Nursing 308 Unit 1-4 Malnutrition and Chronic Diseases – Flashcards
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Malnutrition
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Excess, deficit, or imbalance in the essential components of a balanced diet. undernutrition or overnutrition
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24 hours
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Joint commission requires nutritional screening for all patients within ___ ____ of admission
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adequate food sources
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Countries lacking __________ _____ _______ (quality of quantity of food)
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industrialized
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_________countries due to increased consumption of fast food
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undernutrition
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______________ common in hospital patients (30 - 50%)
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BMI WHR Body Shape
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Determine nutritional status ___, ___, _____ _______
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BMI (Body Mass Index)
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General indicator of whether and individual is underweight overweight obese morbidly obese
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WHR (waist to hip ratio)
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Optimal ratio is < 0.8
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Body Shape
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Apple or Pear
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android
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apple shaped
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gynoid
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pear shaped
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BMI weight (Kg) over height (m²)
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estimates total body fat stores by relating height and weight
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Underweight
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BMI below 18.5 kg/m²
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Normal weight
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BMI between 18.5 and 24.9 kg/m²
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Overweight
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BMI between 25- 29.9 kg/m²
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Obese
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BMI >= 30 kg/m²
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Morbidly obese
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BMI >= 30 kg/m²
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Protein-Calorie Malnutrition (PCM)
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most common type of undernutrition
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Primary PCM
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PCM caused by poor eating habits
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Secondary PCM
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alteration/defect in digestion, absorption, or metabolism
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Fasting pathophsyiology
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? glucose ? ? insulin and ? counter-regulatory hormones stimulate glucose production ? insulin ? lypolisis and ? ketones ? ANS ? Leptin to stimulate appetite
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Causes of undernutrition
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Low socioeconomic status Cultural influences: ideal body image Psychological disorders: anorexia nervosa Medical treatments: chemotherapy Medical conditions: IBD, COPD Malabsorption syndrome Incomplete diets
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malabsorption syndrome
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decreased enzymes (cystic fibrosis) drug interactions (antibiotics) reduced bowel surface area (Chrohn.s disease)
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incomplete diets
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alcohol drug abuse fad diets
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Clinical Manifestations
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Obvious clinical signs of inadequate protein/calorie intake apparent in: Skin Eyes Mouth Muscles CNS Decreased wound healing/delay in recovery More susceptible to infection Anemia (usually from PCM)
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Diagnostic studies (malnutrition)
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Diet history for the past week Height Weight VS (nutrition affects cardiovascular system) Physical exam Psychological exam Lab values
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Lab values (malnutrition)
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Pre-albumin (PAB) Most sensitive indicator of protein deficiency normal value = 20mg/dl Serum albumin (3.5 - 5.0g/dl) Serum transferrin (250 - 425 mg/dl) TIBC correlates with transferrin levels Electrolyte levels Lymphocyte count Liver enzymes Plasma levels of vitamins Anthropometric measurements
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20 mg/dl
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Pre-albumin (PAB) normal value =
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3.5 - 5.0g/dl
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Serum albumin normal range
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250 - 425 mg/dl
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Serum transferrin normal range
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TIBC (total iron binding capacity)
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correlates with transferrin levels
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Anthropometric measurements
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Mid-arm circumference Skinfold thickness
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Nursing Assessment (malnutrition)
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Weight changes Diet history Contributing factors Medications Labs Physical exam, dental exam, oral health Anthropometric measurements
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Contributing factors (undernutrition)
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no teeth, dysphagia, anorexia, depression, diarrhea, extensive burns, extended hospital stay, smell and taste deficits
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Nursing Diagnoses (undernutrition)
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Imbalanced nutrition: < body requirements Self-care deficit (feeding) Constipation or diarrhea Deficient fluid volume Risk for impaired skin integrity Noncompliance Activity intolerance Risk for Infection Impaired body image
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Nursing goals (undernutrition)
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Achieve and maintain optimal body weight Consume a well-balanced diet as evidenced by ....... Experience no adverse outcomes related to malnutrition
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Implementation (undernutrition interventions)
