Chapter 39: Nutritional Problems

Delegate to Licensed Practical/Vocational Nurse (LPN/VN) EN

- Insert NG tube for stable patient -Flush 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 gastronomy or jejunostomy tubes

Ensuring patient safety (EN)

-Give medications in the safest form possible -dilute viscous liquid medications -use liquid medication only if they are designated safe for enteral use -do not add medications to enteral feeding formula -if using tablets, only use immediate-release forms -Crush drugs to a fine powder and dissolve in 30-60mL of purified water -employ measures to decrease aspiration risk -keep HOB elevated 30-45 degree angle -Check for GVR over agency policy -assess regularly for complications related to tubes and enteral feedings (aspiration, diarrhea, abdominal distention, hyperglycemia, fecal impaction) -Teach patient and caregiver about home EN and tube care

Gerontologic Considerations: Enteral Nutrition

-Used to improve nutritional status - The older adult is more vulnerable to complications associated with EN, esp fluid and electrolyte imbalances. -Complications (diarrhea) can leave patient dehydrated. -Decreased thirst perception/impaired cognitive function decreases the patients ability to seek needed fluids. -with aging, there is a risk for glucose intolerance. -Compromised cardiovascular function (heart failure)-hard time handling large volumes of formula. -Increased risk for aspiration caused by GERD, delayed gastric emptying, hiatal hernia, or decreased gag reflex. * physical mobility, fine motor movement, and visual system changes associated with aging may contribute to problems managing EN in the home settings.

Indications for EN

-anorexia -orofacial fractures -head and neck cancer -neurological/psychiatric conditions that prevent oral intake -extensive burns -critical illness -people on chemotherapy/radiation

Major minerals

-calcium -chloride -magnesium -phosphorus -potassium -sodium -sulfur

Maintaining EN Infusions

-check tube placement before feeding and before each medication administration -assess for bowel sounds before feeding -flush NG or gastrostomy tube as needed -Evaluate nutritional status of patient receiving enteral feedings

Trace Elements

-chromium -copper -fluoride -iodine -iron -manganese -molybdenum -selenium -zinc

Collaborate with dietician (EN)

-evaluate nutritional status of patient receiving EN -Select appropriate EN formula -Monitor for and manage complications related to EN -Teach patient and caregiver about home EN

Oversee unlicensed assistive personnel (UAP)

-provide oral care to patient with NG, gastrostomy, or jejunostomy tube -Weigh patient who is receiving EN -Keep HOB elevated 30-45 degrees -Report patient symptoms ( nausea, diarrhea) that may indicate problems with EN to RN or LPN -Alert RN or LPN about infusion pump alarms -empty drainage devices and measure output

Collaborate with a pharmacist (EN)

-select appropriate form of each medication being given enterally -determine if medication must be given separately

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)? a. A 23-year-old who has a history of fluctuating weight gains and losses b. A 35-year-old who complains of intermittent nausea for the past 2 days c. A 64-year-old who is admitted for débridement of an infected surgical wound d. A 52-year-old admitted with chest pain and possible myocardial infarction (MI) e. A 48-year-old with rheumatoid arthritis who takes prednisone (Deltasone) daily

A, C, E rationale: weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.

A health 28-year-old woman patient who weighs 145 lbs asks the nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? A. 53 B. 66 C. 75 D. 98

A. 53 rationale: the recommended daily protein is 0.8 to 1 g/kg of body weigh, which for this patient is 66 kg 0.8g= 52.8 or 53 g/day

Which finding for a 19-year0old female who is a vegan may indicate the need for cobalamin supplementation? A. paresthesias B. ecchymoses C. dry, scaly skin D. gingival swelling

A. paresthesias rationale: cobalamin (Vitamin b12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.

Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Providing skin care to the area around the tube site b. Teaching the patient how to administer tube feedings c. Determining the need for adding water to the feedings d. Assessing the patient's nutritional status at least weekly

A. providing skin care to the area around the tube site rationale: LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN) level education and scope of practice.

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when the patient has computed tomography (CT) can be ordered? A. shut the feeding off 30-60 min before the scan B. ask the health care provider to reschedule the CT scan C. connect the feeding tube to continuous suction during the scan D. send the patient to CT scan with oral suction in case of aspiration

A. shut the feeding off 30-60 min before the scan rationale: the tube feeding should be shut off 30-60 min before any procedure required the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.

A 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? A. slow the infusion rate of the tube feeding B. check gastric residual volumes more frequently C. change the enteral feeding system and formula every 8 hours D. discontinue administration of water through the feeding tube

A. slow the infusion rate of the tube feeding rationale: loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24hours. High residual volumes do not contribute to diarrhea.

Which action should the nurse take first when preparing to teach a frail 79-year old hispanic man who lives with an adult daughter about ways to improve nutrition? A. ask the daughter about the patients food preferences B. determine who shops for groceries and prepares the meals C. question the patient about how many meals per day are eaten D. assure the patient that culturally preferred foods will be included.

