Nutrients in various types of artificial feeding. Feeding the seriously ill. Artificial feeding of the patient. Selecting and placing an enteral feeding tube

Concepts and possibilities

The problem of artificial nutrition in cases where the patient cannot, does not want or should not eat, still remains one of the priorities in domestic medicine. The issues of feeding patients remain on the periphery of the attention of many resuscitators, although major monographs on nutrition have been published and are widely known (A.L. Kostyuchenko, E.D. Kostina and A.A. Kurygin, A. Vretlind and A.V. Sudzhyan). Familiarity with physiology does not prevent sometimes prescribing anabolic steroids in the absence of any nutritional support, and media intended for plastic assimilation should be administered in the first few days after major operations. All these contradictions make relevant a reminder of some of the principles and possibilities of modern artificial nutrition. Like natural, artificial nutrition should solve several main related tasks:

maintaining the water-ion balance of the body, taking into account the loss of water and electrolytes,

energy and plastic provision in accordance with the inherent this stage metabolic rate development.

It is the state of nutrition that largely determines the patient's ability to endure diseases and critical conditions (due to trauma, infection, surgical operation etc.) with less functional loss and more complete rehabilitation.

The studies of domestic and foreign experts have made it possible to put forward three basic principles artificial nutrition.

1) the timeliness of the start of its implementation, which allows to exclude the development of intractable cachexia;

2) the optimal timing of artificial feeding, which ideally should be carried out until the trophic status is completely stabilized;

3) the adequacy of artificial nutrition to the patient's condition must be observed.

The quantity and quality of essential and non-essential nutrients should provide not only energy, but also plastic processes (contain essential amino acids, essential fatty acids, electrolytes, trace elements and vitamins).

There are two main types or methods of artificial nutrition - enteral(probe) and parenteral(intravenous).

Enteral artificial nutrition

Artificial feeding through a tube was most popular at a time when the possibilities of parenteral nutritional support were still very limited. Over the past 10-15 years, protocols, standards and schemes have been developed abroad that revive the old, but more physiological method based on new principles and technological capabilities.

Tube feeding is still indicated when oral feeding is not possible, eg, maxillofacial surgery, esophageal injury, impaired consciousness, food refusal. There are no exact formalized boundaries for the transition from parenteral to enteral nutrition; the decision is always in the competence of the attending physician. In order to switch to enteral nutrition earlier, enhanced parenteral nutrition, contributing to the gradual restoration of the functions of digestion and resorption.

The basis for the revival of enteral artificial nutrition was balanced diets - mixtures of nutrients that make it possible to qualitatively and quantitatively cover the needs of the body and are produced in a ready-to-use liquid form or in the form of powders diluted in water.

Balanced diets are divided into low and high molecular weight. The energy carriers of low-molecular diets are mainly carbohydrates, and in high-molecular diets, natural proteins predominate - meat, dairy, soy. The content of vitamins, minerals and trace elements is adjusted according to the clinical situation and the amount of essential nutrients. An important advantage of balanced diets is the possibility of their industrial production.

The most popular option for accessing the digestive tract remains the use of nasogastric and nasoenteric catheters. They differ in length, shape, material of manufacture, they can be single-lumen and double-lumen, with holes of different levels, which allows solving a number of other tasks in addition to power supply.

The simplest probing of the stomach through the nose or mouth is still often used; intestinal insertion of the probe is facilitated by various olives. Recently, along with thread-like transnasal probes of long-term use made of silicone rubber and polyurethane, systems for percutaneous endoscopic gastrostomy and puncture catheter jejunostomy have appeared that solve cosmetic problems. A great contribution to the technique of setting probes-catheters was made by the development of endoscopic techniques, which make it possible to carry out these manipulations painlessly and atraumatically. An important step in the development of the technology was the introduction of infuser pumps that provide continuous uniform injection of solutions. The supply of the mixture can be carried out around the clock, without disturbing the night's rest. In most cases, this also allows you to avoid complications in the form of a feeling of fullness in the stomach, nausea, vomiting and diarrhea, which are not uncommon with portioned administration of balanced mixtures.

PARENTERAL NUTRITION

Basic concepts

Parenteral nutrition is understood as a special form of intravenous therapeutic nutrition that provides correction of impaired metabolism (with various pathological conditions) with the help of special infusion solutions that can be actively involved in the metabolic processes of the body, which are introduced, bypassing gastrointestinal tract

In the practice of any doctor, there are cases when, for one reason or another, patients experience a significant nutritional deficiency. The most important reason for the resulting deficiency is the inability to use the normal oral method of nutrition in cases where the patient: 1) is not able to swallow food, 2) does not tolerate it, or 3) is not able to digest food coming from the enteral route.

If possible, nutritional support should be carried out with the help of a probe, because the supply of nutrients directly into the bloodstream, bypassing the enteral route, is fundamentally non-physiological for the body, since in doing so they bypass all the protective mechanisms of organs that perform the functions of filters (gastrointestinal tract , liver) and transformers. However, for those patients who are unable to eat normally, cannot absorb nutrients effectively, or are impaired by oral feeding, partial or complete parenteral nutrition is indicated until they are able to take food by mouth and assimilate her.

Parenteral nutrition, even with careful monitoring, does not exclude the possibility of complications. Therefore, it is canceled as soon as possible.

Types of parenteral nutrition

By volume, parenteral nutrition is divided into complete and partial.

Total parenteral nutrition

Total parenteral nutrition (TPN) consists in the intravenous administration of all nutritional components (nitrogen, water, electrolytes, vitamins) in amounts and ratios that most closely correspond to the needs of the body at the moment. Such food, as a rule, is necessary with complete and prolonged fasting.

The purpose of PPP is to correct violations of all types of metabolism.

Indications for total parenteral nutrition

As mentioned above, TPN is indicated for patients who cannot, should not, or do not want to eat enterally. These include the following categories of patients:

1. Patients who are unable to take or digest food normally. When diagnosing malnutrition, the presence of muscle wasting, hypoalbuminemia, protein-free edema, a decrease in the thickness of the skin fold and a significant decrease in body weight are taken into account in the patient. But isolated weight loss should not be considered a sign of malnutrition, since the presence of edema or previous obesity may mask the actual degree of endogenous nitrogen depletion.

2. Patients with an initially satisfactory state of nutrition, who temporarily (for one reason or another) cannot eat and, in order to avoid excessive exhaustion, require TPN. This is especially important in pathological conditions accompanied by increased catabolism and tissue depletion (postoperative, post-traumatic, septic patients).

3. Patients suffering from Crohn's disease, intestinal fistulas and pancreatitis. The usual diet in such patients exacerbates the symptoms of the disease and worsens general state sick. Transferring them to PPP accelerates the healing of fistulas, reduces the volume of inflammatory infiltrates.

4. Patients with a prolonged coma, when it is impossible to carry out feeding through a tube (including after operations on the brain).

5. Patients with severe hypermetabolism or significant protein losses, for example, in patients with injuries, burns (even when it is possible to carry out normal nutrition).

6. To provide nutritional support to patients receiving therapy for malignant tumors especially when malnutrition is due to reduced food intake. Often the effects of chemotherapy and radiation treatment is anorexia and inflammation of the mucous membranes of the gastrointestinal tract, which limits the possibilities of enteral nutrition.

7. It is possible to perform PPP in malnourished patients before the upcoming surgical treatment.

8. Patients with mental anorexia. PPN in such patients is necessary, since theoretically justified tube feeding under anesthesia is fraught with dangers associated not only with complications of anesthesia, but also with the possibility of pulmonary complications due to food or gastric contents entering the Airways.

Partial parenteral nutrition

Partial parenteral nutrition is most often an addition to enteral (natural or tube) if the latter does not provide full coverage of nutritional deficiencies arising from reasons such as: 1) a significant increase in energy costs; 2) low-calorie diet; 3) inadequate digestion of food, etc.

Indications for partial parenteral nutrition

Partial parenteral nutrition is indicated in cases where enteral nutrition does not give the desired effect due to impaired intestinal motility or insufficient absorption of nutrients in the digestive tract, and also if the level of catabolism exceeds the energy capacity of normal nutrition.

The list of diseases in which partial parenteral nutrition is indicated:

• peptic ulcer of the stomach and peptic ulcer of the duodenum;
• pathology of the organs of the hepatobiliary system with functional liver failure;
• various forms of colitis;
• acute intestinal infections (dysentery, typhoid fever);
• pronounced catabolism in the early period after major extraperitoneal operations;
• burns;
• purulent-septic complications of injuries;
• sepsis;
• hyperthermia;
• chronic inflammatory processes (lung abscesses, osteomyelitis, etc.);
• oncological diseases;
• pronounced endo- and exotoxicoses;
• severe diseases of the blood system;
• acute and chronic kidney failure.

Conditions for the effectiveness of parenteral nutrition

To ensure the effectiveness of parenteral nutrition, the following conditions must be met:

1. The beginning of parenteral nutrition should be preceded by the most complete correction of BCC, EBV, acid-base state. Hypoxia must be eliminated because the complete assimilation of the components of parenteral nutrition occurs under aerobic conditions. Therefore, in the first hours after major traumatic operations, burns, in the early post-resuscitation period, with terminal states and clinical manifestations of severe centralization of blood circulation, only glucose solutions can be used.

2. The rate of administration of drugs should correspond to the rate of their optimal assimilation.

3. PPP is most expedient to be carried out in the intensive care unit, where it is possible to carry out both round-the-clock dynamic monitoring of the patient and appropriate control over the effectiveness of measures.

4. When calculating the daily calorie content of parenteral nutrition, the contribution of protein should not be taken into account, because otherwise the lack of energy will lead to the burning of amino acids and the synthesis processes will not be implemented in full.

5. Parenteral nutrition should be adequate, deficient-replacement, which requires appropriate research before starting and constantly during treatment.

Routes of introduction of parenteral nutrition

Catheterization of the central veins. This route of administration allows infusion of fluids of any osmolality and minimizes the need for repeated venipunctures. However, if the catheter is inserted incorrectly and not properly cared for, there is a risk of septic complications and/or thrombosis. Basic principles of catheter insertion and care:

1. Catheters should be inserted and cared for with asepsis. A face mask and sterile gloves must be used.

2. Before initiating TPN with hypertonic fluids, X-ray examination should ensure that the catheter is in the superior vena cava. If the tip of the catheter is located in any other central vein (for example, in v. jugularis interna), thrombosis may develop.

3. Catheters should be inserted through a large central vein, not a peripheral one.

4. The catheter must not be used for taking blood samples or for measuring central venous pressure.

5. The skin puncture site should be regularly treated with detergent, iodine solution and covered with a bandage.

6. Catheters made of silicone rubber impregnated with barium do not injure the veins, as a result of which the likelihood of the formation of a fibrin thrombus around them is reduced.

Infusion into peripheral veins. This route of administration is safer, as it is less likely to develop air embolism, sepsis, or thrombosis. However, infused fluids should be isotonic or only mildly hypertonic. To ensure that these conditions are met, lipids should be used primarily as a non-protein energy source.

Methodology and technique of total parenteral nutrition

PPP is a serious and complex therapeutic measure and requires compliance with a number of conditions.

The attending physician must clearly establish the indications for PPP and record this in the medical history or a special card.

When determining the indications and conditions for PPP, one should take into account the nature of the main and concomitant pathology, highlighting the leading syndrome that requires priority correction.

The patient's daily needs for energy, nitrogen, fluids, electrolytes, and vitamins must first be calculated.

A basic approximate calculation of the daily requirement can be made according to special tables. In the process of conducting PPP, the necessary adjustments are made based on the data obtained during control studies.

A daily infusion program is drawn up, which indicates the method and sequence of drug administration, the rate of their administration and the volumes of solutions for infusion, the necessary drug additions, the time and nature of the control laboratory research and determination of indicators of hemodynamics, respiration, temperature, etc.

