Nutrition ("undernutrition")

TEN is administered as...

"tube feedings" through one of the available GI tubes, either through a nasoenteric or enterostomal tube. It can be used in the patient's home or any health care setting.

Nursing Interventions for malnutrition

-Encourage patient to eat -Instruct UAP who are feeding patients to keep food at the appropriate temperature and to provide mouth care before feeding. -Assess for other needs, such as pain management, and provide interventions to make the patient comfortable. Pain can prevent patients from enjoying their meals. -Remove bedpans, urinals, and emesis basins from sight. -Provide a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. -Appropriate time should be taken so the patient does not feel rushed through a meal.

When should you weigh a patient that requires daily or sequential weights?

-You should weigh the patient at the same time everyday, preferably before breakfast. -Conditions such as congestive heart failure and renal disease cause weight gain; dehydration and conditions such as cancer cause weight loss

Thyroxine-binding prealbumin (PAB) range

15 to 36 mg/dL or 150 to 360 mg/L

The least risk for malnutrition is associated with scores between....

18.5 and 25. BMIs above and below these values are associated with increased health risks.

albumin range

3.5 to 5.0 g/dL or 35 to 50 g/L

protein-calorie malnutrition (PCM)

A disorder of nutrition that may present in three forms: marasmus, kwashiorkor, and marasmic-kwashiorkor. Also called protein-energy malnutrition.

What might indicate malnutrition

A weight loss of 5% or more in 30 days, a weight loss of 10% in 6 months, or a weight that is below ideal.

Risk Assessment for Malnutrition

Assess for: • Decreased appetite • Weight loss • Poor-fitting or no dentures/poor dental health • Poor eyesight • Dry mouth • Limited income • Lack of transportation • Inability to prepare meals because of functional decline or fatigue • Loneliness and/or depression • Chronic constipation (e.g., in patients with Alzheimer's disease) • Decreased meal enjoyment • Chronic physical illness • "Failure to thrive" (a combination of three of five symptoms, including weakness, slow walking speed, low physical activity, unintentional weight loss, exhaustion) • Prescription and over-the-counter (OTC) drugs (including herbs, vitamins, and minerals) • Acute or chronic pain

Which conditions increase the need for nutrients?

Fever, burns, injury, sepsis, or antineoplastic therapies

what should you monitor for in patients receiving fat emulsions?

For fever, increased triglycerides, clotting problems, and multi-system organ failure to recognize indications of fat overload syndrome, especially in those who are critically ill. If any of these signs and symptoms is present, respond by discontinuing the IVFE infusion and reporting the changes to the health care provider immediately.

Physical Assessment/Signs and Symptoms (malnutrition):

Inspect the patient's hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems. Examine the condition of the skin, including any reddened or open areas. Anthropometric measurements may also be obtained as described in the section of the same name. *The nurse or UAP monitors all food and fluid intake and notes any mouth pain or difficulty chewing or swallowing.* A 3-day caloric intake may be collected and then calculated by the dietitian.

Proper nutrition plays a major role in promoting and maintaining health by....

Maintaining temperature, respiration, cardiac output, muscle function, protein synthesis, and the storage and metabolism of food sources.

Hemoglobin range

Male: 14-18 g/dL Female: 12-16 g/dL

What electrolyte imbalances are associated with TPN?

Potassium and sodium imbalances are common, especially when insulin is also administered as part of the therapy. Calcium imbalances, particularly hypercalcemia.

Nutrition Medical History for any patient for suspected malnutrition:

Review the medical history to determine the possibility of increased metabolic needs or NUTRITION losses, chronic disease, trauma, recent surgery of the GI tract, drug and alcohol use, and recent significant weight loss. Usual daily food intake • Eating behaviors • Change in appetite • Recent weight changes. Ask the patient or family if patient cannot communicate, about: • Usual foods eaten • Cultural food preferences • Times of meals and snacks Ask about changes in eating habits as a result of illness and document any change in appetite, taste, and weight loss.

anorexia of aging

The average daily energy intake expended by the elderly tends to be more than the average energy intake. Body weight and BMI usually increase throughout adulthood until about 60 years of age. As adults get older, they often become less hungry and eat less, even if they are healthy. Ideally, older adults should have a BMI between 23 and 27. Many older adults are underweight, leading to undernutrition and increased risk for illness.