B. Determine who shops for groceries and prepared the meals rationale: the family member who shops for groceries and cooks will be in control of the patients diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patients nutritional needs. The other information will also be assessed and used but will not be useful in meeting the patients nutritional needs unless nutritionally appropriate foods are purchased and prepared.

After change-of-shift report, which patient will the nurse assess first? A. a 40 year old woman who's parenteral nutrition infusion bag has 30 min of solution left B. a 40 year old man with continuous enteral feedings who has developed pulmonary crackles C. a 30 year old man with 4+ generalized pitting edema and severe protein-calorie malnutrition D. a 30 year old woman whose gastrostomy tube is plugged after crushed medications were administered.

B. a 40 year old man with continuous enteral feedings who has developed pulmonary crackles rationale: the patient dates suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients should also be assessed as quickly as possible, but the data about them do not suggest any immediate life-threatening complications.

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? a. Ask the health care provider to clarify the written PN order. b. Add a new container of PN using the current tubing and filter. c. Hang a new container of PN and change the IV tubing and filter. d. Infuse the remaining 50 mL and then hang a new container of PN.

B. add a new container of PN using the current tubing and filter Rationale: all PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase the patient risk for infection. Change the IV tubing and filter more frequently than required will unnecessarily increase cost. The nurse ( Not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

A 20-year-old man with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? A. keep the patient positioned the left side B. check the gastric residual volume every 4-6 hours C. avoid giving bolus tube feedings through the PEG tube D. obtain a daily abdominal x-ray to verify tube placement.

B. check the gastric residual volume every 4 to 6 hours rationale: the gastric residual volume is assessed every 4-6 hours to decrease the risk for aspiration. The patient does not need to be positioned on the left side. Bolus feedings can be administered through a PEG tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed.

When caring for a 63 year old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will A. avoid giving medications through the feeding tube B. flush the tubing after checking for residual volume C. administer continuous feedings using an infusion pump D. replace the tubing every 3 days to avoid mucosal damage

B. flush the tubing after checking for residual volumes Rationale: the soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medication can be given through these tubes, but flushing after medication administration is important to avoid clogging.

A 48-year old woman has a BMI of 31 kg/m2, a normal c-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patients intake of food that are high in A. iron B. protein C. calories D. carbohydrates

B. protein Rationale: the patients C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.

A 19-year-old female admitted with anorexia nervosa is 5 ft 6 in tall and weighs 88 lbs. Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which nursing diagnosis has the highest priority? A. risk for activity intolerance related to anemia B. risk for electrolyte imbalance related to eating patterns C. ineffective health maintenance related to body image obsession D. imbalanced nutrition: less than body requirements related to anorexia

B. risk for electrolyte imbalance related to eating patterns rationale: the patients hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports feeling too tired to eat. Which actions should the nurse take first? A. teach the patient about the importance of good nutrition B.serve multiple small feedings of high-calorie, high-protein foods C. obtain an order for enteral feedings of liquid nutritional supplements D. consult with the health care provider about providing parenteral nutrition (PN)

B. serve multiple small feedings of high-calorie, high-protein foods rationale: eating small amounts of food frequently throughout the day is less fatiguing and will improve the patients ability to take in more nutrients.Teaching the patient may be appropriate, but will not address the patients inability to eat more because of fatigue. Tube feedings or PN may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.

A patient's peripheral parenteral nutrition (PN) bag is nearly empty and a new PN bag has not arrived yet from the pharmacy. Which intervention is the priority? a. Monitor the patient's capillary blood glucose until a new PN bag is hung. b. Flush the peripheral line with saline and wait until the new PN bag is available. c. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. d. Decrease the rate of the current PN infusion to 10 mL/hr until the new bag arrives.

C. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. rationale: to prevent hypoglycemia, the nurse should infuse a 5% dextrose solution solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurses scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.

A 20 year old female is being admitted for electrolyte disorders of unknown etiology. Which assessed finding is most important to report to the health care provider? A.the patient uses laxatives daily B. the patients knuckles are macerated C. the patients serum potassium level is 2.9 mEq/L D. the patient has a history of large weight fluctuations

C. The patients serum potassium level is 2.9 mEq/L rationale: the Lowe serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patients electrolyte disturbances, but it does not suggest imminent life-threatening complication.

The nurse is planing care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to the UAP? A. assist the patient to choose high-nutrition items from the menu B. monitor the patient for skin breakdown over the bony prominences C. offer the patient the prescribed nutritional supplement between meals D. assess the patients strength while ambulating the patient in the room

C. offer the patient the prescribed nutritional supplement between meals rationale: feeding the patient and assisting with oral intake are included in UAP education and scope of practice. Assessing the patient and assisting the patient in choosing high-nutrition foods require LPN/LVN or RN level education and scope of practice.

