Feeding the sick. Types of food, their characteristics

Artificial nutrition is the introduction of nutrients through a tube, fistulas or enemas, as well as intravenously or subcutaneously.

There are the following types of artificial nutrition.

Feeding through a tube. Indications for feeding through a gastric tube: inability to swallow on their own or refusal to eat (with mental illness). A thin gastric tube is inserted through the lower nasal passage and nasopharynx, then along the back wall of the pharynx into. If the probe enters the larynx instead of the esophagus, then the patient begins to cough and a stream of air enters and exits through the probe when breathing. When the probe is inserted, the patient is in a sitting position with his head slightly thrown back. After the probe enters the esophagus, a funnel is put on its free end, into which 2-3 glasses of liquid food are poured (strong broth with egg yolk, milk, sweets, etc.). Introduce food slowly, under slight pressure, several times a day. If necessary, the probe can be left in the stomach for 3-4 weeks. The outer end of the probe is fixed sticky to the skin of the cheek or auricle.

In restless patients, as well as in an unconscious state, the rubber tube is fixed to the skin or cheeks with a silk suture, tied with the same silk thread. The indication for nutrition through a thin probe inserted into the duodenum or jejunum is the stomach (for non-operative exclusion of the stomach from the digestive process).

Given the great difficulties for the patient (the probe is left in the small intestine for 2-3 weeks) and the lack of advantages over other methods of treating peptic ulcer, this method can be used only in exceptional cases.

Nutrition through an operating fistula of the stomach or small intestine. Indications for nutrition through the fistula of the stomach: a sharp narrowing or obstruction of the esophagus, and through the fistula of the small intestine - obstruction of the pylorus. In the presence of a fistula, the probe is directly inserted into or into the small intestine. In the first days after the operation, small portions of food (150-200 ml) are introduced into the stomach 5-6 times a day in a warm form. In the future, the number of single doses is reduced to 3-4 per day, and the amount of food administered is increased to 300-500 ml. For better digestion, sometimes such a patient is given food to chew, so that it mixes with saliva. Then the patient collects it in a mug, dilutes with the required amount of liquid and pours it into the funnel. With a fistula of the small intestine, 100-150 ml of food mass is administered. With the introduction of a larger amount, circular muscles of the intestine may occur and food is excreted back through the fistula.

Rectal nutrition - the introduction of nutrients through the use of enemas. Replenishes the body's need for fluid, and to a lesser extent for nutrients. For rectal artificial nutrition, an isotonic sodium chloride solution, a 5% glucose solution, an isotonic mixture of 25 g of glucose and 4.5 g of sodium chloride per 1 liter of water, and amino acid solutions are most often used. Approximately 1 hour before the nutrient enema, the intestines are cleansed with a regular enema. Small nutrient enemas (up to 200-500 ml of a solution heated to t ° 37-38 °, with the addition of 5-40 drops of opium tincture to suppress intestinal motility) can be administered 3-4 times a day. Larger amounts of the solution (1 liter or more) are administered once by the drop method.

Parenteral nutrition - the introduction of nutrients intravenously or subcutaneously. Use mixtures of amino acids, solutions of glucose, vitamins, minerals. The introduction of these solutions is carried out as directed and under the supervision of a physician.

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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 "banal" issues of feeding patients remain on the periphery of the attention of many resuscitators, although major monographs on nutrition- it is enough to name the works of A.L. Kostyuchenko, ED. Kostina and A.A. Kurygin or A. Vretlind and A.V. Sudzhyan. The abundance of solutions and mixtures on the market, due to their high cost, does not affect the diet of the "insolvent", that is, the most massive, domestic patient. 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 must solve several problems. major conjugated 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 level of metabolism characteristic of this stage of development.

It is the state of nutrition that largely determines the patient's ability to endure diseases and critical conditions (due to trauma, infection, surgery, 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.

This is, firstly, timeliness of its start , allowing to exclude the development of intractable cachexia. Secondly, optimal timing of implementation artificial nutrition, which ideally should be carried out until the trophic status is completely stabilized. Finally, thirdly, there must be adequacy artificial nutrition the patient's condition . 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).

