Chapter 39: Nutritional Problems

What are the two main eating disorders?

1. Anorexia nervosa 2. Bulimia nervosa

What are two "non-blood" tests that can be done to assess for malnutrition?

1. Anthropometric measurements 2. Functional measurements

What are two primary concerns with tube feedings?

1. Aspiration 2. Dislodgment

What are the methods of administration for PN?

1. Central PN 2. Peripheral PN

Nursing Management of Tube Feedings

1. Check tube placement before feeding and before each drug administration. 2. Assess for bowel sounds before feeding. 3. Use liquid medications rather than pills. • Dilute viscous liquid medications. • Do not add medications to enteral feeding formula. 4. If using tablets, crush drugs to a fine powder and dissolve in water to avoid clogging feeding tubes. 5. Follow measures to decrease aspiration risk: • Keep head of bed elevated to 30- to 45-degree angle. • Check for residual volumes per facility policy. 6. Assess regularly for complications (e.g., aspiration, diarrhea, abdominal distention, hyperglycemia, constipation, and fecal impaction).

What are the major components of the food groups?

1. Macronutrients: carbs, fats, proteins 2. Micronutrients: vitamins, minerals, electrolytes 3. Water

What are the two diagnostic studies we use for malnutrition?

1. Serum albumin 2. Prealbumin

What are the types of malnutrition?

1. Starvation-related malnutrition 2. Chronic disease-related malnutrition 3. Acute disease-or injury-related malnutrition

What are the two types of malnutrition?

1. Undernutrition 2. Overnutrition

What are the four common problems associated with tube feedings?

1. Vomiting 2. Dehydration 3. Diarrhea 4. Constipation

2. Place in order the substrates the body uses for energy during starvation, beginning with 1 for the first component and ending with 4 for the last component. ___ a. skeletal protein. ___ b. glycogen. ___ c. visceral protein. ___ d. fat stores.

1. b 2. a 3. d 4. c

Saturated fats should be no more than what % of one's diet?

10%

Fat should be no more than what % of one's diet?

20-35%

When a patient is using PN, what is the recommended energy intake?

24-35 cal/kg/day in a non-obese patient.

How many calories should an adult consume to maintain body weight?

25-30 cals/kg

Carbs should be no more than what % of one's diet?

45-60%

1. The percentage of daily calories for a healthy person consists of a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids. b. 65% carbohydrates, 25% protein, 25% fat, and >10% of fat from saturated fatty acids. c. 50% carbohydrates, 40% protein, 10% fat, and <10% of fat from saturated fatty acids. d. 40% carbohydrates, 30% protein, 30% fat, and >10% of fat from saturated fatty acids.

A

4. Which method is best to use when confirming initial placement of a blindly inserted small-bore NG feeding tube? a. x-ray. b. air insufflation. c. observing patient for coughing. d. pH measurement of gastric aspirate.

A

What can we do if the PN formula bag empties before the next one is ready?

A 10% or 20% dextrose solution (based on the amount of dextrose in the central PN solution) or 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) can be given to prevent hypoglycemia.

What is acute disease-or injury-related malnutrition?

Acute disease or injury with marked inflammatory (major infection, burns, trauma, surgery)

What is PN?

Administration of nutrients directly into the blood stream. We use it when the patient's GI tract cannot be used.

What type of patient could we see a vitamin imbalance in?

Alcohol and drug abuse, chronically ill, or individuals who follow poor dietary practices.

What must the patient have to receive a gastronomy tube?

An unobstructed GI tract.

What types of nutritional deficiencies will a malnourish person have?

Anemia, iron and folic acid which are necessary building blocks for RBC's.

What are some indications of EN?

Anorexia, orofacial fractures, head & neck cancer, neurologic/psychiatric conditions that prevent oral intake, extensive burns, or critical illness (patient is on a vent), chemo, or radiation therapy.

What does functional methods consist of?

Assess performance of ADL's to include measuring muscle strength, handrail strength using a dynamometer, timed gait and chair stands.

What must we avoid when assessing a patient's diet history?

Avoid cultural stereotyping

5. A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse gives a. 20% intralipids. b. 5% dextrose solution. c. 0.45% normal saline solution. d. 5% lactated Ringer's solution.