A 76-year-old woman with a body mass index (BMI) of 17 kg/m2 and a lower serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? A. restlessness B. hypertension C. pitting edema D. food allergies

C. pitting edema rationale: edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to a. obtain a venous blood glucose specimen. b. slow the infusion rate of the PN infusion. c. recheck the capillary blood glucose in 4 to 6 hours. d. notify the health care provider of the glucose level.

C. recheck the capillary blood glucose in 4 to 6 hours rationale: mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, notification of the health care provider is not necessary. There is no need to obtain venous specimen for comparison. Slowing the rate of the infusion is beyond the nurses scope of practice and will decrease the patient nutritional intake.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.

C. surgical incision is healing normally rationale: because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patients nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.

EN problems/causes (DIARRHEA)

Caused by: -contaminated formula -feeding too fast -formula -infection -medications -tube moving distally Management: -refrigerate unused formula and record date opened -discard outdated formula -discard formula left standing for longer than manufacture's guidelines -8 hours for ready-to-feed formulas (cans) -4 hrs for reconstituted formula -24 hours for closed-system enteral formulas -use closed system -dilute or decrease rate of feeding -change to continuous feedings -stop excess water boluses -change to formula that has more fiber or is less hypertonic -obtain stool culture for fecal leukocyte determination, C.diff and/or toxic assay -check for drugs that may cause diarrhea (sorbitol in liquid medications, antibiotics) -properly secure tube before beginning feeding -check placement before each bolus feeding or at least every 4 hours if continuous feedings

EN problem/cause ( CONSTIPATION)

Caused by: -decreased fluid intake -formula -inactivity Management: -increase fluid intake if not contraindicated -give total fluid intake of 30 mL/kg body weight -change formula to one with more fiber content -give as-needed laxatives -encourage ambulation unless contraindicated -collaborate with physical therapy to promote activity

EN problems and causes (VOMITING)

Caused by: -delayed gastric emptying -improper placement of tube Management: -consult with HCP about use of prokinetic drug -follow agency policy to manage GRV -replace tube in proper position -check tube position before each bolus feeding and every 4 hours if continuous feedings

EN problem/cause (DEHYDRATION)

Caused by: -diarrhea, vomiting -fluid intake -high-protein formula -hyperosmotic diuresis Management: -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 glucose -change formula to one with less protein -check blood glucose levels often

The nurse is caring for a 47-year old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patients lungs. In which order will the nurse take action? A. check the patients oxygen saturation B. notify the patients health care provider C. Measure the tube feeding residual volume D. Stop administering the continuous feeding

D, A, C, B rationale: the assessment data indicate that aspiration may have occurred, and the nurses first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.

Which menu choice indicates that the patient is implementing plans to choose high-calorie, high-protein foods? A. baked fish with applesauce B. beef noodle soup and canned corn C. fresh fruit salad with yogurt topping D. fried chicken with potatoes and gravy

D. fried chicken with potatoes and gravy rationale: foods that are high in calories include fried foods and those covered with sauces. High protein foods include meat and dairy products. The other choices are lower in calories and proteins.

A 60-year-old man who is hospitalized with an abdominal wound infection has only been eating about 50% of meals and states. Nothing on the menu sounds good. Which action by the nurse will be most effective in improving the patients oral intake? A. order six small meals daily B. make a referral to the dietician C. teach the patient about high-calorie foods D. have. family members bring in favorite foods

D. have family members bring in favorite food Rational:the patients statement that the hospital foods are unappealing indicate that favorite home-cooked foods might improve intake. The other interventions may also help improve the patients intake, but the most effective action will be to offer the patient more appealing food.

malabsorption syndrome

Impaired absorption of nutrients from GI tract May result from ↓ Enzymes Drug side effects ↓ Bowel surface area Fever increases BMR

Referring syndrome only found with:

Parenteral feedings because it goes into the bloodstream

tube feeding

Provision of food to the stomach through a tube (nose or small intestine)

malnutrition

a deficit, excess or imbalance of essential nutrients

Bulimia Nervosa (BN)

a disorder characterized by episodes of binge eating with inappropriate compensatory behaviors to avoid weight gain (vomiting, laxative misuse, overexercise)

Parenteral Nutrition (PN)

administration of nutrients directly into the bloodstream

Entereal Nutrition (EN)

also known as tube feeding; nutrition delivered directly into the GI tract by bypassing the oral cavity.

Important safety concerns related to EN

aspiration and dislodged tubes

A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to a. have family members bring in food. b. ask the patient about food preferences. c. teach the patient about nutritious Kosher foods. d. order nutrition supplements that are manufactured Kosher.

b. ask the patient about food preferences. rationale: the nurses first action should be further assessment whether or not the patient follows any specific religious guidelines that impact nutrition. The other actions may also be appropriate, based on the information obtained during the assessment.

Refeeding syndrome

can occur any time that a malnourished patients starts aggressive nutritional support

Anorexia Nervosa (AN)

restricting energy intake, difficulties in maintaining appropriate weight, an intense fear of gaining weight or being fat, and distorted body image.