To these classical provisions, one more, no less important, rule can be added: the decisive criterion for evaluating and correcting artificial nutrition should not be a priori plan And calculation, no matter how modern and perfect the underlying algorithms may be. Clinical, more precisely - clinical and physiological result , controlled daily according to clearly understood and unambiguously interpreted indicators - this is the only legitimate basis for making decisions in this, as, in fact, in any other area of therapy.

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

parenteral nutrition

The very possibility of the parenteral method and its technical basis fully followed from the development of infusion therapy in general.

Despite the fact that images of intravenous infusions appear already on the pages of medieval books, and in 1831 Thomas Latta first performed intravenous infusions of saline solutions to cholera patients, it took more than one decade before infusion therapy turned from extremism into an everyday routine. Its progress was determined primarily by the level of understanding not only of the composition of blood and plasma, but also of their physicochemical properties and, most importantly, the immediate metabolic fate of the substances introduced into the vessels. And although back in 1869 I.R. Tarkhanov in Russia and R. Konheim in Germany experimentally showed that intravenous infusion of saline solutions can support the life of a bloodless animal, the era of mass introduction crystalloid plasma substitutes became World War I.

After the publication in 1915 of RT. Woodyatt, W.D. Sansum and RM. Wilder began the widespread clinical use of intravenous glucose solution - one of the main food substrates. At the same time, ideas about the dynamics of trophic homeostasis under conditions of a post-aggressive metabolic stress response to damage of any kind were developed. The basis of modern views on this problem was laid by D.P. Guthbertson, ED. Moore and J.M. Kinney studies of metabolism after surgical aggression. Although they dealt primarily with protein metabolism and nitrogen loss by the traumatized organism, as well as the electrolyte disturbances that are inevitable, their results formed the basis of aggression and played a decisive role in the development of parenteral artificial nutrition.

For nitrogenous parenteral nutrition initially used protein hydrolysates , which consisted of a mixture of poly- and oligopeptides of various molecular weights. The inability of our proteolytic systems, localized outside the gastrointestinal tract, to hydrolyze such substrates significantly reduced their nutritional value and often prompted the use of hydrolysates for tube feeding. Although until recently one could still hear about the "nutrition" of patients with albumin infusions, the actual period of complete hydrolysis of this protein outside the gastrointestinal tract - 70 days - clearly illustrates the futility of such hopes.

In 1943-1944. at the Karolinska Institute in Stockholm, Arvid Wretlind created dialyzed casein hydrolyzate- aminosol, which is still considered one of the best among analogues and even continues to be produced. In our country, the creation of high-quality protein hydrolysates as parenteral sources of amine nitrogen became possible in the 60s thanks to the work of A.N. Filatov (LIPC) and N.F. Koshelev (VMedA).

The direct relationship between the degree of protein hydrolysis and the possibilities of its assimilation led to the next logical step - mixtures of free synthetic L-amino acids . It became possible to translate into reality the classic recommendations for the ratio of amino acids put forward by W.C. Rose back in 1934-1935. (by the way, in 1938 he formulated the provision on essential amino acids). Intravenous administration of just such drugs, provided there is sufficient energy support with carbohydrates and fat emulsions, really provides a vitally important synthesis of one's own protein. So, further development was already in the direction of creating amino acid mixtures - like general purpose (Aminosteril, Moriamin, Freamin, Vamin etc.), and special- for example, safe against the background of hepatocellular ( Hepasteril, Aminosteril-Nera) or renal ( Nephramin, Aminosteril-Nephro) insufficiency.

The combination of carbohydrate and nitrogen components, along with the development of the technique of catheterization of the main veins, for the first time created the possibility of long-term total parenteral artificial nutrition. The priority of this approach, called "American method" , is owned by American Stanley Dudrick and his staff. According to this group (1966-1971), energy needs can be coated with concentrated glucose solutions, A plastic - with the help of protein hydrolysates or other amino acid preparations with the addition of electrolytes, vitamins and trace elements. It turned out that the complete satisfaction of the primary and unconditional needs of the body - energy - with carbohydrates allows it to use the amino acid "surplus" for plastic needs. These studies for the first time convincingly proved the possibility of not only adequate plastic support for patients in the post-aggressive period or long-term, months-long nutrition of patients with severe insufficiency of intestinal digestion, but also the normal development of the child's body receiving only parenteral nutrition.