The daily infusion program is issued either by an entry in the medical history, or by filling out a special parenteral nutrition card.

Then the appropriate preparations are selected, taking into account their composition and properties, as well as the tasks of infusion therapy.

The technical features of providing parenteral nutrition are practically the same as those of the general methods of infusion therapy.

When conducting PPP, there is a need for the simultaneous and uniform introduction of a large number of ingredients of different properties (carbohydrates, proteins, fats, etc.), which creates certain technical difficulties. Direct mixing of solutions in vials is unacceptable, because when they are depressurized, the sterility of the preparations is violated. Therefore, mixing is carried out directly in the infusion system by using special tees mounted above the injection needle (catheter). It is also possible to combine two (or more) disposable systems. In the presence of perfusion dosing pumps, they are installed below the place where the systems are combined.

It should be emphasized that this method of infusion is preferable to the separate, sequential administration of drugs, since it allows to reduce the negative consequences of the same sequential rearrangement of metabolism for each of the injected ingredients. This applies to almost all multicomponent mixtures and large infusion volumes. In such cases, it is recommended to mix all non-interacting (compatible) drugs for infusion therapy, especially when conducting parenteral nutrition. Infused mixtures should be prepared with great care, this can only be done by specially trained pharmacists.

Components of parenteral nutrition

Leading drugs of parenteral nutrition are:

1) amino acid solutions, protein hydrolysates;

2) solutions of carbohydrates;

3) fat emulsions;

4) electrolyte solutions;

5) vitamins.

For high-quality assimilation of substances administered parenterally, anabolic steroid hormones are connected to the main scheme of parenteral nutrition.

Proteins, protein preparations and amino acid mixtures

A normally functioning organism seeks to maintain protein balance, i.e. income and consumption of proteins almost coincide. The intake of proteins into the body from the outside occurs exclusively with food. Therefore, if there is an insufficient intake of protein products, as well as with a high consumption of proteins, a negative nitrogen balance inevitably develops. Possible reasons for the increased consumption of proteins are loss of blood, digestive juices, profuse exudation during burns, suppurative processes (abscesses, bronchiectasis, etc.), diarrhea, etc. In addition to the loss of proteins with body fluids, there is another way leading to protein deficiency - increased catabolic processes (hyperthermia, intoxication, stress and post-stress - postoperative and post-traumatic - conditions). Protein losses can reach significant numbers: up to 10–18 g per day. The occurrence of protein deficiency is a very undesirable phenomenon, therefore it is necessary to minimize the possibility of its development, and if this could not be prevented, then measures are taken to restore the normal nitrogen balance.

The nitrogen component in the parenteral diet can be represented by protein hydrolysates and amino acid mixtures obtained by synthesis. As mentioned earlier, the use of unsplit protein preparations (plasma, protein, albumin) for parenteral nutrition is ineffective due to the too long half-life of exogenous protein. More justified is the use of amino acid mixtures, from which specific organ proteins are then synthesized.

Amino acid mixtures for parenteral nutrition must meet the following requirements:

2) be biologically adequate, i.e. so that the body can transform amino acids into its own proteins;

3) not cause adverse reactions after they enter the vascular bed.

Of the solutions of synthetic amino acids, the most widely used drugs are Moriamin C-2, Moripron (Japan), Alvezin (Germany), Vamin, Freamin (Sweden), Polyamine (Russia), Aminosteril (Haemopharm), Azonutril (France). These solutions have a pronounced positive effect on protein metabolism, providing protein synthesis from the introduced amino acids, a positive nitrogen balance, and stabilization of the patient's body weight. In addition, amino acid mixtures have a detoxifying effect by reducing the concentration of ammonia, which is associated with the formation of non-toxic metabolites - glutamine, urea.

Protein hydrolysates used for parenteral nutrition are solutions of amino acids and simple peptides obtained by hydrolytic cleavage of heterogeneous proteins of animal or plant origin. Among the preparations of this series, hydrolysine solution and its analog aminosol (Sweden) are most widely used in our country. Protein hydrolysates produced in our country are much worse (compared to amino acid mixtures) utilized by the body due to the presence of high-molecular fractions of peptides in them. Insufficiently complete their purification from impurities causes in their application adverse reactions. At the same time, a relatively low concentration of nitrogenous components (about 5%) causes the introduction of an increased volume of fluid into the body, which is extremely undesirable, especially in patients in serious condition.

Contraindications to the introduction of protein hydrolysates and amino acid mixtures:

• impaired liver and kidney function - liver and kidney failure;
• any form of dehydration;
• shock conditions;
• conditions accompanied by hypoxemia;
• acute hemodynamic disturbances;
• thromboembolic complications;
• severe heart failure;
• conditions in which prolonged drip infusion is difficult.

Fat emulsions

Fat emulsions during parenteral nutrition are widely used due to the fact that they are high-calorie energy preparations, and this makes it possible to confine ourselves to a relatively small volume of fluid administration while replenishing a significant part of the body's energy deficit. The value of fat emulsions is also in the fact that they contain essential fatty acids (linoleic, linolenic, arachidonic). According to Wretlind (1972), the optimal dose of fat in the clinical setting is 1–2 g/kg of body weight per day.

The introduction of fat emulsions in an isolated form is impractical and even unhelpful, because it leads to ketoacidosis. To prevent such a complication, it is necessary to use a lipid-glucose solution with a ratio of the number of calories received from both energy sources equal to 1:1. This combination of substances in quality resembles a normal diet, and this prevents the development of hyperinsulinemia, hyperglycemia (Jeejeebhoy, Baker, 1987).

Of the drugs used in our country, intralipid and lipofundin are the most widely used. The advantage of intralipid is that at 20% concentration it is isotonic to plasma and can be administered even into peripheral veins.

Contraindications to the introduction of fat emulsions are basically the same as for the introduction of protein solutions. We must remember that it is not advisable to administer them to patients with hyperlipidemia and diabetics.

Solutions of carbohydrates

Carbohydrates are used for parenteral nutrition due to the fact that they are the most accessible sources of energy for the patient's body. Their energy value is 4 kcal/g. Considering that the daily energy requirement is about 1,500–2,000 kcal, the problem of the isolated use of carbohydrates to cover it becomes understandable. If you transfer the calculation to an isotonic glucose solution, then you will need to transfuse at least 7–10 liters of fluid, which can lead to complications such as overhydration, pulmonary edema, and cardiovascular disorders.

The use of more concentrated glucose solutions is fraught with the risk of plasma hyperosmolarity, as well as irritation of the intima of the veins with the development of phlebitis and thrombophlebitis.

In order to exclude osmotic diuresis, the rate of glucose infusion should not be allowed to exceed 0.4–0.5 g/kg/h. In terms of isotonic glucose solution, this is just over 500 ml for a patient weighing 70 kg. To warn possible complications, caused by impaired carbohydrate tolerance, it is necessary to add insulin to the glucose solution in the ratio of 1 IU of insulin per 3-4 g of glucose dry matter. In addition to a positive effect on glucose utilization, insulin plays an important role in the absorption of amino acids.

Among the numerous carbohydrates that exist in nature, glucose, fructose, sorbitol, glycerol, dextran, and ethyl alcohol are used in the practice of parenteral nutrition.

Water

The water requirement for parenteral nutrition is calculated based on the amount of excretion, insensitive losses, tissue hydration. Clinically, this is assessed according to the following criteria: the amount of urine and its relative density; skin elasticity, tongue moisture; the presence or absence of thirst; change in body weight.

Normally, water requirements exceed diuresis by 1,000 ml. In this case, the endogenous formation of water is not taken into account.

Loss of proteins, electrolytes and glucosuria significantly increase the body's need for exogenous water. It is necessary to keep records of water losses with vomit, feces, through intestinal fistulas and drainage drains.

According to Elman (1947), it is recommended to introduce 30-40 ml of water per 1 kg of body weight for adults and children over one year old. It is believed that the digital number of kilocalories administered should correspond to the digital value of the volume of the transfused liquid (in milliliters).

electrolytes

Electrolytes are essential components of total parenteral nutrition. Potassium, magnesium and phosphorus are essential for optimal nitrogen retention in the body and for tissue formation; sodium and chlorine - to maintain osmolality and acid-base balance: calcium - to prevent bone demineralization.

To cover the body's need for electrolytes, the following infusion media are used: isotonic sodium chloride solution, balanced electrolyte solutions (lactosol, acesol, trisol, etc.), a solution of 0.3% potassium chloride, solutions of chloride, gluconate and calcium lactate, lactate and magnesium sulfate.

When calculating the volume of infusions of electrolyte solutions, you can use the table of the average daily requirement for minerals and electrolytes (Pokrovsky, 1965; Wretlind, 1972):

vitamins

Carrying out parenteral nutrition involves the use of vitamin complexes. The amount of vitamins sufficient to meet daily requirements should be added to the main solution for parenteral nutrition. The use of vitamins in the diet is justified with full amino acid supply, otherwise they are simply not absorbed, but are excreted mainly in the urine. It must also be remembered that excessive amounts of fat-soluble vitamins (A, D) should not be administered, because this significantly increases the risk of developing hypercalcemia and other toxic effects.

The average daily requirement for vitamins in parenteral nutrition (according to M.F. Nesterin, 1992).

Separate preparations of water-soluble and fat-soluble vitamins are produced. IN last years produce combined preparations containing amino acids, mineral elements and glucose. In our country, solutions of mineral substances and vitamins for parenteral nutrition have not been produced until recently.

The current level of scientific concepts and artificial nutrition technologies allows solving clinical problems that were inaccessible 20-30 years ago. Extensive resections of the intestine, failure of digestive anastomoses, severe malformations of the gastrointestinal tract became compatible with life and even normal growth. However, before the latest achievements in this area become a daily (and ubiquitous!) reality in our country, there is still a long way to go, the main condition of which is a consistent, fundamental and objective educational program.

Artificial nutrition is understood as the introduction of food (nutrients) into the patient's body enterally, i.e. through the gastrointestinal tract, and parenterally - bypassing the gastrointestinal tract.

Patients who cannot swallow or refuse to eat on their own must be fed through a gastric tube, with nutrient enemas, or parenterally. It is possible to identify the main indications for artificial nutrition of patients: extensive traumatic injuries and swelling of the tongue, pharynx, larynx, esophagus; unconscious state; obstruction of the upper gastrointestinal tract (tumors of the esophagus, pharynx, etc.); refusal of food in mental illness, the terminal stage of cachexia.

There are several ways to enterally administer nutrients:

Separate portions (fractional

Drip, slowly, for a long time;

Automatically adjusting the intake of food using a special dispenser.

For enteral feeding, liquid food (broth, fruit drink, milk mixture), mineral water are used; homogeneous dietary canned food (meat, vegetables) and mixtures balanced in terms of the content of proteins, fats, carbohydrates, mineral salts and vitamins can also be used. Use the following nutrient mixtures for enteral nutrition.

Mixtures that contribute to the early recovery in the small intestine of the function of maintaining homeostasis and maintaining the body's water and electrolyte balance: Glucosolan, Gastrolit, Regidron.

Elemental, chemically accurate nutrient mixtures - for feeding patients with severe digestive disorders and obvious metabolic disorders (liver and kidney failure, diabetes mellitus, etc.): Vivonex, Travasorb, Hepatic Aid (with a high content of branched amino acids - valyan, leucine, isoleucine), etc.

Semi-element balanced nutrient mixtures (as a rule, they also include a complete set of vitamins, macro- and microelements) for the nutrition of patients with digestive disorders: Nutrilon Pepti, Reabilan, Pcptamen, etc.