B

How are we going to reinforce nutritional teaching?

By providing written information, using MyPlate, interactive web-based programs, mobile apps.

What are local and systemic manifestations of infections with individuals receiving PN?

Catheter-related infection and septicemia can occur. Local manifestations: erythema, tenderness, and exudate at the catheter insertion site. Systemic manifestations: fever, chills, nausea, vomiting, and malaise

What is a complex carb?

Cereal grains, potatoes, and legumes.

What should be checked prior to administration of a feeding (for an EN tube)?

Check gastric residuals

What is starvation-related malnutrition?

Chronic starvation without inflammation (anorexia nervosa)

3. A complete nutritional assessment including anthropometric measurements is most important for the patient who a. has a BMI of 25.5 kg/m2. b. complains of frequent nocturia. c. reports a 5-year history of constipation. d. reports an unintentional weight loss of 10 lb in 2 months.

D

6. A patient with anorexia nervosa shows signs of malnutrition. During initial refeeding, the nurse carefully assesses the patient for a. hyperkalemia. b. hypoglycemia. c. hypercalcemia. d. hypophosphatemia.

D

How often should we assess the site of the feeding tube?

Daily

What will we see with a patient's immune response when they have malnutrition?

Deficient humoral and cell-mediated immunity.

What is anorexia nervosa?

Deliberate self-starvation due to the patient thinking they are fat or they have a disrupted self image.

What is chronic disease-related malnutrition?

Dietary intake doesn't meet tissue needs and includes mild to moderate inflammation (organ failure, cancer, RA, obesity, and metabolic syndrome)

What are the clinical manifestations of malnutrition?

Dry, scaly skin; brittle nails; rashes; hair loss; crusting and ulcerations; changes in tongue; decreased muscle mass; weakness; mental changes; confusion; and irritability.

When else is CRP elevated?

During inflammation. A high CRP and low albumin or prealbumin suggests that that inflammation is driving the change in albumin & prealbumin levels.

What are some benefits of using EN as opposed to PN?

EN is easy to administer, safer, cheaper, and more physiologically efficient.

How should the patient be positioned when receiving a EN tube feeding?

Elevate HOB @ 45 degrees (no less than 30).

What lab work would we see with an anorexic patient?

Elevated BUN, abnormal renal function, osteopenia, osteoporosis, iron-deficiency anemia, hypokalemia, cardiac dysrhythmias, leukopenia, hypoglycemia, hypomagnesemia, hypochloremia.

What should we encourage the family to do for a patient who doesn't like/want hospital food?

Encourage them to bring food for the patient; however, we must teach the patient if certain foods are contraindicated like patient's with heart disease.

What do we need to ensure when we are assessing a patient's diet?

Ensure that they're diet is sufficient

If a patient is still unable to meet their caloric intake, what can be done?

Enteral feedings may be needed.

What medications can we use to promote gastric emptying?

Erythromycin and metoclopramid (Reglan)

What are the causes associated with diarrhea?

Feeding too fast, infection, medications, low fiber formulas, tube moving distally, contaminated formula

What are contributing factors to malnutrition?

Food insecurity (inadequate access)

What are the causes associated with constipation?

Formula components, poor fluid intake, drug impaction, and inactivity

What is a simple carb?

Fruits, honey, malted cereal, and milk.

What are some contraindications to enteral feedings?

GI obstruction, prolonged ileus, severe diarrhea, vomiting, enterocutaneous fistula.

What are incomplete proteins?

Grains, legumes, nuts, seeds

What are some food/drug interactions?

Grapefruit juice, meds (antihistamines), alcohol, ACE inhibitors & potassium, caffeine & bronchodilators

Serum albumin

Half-life 20-22 days but it lags behind actual protein changes by more than 2 weeks.

Prealbumin

Half-life is 2 days

What value must we assess in a CBC?

Hgb: Males-13.2-17.3 g/dL, females-11.7-16.0 g/dL Htc: Males: 39-50%, females: 35-47%

What lab values may we see in an individual who has bulimia nervosa?