However, the introduction of large volumes of high-osmolar solutions created independent problems - from osmodiuresis to phlebitis, and the absence of a fatty component in the "Dadrik scheme" did not allow parenteral nutrition to be fully adequate. Patients often suffered from specific dermatitis and other complications caused by a deficiency of essential fatty acids - linoleic, linolenic and others.

Further development of parenteral nutrition required a more complete and comprehensive restoration of trophic homeostasis. So-called "European method" of total parenteral nutrition , unlike the American one, suggests combination of monosaccharide solutions and amino acid mixtures with fat emulsions. Creation in 1957 in the laboratory of A. Wretlind on the basis of soybean oil of a highly dispersed fat emulsion "Intralipid" and conducting its extensive clinical trials represented the first major step in this direction. Even earlier, the cofactor role of heparin in the absorption of fat emulsions, consisting in the activation of lipoprotein lipase, became clear (N. Endelberg, 1956). Initially, the difficulties of combining dissimilar ingredients in one program were associated with the need to accurately maintain the proportions, pace and sequence of administration of each of them, which required several precisely regulated infusion pumps. Modern technologies of sterilization and pH stabilization have made it possible to produce combined media combining both carbohydrates and amino acids without degradation of the latter in the Maillard reaction. This led to the creation of drugs such as "Aminomvx 1" or "AKE 3000"(Fresenius), containing amino acids, monosaccharides and polyols in concentrations that provide adequate nutrition with a balanced volume of fluid and electrolyte load. This approach simplifies the method of parenteral nutrition itself, allowing it to be used not only in the clinic, but also at home for many months. This direction has found further development in the concept of complex intravenous nutrition. "all in one" .

It consists in combining in one bottle immediately before using all the ingredients of nutrition (carbohydrates, fats, amino acids, electrolytes, trace elements and vitamins), followed by a round-the-clock infusion of the resulting mixture. The technology was developed and first introduced by S. Solasson and H. Joyeux at the Montpellier Hospital in 1972. Studies have proven the stability of various nutrient substrates combined in one container. The optimal material for containers was also found: it turned out that it can only be ethyl vinyl acetate film, but not polyvinyl chloride, from which the lipids of the nutrient mixture extract toxic diethyl phthalate. To exclude bacterial and fungal contamination, the infusion path should include a filter that retains particles larger than 1.2 microns.

With this method, the calorie content of non-protein nutrieites is brought to 159.6 kcal per 1 g of nitrogen, which is close to the optimal ratio of 150/1. It turned out that fat emulsions are better tolerated and absorbed when implementing this particular scheme. Damage to the walls of the veins and lung parenchyma by high-osmolar solutions is excluded, the risk of metabolic disorders characteristic of total parenteral nutrition is reduced. According to M. Deitel (1987), the main advantages of complex parenteral nutrition "all in one" include:

a minimum of manipulations with containers containing nutrient substrates, and, consequently, a minimum risk of infection of infusion media and systems;
saving time of personnel, consumables and technical means (infusion systems, infusion pumps);
greater freedom of movement of the patient with continued infusion;
the possibility of parenteral nutrition in a more comfortable home environment.

However, the massive introduction of parenteral nutrition technologies has put on the agenda the problem complications- technical, metabolic, organopathological, septic and organizational or economic.

Technical complications associated with vascular access, venous catheterization, and catheter care. Among them, as potentially lethal, the most dangerous are hemo- and pneumothorax, vein damage with the development of bleeding, perforation of the heart chambers with pericardial tamponade, rhythm disturbances and air embolism.

Metabolic Complications occur, as a rule, in connection with inadequate parenteral nutrition and include instability of blood glucose levels, disturbances in the metabolism of administered triglycerides, acid-base balance and electrolyte composition of the extracellular fluid.