How is Partial, or peripheral, parenteral nutrition (PPN) given?

Through a cannula or catheter in a large distal vein of the arm or through a peripherally inserted central catheter (PICC line).

What is most reliable indicator of fluid gain or loss?

Weighing the patient

The priority collaborative problem for the patient with malnutrition is:

Weight loss due to inability to ingest or digest food or absorb nutrients

What is the most accurate way to check tube placement?

X-ray

Marasmus

a calorie malnutrition in which body fat and protein are wasted. Serum proteins are often preserved.

Failure to thrive

a combination of three of five symptoms, including weakness, slow walking speed, low physical activity, unintentional weight loss, exhaustion

Marasmic-kwashiorkor

a combined protein and energy malnutrition. This problem often presents clinically when metabolic stress is imposed on a chronically starved patient.

Kwashiorkor

a lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low.

Many diagnostic tests, surgery, trauma, and unexpected medical complications require....

a period of NPO or cause anorexia (loss of appetite).

Refeeding syndrome

a potentially life-threatening metabolic complication that can occur when nutrition is restarted for a patient who is in a starvation state.

Mini Nutritional Assessment (MNA)

a two-part tool that has been tested worldwide, provides a reliable, rapid assessment for patients in the community and in any health care setting.

Acute PEM may develop in patients who are...

adequately nourished before hospitalization but experience starvation while in a catabolic state from infection, stress, or injury.

Common factors that affect these nutrition requirements include...

age, gender, disease, infection, and psychological stress, eating behavior, economic implications, emotional stability, disease, drug therapy, and cultural factors influence nutrient intake.

Bolus feeding is

an intermittent feeding of a specified amount of enteral product at set intervals during a 24-hour period, typically every 4 hours.

transferrin

an iron-transport protein, can be measured directly or calculated as an indirect measurement of total iron-binding capacity (TIBC). It has a short half-life of 8 to 10 days and therefore is also a more sensitive indicator of protein status than albumin.

Low hematocrit levels may indicate:

anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis.

A low hemoglobin level may indicate:

anemia, recent hemorrhage, or hemodilution caused by fluid retention.

Anthropometric measurements

are noninvasive methods of evaluating NUTRITION status. These measurements include height and weight and assessment of BMI. -Obtain a current height and weight to provide a baseline. -*Be sure to obtain accurate measurements because patients tend to overestimate height and underestimate weight.* -Measurements taken days or weeks later may indicate an early change in nutrition status. -*You may delegate this activity to unlicensed assistive personnel (UAP) under your supervision.*

If enteral tubes are misplaced or become dislodged, the patient is likely to...

aspirate. Aspiration pneumonia is a life-threatening complication associated with TEN, especially for older adults.

what medical complications are common in older adults who are tube-fed?

aspiration, pressure injuries

Cholesterol levels

between 160 and 200 mg/dL in adult men and women.

when calorie intake is insufficient

body proteins are used for energy

Total lymphocyte count (TLC)

can be used to assess immune function. Malnutrition suppresses the immune system and leaves the patient more likely to get an infection. When a patient is malnourished, the TLC is usually decreased to below 1500/mm3.

What does total parenteral nutrition therapy contain?

carbohydrates, proteins, fats, vitamins, minerals, and trace elements

what can happen with an electrolyte shift of refeeding syndrome?

cardiovascular, respiratory, and neurologic problems, primarily as a result of hypophosphatemia.

iron can cause

constipation

High hematocrit levels may indicate

dehydration or hemoconcentration.

The nasoduodenal tube (NDT) are used for

delivering short-term enteral feedings (usually less than 4 weeks) because they are easy to use and safer for the patient at risk for aspiration if the tip of the tube is placed below the pyloric sphincter of the stomach and into the duodenum.