Polymeric, well-balanced nutrient mixtures (artificially created nutritional mixtures containing all the main nutrients in optimal proportions): dry nutritional mixtures Ovolakt, Unipit, Nutrison, etc.; liquid, ready-to-use nutrient mixtures (“Nutrison Standart”, “Nutrison Energy”, etc.).

Modular nutrient mixtures (a concentrate of one or more macro- or microelements) are used as an additional source of nutrition to enrich the daily human diet: "Protein EN-PIT", "Fortogen", "Diet-15", "AtlanTEN", "Peptamine" and others. There are protein, energy and vitamin-mineral modular mixtures. These mixtures are not used as an isolated enteral nutrition of patients, as they are not balanced.

The choice of mixtures for adequate enteral nutrition depends on the nature and severity of the course of the disease, as well as on the degree of preservation of the functions of the gastrointestinal tract. So, with normal needs and the preservation of the functions of FA "G, standard nutrient mixtures are prescribed, in critical and immunodeficiency states - nutrient mixtures with a high content of easily digestible protein, enriched with microelements, glutamine, arginine and omega-3 fatty acids, in case of dysfunction of the nights - nutrient mixtures with the content of highly biologically valuable protein and amino acids.With a non-functioning intestine (intestinal obstruction, severe forms of malabsorption), the patient is shown parenteral nutrition.

When feeding a patient through a probe, you can enter any food (and drugs) in liquid and semi-liquid form. Vitamins must be added to food. Cream, eggs, broth, slimy vegetable soup, jelly, tea, etc. are usually introduced.

For feeding you need: 1) a sterile gastric tube with a diameter of 8-10 mm; 2) 200 ml funnel or Janet syringe; 3) vaseline or glycerin.

Before feeding, the tools are boiled and cooled in boiled water, and the food is heated.

Before insertion, the end of the gastric tube is lubricated with glycerol. The probe is inserted through the nose, moving it slowly along the inner wall, while tilting the patient's head. When 15-17 cm of the probe passes into the nasopharynx, the patient's head is slightly tilted forward, the index finger is inserted into the mouth, the end of the probe is felt for and, slightly pressing it against the back wall of the pharynx, is advanced further with the other hand. If the probe enters the larynx instead of the esophagus, then the patient begins to cough sharply. If the patient is unconscious and cannot be planted, the probe is inserted in the supine position, if possible under the control of a finger inserted into the mouth. After the introduction, they check whether the probe has entered the trachea; for this, a piece of cotton wool is brought to the outer edge of the probe and they look to see if it sways when breathing. If necessary, the probe is advanced further - into the stomach. A funnel is attached to the outer end of the probe, food is poured into it in small portions. After feeding, the tube, if necessary, can be left until the next artificial feeding. The outer end of the probe is folded and fixed on the patient's head so that it does not interfere with him.

Sometimes patients are fed with the help of drip enemas. Nutrient enemas put only after the release of the rectum from the contents. Solutions heated to 36-40 ° C are usually injected into the rectum for better absorption - 5% glucose solution, 0.85% sodium chloride solution. IN modern medicine this method is rarely used, since it has been proven that fats and amino acids are not absorbed in the colon. Nevertheless, in some cases, for example, with severe dehydration due to indomitable vomiting, the technique is used. Administered dropwise at a time of 100-200 ml of solution 2-3 times a day. Small amounts of liquid can be injected with a pear rubber balloon.

Parenteral nutrition (feeding) is carried out by intravenous drip injection drugs. The technique of administration is similar to intravenous administration of drugs.

Main indications:

A mechanical obstacle to the passage of food in various parts of the gastrointestinal tract: tumor formations, burn or postoperative narrowing of the esophagus, inlet or outlet of the stomach.

Preoperative preparation of patients with extensive abdominal operations, exhausted patients.

Postoperative management of patients after operations on the gastrointestinal tract.

Burn disease, sepsis.

Big blood loss.

Violation of the processes of digestion and absorption in the gastrointestinal tract (cholera, dysentery, enterocolitis, disease of the operated stomach, etc.), indomitable vomiting.

Anorexia and food refusal.

For parenteral feeding, the following types of nutrient solutions are used:

Proteins - protein hydrolysates, solutions of amino acids: "Vamin", "Aminosol", polyamine, etc.

Fats - fatty emulsions (lipofundin).

Carbohydrates - 10% glucose solution, usually with the addition of trace elements and vitamins.

Blood products, plasma, plasma substitutes.

There are three main types of parenteral nutrition.

Complete - all nutrients are introduced into the vascular bed, the patient does not even drink water.

Partial (incomplete) - use only the main nutrients (for example, proteins, carbohydrates).

Auxiliary - nutrition through the mouth is not enough and additional administration of a number of nutrients is necessary.

About 2 liters of solutions are administered per day.

Before administration, the following drugs should be heated in a water bath to a temperature of 37-38 ° C: hydrolysin, casein hydrolyzate, aminopeptide. With intravenous drip administration of the "named drugs", a certain rate of administration should be observed: in the first 30 minutes, solutions are administered at a rate of 10-20 drops per minute, then, if the patient is well tolerated by the administered drug, the rate of administration is increased to 30-40 drops per minute. On average, the administration of 500 ml of the drug lasts about 3-4 hours. With a more rapid administration of protein preparations, the patient may experience a feeling of heat, flushing of the face, and difficulty in breathing.

When food is obstructed through the esophagus, the patient is fed through a fistula (gastrostomy) created by surgery. A probe is inserted into the stomach through the fistula, through which food is poured into the stomach. A funnel is attached to the free end of the inserted probe and warmed food is introduced into the stomach in small portions (50 ml each) 6 times a day. Gradually, the volume of the injected liquid is increased to 250-500 ml, and the number of feedings is reduced! up to 4 times. At the same time, it is necessary to ensure that the edges, gastrostomy are not contaminated with food, for which the inserted probe is strengthened with a sticky patch, and after each feeding, the skin around the fistula is toileted, lubricated with 96% ethyl alcohol and a sterile dry bandage is applied.

To comply with the regimen of therapeutic nutrition in each department, control over the food products brought by visitors should be organized. Refrigerators for food storage should be in each department in the wards. The doctor and paramedical personnel systematically check the quality of the products in refrigerators or bedside tables.



Depending on the method of eating, the following forms of nutrition of patients are distinguished.

Active nutrition - the patient eats independently.

Passive nutrition - the patient takes food with the help of a nurse. (Tya-

the coveted patients are fed by a nurse with the help of junior medical staff.)

Artificial nutrition - feeding the patient with special nutrient mixtures

by mouth or tube (gastric or intestinal) or by intravenous drip

drugs.

Passive power

With strict bed rest, weakened and seriously ill, and, if necessary,

and patients in the elderly and senile age, assistance in feeding is provided by medical

sister. With passive feeding, you should raise the patient's head with one hand along with

darling, the other is to bring a bowl of liquid food or a spoonful of food to his mouth. Feed the pain

much is needed in small portions, always leaving the patient time to chew and swallow;

nie; it should be watered with a drinking bowl or from a glass using a special tubular

The order of the procedure (Fig. 4-1).

1. Ventilate the room.

2. Treat the patient's hands (wash or wipe with a damp warm towel).

3. Put a clean napkin on the neck and chest of the patient.

4. Place on the bedside table (table) dishes with warm

6. Give the patient a comfortable position (sitting or half-sitting).

6. Choose a position that is comfortable for both the patient and the nurse (on-

For example, if a patient has a fracture or an acute disorder cerebral circulation). 7. Feed small portions of food, be sure to leave the patient time to chew

gagging and swallowing.

8. Give the patient water with a drinker or from a glass using a special

tubules.

9. Remove dishes, a napkin (apron), help the patient rinse his mouth, wash (prote-

tho) his hands.

10. Place the patient in the starting position.

artificial nutrition

Artificial nutrition is understood as the introduction of sick food into the body (nutrient-

substances) enterally (Greek entera - intestines), i.e. through the gastrointestinal tract, and parenterally (Greek para - row-

house, entera - intestines) - bypassing the gastrointestinal tract.

The main indications for artificial nutrition.

Damage to the tongue, pharynx, larynx, esophagus: edema, traumatic injury, wound

ion, swelling, burns, cicatricial changes, etc.

Swallowing disorder: after an appropriate operation, with brain damage - on-

rupture of cerebral circulation, botulism, with traumatic brain injury, etc.

Diseases of the stomach with its obstruction.

Coma.

Mental illness (refusal of food).

Terminal stage of cachexia.

Enteral nutrition is a type of nutritional therapy (lat. nutricium - nutrition), using

mine when it is impossible to adequately meet energy and plastic needs

body in a natural way. In this case, nutrients are administered through the mouth or through

through a gastric tube, or through an intra-intestinal tube. Previously used and rectal route

the introduction of nutrients - rectal nutrition (the introduction of food through the rectum), one

but in modern medicine it is not used, since it has been proven that it is not absorbed in the large intestine.

fats and amino acids. However, in some cases (for example, with severe dehydration)

living due to indomitable vomiting), rectal administration of the so-called physio-

logical solution (0.9% sodium chloride solution), glucose solution, etc. A similar method

called a nutrient enema.

The organization of enteral nutrition in medical institutions is carried out

a team of nutritional support, including anesthesiologists-resuscitators, gastro-

roenterologists, internists and surgeons who have received special training in enteral

Main indications:

Neoplasms, especially in the head, neck and stomach;

CNS disorders - coma, cerebrovascular accident;

Radiation and chemotherapy;

Gastrointestinal diseases - chronic pancreatitis, nonspecific ulcerative colitis and etc.;

Diseases of the liver and biliary tract;

Meals in pre- and postoperative periods;

Trauma, burns, acute poisoning;

Infectious diseases - botulism, tetanus, etc.;

Mental disorders - neuropsychic anorexia (persistent, conditioned

mental illness refusal to eat), severe depression.

Main contraindications: intestinal obstruction, acute pancreatitis, heavy

forms of malabsorption (lat. talus - bad, absorptio - absorption; malabsorption in tone

colon of one or more nutrients), ongoing gastrointestinal

bleeding; shock; anuria (in the absence of acute substitution of renal functions); the presence of pi

joint allergy to the components of the prescribed nutritional formula; uncontrollable vomiting.

Depending on the duration of the course of enteral nutrition and the safety of the

the rational state of various parts of the gastrointestinal tract, the following ways of introducing nutritional

mixtures.

1. The use of nutritional mixtures in the form of drinks through a tube in small sips.

2. Tube feeding using nasogastric, nasoduodenal, nasojejunal and

two-channel probes (the latter - for aspiration of gastrointestinal contents and intra-

intestinal administration of nutrient mixtures, mainly for surgical patients). 3. By imposing a stoma (Greek stoma - hole: created by an operative method of external

fistula of a hollow organ): gastrostomy (hole in the stomach), duodenostoma (hole in the

duodenum), jejunostomy (hole in the jejunum). Stomas can be imposed by chi-

surgical laparotomy or surgical endoscopic methods.

There are several ways to enterally administer nutrients:

In separate portions (fractionally) according to the prescribed diet (for example, 8 times a day

day, 50 ml; 4 times a day, 300 ml);

Drip, slowly, for a long time;

Automatically adjusting the intake of food using a special dispenser.

For enteral feeding, liquid food is used (broth, fruit drink, milk mixture),

mineral water; homogeneous dietary canned food (meat,

vegetable) and mixtures balanced in terms of the content of proteins, fats, carbohydrates, mineral

lei and vitamins. Use the following nutrient mixtures for enteral nutrition.

1. Mixtures that promote early recovery in the small intestine of the support function

homeostasis and maintaining the body's water and electrolyte balance: Glucosolan, Gast-

roll", "Regidron".

2. Elemental, chemically accurate nutrient mixtures - for the nutrition of patients with severe

digestive disorders and overt metabolic disorders (pe-

liver and kidney failure, diabetes mellitus, etc.): Vivonex, Travasorb, Hepatic

Aid" (with a high content of branched amino acids - valine, leucine, isoleucine), etc.