TO organopathological complications include, for example, acute respiratory failure and impaired liver function.

Septic complications associated with infection of the catheter, infusion tract or the injected solutions themselves.

Organizational problems , which are especially relevant today for our medicine, stem from the high cost of amino acid solutions and fat emulsions, and even more so modern systems for the programmed administration of such solutions and equipment that makes it possible to assess the adequacy of artificial nutrition - for example, the so-called gas metabolographs.

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 is used, which contributes 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. energy carriers low molecular weight diets are predominantly carbohydrates, and in macromolecular 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 (nasoduodenal, nasojejunal) tube 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. They are of two types - refrigerated and small-sized individual, with which you can only enter the mixture at a given pace. 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.

Until recently, artificial nutrition was the prerogative of the clinic; today it has become possible to continue it at home. Successful implementation of outpatient artificial nutrition requires patient education and the provision of specialized illustrated literature. After a brief consultation in the clinic, the patient receives a system for artificial nutrition; constant counseling is guaranteed to him further.

When enteral nutrition is not possible, long-term parenteral nutrition can also be administered at home through an implanted indwelling venous catheter. Night infusions make the patient mobile, allowing him to do his usual activities during the day. Returning home, to family and friends, significantly improving the quality of life, favorably affects the general condition of the patient.

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.

Postgraduate student of the Department of Anesthesiology and Resuscitation
and emergency pediatrics with the course of FPC and PP SPbGPMA
Vadim Yurievich Grishmanov;
cand. honey. Sciences, Associate Professor of the Department of Anesthesiology -
reimmatology and emergency pediatrics with the course of FPC and
PP SPbGPMA Konstantin Mikhailovich Lebedinsky

Patient nutrition. Artificial feeding of the patient

Lecture

The student must know:

basic principles of 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

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

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, maintains 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)

It is part of the thyroid hormone - thyroxine, affects the 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 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.

from one diet to another:

1 gradual - for example, table 1a, 1b, 1 for stomach ulcers.

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 requirement is signed by the chief physician of the hospital, the chief accountant and the dietitian.

Based on this portion requirement, the dietician draws up a menu for the day 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

Branch: 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

nutrition

Fasting days

Ophthalmic

Surgical

Traumatological

And that:

269

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 are stored (comb, toothbrush, paste, 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 are carried by a special person - a peddler, she most often does not have a medical education, therefore her function is not to accept 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 bowel disease 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 deciduous) and raw fruits, in large quantities (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: white bread crumbs. 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 greens (salads, vinaigrettes), non-sour 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 diseases of the 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 marked changes in 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, limiting the energy value of the diet mainly due to 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 are 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, 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 meat dishes, fish, pastry, 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. Exclusion of foods and drinks that excite 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; 10 g of butter is added to rice broth 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 meals

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.

Acute 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) 270 g of boiled meat, 100 ml of milk, 120 g of green peas, 280 g of 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 a thick stomach tube and funnel.

Determine the depth of insertion of the probe:

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.

Collect the probe in one hand, with the other hand, lift the tip of the nose with your thumb and insert the probe 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 a Janet syringe with warm boiled water to the probe, 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.

Treat the 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 had a probe inserted through the nose, use only a towel or glove 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 is a special type of replacement therapy, in which nutrients are administered bypassing the digestive tract to replenish energy and plastic costs and maintain a normal level of metabolic processes.

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 abdominal organs, 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

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

Sometimes normal nutrition of the patient through the mouth is difficult or impossible (some diseases of the oral cavity, esophagus, stomach, unconsciousness). In such cases, organize artificial nutrition.

Artificial feeding can be carried out using a probe inserted into the stomach through the nose or mouth, or through a gastrostomy. You can enter nutrient solutions with an enema, as well as parenterally, bypassing the digestive tract (intravenous drip).

Tube feeding

material support : sterile thin rubber probe with a diameter of 0.5-0.8 cm, petroleum jelly or glycerin, Janet funnel or syringe, liquid food (tea, fruit drink, raw eggs, gas-free mineral water, broth, cream, etc.) in the amount of 600-800 ml.