Hypokalemia, metabolic alkalosis, elevated serum amylase.

What is the hallmark sign associated with refeeding syndrome?

Hypophosphatemia

What should be drawn and done if a catheter-related infection is suspected?

If no other causes can be identified, a catheter-related infection is suspected. Blood cultures are drawn. A chest x-ray is taken to detect changes in pulmonary status.

What is malabsorption syndrome? Which population do we see it with?

Impaired absorption of nutrients from GI tract. Bariatric patients.

What are the causes associated with vomiting?

Improper placement of tube and delayed gastric emptying/increased residual volume

What is bulimia nervosa?

Individuals who binge and then use laxatives, vomiting, or over exercise to lose weight. They generally maintain a normal weight.

What is a binge-eating disorders?

Individuals who simply binge eat. They are generally overweight or obese and do not have a self-distorted image. It's a coping mechanism to deal with stress.

What is malnutrition?

Is a deficit, excess, or imbalance of essential nutrients.

What are some complications of EN tubes?

It can get clogged or kinked.

What needs to be done before and after drug administration?

It must be flushed

What is the benefit of placing an EN tube into the small intestine?

It reduces the risk of aspiration; however, it can still occur if the stomach is not being emptied completely.

Why do we use enteral nutrition?

It's used when a patient has a functional GI tract but is unable to take any or enough oral nourishment.

For a patient who has chronic reflux, what kind of EN tube is best?

Jejunostomy (J-tube)

How is CPN administered?

Long-term, central venous catheter or PICC,

What are characteristics of an individual who has bulimia nervosa?

Macerated knuckles, swollen salivary glands, broken blood vessels in the eyes, and dental problems.

What conditions predispose a patient to refeeding syndrome?

Malnutrition, alcoholism, vomiting, diarrhea, chemo, and surgery.

What is one way to determine if low albumin or preablumin levels are due to malnutrition?

Measurement of CRP (normal levels 6.8-820 mcg/dL)

What does anthropometric measurements consists of?

Measurement of skin fold thickness at various sites, mid arm muscle circumference. It's then compared with standards of a healthy person of same age & gender.

What are complete proteins?

Milk, milk proteins, eggs, fish, meats, poultry

What screenings can we do to assess for malnutrition? What population are we assessing?

Mini-nutritional assessment (MNA) for the older adult. Minimum data set (MDS) for long-term. We need to screen patients w/in 24 hours.

What types of EN tubes do we use for short-term?

Nasally & orally placed tubes (orograstric, NG, nasoduodenal, & nasojejunal)

Should we rely on the auscultation method to ensure proper EN tube placement?

Nope, x-ray is the best!!!

What can be used as an adjunct to meals and fluid intake? What are some examples?

Oral feedings (ex: milkshakes, puddings, Ensure, Boost, Carnation instant breakfast)

Do we use EN or PN for fat emulsions?

PN

If enteral feedings are not feasible, what can we do?

PN's may be needed.

When are fat emulsion contraindicated?

Patient had elevated hyperlipidemia, patients at risk for FES, and patient's with an allergy to soybeans or eggs.

Which one of these two lab values is a better indicator or recent/current nutritional status?

Prealbumin

Why are nasoduodenal & nasojejunal tubes good for?

Prevent the risk of aspiration b/c they are below the pyloric sphincter.

What are the issues associated with food insecurity?

Purchase less expensive "filling" foods, which are more energy dense, lack nutritional value.

How often should you check gastric residual levels?

Q 4 hours for the first 48, then Q 6-8 hours

What is the main complication associated with PN feedings?

Refeeding syndrome

How often should be flush EN tubes? What type of fluid should the EN tube be flushed with?

Routine flushing; flush tubes with 30 mL of warm tap water Q 4 hours during continuous feeds or before and after each intermittent feed. Also flush before and after each med admin.

Rapid gains and losses are a result of what?

Shifts in the fluid balance

Who do you need to consult with to help patients gain access to government and/or local programs?

Social workers

Who is at risk of having anorexia nervosa?

Teenage girls

Describe CPN solution.

They are hypertonic and have high glucose content.

Describe PPN.

They are less hypertonic than CPN. They are at risk for fluid overload.