When assessing for malnutrition, assess for:

difficulty or pain chewing or swallowing. Unrecognized dysphagia is a common problem among nursing home residents and can cause malnutrition, dehydration, and aspiration pneumonia. Ask the patient whether any foods are avoided and why. Ask UAP to report any choking while the patient eats. Record the occurrence of nausea, vomiting, heartburn, or any other symptoms of discomfort with eating.

what is the outcome of unrecognized or untreated Protein calorie malnutrition?

dysfunction or disability and increased morbidity and mortality.

The USDA recommends that older adults drink

eight glasses of water a day and eat plenty of fiber to prevent or manage constipation. It also suggests daily calcium and vitamins D and B12 supplements and a reduction in sodium and cholesterol-containing foods.

Body Mass Index (BMI)

estimates total fat stores within the body by the relationship of weight to height

Nutrition Medical History assessment for older adults:

explore mental status changes; note poor eyesight, diseases affecting major organs, constipation or incontinence, and slowed reactions. Review prescription and over-the-counter (OTC) drugs, including vitamin, mineral, herbal, and other nutrition supplements.

When a patient is starved for nutrition, the body breaks down....

fat and protein, rather than carbohydrates, for energy.

Lactose intolerance (lactose is found in milk and milk products) is a common problem that is....

found more often in Mexican Americans and black adults and in some American Indian groups, Asian Americans, and Ashkenazi Jews.

Chronic PEM can occur in those who...

have cancer, end-stage kidney or liver disease, or chronic neurologic disease.

High levels of hemoglobin may indicate

hemoconcentration or dehydration or may be found secondary to liver disease.

What kind of diet should a patient with malnutrition be on?

high-calorie, nutrient-rich foods (e.g., milkshakes, cheese, supplement drinks such as Boost or Ensure). Assess the patient's food likes and dislikes. A feeding schedule of six small meals may be tolerated better than three large ones. A pureed or dental soft diet may be easier for those who have problems chewing or are edentulous (toothless).

The two most common electrolyte imbalances associated with enteral nutrition therapy are...

hyperkalemia and hyponatremia Both of these conditions may be related to hyperglycemia-induced hyperosmolarity of the plasma and the resultant osmotic diuresis.

Excessive diarrhea may develop when...

hyperosmolar enteral preparations are delivered quickly. This situation can also lead to dehydration through excessive water loss.

The cause of lactose intolerance is...

inadequate amount of the lactase enzyme, which converts lactose into absorbable glucose.

One in three patients in health care settings is malnourished; This may be caused by..

inadequate intake before being hospitalized or lack of nutrition while hospitalized because of the illness or injury. Those diagnosed with malnutrition have a length of stay that may be three times higher than those who do not have altered nutrition. *Nurses can have a significant impact on patient length of stay when adequately advocating for their client's nutrition status.*

What should watch for in patient who is at risk for their NG tube dislodging?

increasing temperature and pulse and for other signs of dehydration such as dry mucous membranes and decreased urinary output. Auscultate lungs every 4 to 8 hours to check for diminishing breath sounds, especially in lower lobes. Patients may become short of breath and report chest discomfort.

nutrition screening includes:

inspection, measured height and weight, weight history, usual eating habits, ability to chew and swallow, and any recent changes in appetite or food intake.

When refeeding begins what happens in the body?

insulin production resumes; and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels.

Malnutrition (also called undernutrition)

is a multinutrient problem because foods that are good sources of calories and protein are also good sources of other nutrients.

Thyroxine-binding prealbumin (PAB)

is a plasma protein that provides a more sensitive indicator of nutrition deficiency because of its short half-life of 2 days.

albumin

is a plasma protein that reflects the nutrition status of the patient a few weeks before testing; therefore it is not considered to be a sensitive test. *Patients who are dehydrated often have high levels of albumin, and those with fluid excess have a lowered value.*

Anorexia nervosa

is a self-induced starvation resulting from a fear of fatness, even though the patient is underweight.

A nasoenteric tube (NET)

is any feeding tube inserted nasally and then advanced into the GI tract, such as a Keofeed, Entriflex, or Dobbhoff tube. Commonly used NETs include the nasogastric (NG) tube and the smaller (small-bore) nasoduodenal tube (NDT)

Bulimia nervosa

is characterized by episodes of binge eating in which the patient ingests a large amount of food in a short time. The binge eating is followed by some form of purging behavior, such as self-induced vomiting or excessive use of laxatives and diuretics. If not treated, death can result from starvation, infection, or suicide.

