions laSalle University Baltimore, Maryland Philadelphia, Pennsylvania Contributors xi Mary Russell, MS, RD/LD, CNSD Jeremy Z. Williams, MD Director, NutritionServices Resident, Division of Plastic Surgery DukeUniversityHospital JohnsHopkinsMedical Institutions Durham, North Carolina Baltimore,Maryland Robert Schaffner, NP, DPh, MBA,CNSN, CD·N Marion Winkler, MS, RD NursePractitioner Surgical NutritionSpecialist NutritionSupport Service Rhode Island Hospital Universityof RochesterMedical Center BrownUniversitySchool of Medicine Rochester,New York Providence, Rhode Island Phyllis Schiavone-Gatto, MSN, RN, C, CRNP Steven E. Wolf, MD Advanced Practice Nurse Associate Professor Department of Clinical NutritionSupport Services Department of Surgery Hospital of the Universityof Pennsylvania Universityof TexasMedical Branch Philadelphia, Pennsylvania Director, BlockerBurn Unit AssistantChief of StaffShriners Hospital for Children P.B. Soeters, MD, PhD Galveston,Texas Professorof GastrointenstinalSurgery Department of Surgery Rosemary A. Kozar, MD, PhD University Hospital Maastricht Associate Professorof Surgery Maastricht, The Netherlands UniversityofTexasMedical School Departmentof Surgery Ulrich Suchner, MD Houston, Texas Clinic of Anesthesiology GrosshadernUniversityHospital Kenneth J. Woodside, MD Ludwig MaximiliansUniversity Resident in General Surgery Munich, Germany Departmentof Surgery UniversityofTexasMedical Branch james S.Scolapio, MD Galveston,Texas AssociateProfessorof Medicine Directorof Nutrition Donna Zimmaro Bliss, PhD, RN, FAAN Division of Gastroenterology&Hepatology Associate Professor MayoClinic Professorin Long Term Careof Elders Jacksonville, Florida Universityof MinnesotaSchool of Nursing Minneapolis, Minnesota Cynthia Thomson, PhD, RD AssistantProfessor Hans10achimG.jung, PhD Departmentof NutritionalSciences ResearchDairy Scientist Arizona Cancer Center USDept of Agriculture UniversityofArizona Agricultural ResearchService Tucson, Arizona AdjunctProfessor,Departmentof Agronomy Universityof Minnesota Clarivet Torres, MD St.Paul,Minnesota AssistantProfessorof Pediatrics Section of Pediatric Gastroenterologyand Nutrition University of NebraskaMedical Center Omaha,Nebraska jon A. Vanderhoof, MD Professorof Pediatrics and Internal Medicine Director,JointSection of Pediatric Gastroenterology and Nutrition University of NebraskaMedical Center Omaha, Nebraska Foreword Extensive changes have occurred in the delivery of enteral nutritional care since publication of the last edition of this book in 1997.Perhaps the greatest of these changes is the need to continue to provide the highest quality care with fewer resources, and to render this care more efficientlyand expeditiously. A continuing trend inenteral feeding isitsincreased provision at home ratherthan inthe hospital. Thisshiftinvenue hascreated new challengesforboth patientand health care prac titioner. The relevance of these changes and their appropriate resolutions are well expressed within the contentsofthisedition. The indications forenteral feeding continue to be refined. Insome conditions there isgood "evidence-based" rationaletojustifythe use ofenteral feeding whereas inotherinstancesthere iswoefullylittledatatosupportitsclinical utility.Regardless of the availability or quality of evidence-based support, the clinician is still confrontedwiththe dilemmaofwhen and how to feed hisor her patient. Moreover, the morally and ethically vexing alternative of permitting continued starvation frequently confoundsthese decisions. Thisedition remains true to the "raison d'etre" of the three previous editions, namely to communicate the highest quality ofenteral nutritional science to enable the practitioner to feed patients safely and efficaciously. This information is well described inthe sectionsentitled Physiologyofthe Gutand Nutrient Metabolism. Perhapsthe fastestgrowingcomponentofnutritional caredelivery isitstechno logy.Thesection Principles ofEnteral Nutrition integratesthe technologic advances within the context of feasibility, relevance, and cost effectiveness. This theme is underscored in the chapters on reimbursement and pharmacotherapeutics, which are integral to providing carewithin the contextoftoday'sfiscalrealities. Perhaps the newest content of this edition is contained in the Disease Specific Section.Seventeen chaptersaredevoted tothe intricaciesandspecificsofenteral feed ingfordiseases rangingfromcentral nervoussystemtraumato immunodeficiencies. Cancercontinues to be one ofthe most important indications forenteral feed ingasexemplified inthe fivechaptersdevotedtothistopic. Thesacrosanctprinciple ofimproving quality oflifeand not prolongingsuffering ofcancerpatients isunder scored inthiscontent. Finally,a