What are some of the gerontologic considerations for EN?

They have decreased thirst perception increasing risk for dehydration. Increased risk of glucose intolerance making them more susceptible to hyperglycemia. Patient's with cardiac issues have a decreased ability to handle large volumes of fluid. They may need a more concentrated formula. They are also at increased risk for aspiration caused by GERD, delayed gastric emptying, hiatal hernia, and diminished gag reflex.

What are characteristics of an anorexic person?

They have severe weight loss. Lanugo, constipation, dry yellow skin, menstruation issues.

Why does a patient receive PPN?

They receive it for a short time to provide nutritional support or when the risk of a central catheter is too great. They also use it to supplement inadequate oral intake.

How do we determine if the EN tube has moved?

To determine if a feeding tube is still in the proper position, mark the exit site of the feeding tube at the time of the initial x-ray and check the tube external length at regular intervals.

What is serum transferrin?

Transferrin is the iron transport protein in serum. It is an indicator of protein deficiency. The ferritin levels are depressed when there is a deficiency of storage iron.

What are the fat soluble vitamins?

Vitamin A, D, E, K

What is the primary deficiency for a strict vegan?

Vitamin B12 (Cobalamin)

After gastronomy, what vitamin does a bariatric patient need?

Vitamin B12 b/c part of the stomach may have been removed inhibiting they body's ability absorb the vitamin.

What are the water soluble vitamins?

Vitamin C and B-complex

What are the causes associated with dehydration?

Vomiting and diarrhea, poor fluid intake, high protein formula, hyperosmotic diuresis

What can dislodge an EN tube?

Vomiting, coughing, a confused patient.

What must the nurse do to prevent food & drug interactions?

We must asses for compatibilities.

What will we see with a patient's energy level when it comes to malnutrition?

Weakness and fatigue

Why would a patient have a gastronomy tube?

When a patient requires EN for a longer period of time.

When do you pause EN feeds?

When the gastric residual level is greater than 500 mL

How do you verify placement of an EN tube?

X-ray

Is there an electrolyte that is elevated in malnutrition?

Yes, potassium

Can you have nutritional deficiencies with over nutrition?

Yes, they can

When can a patient discontinue PN and transition to oral nutrition?

• A general rule is that 60% of caloric needs should be met orally before discontinuation of PN. • Begin with clear liquids and advance as tolerated to a soft diet. • Limit full liquids because of an increased risk of lactose deficiency resulting in nausea, diarrhea, and bloating.

How are PN solutions prepared?

• All PN solutions must be prepared by a pharmacist or a trained technician using strict aseptic techniques under a laminar flow hood. • Add nothing to PN solutions after they are prepared. Danger of drug incompatibilities and contamination is high. • Limit number of personnel involved in preparing and administering PN. • PN solutions are ordered daily to adjust to the patient's current needs. • PN solution label indicates the nutrient content. In general, solutions are good for 24 hr and must be refrigerated until 30 min before use.

How do we ensure patient safety?

• Before starting PN, check label and ingredients to make sure they match order. • Examine the solution for leaks, color changes, particulate matter, clarity, and fat emulsions cracking (separating into layers). If present, promptly return it to the pharmacy for replacement. • Discontinue PN solution and replace it with a new solution if bag is not empty at the end of 24 hr. At room temperature, the solution (especially when containing fat emulsion) is a good medium for microorganism growth. • If fat emulsions are infused separately from the PN solution, the preferred delivery method is a continuous low volume, such as 20% lipids delivered over 12 hr. • Monitor for adverse reactions, including allergic manifestations, dyspnea, cyanosis, fever, flushing, phlebitis, chest and back pain, and pain at IV site.

How do we perform catheter site care?

• Change dressings covering catheter site according to the institution's protocol. • Carefully observe the catheter site for signs of inflammation and infection. Phlebitis can readily occur in the vein because of the hypertonic infusion, and the area can become infected. • After the catheter is removed, change dressing daily and assess for wound healing. • If an infection is suspected during a dressing change, send a culture specimen of the site and drainage and notify the HCP immediately.

How do we manage the causes associated with constipation in a patient who is receiving EN?