3. Semi-elemental balanced nutrient mixtures (as a rule, they include

diet and a complete set of vitamins, macro- and microelements) for the nutrition of patients with impaired

digestive functions: "Nutrilon Pepti", "Reabilan", "Peptamen", etc.

4. Polymeric, well-balanced nutritional formulas (artificially created

nutrient mixtures containing in optimal ratios all the main nutrients

va): dry nutrient mixtures "Ovolakt", "Unipit", "Nutrison", etc.; liquid, ready to use

nutritional mixtures (“Nutrison Standart”, “Nutrison Energy”, etc.).

5. Modular nutrient mixtures (concentrate of one or more macro- or micro-

elements) are used as an additional source of nutrition to enrich the daily

human diet: "Protein ENPIT", "Fortogen", "Diet-15", "AtlanTEN", "Pepta-

min”, etc. There are protein, energy and vitamin-mineral modular mixtures. These

mixtures are not used as an isolated enteral nutrition of patients, since they do not

are balanced.

The choice of mixtures for adequate enteral nutrition depends on the nature and severity of the flow.

disease, as well as the degree of preservation of the functions of the gastrointestinal tract. Thus, under normal

ties and preservation of the functions of the gastrointestinal tract, standard nutrient mixtures are prescribed, with critical and

immunodeficiency states - nutrient mixtures with a high content of easily digestible

proteins enriched with trace elements, glutamine, arginine and omega-3 fatty acids,

in case of impaired renal function - nutrient mixtures containing highly biologically valuable

protein and amino acids. With a non-functioning intestine (intestinal obstruction, severe

forms of malabsorption) the patient is shown parenteral nutrition.

Parenteral nutrition (feeding) is carried out by intravenous drip

administration of drugs. The technique of administration is similar to intravenous drug administration.

Main indications.

Mechanical obstruction to the passage of food in various parts of the gastrointestinal tract: tumor

formations, burn or postoperative narrowing of the esophagus, inlet or outlet

section of the stomach.

Preoperative preparation of patients with extensive abdominal operations, historical

pregnant patients.

Postoperative management of patients after operations on the gastrointestinal tract.

Burn disease, sepsis.

Big blood loss.

Violation of the processes of digestion and absorption in the gastrointestinal tract (cholera, dysentery, entero-

colitis, disease of the operated stomach, etc.), indomitable vomiting.

Anorexia and food refusal. For parenteral feeding, the following types of nutrient solutions are used. "

Proteins - protein hydrolysates, solutions of amino acids: "Vamin", "Aminosol", polyamine, etc.

Fats are fat emulsions.

Carbohydrates - 10% glucose solution, usually with the addition of trace elements and vitamins

Blood products, plasma, plasma substitutes. There are three main types of parent

ral nutrition.

1. Complete - all nutrients are injected into the vascular bed, the patient does not drink

even water.

2. Partial (incomplete) - use only the main nutrients (for example,

proteins and carbohydrates).

3. Auxiliary - nutrition through the mouth is not enough and additional

supply of a number of nutrients.

Large doses of hypertonic glucose solution (10% solution) prescribed for pa-

enteral nutrition, irritate peripheral veins and can cause phlebitis, so they

injected only into the central veins (subclavian) through an indwelling catheter, which is placed

puncture method with careful observance of the rules of asepsis and antisepsis.

Patient nutrition. Artificial feeding of the patient

Lecture

The student must know:

basic principles rational nutrition;

basic principles of clinical nutrition;

characteristics of treatment tables;

catering for patients in the hospital;

types of artificial nutrition, indications for its use;

contraindications to the introduction of a gastric tube;

problems that may arise when feeding the patient.

The student must be able to:

draw up a portion requirement;

talk with the patient and his relatives about the diet prescribed by the doctor;

feed a seriously ill patient from a spoon and with the help of a drinker;

insert a nasogastric tube;

artificially feed the patient (on a phantom);

to carry out the nursing process in case of violation of the satisfaction of the patient's need for adequate nutrition and fluid intake using the example of a clinical situation.

Questions for self-preparation:

diet concept,

energy value of food

the main components of the diet: proteins, fats, vitamins, carbohydrates, etc., concept, meaning,

healthy diet,

concept of diet therapy,

basic principles of clinical nutrition,

organization of medical nutrition in a hospital, the concept of medical tables or diets,

characteristics of treatment tables - diets,

organization and feeding of seriously ill patients,

artificial nutrition, its types, features.

Glossary

terms

wording

Anorexia

Lack of appetite

Diet

Lifestyle, diet

diet therapy

Health food

Diarrhea

Diarrhea

pancreatitis

Inflammation of the pancreas

Stoma

An opening that connects the cavity of internal organs with the external environment

Theoretical part

Food consists of organic and inorganic substances.

Organic - these are proteins, fats and carbohydrates, inorganic - mineral salts, micro and macro elements, vitamins and water.

organic compounds

Substances

Structure

Functions

Squirrels(albumins, proteins)

made up of amino acids

1 construction; 2 enzymatic; 3 motor (contractile muscle proteins); 4 transport (hemoglobin); 5 protective (antibodies); 6 regulatory (hormones).

Fats

(lipids)

composed of glycerol and fatty acids

1 energy; 2 building;

3 thermoregulatory 4 protective 5 hormonal (corticosteroids, sex hormones) 6 are part of vitamins D, E 7 source of water in the body 8 supply of nutrients.

CarbohydratesMonosaccharides : glucose fructose,

ribose,

deoxyribose

Well soluble in water

Energy

Energy

disaccharides : sucrose , maltose ,

Soluble in water

1Energy 2 Components of DNA, RNA, ATP.

Polysaccharides : starch, glycogen, cellulose

Poorly soluble or insoluble in water

1energy

2 supply of nutrients

inorganic compounds

Substances

Functions

Products

Macronutrients

O2, C, H, N

They are part of all organic substances of the cell, water

Phosphorus (P)

It is part of nucleic acids, ATP, enzymes, bone tissue and tooth enamel.

Milk, cottage cheese, cheese, meat, fish, nuts, herbs, legumes.

Calcium (Ca)

It is part of the bones and teeth, activates blood clotting.

Dairy products, vegetables, fish, meat, eggs.

trace elements

Sulfur (S)

It is part of vitamins, proteins, enzymes.

Legumes, cottage cheese, cheese, lean meat, oatmeal

Causes the conduction of nerve impulses, an activator of protein synthesis enzymes.

Vegetables, mostly potatoes, fruits, mostly dry - apricots, dried apricots, raisins, prunes.

Chlorine (Cl)

It is a component of gastric juice (HCl), activates enzymes.

Sodium (Na)

Provides conduction of nerve impulses osmotic pressure in cells, stimulates the synthesis of hormones.

The main source is table salt, (NaCl)

Magnesium (Mg)

Contained in bones and teeth, activates DNA synthesis, participates in energy metabolism.

Bran, rye bread, vegetables (potatoes, cabbage, tomatoes), millet, beans, cheese, almonds.

Iodine (I)

Part of the hormone thyroid gland- thyroxine, affects metabolism.

Seaweed, shrimps, mussels, sea fish.

Iron (Fe)

It is part of hemoglobin, myoglobin, the lens and cornea of ​​the eye, an enzyme activator. Provides oxygen transport to tissues and organs.

Liver, meat, egg yolk, tomatoes, greens, green (by color) apples.

Water (H2O)

60 - 98% is found in the human body. It makes up the internal environment of the body, participates in the processes of hydrolysis, structures the cell. Universal solvent, catalyst for all chemical processes. Loss of 20% - 25% of water leads the body to death.

Principles of rational nutrition

1 Principle – balanced diet, variety of food - the ratio of proteins, fats and carbohydrates in food should be respectively - 1.0: 1.2: 4.6 by weight of these substances.

2 Principle - caloric content of food - food products should have sufficient energy value, approximately 2800 - 3000 kcal of the daily diet.

3 Principle –diet - 4 times a day, breakfast - 25%, lunch - 30%,

afternoon tea - 20%, dinner - 25% . Of great importance is the method of cooking, for example, if boiled for too long, vitamins are destroyed. It is also necessary to store food correctly, since improper storage (repeated defrosting and freezing, long-term storage, etc.) changes the chemical composition of food, destroys vitamins.

Principles of therapeutic nutrition

Diet(treatment table) - clinical nutrition, this is a diet (daily amount of food), which is compiled for the patient for the period of the disease or its prevention. diet therapy- treatment with diet and diet.

1. principle– sparing bodies. Sparing can be: chemical (restriction or salts, or proteins, or fats, or carbohydrates, or water); mechanical (food, steamed, ground, grated); thermal - cool food or vice versa - hot (hot tea, coffee).

   principle- as the patient recovers, his diet changes. There are two ways to go

from one diet to another:

1 gradual - for example, table 1a, 1b, 1 with peptic ulcer stomach.

2 stepped - the "zigzag" method recommended by the Institute of Nutrition

Russian Academy of Medical Sciences for the majority of patients with chronic diseases, when previously prohibited foods are allowed once every 7-10 days, i.e. contrast days are recommended. A strict diet remains in the form of 1 - 2 fasting days per week.

In hospitals, the diet is controlled by ward nurses, senior

nurses, heads of departments, dieticians, dieticians.

Compilation of a ward portioner and

statement of portion requirement

Every day, after going around the doctor, the guard (ward) nurse makes a ward portion, where she indicates the number of the ward, the number of patients in the ward and the number of diet tables, sums up, which indicates the number of patients at her post and the number of people receiving this or that diet. Then the portioner surrenders to the head nurse.

Portion requirement is issued today for tomorrow, and on Friday for Saturday and Sunday and Monday.

If the patient arrived after the preparation and submission of a portion requirement to the kitchen, then an additional portion portion is served.

Having received information from the guard nurses, the head nurse writes out a portion requirement for the entire department, which indicates the number of patients in the department and the number of patients receiving a particular diet. This portion requirement is signed by the head nurse and the head of the department. Additional food may be prescribed in the form of cottage cheese, kefir, milk, etc.

The portion requirement is handed over to the kitchen to the dietitian no later than 12 noon.

The head nurse returns the ward portion requirements to the ward nurses so that they can control the nutrition of patients.

The dietitian writes a hospital-wide ration requirement that lists the number of patients in the entire hospital and the number of patients on a particular diet. This portion claim signs chief physician hospitals, chief accountant and dietitian.

Based on this portion requirement, the dietician draws up a daily menu for each diet.

According to this menu, the dietitian makes menu-requirement(menu-layout) in which the number of products required for cooking is calculated.

Based menu-requirements(layout menus) receive products in stock today for tomorrow (or Saturday, Sunday, and Monday).

In addition, the nurse on duty is obliged to submit information (by surname) to the buffet to the barmaid (distributor).

ward number

Full Name

diet number

Mode

Ivanov Petr Alekseevich

Petrov Igor Vladimirovich

Sidorov Oleg Ivanovich

Sokolova Anna Alekseevna

Petrova Victoria Alexandrovna

+

+

+

+

Portion Requirement

Department: Ophthalmic____ Post #_ 1 __ issue date_ 24. 11_2008

On _ 25. 11. 2008 G.

chambers

Qty

patients

D i e t. tables

Additional

nutrition

Fasting days

And that:

duty nurse _____________

Portion Requirement

Department: _ Ophthalmic______ date of: 24.11. 2008y.