Execution sequence:

1. Treat the probe with petroleum jelly (glycerin).

2. Through the lower nasal passage, insert the probe to a depth of 15-18 cm.

Rice. 30. Feeding the seriously ill.

3. With the finger of your left hand, determine the position of the probe in the nasopharynx and press it against the back wall of the pharynx so that it does not enter the trachea.

4. Tilt the patient's head slightly forward and move the probe with your right hand to the middle third of the esophagus. If the air does not come out of the probe during exhalation and the patient's voice is preserved, then the probe is in the esophagus.

5. Connect the free end of the probe to the funnel.

6. Slowly pour the cooked food into the funnel.

7. Pour clean water into the funnel (washing the probe) and remove the funnel.

8. Fix the outer end of the probe on the patient's head so that it does not interfere with him (the probe is not removed during the entire period of artificial feeding, about 2-3 weeks).

Feeding the patient through the surgical fistula(Fig. 31) .

Indications for the imposition of a gastric fistula are obstruction of the esophagus, pyloric stenosis. At the same time, food is administered in small portions (150-200 ml) 5-6 times a day in a heated form. Then gradually a single amount of food is increased to 250-500 ml, but the number of injections is reduced to 3-4 times. Through the funnel, you can enter crushed food products diluted with a liquid: finely mashed meat, fish, bread, crackers.

Rice. 31. Feeding a seriously ill person

Through the operating fistula.

Sometimes patients chew food, dilute it with liquid and pour it into the funnel themselves. Care should be taken to introduce large amounts of food into the funnel, as a spasm of the muscles of the stomach may occur, and food can be thrown out through the fistula.

Rectal artificial nutrition- the introduction of nutrients through the rectum to replenish the body's need for fluid and salt. It is used for severe dehydration, complete obstruction of the esophagus and after operations on the esophagus and cardia of the stomach. In addition, nutrient enemas increase diuresis and promote the release of toxins from the body.

Tactics of implementation: an hour before the nutritional enema, a cleansing enema is put until the intestines are completely emptied. Due to the fact that 5% glucose solution and 0.85% sodium chloride solution are well absorbed in the rectum, they are mainly used for artificial nutrition. Small nutrient enemas are made from a rubber pear in an amount of 200 ml of solution (37-38 ° C). Repeat the procedure 3-4 times a day. A larger amount of liquid (up to 1 liter) is administered once by drop. Frequent use of nutrient enemas is not recommended because of the danger of irritation of the rectal sphincter and the appearance of anal fissures. In order to avoid these complications, a thorough toilet of the anus is necessary.

With parenteral nutrition nutrient solutions can be administered intravenously. For this purpose, protein hydrolysis products (hydrolysin, aminopeptide, aminocrovin, polyamine, etc.), fat emulsions (lipofundin), as well as 5-10% glucose solution, isotonic sodium chloride solution, and vitamins are used. 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 these drugs, a certain rate of administration should be observed: in the first 30 minutes, a solution is injected at a rate of 10-20 drops per minute, then, with good tolerance to the patient of 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 introduction of protein preparations, the patient may have a feeling of heat, flushing of the face, difficulty breathing.

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. The maintenance of trophic homeostasis, along with its internal factors, is determined primarily by the possibility and reality of obtaining the nutrient substrates necessary for life support by the body. 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 various authors, from 18 to 86%. At the same time, its severity significantly depends on the type and characteristics of the clinical course of the 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 presented far from complete list of metabolic disorganization that occurs in the body due to post-aggressive effects (illness, injury, surgery) can significantly reduce the effectiveness of therapeutic 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.

Consequences of metabolic disorders

Under 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 healing of wounds 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 trophic chain dysfunction 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 optimal method of 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 a necessary condition for a 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:

determination of the needs of patients in the required volume of substrate provision;
selection of nutrient mixtures and the formation of a daily ration of artificial medical nutrition;
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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Feeding the sick. Types of food, their characteristics

Consequences of metabolic disorders

These methods include:

Basic principles of active nutritional support:

A. Action standard

Absolute indications for prescribing active nutritional support to patients are:

Priority method

B. Content standard

Has three components:

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