Complications of Total Enteral Nutrition. The nursing priority for care:

is patient safety, including preventing, assessing, and managing complications associated with tube feeding. Some complications of therapy result from the type of tube used to administer the feeding, and others result from the enteral product itself. The most common problem is the development of an obstructed ("clogged") tube.

Continuous feeding

is similar to IV therapy in that small amounts are continuously infused (by gravity drip or by a pump or controller device) over a specified time.

cyclic feeding

is the same as continuous feeding except that the infusion is stopped for a specified time in each 24-hour period, usually 6 hours or longer ("down time"). Down time typically occurs in the morning to allow bathing, treatments, and other activities. *MOST COMMON*`

jejunostomy is used for

long-term feedings when it is desirable to bypass the stomach, such as with gastric disease, upper GI obstruction, and abnormal gastric or duodenal emptying.

Hemoglobin may be decreased secondary to conditions such as

low serum albumin, infection, catabolism, or chronic disease.

Cholesterol levels are typically

low with malabsorption, liver disease, pernicious anemia, end-stage cancer, or sepsis. A cholesterol level below 160 mg/dL has been identified as a possible indicator of malnutrition.

What conditions can cause nutrient loss?

malabsorption syndromes, draining abscesses, wounds, fistulas, or prolonged diarrhea

Hematocrit range

male: 42-52% female: 37-47% vascular volume depletion with concentration results in an elevated hematocrit

diarrhea may be the result of...

multiple liquid medications, such as elixirs and suspensions that have a very high osmolarity. Examples include acetaminophen (Tylenol), furosemide (Lasix), and phenytoin (Dilantin). Patients receiving multiple liquid drugs should be evaluated by the health care provider to determine whether their drug regimen can be changed to prevent diarrhea. Diluting these liquids may also be an option.

Protein catabolism leads to..

muscle and cell loss, often in major organs such as the heart, liver, and lungs. The body's cells lose valuable electrolytes, including potassium and phosphate, into the plasma. Insulin secretion decreases in response to these changes.

cachexia

muscle wasting with prolonged malnutrition

zinc can cause

nausea and vomiting

An unintentional weight loss of 10% over a 6-month period at any time significantly affects...

nutrition status and should be evaluated.

Abdominal distention, nausea, and vomiting during tube feeding are often caused by....

overfeeding. To prevent overfeeding, check gastric residual volumes every 4 to 6 hours, depending on facility policy and the needs of the patient.

signs and symptoms of circulatory overload from TPN

peripheral edema sudden weight gain crackles, dyspnea increased blood pressure bounding pulse.

What is included in a Psychosocial Assessment for malnutrition?

provides information about the patient's economic status, occupation, educational level, gender orientation, ethnicity/race, living and cooking arrangements, and mental status. Determine whether financial resources are adequate for providing the necessary food.

For patients who live independently in the community, the nurse may assess...

pts performance of instrumental activities of daily living. Functional status can best be evaluated for institutionalized patients by assessing their ADL performance. *Poor NUTRITION is a major contributing factor to decreased functional ability.*

Patients receiving TEN are at risk for several complications, including:

refeeding syndrome; tube misplacement and dislodgment; abdominal distention and nausea/vomiting; and FLUID AND ELECTROLYTE imbalance, often associated with diarrhea. These problems can be prevented if the patient is monitored carefully and complications are detected early.

signs and symptoms of electrolyte imbalance due to refeeding syndrome

shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency. Respond by reporting to the health care provider and documenting your findings immediately.

Ask the patient about dental health problems including:

the presence of dentures. Dentures or partial plates that do not fit well interfere with food intake. Dental caries (decay) or missing teeth may also cause discomfort while eating.

For patients who cannot stand or those who cannot stand erect....

use a sliding-blade knee height caliper, if available. This device uses the distance between the patient's patella and heel to estimate height. It is especially useful for patients who have knee or hip contractures.