On 25.11. 2008 G. Time: 12 hour 00 min.

post

Qty

patients

Additional

nutrition

Fasting days

And that:

Head department _________________

Art. nurse ___________________

Portion Requirement

MUGB No. 1 __________________________ date 24.11. 2008 G.

name of health facility

On 25. 11. 200 8 g. Time: 12 hour 30 min.

branch

Qty

patients

Additional

th

nutrition

Fasting days

Ophthalmic

Surgical

Traumatological

And that:

269

26

15

53

34

21

24

10

1

11

50

10

14

Ch. doctor _________________

Ch. accounting _________________

Dietitian _________________

Checking patients' bedside tables

Goals: 1. checking the sanitary condition of the bedside tables; 2. checking for the presence of prohibited products.

Bedside tables are checked daily, for patients who do not inspire confidence in the nurse, bedside tables are checked twice a day

Usually bedside tables consist of 3 departments:

V first - personal hygiene items (comb, Toothbrush, pasta, etc.);

in second - food products that are subject to longer storage (cookies, sweets, apples, etc.). All products must be in packaging;

Remember !You can not store food without packaging in the nightstand!

IN third - linen and other care items.

Bedside tables are treated with disinfectant solutions after each patient is discharged.

Checking refrigerators

Refrigerators, depending on the volume, are located either in a ward for one ward, or in a separate room for several wards.

Refrigerators are checked every three days 1 time.

Goals checks: 1- the presence of expired and spoiled products; 2- sanitary condition of refrigerators.

When laying products for storage in the refrigerator, the nurse must warn the patient that he must write a label in which he notes the full name, room number and date of laying the product.

If products are found that are out of shelf life or spoiled, the nurse is obliged to inform the patient about this and remove the product from the refrigerator (if the patient is in general mode).

When checking products that have gone beyond the shelf life, they are laid out on a special table next to the refrigerator so that patients can sort them out.

Refrigerators are defrosted and washed once every 7 days.

Refrigerators (inner surface)

Hydrogen peroxide with 0.5% detergent

3% solution

2-fold wiping followed by washing with water

Gear check

Purpose: To check for prohibited products

Transfers to patients delivers special person- a peddler, she most often does not have a medical education, therefore, her functions include not accepting perishable products, the rest of the products should be checked by a ward nurse.

The ward nurse checks the transfers of patients who do not inspire confidence in her and violate the regime, for this she compiles a list of such patients, in which she indicates the department, full name. patients and room number.

This list is given to the peddler so that she can show the transfer of these patients to the nurse before giving them to them.

If prohibited products are found, they are returned to the person who brought them.

Characteristics of diets

Diet number 1a

Indications: peptic ulcer of the stomach and duodenum, the first 8-10 days of exacerbation; acute gastritis and exacerbation of chronic gastritis, the first 1 - 2 days.

Characteristic: mechanical, chemical and thermal sparing of the mucous membrane of the stomach and duodenum; all food in liquid and semi-liquid form. Eating 6 - 7 times a day, the weight of the diet is about 2.5 kg, salt up to 8 g.

milk and mucous soups from cereals and wheat bran with butter, pureed vegetables (carrots, beets) and

mashed boiled lean meat and fish, semolina milk soup. Soufflé made from boiled lean meat and fish. Liquid, mashed, milky porridges. Soft-boiled eggs, steam omelet. Whole milk. Soufflé from freshly prepared cottage cheese. Rosehip broth, not strong tea. Butter and olive oil are added to dishes.

Excluded: vegetable fiber, broths, mushrooms, bread and bakery products, lactic acid products, spices, snacks, coffee, cocoa.

Diet number 1b

Indications: exacerbation of peptic ulcer of the stomach and duodenum, 10-20th day of the disease, acute gastritis, 2-3rd day.

Characteristic: more moderate in comparison with diet No. 1a mechanical, chemical and thermal sparing of the mucous membrane of the stomach and duodenum; all food in a semi-liquid and puree form. Eating 6 - 7 times a day, diet weight up to 2.5 - 3 kg, table salt up to 8 - 10 g.

Assortment of products and dishes: dishes and products of diet No. 1a, as well as white, thinly sliced, unroasted crackers - 75 - 100g, 1 - 2 times a day - meat or fish dumplings or meatballs; mashed milk porridges and milk soups from rice, barley and pearl barley, mashed vegetable purees. Kissels, jelly from sweet varieties of berries and fruits, juices diluted in half with water and sugar, sugar, honey.

Excluded: the same as in diet No. 1a.

Diet number 1

Indications: exacerbation of peptic ulcer, remission stage; chronic gastritis with preserved and increased secretion in the acute stage.

Characteristic: moderate mechanical, chemical and thermal sparing of the mucous membrane of the stomach and duodenum; food boiled and mostly mashed. Eating 5 - 6 times a day, diet weight 3 kg, table salt 8 - 10 g.

Assortment of products and dishes: yesterday's white and gray bread, white crackers, biscuit. Milk, pureed, cereal and vegetable soups (except cabbage). Steam cutlets (meat and fish), chicken and fish, boiled or steamed; Vegetable puree, cereals and puddings, mashed, boiled or steamed; soft-boiled eggs or steam omelet. Sweet varieties of berries, fruits, juices from them, sugar, honey, jam, baked apples, jelly, mousse, jelly. Whole milk, cream, fresh sour cream, fresh low-fat cottage cheese. Tea and cocoa are not strong, with milk. Butter unsalted and vegetable.

Limited: coarse vegetable fiber, broths.

Excluded: spices, coffee, mushrooms.

Diet number 2

Indications : chronic gastritis with secretory insufficiency; acute gastritis, enteritis, colitis during convalescence as a transition to rational nutrition.

Characteristic : mechanically sparing, but contributing to an increase in gastric secretion. Food boiled, baked, fried without breading. Table salt up to 15g per day.

Assortment of products and dishes: yesterday's white bread, not rich crackers, 1 - 2 times a week not rich cookies, pies. Cereal and vegetable soups in meat and fish broth. Lean beef, chicken boiled, stewed, steamed, baked, fried without breading and jelly. The fish is not greasy in a piece or in chopped form, boiled, steam aspic. Vegetables:

potatoes (limited), beets, grated carrots, boiled, stewed, baked; raw tomatoes. Compotes, kissels, jelly mousses from ripe fresh and dry fruits and berries (except melons and apricots), fruit and vegetable juices, baked apples, marmalade, sugar. Whole milk with good tolerance. Acidophilus, kefir fresh non-acidic, raw and baked cottage cheese; mild grated cheese; sour cream - in dishes. Sauces meat, fish, sour cream and vegetable broth. Bay leaf, cinnamon, vanilla. Tea, coffee, cocoa on the water with milk. Butter and sunflower oil. Soft-boiled eggs, fried scrambled eggs.

Excluded: beans and mushrooms.

Diet number 3

Indications : chronic diseases intestines with a predominance of constipation, a period of not sharp exacerbation and a period of remission.

Characteristic : Increase in the diet of foods rich in vegetable fiber, and foods that enhance the motor function of the intestine. Table salt 12 - 15g per day.

Assortment of products and dishes: wheat bread from wholemeal flour, black bread with good tolerance. Soups in fat-free broth or vegetable broth with vegetables. Meat and fish boiled, baked, sometimes chopped. Vegetables (especially leafy) and raw fruits, in in large numbers(prunes, figs), sweet dishes, compotes, juices. Friable cereals (buckwheat, pearl barley). Cottage cheese and syrniki, one-day kefir. Hard boiled egg. Butter and olive oil - in dishes

Excluded: turnip, radish, garlic, mushrooms.

Diet number 4

Indications : acute enterocolitis, exacerbation of chronic colitis, period of profuse diarrhea and pronounced dyspeptic phenomena.

Characteristic: chemical, mechanical and thermal sparing of the intestine. Eating 5 - 6 times a day. All dishes are steamed, pureed. Table salt 8 - 10g. The duration of the diet is 5 - 7 days.

Assortment of products and dishes: crackers from white bread. Soups on fat-free meat broth, decoctions of cereals with egg flakes, semolina, mashed rice. Meat is not fatty in minced form, boiled

or steam. Poultry and fish in their natural form or minced, boiled or steamed. Porridges and puddings from pureed cereals in water or low-fat broth. Juices from fruits and berries, decoction of wild rose, blueberries. Tea, cocoa on the water, jelly, kissels. Eggs (with good tolerance) - no more than 2 pieces per day (soft-boiled or steam omelet). Butter 40 - 50g.

Restrictions: sugar up to 40g, cream.

Excluded: milk, vegetable fiber, spices, snacks, pickles, smoked products, legumes.

Diet number 5

Indications : acute hepatitis and cholecystitis, recovery period; chronic hepatitis and cholecystitis; cirrhosis of the liver.

Characteristic: mechanical and chemical sparing, maximum liver sparing. Restriction of animal fats and extractives High content of carbohydrates Food is not crushed. Roasting is not allowed. Eating 5 - 6 times a day, diet weight 3.3 - 3.5 kg, table salt 8 - 10 g.

Assortment of products and dishes: yesterday's wheat and rye bread. Soups from vegetables, cereals, pasta on vegetable broth, dairy or fruit. Low-fat varieties of meat and fish boiled, baked after boiling; soaked herring. Raw vegetables and herbs (salads, vinaigrettes), non-acidic sauerkraut. Fruits and berries, except very acidic. Sugar up to 100g, jam, honey. Milk, curdled milk, acidophilus, kefir, cheese. Egg - in a dish, and with good tolerance - scrambled eggs 2 - 3 times a week.

Excluded: mushrooms, spinach, sorrel, lemon, spices, cocoa.

Diet number 5a

Indications : acute illnesses liver and biliary tract with concomitant diseases of the stomach, intestines; acute and chronic pancreatitis, exacerbation stage.

Characteristic : the same as with diet number 5, but with mechanical and chemical sparing of the stomach and intestines (food is given to the patient mainly in a pureed form).

Assortment of products and dishes: dried wheat bread. Mucous soups from vegetables, cereals, noodles, on vegetable broth or dairy, pureed, soup-puree. Steam meat cutlets, meat soufflé. Low-fat boiled fish, steam soufflé from it. Vegetables boiled, steamed,

frayed. Porridges, especially buckwheat, mashed with water or with the addition of milk. Egg - only in the dish. Sugar, honey, kissels, jelly, compotes from sweet fruits and berries. Milk - only in the dish, lactic acid products and fresh cottage cheese (soufflé). The tea is not strong. Sweet fruit juices. Butter and vegetable oil - only in dishes.

Excluded: snacks, spices, turnip, radish, sorrel, cabbage, spinach, cocoa.

Diet number 7

Indications : acute nephritis, convalescence period; chronic nephritis with slight changes in urine sediment.

Characteristic : chemical sparing of the kidneys. Restriction of table salt (3 - 5 g per patient's hands), liquids (800 - 1000 ml), extractives, hot spices.

Assortment of products and dishes: white and bran bread without salt (3 - 5 g per patient's hands), liquids (800 - 1000 ml), fatty meats and poultry boiled, in pieces, chopped and mashed, baked after boiling. Fish lean piece, chopped, mashed, boiled and lightly fried after boiling. Vegetables in natural, boiled and baked form, vinaigrettes, salads (without salt). Cereals and pasta in the form of cereals, puddings, cereals. Egg - one per day. Fruits, berries in any form, especially dried apricots, apricots, sugar, honey, jam. Milk and dairy products, cottage cheese. White sauce, vegetable and fruit sauces. Butter and vegetable oil.

Limited: cream and sour cream.

Excluded: soups.

Diet number 7a

Indications : acute nephritis, exacerbation of chronic nephritis with pronounced changes in the urine sediment.

Characteristic : chemical sparing, strict restriction of liquid (600 - 800 ml) and salt (1 - 2 g per patient's hands); all dishes are pureed, boiled or steamed.

Product range: the same as with diet number 7, meat and fish are limited to 50g per day. Vegetables only in boiled or grated form. Raw and boiled fruits only in pureed form.

Excluded: soups.

Diet number 8

Indications : obesity.