majorstrength ofthisbook isreflected in the extensive experience of itsEditorand co-contributors. Dr.Rolando Rolandelli isaworld renowned expert in enteral feeding and has contributed extensively to past editions of this book. He remains dedicatedtoproviding both highqualityscienceandthe best availableclin ical information. Dr. Rolandelli has included a group of outstanding international contributorsfroma multitudeofdisciplineswho sharehiscommitmenttoacademic excellence. Insummary, enteral feeding continuesto be an integral componentofthe care ofmany hospitalized and home patients. The science and application ofthis impor tant therapy are well expressed in this book in a scholarly and clinically relevant manner. JohnL.Rambeau, MD Professor ofSurgery Universityof Pennsylvania xiii • The Multidisciplinary Approach to Enteral Nutrition Peggi Guenter, PhD, RN, CNSN CHAPTER OUTLINE with the founding of the American Dietetic Association in 1917.2 Introduction Formal nutrition support teams were not established untilthe developmentofparenteral nutrition inthe early Traditional Multidisciplinary Nutrition 19705,beginningwithlargemedicalcenters. Theseteams Support Teams had amultidisciplinarypatternand weregenerallymade Traditional Roles of Team Members up ofa physician, nurse, dietitian, and pharmacist. The Physician's Role number of these teams grew throughout the 1970sand Nurse's Role 1980s.1n1985,Dr.John Wesleywrote, "Itisapparentthat Dietitian's Role any well-organized multidisciplinary approach to nutri Pharmacist's Role tion support can be clinically and economically advan Contemporary Definition tageous, whether or not it embodies a formal nutrition Evolution of the Nutrition Support Service supportteam."?Asthe prospective paymentsystem and capitated health care plans took hold and began Impact of Nutrition Support Teams on to drive financing of hospitals, these teams began to Patient Outcome disband, decentralize, or disperse. Conclusion Despiteadecreaseinthe useofformalnutritionsupport Editors' Note teams and insufficient administrative support in health care systems, the multidisciplinary group of health care professionalsspecializing in nutritionalsupportand car ing for the patient receiving enteral nutrition isvital. In INTRODUCTION the absenceofthe multidisciplinarygroupofspecialists, despite well-intentioned policies and procedures, patient Since the introduction of enteral nutrition therapy by carecan suffer.Inthischapterthe history,evolution, and John Hunter in 1790, a varietyofhealth care profession impact of the multidisciplinary approach on the overall als have been involved inthis process.1Health care has delivery ofenteral nutrition willbe presented. been multidisciplinary as far back as Greek civilization and possiblyearlier.Thefirstmedical textwasa pharma ceutical compendium containing nutritional therapies TRADITIONAL MULTIDISCIPLINARY fromMesopotamia circa 2100Be. Three Greek gods per NUTRITION SUPPORT TEAMS sonified the multidisciplinary concept: Asklepios, god of medicine; Hygieia, goddess of health maintenance Withthe developmentofnutritionsupportservices (NSS) (nursing); and Panacea, goddess of medication (phar inthe early 1970s,whichwere formed initiallytocarefor macy). Hippocrates was born during this time and con patientsreceiving parenteralnutrition, camethe reawak tributed greatly to the fields of medicine and nursing." ening ofinterestinthe patient'snutritionalstatus andthe During the mid-1850s Florence Nightingale, founder of use ofenteral nutrition. Advances inthe composition of modern nursing, was very concerned about nutrition.' liquid diets resulted from the aerospace program, Withthe advent ofnursing schools in the United States, because ofthe need to nourish astronauts on the much student nurses were taught about "invalidcookery" and anticipatedtriptoand fromthe moon. Research into the provided therapeutic diets to hospitalized patients. As development of more comfortable feeding tubes and providing nutrition became a more specialized role, enteral feeding pumps led to the expansion of NSS into the discipline of dietetics emerged in the early 1900s care fortube-fed patientsaswell.' 3 4 1• TheMultidisciplinaryApproach to EnteralNutrition The American Society for Parenteral and Enteral finance, and quality improvement issues pertaining to Nutrition (AS.P.E.N.) was founded in 1976to serve as a nutritionalsupport.'