BMI Calculation

weight in lbs/(height in inches) squared X 703

When would a patient need either partial or total parenteral nutrition therapy ?

when the patient cannot effectively use the GI tract for NUTRITION.

Nursing Interventions for the Older Adult/Promoting Nutrition Intake

• Be sure that patient is toileted and receives mouth care before mealtime. • Be sure that patient has glasses and hearing aids in place, if appropriate, during meals. • Be sure that bedpans, urinals, and emesis basins are removed from sight. • Give analgesics to control pain and/or antiemetics for nausea at least 1 hour before mealtime. • Remind unlicensed assistive personnel (UAP) to have patient sit in chair, if possible, at mealtime. • If needed, open cartons and packages and cut up food at the patient's and/or family's request. • Observe the patient during meals for food intake. • Ask the patient about food likes and dislikes and ethnic food preferences. • Encourage self-feeding or feed the patient slowly; delegate this activity to UAP if desired and provide appropriate supervision. • If feeding patient, sit at eye level if culturally appropriate. • Create an environment that is conducive to eating and socialization and relaxation, if possible • Decrease distractions, such as environmental noise from television, music, or other people. • Provide adequate, nonglaring lighting. • Keep patient away from offensive or medicinal odors. • Keep eye contact with the patient during the meal if culturally appropriate. • Serve snacks with activities, especially in long-term care settings; delegate this activity to UAP if desired. • Document the percentage of food eaten at each meal and snack; delegate this activity to UAP if appropriate. • Ensure that meals are visually appealing, appetizing, appropriately warm or cold, and properly prepared. • Do not interrupt patients during mealtime for nonurgent procedures or rounds. • Assess for need for supplements between meals and at bedtime. • Review the patient's drug profile and discuss with the health care provider the use of drugs that might be suppressing appetite. • If the patient is depressed, be sure that the depression is treated by the health care provider.

Common complications of severe malnutrition in adults include:

• Leanness and cachexia (muscle wasting with prolonged malnutrition) • Decreased activity tolerance • Lethargy • Intolerance to cold • Edema • Dry, flaking skin and various types of dermatitis • Poor wound healing • Infection, particularly postoperative infection and sepsis • Possible death Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to: • Poverty • Lack of education • Substance abuse • Decreased appetite • Vomiting • Decline in functional ability to eat independently • Infectious diseases, such as tuberculosis and human immune deficiency virus (HIV) infection • Diseases that produce diarrhea and infections leading to anorexia. (Anorexia then leads to poor food intake.) • Medical treatments such as chemotherapy • Catabolic processes, such as prolonged immobility, that increase nutrient requirements and metabolic losses

In the malnourished patient many problems may be identified such as:

• Protein catabolism that exceeds protein intake and synthesis • Negative nitrogen balance • Weight loss • Decreased muscle mass • Weakness • Decrease in serum proteins (hypoproteinemia) as protein synthesis in the liver decreases • Vital capacity reduced as a result of respiratory muscle atrophy • Diminished cardiac output • Malabsorption because of atrophy of GI mucosa and the loss of intestinal villi

Nutrition Assessment includes:

• Review of the nutrition history • Food and fluid intake record • Laboratory data • Food-drug interactions • Health history and physical assessment • Anthropometric measurements • Psychosocial assessment Monitor the NUTRITION status of a patient during hospitalization as an important part of your initial assessment. Collaborate with the interdisciplinary health care team to identify patients at risk for nutrition problems.

What are some other safe way to check tube placement Q-4hrs after the initial X-ray check?

• Testing aspirated contents for pH, bilirubin, trypsin, or pepsin • Assessing for carbon dioxide using capnometry Capnometry can determine if carbon dioxide is emitted from the tube. A device to measure the presence of the gas is attached to the end of the tube after placement. The test is positive for carbon dioxide if the tube is placed into the lungs rather than the stomach. The tube should be removed immediately if the gas is detected

Patients likely to receive Total Enteral Nutrition.

•Those who can eat but cannot maintain adequate NUTRITION by oral intake of food alone • Those who have permanent neuromuscular impairment and cannot swallow • Those who do not have permanent neuromuscular impairment but cannot eat because of their condition