Characteristic : chemical sparing, restriction energy value diet is mainly based on carbohydrates and fats. Increasing the amount of protein. Restriction of table salt to 3 - 5 g, liquids to 1 liter, extractives, spices and seasonings. Increase in plant fiber. Eating 5 - 6 times a day.

Assortment of products and dishes: black bread (100 - 150g). Soups meat, fish, vegetarian - half a plate. Meat and fish are lean, boiled in pieces. Buckwheat porridge crumbly. Vegetables in all forms (especially cabbage) with vegetable oil. Potatoes are limited. fruits and

raw berries and juices from them, excluding sweet ones: grapes, figs, dates. Butter and sour cream are limited; fat-free milk and dairy products, fat-free cottage cheese. Compote, tea, coffee with xylitol.

Excluded: seasonings.

Diet number 9

Indications : diabetes.

Characteristic : chemical sparing, restriction or complete exclusion of refined carbohydrates, restriction of cholesterol-containing products. Individual selection of daily energy value. Food boiled or baked fried foods limited.

Assortment of products and dishes: black rye bread, protein-bran bread, coarse wheat bread (no more than 300 g per day). Soups on vegetable broth. Lean meats and fish. Kashi: buckwheat, oatmeal, barley, millet; legumes; eggs - no more than 1.5 pieces per day (yolks are limited).

Lactic acid products, cottage cheese. Fruits and vegetables in large quantities.

Limited: carrots, beets, green peas, potatoes, rice.

Excluded: salty and marinated dishes; semolina and pasta; figs, raisins, bananas, dates.

Diet number 10

Indications : diseases of the cardiovascular system without symptoms of circulatory failure.

Characteristic : chemical sparing, restriction of animal fats, cholesterol-containing products, table salt (5g per patient's hands). Eating 5 - 6 times a day. Food boiled or baked.

Assortment of products and dishes: coarse gray bread, crackers, non-butter biscuits, crispbread. Soups (half a plate) vegetarian, cereal, dairy, fruit; borscht, beetroot; low-fat meat broth - once a week. Meat, poultry are low-fat, boiled and baked, roasting after boiling is allowed. Low-fat fish, soaked herring - 1 time per week. Protein omelet. Vegetable vinaigrettes and salads (except leaf and head lettuce, sorrel and mushrooms) with vegetable oil. Oatmeal and buckwheat porridge crumbly, puddings, casseroles. Lactic acid products, milk, cottage cheese, low-fat cheese. Fruits, berries,

any fruit juices. Fats for cooking and eating - 50g, of which half are vegetable. Weak tea and coffee. Sugar - up to 40g per day.

Excluded: fatty meals meat, fish, butter dough, brains, liver, kidneys, caviar, refractory fats, ice cream, salty snacks and canned food, alcohol, cocoa, chocolate, beans.

Diet number 10a

Indications : diseases of the cardiovascular system with severe symptoms of circulatory failure.

Characteristic : chemical sparing, a sharp restriction of salt and free fluid. Exception nutrients and drinks that stimulate the central nervous system,

heart activity and irritating kidneys. Food is prepared without salt. Food is given in pureed form.

Assortment of products and dishes: the same as with diet No. 10, but meat and fish are limited to 50 g per day, they are given only boiled, vegetables -

only boiled and mashed. Raw and boiled fruits only in pureed form.

Excluded: soups, spicy and salty dishes, strong tea and coffee, fatty and floury dishes.

Diet number 11

Indications : tuberculosis without disorders of the intestines and without complications; general exhaustion.

Characteristic : a complete, varied diet for enhanced nutrition (increased energy value), with a large amount of complete proteins, fats, carbohydrates, vitamins and salts, especially calcium.

Assortment of products and dishes: variety of foods and dishes. Foods rich in calcium salts: milk, cheese, buttermilk, figs. At least half of the protein comes from meat, fish, cottage cheese, milk and eggs.

Excluded: ducks and geese.

Diet number 13

Indications : Acute infectious diseases (febrile conditions).

Characteristic : thermal sparing (with high fever), varied, mostly liquid, food with the advantage of coarse vegetable fiber, milk, snacks, spices. Eating 8 times a day, in small portions.

Assortment of products and dishes: white bread and crackers, meat broth, soup-puree from meat on a slimy broth. Meat soufflé. Soft-boiled eggs and scrambled eggs.

The porridges are mashed. Fruit, berry, vegetable juices, fruit drinks, kissels. Butter.

Diet number 15

Indications: all diseases in the absence of indications for the appointment of a special diet.

Characteristic : a physiologically complete diet with twice the amount of vitamins and the exclusion of fatty meat dishes. Eating

4 - 5 times a day.

Assortment of products and dishes: white and rye bread. Soups are different.

Meat varied piece (except for fatty varieties). Any fish. Dishes from cereals, pasta, legumes. Eggs and dishes from them. Vegetables and fruits are different. Milk and dairy products. Sauces and spices are different (pepper and mustard - according to special indications). Snack food in moderation. Tea, coffee, cocoa, fruit and berry juices, kvass. Butter and vegetable oil in its natural form, in salads and vinaigrettes.

Diet number 0

Indications : the first days after operations on the stomach and intestines (appointed for no more than 3 days). Characteristic : chemical, mechanical sparing. Eating every 2 hours (from 8.00 to 22.00). Food is given in liquid and jelly-like form.

Assortment of products and dishes: tea with sugar (10g), fruit and berry kissels, jelly, apple compote (without apples), rosehip broth with sugar; 10g each butter added to rice water and weak meat broth.

Fasting days

The name of the diet and its composition

Indications

Dairy Day #1

Every 2 hours, 6 times a day, 100 ml of milk or kefir, curdled milk, acidophilus; At night 200 ml of fruit juice with 20 g of glucose or sugar; you can also 2 times a day for 25 g of dried white bread.

Diseases of the cardiovascular system with symptoms of circulatory failure

Dairy Day #2

1.5 liters of milk or curdled milk for 6 servings

250ml every 2-3 hours

Gout, obesity.

cottage cheese day

400 - 600 g of fat-free cottage cheese, 60 g of sour cream and 100 ml of milk for 4 doses in kind or in the form of cheesecakes, puddings. You can also 2 times coffee with milk.

Obesity, heart disease, atherosclerosis

cucumber day

2kg fresh cucumbers for 5 - 6 receptions

Obesity, atherosclerosis, gout, arthrosis

salad day

1.2 - 1.5 kg of fresh vegetables and fruits for 4 - 5 meals a day - 200 - 250 g each in the form of salads without salt. A little sour cream or vegetable oil is added to vegetables, and sugar is added to fruits.

syrup

hypertension, atherosclerosis,

kidney disease, oxaluria, arthrosis.

potato day

1.5 kg of baked potatoes with a small amount of vegetable oil or sour cream (without salt) for 5 meals - 300g each.

Heart failure, kidney disease

watermelon day

1.5 kg of ripe watermelon without peel for 5 doses - 300g.

Liver diseases, hypertension, nephritis, atherosclerosis.

Apple Day #1

1.2 - 1.5 kg of ripe raw peeled and mashed apples for 5 doses - 300 g each.

spicy and chronic colitis with diarrhea.

Apple Day #2

1.5 kg of raw apples for 5-6 meals. In case of kidney disease, 150-200 g of sugar or syrup are added. You can also serve 2 servings of rice porridge from 25g of rice each

Obesity, nephritis, hypertension, diabetes mellitus.

Unloading day from dried apricots

Pour boiling water over 500g dried apricots or slightly steam them and divide into 5 doses

Hypertension, heart failure

compote day
1.5 kg of apples, 150 g of sugar and 800 ml of water are boiled and divided into 5 doses during the day.

Diseases of the kidneys and liver.

Rice Compote Day

Prepare 1.5 l of compote from 1.2 kg of fresh or 250 g of dried fruits and berries; cook porridge on water from 50 g of rice and 100 g of sugar. 6 times a day give a glass

compote, 2 times - with sweet rice porridge.

Diseases of the liver, gout, oxaluria.

sugar day

5 times a glass of hot tea from 30 -

40g sugar each.

Liver disease, nephritis, chronic colitis with diarrhea

Meat

a) 270g boiled meat, 100ml milk, 120g green peas, 280g fresh cabbage for the whole day.

b) 360g of boiled meat for the whole day.

Obesity

artificial nutrition

theoretical part

Artificial nutrition is understood as the introduction of food (nutrients) into the patient's body enterally (Greek entera - intestines), i.e. through the gastrointestinal tract, and parenterally (Greek para - near, entera - intestines) - bypassing the gastrointestinal tract.

Types of artificial nutrition:

I. Enteral (through the gastrointestinal tract):

a) through a nasogastric tube (NGZ);

b) using a gastric tube inserted through the mouth;

c) through a gastrostomy;

d) rectal (using nutrient enemas).

II. Parenteral (bypassing the gastrointestinal tract):

a) by injection; b) by infusion

using a probe and funnel

When it is impossible to feed the patient naturally, food is introduced into the stomach or intestines through probe or stoma, or with an enema. When such an administration is not possible, then nutrients and water (saline solutions) are administered parenterally. Indications for artificial nutrition and its methods are chosen by the doctor. The nurse must have a good command of the method of feeding the patient through probe. A funnel or a system for dripping nutrient solutions, or a Janet syringe, is connected to the inserted probe and the patient is fed with these devices.

See Algorithms for tube insertion and artificial feeding through the tube.

Feeding a patient with a large stomach tube and funnel

Equipment: nutrient mixture "Nutrison" or "Nutricomp" 50-500ml, heated to a temperature of 38º-40º, boiled fresh water 100-150ml, oilcloth, napkin, gloves, gauze wipes, container for used material, waterproof bag, sterile glycerin or Vaseline oil, cotton turundas, a sterile funnel with a capacity of 0.5 l, a sterile thick gastric tube, a plug.

Note:

Check the packaging with the probe for tightness and expiration date.

Open the package with thick gastric tube and funnel.

Determine the depth of insertion of the probe:

• 2 - 3 marks (50 - 55, 60 - 65 cm)

  Height - 100

  Measure the distance from the tip of the nose to the earlobe and to the navel

Treat the inner end of the probe with glycerin or vaseline oil

During insertion, ask the patient to breathe deeply and swallow.

Put on the outer end of the probe the funnel or cylinder of Janet's syringe.

Windpipe Esophagus Posterior pharyngeal wall

Place the funnel or cylinder of Janet's syringe at the level of the stomach and pour in the nutrient mixture 50-500 ml (as prescribed by the doctor), temperature - 38 ° - 40 °.

Then slowly raise the funnel or cylinder of Janet's syringe up (keep the funnel in an inclined position), make sure that no air enters the stomach.

After feeding, pour 50-100 ml of boiled water into the funnel or cylinder of Janet's syringe and rinse the probe.

Disconnect the funnel or cylinder of the Janet syringe from the probe, place it in a waterproof bag, close the end of the probe with a plug.

Attach the probe to the pillow.

Remove gloves, wash hands.

Problems patient: nausea, vomiting.

Insertion of a nasogastric tube (NGZ) through the nose

Indications : the need for artificial feeding.

Contraindications : varicose veins of the esophagus, gastric and esophageal ulcers, neoplasms, burns and cicatricial formations of the esophagus, gastric bleeding.

Equipment: sterile nasogastric tube in the package; plug; putty knife; glycerin or vaseline oil; sterile wipes; syringe - 10 ml .; fixative (a piece of bandage); clean gloves; sterile gloves; sterile tray; napkins; waterproof bag for used material, napkin on the chest

Wash your hands to a hygienic level, put on gloves and treat them with an antiseptic for gloves.

Explain to the patient (if he is conscious) the purpose and course of the procedure, obtain consent.

Give the patient the Fowler position (if he is allowed), cover the chest with a napkin.