? forum for nutrition support clinicians and researchers from all disciplines to exchange information about the care ofpatientswith nutritional needs. The firstpurpose Nurse's Role ofA.S.P.E.N. isto promote professional communication amongdisciplines inthe broad fieldofclinical nutrition The nurse's contribution comes from direct observation including parenteral and enteral nutrition. The second of enteral feeding delivery and patient response in all purpose is to promote the application of clinical and settings. The nurse on the nutrition service team com researchexperienceinthe practiceofnutritionallysound municates directly with the primary care nurses and medicine (see www.nutritioncare.org/bylaws.html). otherhealthcareprovidersandservesasthe liaison with The rapid growth in the numbers of nutrition support other team members," The nurse's scope of practice teams during the 1970sand early 1980shas been well includes direct patient care; consultation with other documented.Ylna 1991survey conductedbyAS.P.E.N., nurses and health care professionals; education of 29% ofhospitals with greater than 150beds had a nutri patients, caregivers, students, colleagues, and the pub tion support team, suggesting that the growth of new lic;and participation in research activities and adminis teams had tapered off and many institutions did not trative functions.J1 perceivea need fora nutritionsupportteam." However, The AS.P.E.N.Standards forAdult Hospitalized Patients have recentlystatedthat ifan institutiondoesnot havea Dietitian's Role defined nutrition support service or team, an interdisci plinary group of clinicians should provide specialized Thedietitianprovidesnutritionscreeningandassessment, nutritional support," developsand implementsaspecialized nutritionsupport Thepurposeofthe nutritionsupportteam istoprovide care plan, monitors the nutritional effectiveness of ther quality nutritional care. This is accomplished through apy, and develops the transitional feeding care plan." identification of patients who are at risk nutritionally, The dietitian's role also includes education and training performanceofa comprehensivenutritional assessment of patients, caregivers, and health care professionals's; that guides nutritionaltherapy,and provision ofsafe and management of patients receiving home enteral and effectivenutritional support," To accomplish these goals, parenteral nutrition, and research. nutrition support teams have developed services that include inpatient consultations, staff educational pro grams, quality assurance protocols, research programs, Pharmacist's Role and home nutrition support services. The overall goals of the nutrition support team include recognition and The role of the pharmacist in the care of the patient treatmentofmalnutritionand reductionofcomplications, receivingenteral nutrition isderived from knowledge of morbidity, and mortality ina cost-effective manner."The pharmacokinetics, drug metabolism, and drug-drug and quantitative impact of these teams on the delivery of drug-nutrient interactions." The pharmacist's scope of enteral nutrition willbe presented later inthis chapter. practice in the nutrition support team includes direct patient care; administrative management of the special ized nutrition support program; quality improvement; TRADITIONAL ROLESOF education of health care professionals, patients, and TEAM MEMBERS caregivers; and research." A recent study of this role confirmed that pharmacists continue to intervene with An organized nutrition support service or team should patientsreceivingenteral nutrition inthe clinical setting include a physician, nurse, dietitian, and pharmacist," to ensure positive effects on patientcare." Althoughthestructureandfunction ofNSSvaryfromone healthcaresetting to the next based on needsandavail able personnel,sometraditional rolesare reviewed here. Contemporary Definition Amorecontemporarydefinition ofthe nutritionsupport Physician's Role team includessome ofthe discipline-specific role delin eation described in the preceding paragraphs and else The nutrition support physician needs to be familiar where but also includes the recognition that clinicians, withallaspectsofenteralnutrition careincludingpatient who are board-eertifiedin nutritional supportare capable screening andassessment, developmentand implemen ofaddressingallofthe nutritionsupportneedsofpatients tation of an enteral care plan, and termination of ther in acute care, extended care, or home care settings. In apy. Adistinctive role ofthe nutrition support physician addition, a board-eertified nutrition support team mem istoselectthe appropriatefeeding access, and, depend ber, regardlessofdiscipline, isresponsible fora patients' ingon hisor hermedicalspecialty,the actual placement nutritional assessment, plan of care, monitoring, dis ofthe feeding access.The physician must be capableof charge planning, and follow-up. Much of the nutritional managing the policy, procedure, personnel, education, careisbased on sharedknowledge,with team members
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