• Change formula to one with more fiber content. • Give as-needed laxative. • Increase fluid intake if not contraindicated. • Give total fluid intake of 30 mL/kg body weight. • Check for drugs that may be constipating. • Perform rectal examinations and manually remove feces if present. • Encourage ambulation unless contraindicated. • Collaborate with physical therapy to promote activity.

Hyperglycemia and PN feedings

• Check glucose blood levels at bedside q4-6hr with glucose-testing meter. • Maintain a glucose range of 110-150 mg/dL. Give sliding scale doses of insulin to keep the glucose level in normal range. • Insulin can be added to the PN admixture, but the dosage will not be able to be changed for 24 hr.

How do we manage the causes associated with dehydration in a patient who is receiving EN?

• Decrease rate or change formula. • Check drugs that patient is receiving, especially antibiotics. • Avoid bacterial contamination of formula and equipment. • Increase intake and check amount and number of feedings. • Increase amount of fluid intake if appropriate. • Change formula to one with less protein. • Check blood glucose levels frequently. • Change formula to one with less glucose.

How do we manage the causes associated with diarrhea in a patient who is receiving EN?

• Dilute or decrease rate of feeding. • Change to continuous drip feedings. • Discontinue excess water boluses. • Obtain stool culture for fecal leukocyte determination, C. difficile, and/or toxin assay. • Check for drugs that may cause diarrhea (e.g., sorbitol in liquid medications, antibiotics). • Change to formula with more fiber. • Properly secure tube before beginning feeding. • Check placement before each feeding or at least every 24 hr if continuous feedings. • Refrigerate unused formula and record date opened. • Discard outdated formula. • Discard formula left standing for longer than manufacturer's guidelines. -8 hr for ready-to-feed formulas (cans) -4 hr for reconstituted formula -24-48 hr for closed-system enteral formulas • Use closed system to prevent contamination.

How do we maintain PN infusions?

• Follow proper aseptic techniques to reduce infection risk. • Use a 0.22-micron Millipore filter with parenteral solutions not containing fat emulsion and a 1.2-micron filter with solutions containing fat emulsion. • Change filters and IV tubing q24 hr if giving PN with lipids and q72 hr for PN with amino acids and dextrose. • Label tubing and filter with date and time they are put into use. • If a multilumen catheter is present, use a dedicated line for PN. • Control the infusion rate. Give PN using an infusion pump. • Set an alarm to alert for tubing obstruction. • Periodically check the volume infused because pump malfunctions can alter the rate.

What can be delegated to an LVN?

• Insert NG tube for stable patient. • Irrigate NG and gastrostomy tubes. • Give bolus or continuous enteral feeding for stable patient. • Remove NG tube. • Give medications through NG or gastrostomy tube to stable patient. • Provide skin care around gastrostomy or jejunostomy tubes.

How do we assess effectiveness of PN?

• Monitor initial vital signs q4-8hr. • Daily weights to measure patient's hydration status. • Monitor I&O's. • Determine cause of weight changes (e.g., fluid gained from edema, actual increase or decrease in tissue weight). • Assess blood levels of glucose, electrolytes, and urea nitrogen. • CBC and hepatic enzyme studies are followed a minimum of three times per week until stable and then weekly as the patient's condition warrants.

What can be delegated to a UAP?

• Provide oral care to patient with NG, gastrostomy, or jejunostomy tube. • Weigh patient who is receiving enteral feeding. • Position and maintain patient receiving enteral feeding with the head of bed elevated. • Notify RN or LPN about patient symptoms (e.g., nausea, diarrhea) that may indicate problems with enteral feedings. • Alert RN or LPN about enteral feeding infusion pump alarms. • Empty drainage devices and measure output.

How do we manage the causes associated with vomiting in a patient who is receiving EN?

• Replace tube in proper position. • Check tube position before beginning feeding and every 4 hr if continuous feedings. • If gastric residual volume is ≥250 mL after second gastric residual check, consider a promotility drug. • If gastric residual volume is >500 mL, hold feeding and reassess patient tolerance. • Advance tube below the ligament of Treitz if gastric residual volume consistently remains >500 mL.