Check the nasal passages for patency (you need to insert the probe into the free nasal passage).

Open the package with the probe, put it on a sterile tray.

Remove gloves, put on sterile gloves.

Determine the depth of insertion of the probe, this is 1) the distance from the earlobe to the tip of the nose and to the navel; 2) height - 100cm; 3) up to 2-3 marks on the probe.

Treat the inner end of the probe with glycerin or vaseline oil at a distance of 10-15 cm.

Irrigation of the probe with glycerol Pressing the probe to the back Fixing the probe with

the wall of the pharynx with a spatula using a bandage

Slightly tilt the patient's head forward.

Assemble the probe in one hand, with the other hand thumb lift the tip of the nose and insert the probe by 15-18 cm. Release the tip of the nose.

Press the probe against the back wall of the pharynx with a spatula or two fingers of your free hand (so as not to get into the trachea), while advancing the probe, this must be done quickly so as not to cause a gag reflex, continue to insert the probe to the desired mark.

Note :if the patient is conscious and can swallow, give him half a glass of water and, when swallowing small sips of water, slightly help insert the probe to the desired mark.

Attach a syringe to the outer (distal) end of the probe and suck out 5 ml of stomach contents, make sure that the contents do not contain blood impurities (if blood is found, show the contents to the doctor), insert the contents back into the probe.

Fix the probe with a safety pin to the pillow or to the patient's clothing.

Fix the probe with a bandage, tying it over the neck and face without capturing the ears. Make a knot on the side of the neck, you can fix the probe with adhesive tape by attaching it to the back of the nose.

Remove the napkin, place in a bag,

Help the patient to take a comfortable position, straighten the bed, cover the patient with a blanket.

Remove gloves, wash hands. Make an entry in the medical record.

Note: the probe is left for 2 weeks. After 2 weeks, it is necessary to remove the probe, decontaminate it, then, if necessary, insert it again.

Patient problems when inserting the probe: psychological, penetration of the probe into the respiratory tract, trauma to the mucous membrane, bleeding, gag reflex, nausea, vomiting.

Feeding the patient through a nasogastric tube (NGZ) drip

Equipment: filled system with nutrient mixture "Nutrison" or "Nutricomp" 200-500ml (as prescribed by a doctor) 38º-40º, tripod, gloves, warm boiled water 50-100ml, Janet syringe, napkins, napkin (on the chest), heating pad 40º, sterile glycerin or vaseline oil, cotton turundas,

Ventilate the ward, remove the vessel.

Warn the patient about the upcoming feeding.

Place the patient in Fowler's position (if allowed).

Lay a napkin on the patient's chest.

Remove plug.

Connect the system to the probe, adjust the frequency of drops (the rate is determined by the doctor).

Put a heating pad on top of the tube of the system on the bed (temperature - + 40 °).

Enter the prepared amount of the mixture (temperature 38°-40°) at a rate of 100 drops per minute.

Close the clamp on the system and disconnect the system.

Attach Janet's syringe with warm water to the probe. boiled water, rinse the probe under slight pressure.

Disconnect the syringe.

Close the distal end of the probe with a plug.

Change the position of the probe, treat the nasal passage with petroleum jelly or glycerin, dry the skin around the nose with blotting movements, change the retainer.

Attach the probe to the patient's pillow or clothing with a safety pin. Remove napkin.

Help the patient to get into a comfortable position. Fix the bed, cover with a blanket.

Remove gloves, wash hands.

Make a record of the feeding in the medical record.

Feeding a patient through NHZ using a Janet syringe

Equipment: Janet syringe, nutrient mixture "Nutrison" or "Nutricomp" 50-500ml, heated to a temperature of 38º-40º, boiled fresh water 100-150ml, napkin, gloves, gauze wipes, container for used material, waterproof bag, sterile glycerin or vaseline oil, cotton turundas,

Tell the patient what to feed him.

Ventilate the ward, remove the vessels.

Wash your hands, put on gloves.

Raise the head end of the bed (if the patient is allowed), lay a napkin on the chest.

Check the temperature of the nutrient mixture.

Draw the required amount of the nutrient mixture into Janet's syringe.

Remove the cap, connect the syringe to the probe and slowly (20 - 30 ml per minute) pour in the nutrient mixture 50 - 500 ml (as prescribed by the doctor), temperature - 38 ° -40 °.

Rinse the syringe with boiled water, fill it with 50-100 ml of boiled water and rinse the probe under slight pressure.

Disconnect the syringe from the probe, place the syringe in a waterproof bag, close the end of the probe with a plug.

Remove the napkin, place them in a bag.

Help the patient to give a comfortable position, straighten the bed, cover.

Remove gloves, wash hands.

Feeding the patient through Flushing the tube after

NGZ using Janet syringe feeding

Make an entry in the medical record about the procedure.

Patient problems

Feeding the patient through the NGZ using a funnel

Equipment: funnel, nutrient mixture "Nutrison" or "Nutricomp" 50-500ml, heated to a temperature of 38º-40º, sterile glycerin or vaseline oil, cotton turundas, boiled fresh water 100-150ml, oilcloth, napkin, gloves, gauze wipes, container for used material, waterproof bag,

Note:instead of a funnel, it is not uncommon to use a Janet syringe barrel

Tell the patient what to feed him.

Ventilate the ward, remove the vessels.

Wash hands with a hygienic level, put on gloves, treat gloves with an antiseptic for gloves.

Raise the head end of the bed (if the patient is allowed), lay an oilcloth, a napkin on the chest.

Check the temperature of the nutrient mixture.

Remove the plug, connect the funnel or Janet syringe barrel to the probe.

Place the funnel or cylinder of Janet's syringe at the level of the stomach, pour 50 ml of the nutrient mixture into it, and slowly raising it, add the mixture to the desired volume (as prescribed by the doctor), while making sure that no air enters the stomach.

Then again lower the funnel or cylinder of Janet's syringe and pour 50-100 ml of boiled water into it and rinse the probe with the same movements.

Disconnect the funnel or cylinder of the Janet syringe from the probe and place it in a waterproof bag, close the end of the probe with a plug.

Change the position of the probe by attaching it to the patient's pillow or clothing.

Handle nasal cavity with the inserted probe, change the latch.

Remove oilcloth, napkin, place them in a bag.

Help the patient to give a comfortable position, straighten the bed, cover.

Remove gloves, wash hands.

Make an entry in the medical record about the procedure.

Problems patient: necrosis of the nasal mucosa, nausea, vomiting.

Remember!

After feeding the patient through a probe inserted through the nose or gastrostomy, the patient should be left in a reclining position for at least 30 minutes.

When washing a patient who has a probe inserted through the nose, you need to use only a towel or mitten soaked in warm water Do not use cotton wool or gauze pads.

Feeding the patient through a gastrostomy

Equipment: Janet funnel or syringe, container with nutrient mixture (38º-40º) 50-500 ml., boiled water 100-150 ml., absorbent diaper, sterile probe in the package, gloves, container for used material, waterproof bag, glycerin (if required) .

Tell the patient what to feed him.

Ventilate the room, remove the vessel.

Wash your hands to a hygienic level, put on gloves.

Place an absorbent pad on the patient's abdomen

Check feed temperature(38º- 40º)

Feeding the patient through the gastrostomy Washing the tube after feeding

using Janet's syringe

Draw 50-500 ml of the mixture into Janet's syringe (as prescribed by the doctor).

Remove the cap on the probe

Attach Janet's syringe to the probe.

Enter the nutrient mixture at a rate of 20-30 ml per minute.

Disconnect the syringe from the probe, close the distal end of the probe with a plug.

Rinse the syringe and collect boiled water 50 - 100 ml,

Remove the cap and rinse the probe with warm boiled water under slight pressure.

Disconnect Janet's syringe and place it in a waterproof bag.

Put a cap on the distal end of the probe.

If it is necessary to treat the skin around the stoma, apply an aseptic dressing.

Remove the diaper, help the patient to give a comfortable position, straighten the bed, cover with a blanket.

Remove gloves, wash hands.

Make an entry in the medical record about the procedure.

Patient problems: tube prolapse, peritonitis, irritation and infection of the skin around the stoma, nausea, vomiting, psychological problems.

REMEMBER ! If the tube falls out of the stoma, do not try to insert it yourself, you should immediately inform the doctor!

parenteral nutrition

Injection- the introduction of nutrients into soft and liquid tissues.

Infusion- infusion of large amounts of fluids intravenously.

With artificial nutrition of the patient, the daily calorie content of food is about 2000 kcal, the ratio of proteins - fats - carbohydrates:

1: 1: 4. The patient receives water in the form of water-salt solutions on average 2 liters per day.

Vitamins are added to nutrient mixtures or administered parenterally. Only liquid food can be introduced through a probe or gastrostomy: broths, milk, cream, raw eggs, melted butter, slimy or pureed soup, liquid jelly, fruit and vegetable juices, tea, coffee, or specially prepared mixtures.

Parenteral nutrition - a special kind replacement therapy, in which nutrients to replenish energy and plastic costs and maintain normal level metabolic processes, enter bypassing digestive tract.

Types of parenteral nutrition:

1. Complete parenteral nutrition - nutrients are administered only parenterally (bypassing the gastrointestinal tract).

2. Partial parenteral nutrition - nutrients are administered

parenterally and enterally.

Total parenteral nutrition is performed when the introduction of nutrients through the digestive tract is not possible or effective. At

some operations on the organs abdominal cavity, severe lesions of the mucosa of the digestive tract.

Partial parenteral nutrition is used when the introduction of nutrients through the digestive tract is possible, but not very effective. With extensive burns, pleural empyema and other purulent diseases associated with large losses of pus (hence, fluid).

Adequacy of parenteral nutrition is determined by nitrogen balance

To meet the plastic processes used protein drugs : casein hydrolyzate; hydrolysine; fibrinosol; balanced synthetic amino acid mixtures: aminosol, polyamine, new alvezin, levamine.

High concentrations are used as energy sources. carbohydrate solutions : (5% - 50% solutions of glucose, fructose) , alcohol (ethyl ) ,fatty emulsions : intralipid, lipofundin, infuzolinol .

The introduction of protein preparations without meeting energy needs is inefficient, since most of them will be spent

to cover energy costs, and only a smaller one - for plastic ones.

Therefore, protein preparations are administered simultaneously with carbohydrates.

The use of donor blood and plasma as food is not effective because plasma proteins are utilized by the patient's body after 16-26 days, and hemoglobin - after 30-120 days.

But as a replacement therapy for anemia, hypoproteinemia and hypoalbuminemia, they are not replaceable (erythrocyte mass, all types of plasma, albumin).

Parenteral nutrition will be more effective if it is supplemented with the introduction of anabolic hormones ( nerobol, retabolil).

Means for parenteral nutrition are administered by drip intravenously. Before the introduction, they are heated in a water bath to a temperature of 37 ° - 38 °. It is necessary to strictly observe the rate of administration of drugs: hydrolysin, casein hydrolyzate, fibrinosol - in the first 30

min injected at a rate of 10 - 20 drops per minute, and then, with good tolerance, the rate of administration is increased to 40 - 60 (prevention of allergic reactions and anaphylactic shock).

Polyamine in the first 30 minutes, they are administered at a rate of 10-20 drops per minute, and then - 25-35 drops per minute. A more rapid administration of the drug is impractical, since the excess of amino acids does not have time to be absorbed and is excreted in the urine. With a more rapid introduction of protein preparations, the patient may experience sensations of heat, flushing of the face, difficulty breathing.

Lipofundin S(10% solution) and other fat emulsions are administered in the first 10-15 minutes at a rate of 15-20 drops per minute, and then gradually (within 30 minutes) increase the rate of administration to 60 drops per minute. The introduction of 500 ml of the drug should last approximately 3-5 hours.

Carbohydrates are also heated before administration and administered at a rate of 50 drops per minute. When administering carbohydrates, it is very important to administer insulin at the same time. for every 4 g of glucose - 1 U. insulin for the prevention of hyperglycemic coma.

Vitamins are administered in / in (intravenously), s / c (subcutaneously), and / m (intramuscularly).

Remember! All components for parenteral nutrition should be administered at the same time!

Patient problems with parenteral nutrition: hyperglycemic coma, hypoglycemic coma, allergic reactions, anaphylactic shock, pyrogenic reactions.

Homework

1. S.A. Mukhina, I.I. Tarnovskaya. Practical guide to the subject "Fundamentals of Nursing", pp. 290 - 300.

   Educational and methodological guide on the basics of nursing, pp. 498 - 525.

   http://video.yandex.ru/users/nina-shelyakina/collections/?p=1 in the collection PM 04 on 7 - 8, pages of films from 64 to 78 and repeat all the manipulations

Numerous studies have established that malnutrition can be accompanied by various structural and functional changes in the body, as well as metabolic disorders, homeostasis and its adaptive reserves. There is a direct correlation between the trophic supply of seriously ill (affected) patients and their mortality - the higher the energy and protein deficiency, the more often they have severe multiple organ failure and death. It is known that trophic homeostasis, together with oxygen supply, is the basis of the life of the human body and the cardinal condition for overcoming many pathological conditions. Maintenance of trophic homeostasis, along with its internal factors, is determined primarily by the possibility and reality of obtaining by the body the nutrient substrates necessary for life support. At the same time, situations often arise in clinical practice in which patients (victims) for various reasons do not want, should not or cannot eat. Patients with sharply increased substrate needs (peritonitis, sepsis, polytrauma, burns, etc.) should also be included in this category of persons, when normal natural nutrition does not adequately provide the body's need for nutrients.

Back in 1936, H. O. Studley noted that if patients lost more than 20% of their body weight before surgery, their postoperative mortality reached 33%, while with adequate nutrition it was only 3.5%.

According to G. P. Buzby, J. L. Mullen (1980), malnutrition in surgical patients leads to an increase in postoperative complications by 6, and mortality by 11 times. At the same time, the timely administration of optimal nutritional support to malnourished patients reduced the number of postoperative complications by 2-3, and mortality by 7 times.

It should be noted that trophic insufficiency in one form or another is quite often observed in clinical practice among patients of both surgical and therapeutic profiles, amounting, according to the data various authors, from 18 to 86%. At the same time, its severity significantly depends on the type and characteristics clinical course existing pathology, as well as the duration of the disease.

The ideological basis of the vital need for early prescription of differentiated nutritional support to seriously ill and injured patients who are deprived of the possibility of optimal natural oral nutrition is due, on the one hand, to the need for adequate substrate supply of the body in order to optimize intracellular metabolism, which requires 75 nutrients, 45-50 of which are indispensable, and on the other hand, the need to quickly stop the syndrome of hypermetabolic hypercatabolism that often develops in pathological conditions and autocannibalism associated with it.

It has been established that it is stress, which is based on glucocorticoid and cytokine crises, sympathetic hypertonicity with subsequent catecholamine depletion, deenergization and dystrophy of cells, circulatory disorders with the development of hypoxic hypoergosis, that leads to pronounced metabolic changes. This is manifested by increased protein breakdown, active gluconeogenesis, depletion of the somatic and visceral protein pools, decreased glucose tolerance with a transition often to diabetogenic metabolism, active lipolysis and excessive formation of free fatty acids, as well as ketone bodies.

The list of metabolic disorganization that occurs in the body due to post-aggressive effects (illness, injury, surgery) can significantly reduce the effectiveness of medical measures, and often, in the absence of appropriate correction of emerging metabolic disorders, generally lead to their complete neutralization with all the ensuing consequences.

Consequences of metabolic disorders

IN normal conditions in the absence of any significant metabolic disorders, the energy and protein requirements of patients, as a rule, average 25-30 kcal / kg and 1 g / kg per day. With radical operations for cancer, severe concomitant injuries, extensive burns, destructive pancreatitis and sepsis, they can reach 40-50 kcal / kg, and sometimes more per day. At the same time, daily nitrogen losses increase significantly, reaching, for example, 20–30 g/day in case of traumatic brain injury and sepsis, and 35–40 g/day in severe burns, which is equivalent to a loss of 125–250 g of protein. This is 2-4 times higher than the average daily loss of nitrogen in a healthy person. At the same time, it should be noted that for a deficiency of 1 g of nitrogen (6.25 g of protein), the body of patients pays 25 g of its own muscle mass.

In fact, under such conditions, an active process of autocannibalism develops. In this regard, rapid exhaustion of the patient can occur, accompanied by a decrease in the body's resistance to infection, delayed wound healing and postoperative scars, poor consolidation of fractures, anemia, hypoproteinemia and hypoalbuminemia, impaired blood transport function and digestive processes, as well as multiple organ failure.

Today we can state that malnutrition of patients is a slower recovery, the threat of developing various complications, a longer stay in the hospital, higher costs for their treatment and rehabilitation, as well as higher mortality of patients.

Nutritional support in a broad sense is a set of measures aimed at proper substrate provision of patients, elimination of metabolic disorders and correction of dysfunction. food chain in order to optimize trophic homeostasis, structural, functional and metabolic processes of the body, as well as its adaptive reserves.

In a narrower sense, nutritional support refers to the process of providing the body of patients with all the necessary nutrients using special methods and modern artificially created nutrient mixtures of various directions.

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These methods include:

• sipping - oral consumption of special artificially created nutritional mixtures in liquid form (partial as an addition to the main diet or complete - consumption of only nutritional mixtures);
• enrichment of ready-made meals with powdered specialized mixtures, which increases their biological value;
• tube feeding, carried out through a nasogastric or nasointestinal tube, and if necessary, long-term artificial nutrition of patients (more than 4-6 weeks) - through a gastro- or enterostomy;
• parenteral nutrition, which can be administered through a peripheral or central vein.

Basic principles of active nutritional support:

• Timeliness of appointment - any exhaustion is easier to prevent than to treat.
• The adequacy of the implementation is the substrate provision of patients, focused not only on the calculated needs, but also on the real possibility of the body absorbing the incoming nutrients (much does not mean good).
• Optimal timing - until the stabilization of the main indicators of the trophological status and the restoration of the possibility of optimal nutrition of patients in a natural way.

It seems quite obvious that the implementation of nutritional support should be focused on certain standards (protocols), which are some guaranteed (at least minimal) list of necessary diagnostic, therapeutic and preventive measures. In our opinion, it is necessary to highlight the standards of action, content and support, each of which includes a sequential list of specific activities.

A. Action standard

Includes at least two components:

• early diagnosis of malnutrition in order to identify patients requiring the appointment of active nutritional support;
• selection of the most best method nutritional support, in accordance with a certain algorithm.

Absolute indications for prescribing active nutritional support to patients are:

1. The presence of a relatively rapidly progressive loss of body weight in patients due to an existing disease, comprising more than:

• 2% per week,
• 5% per month,
• 10% per quarter,
• 20% for 6 months.

2. Initial signs of malnutrition in patients:

• body mass index< 19 кг/ м2 роста;
• shoulder circumference< 90 % от стандарта (м — < 26 см, ж — < 25 см);
• hypoproteinemia< 60 г/л и/ или гипоальбуминемия < 30 г/л;
• absolute lymphopenia< 1200.

3. The threat of developing rapidly progressive trophic insufficiency:

• the lack of the possibility of adequate natural oral nutrition (cannot, do not want, should not take food naturally);
• the presence of pronounced phenomena of hypermetabolism and hypercatabolism.

The algorithm for choosing the tactics of nutritional support for the patient is shown in Scheme 1.

Priority method

When choosing one or another method of artificial therapeutic nutrition of patients, in all cases, preference should be given to more physiological enteral nutrition, since parenteral nutrition, even completely balanced and satisfying the needs of the body, cannot prevent certain undesirable consequences from the gastrointestinal tract. It should be taken into account that the regenerative trophism of the mucous membrane of the small intestine by 50%, and the thick one by 80% is provided by the intraluminal substrate, which is a powerful stimulus for the growth and regeneration of its cellular elements (the intestinal epithelium is completely renewed every three days).

Prolonged absence of food chyme in the intestine leads to dystrophy and atrophy of the mucous membrane, a decrease in enzymatic activity, impaired production of intestinal mucus and secretory immunoglobulin A, as well as active contamination of opportunistic microflora from the distal to the proximal sections of the intestine.

The developing dystrophy of the glycocalyx membrane of the intestinal mucosa leads to a violation of its barrier function, which is accompanied by active transportal and translymphatic translocation of microbes and their toxins into the blood. This is accompanied, on the one hand, by excessive production of pro-inflammatory cytokines and induction of a systemic inflammatory response of the body, and, on the other hand, by depletion of the monocyte-macrophage system, which significantly increases the risk of developing septic complications.

It should be remembered that under the conditions of a post-aggressive reaction of the body, it is the intestine that becomes the main undrained endogenous focus of infection and the source of uncontrolled translocation of microbes and their toxins into the blood, which is accompanied by the formation of a systemic inflammatory reaction and often developing against this background of multiple organ failure.

In this regard, the appointment of patients with early enteral support (therapy), a mandatory component of which is minimal enteral nutrition (200-300 ml / day of the nutrient mixture), can significantly minimize the consequences of the aggressive effects of various factors on the gastrointestinal tract, maintain its structural integrity. and polyfunctional activity, which is necessary condition faster recovery of patients.

Along with this, enteral nutrition does not require strict sterile conditions, does not cause life-threatening complications for the patient, and is significantly (2-3 times) cheaper.

Thus, when choosing a method of nutritional support for any category of seriously ill (affected) patients, one should adhere to the currently generally accepted tactics, the essence of which can be summarized as follows: if the gastrointestinal tract works, use it, and if not, make it work!

B. Content standard

Has three components:

1. determination of the needs of patients in the required volume of substrate provision;
2. selection of nutrient mixtures and the formation of a daily ration of artificial medical nutrition;
3. drawing up a protocol (program) of the planned nutritional support.

The energy needs of patients (victims) can be determined by indirect calorimetry, which, of course, will more accurately reflect their actual energy expenditure. However, such opportunities are currently practically absent in the vast majority of hospitals due to the lack of appropriate equipment. In this regard, the actual energy consumption of patients can be determined by the calculation method according to the formula:

DRE \u003d OO × ILC, where:

• DRE — actual energy consumption, kcal/day;
• OO is the main (basal) energy exchange at rest, kcal/day;
• CMF is the average metabolic correction factor depending on the condition of the patients (unstable - 1; stable condition with moderate hypercatabolism - 1.3; stable condition with severe hypercatabolism - 1.5).

To determine the basal metabolic rate, the well-known Harris-Benedict formulas can be used:

GS (men) \u003d 66.5 + (13.7 × × MT) + (5 × R) - (6.8 × B),

GS (women) \u003d 655 + (9.5 × MT) + + (1.8 × P) - (4.7 × B), where:

• BW — body weight, kg;
• Р — body length, cm;
• B - age, years.

In a more simplified version, you can focus on the average indicators of OO, which are 20 kcal/kg for women and 25 kcal/kg for men per day. At the same time, it should be taken into account that for each subsequent decade of a person's life after 30 years, the TO decreases by 5%. The recommended amount of substrate provision for patients is given in Table. 1.

Scheme 1. Algorithm for choosing nutritional support tactics

B. Security standard

Nutrient mixtures for enteral nutrition of patients

Contraindications for enteral nutrition are

Subtleties of parenteral nutrition

Table 4. Containers "three in one"

Micronutrients

Basic principles of effective parenteral nutrition

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