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Teach/reinforce good eating habits Assess nutritional state and other health problems Weekly weights and daily I&Os Assess food preferences Collaborate with dietitian Daily calorie count High-protein, high-calorie foods Multiple, small feedings Nutritional supplements and vitamins Appetite stimulants (Megace) Instruction to avoid malnutrition in the future, dietitian consult Diet diary
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protein-calorie malnutrion
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with ________-_______ ________ tissue needs are not met
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up to 10%
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one can lose __ __ ___ of body weight without side effects
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40 %
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Losing > ____ body weight can be fatal
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Death
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as a consequence of PCM _____ usually results from heart failure, electrolyte imbalance, and low body temperature
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protein-calorie malnutrition
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Can also be due to consumption of foods deficient in protein Diet usually also low in vitamins and minerals
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Kwashiorkor Marasmus
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Most common types of PCM
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Marasmus
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Results from concomitant deficiency in caloric and protein intake
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Marasmus
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Manifestations of ____________ Generalized loss of muscle and body fat. Dry and lose skin hanging over the buttocks, loss of fat tissue on thighs Appears emaciated but has normal serum protein levels No edema
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Risk for marasmus
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nursing home residents low socio-economic status AIDS cancer chronic renal failure (CRF) inflammatory bowel disease (IBD)
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Kwashiorkor
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Caused by deficiency of protein intake superimposed by catabolic stress event: GI obstruction Surgery Cancer Malabsorption syndrome Infectious disease
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Risk for Kwashiorkor
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Alzheimers patients Drug addicted IBD Hyperemesis gravidarum
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Kwashiorkor
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Manifestations of _____________ Distended abdomen Edema Dry, peeling skin, hair discoloration Immunodeficiency symptoms Diarrhea, vomiting Appears well nourished but has low serum protein levels
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Enteral nutrition
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Nasogastric tube Nasoduodenal tube Gastrostomy tube Jejunostomy tube PEG tubes Delivery of ___________ __________
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Short term enteral nutrition
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NG tube (nasogastric)
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Long terrm enteral nutrition
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PEG tubes
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PEG tubes
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Gastrostomy tube Jejunostomy tube
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Feeding schedules
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Intermittent: bolus feeding Continuous Cyclic
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prior to beginning
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Assess bowel sounds _____ __ ________ nutrition therapy
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Prevention of aspiration
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confirm placement assess residual HOB elevated 30-45° Do Not Push with the plunger
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Enteral nutrition management
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Assess fluid and electrolyte status Assess for hyperglycemia Abdominal assessment Intake and output Maintain patency of the tube (flushes) Monitor stools
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Parental Nutrition
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Intravenous alimentation subclavian vein clavicle superior vena cava
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Total Parenteral Nutrition
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TPN
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Peripheral Parenteral Nutrition
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PPN
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Parenteral nutrition
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Also called hyperalimentation, PPN, TPN Nutrients delivered into the vascular system Requires central line (TPN) and IV pump Do not discontinue abruptly (rebound hypoglycemia) CBGs: may be on insulin scale I&O, monitor electrolytes. Watch for HHNK (hyperglycemic hypersosmolar nonketotic coma)
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Nursing Diagnoses for nutrition support
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R.C. Fluid and electrolyte imbalances R.C. Hyperglycemia - HHNK R.C. Infection - sepsis R.C. pulmonary embolism
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Obesity
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Abnormal increase in the proportion of fat cells Imbalance between energy expenditure and energy intake Complex interaction between genes, the environment, and psychological factors
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Obesity statistics
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65% of Americans over age 20 are either overweight or obese Louisiana is the 3rd most obese state in the nation New Orleans is the 5th most obese city Most common nutritional problem Obesity epidemic in the USA
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Obesity
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Brain can be 'hijacked' by palmitic acid, a saturated fat which blocks insulin and leptin BMI > 30 kg/m2 Waist to Hip Ratio (WHR) > 0.8
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Gynoid Obesity
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pear-shaped better prognosis, more difficult to treat
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Android Obesity
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apple-shaped Abdominal and visceral fat (______ _______) linked to Metabolic Syndrome, a major complication of obesity
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Obesity Etiology
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Genetic factors: familial Hormonal: thyroid, leptin. Obese people produce high levels of leptin but the brain is resistant to its action. Results in the obese patent never feeling full. The stomach produces Ghrelin that increases hunger and appetite Medications: corticosteroids, estrogen, antidepressants Socioeconomic factors Sedentary lifestyle Emotional components, stressors
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Complications of obesity
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Hypertension Hyperlipidemia, cardiovascular disease DM 2 and insulin resistance with hyperinsulinemia DJD, osteoarthritis, gout Respiratory problems, sleep apnea Gallbladder disease and non-alcoholic fatty liver Delayed wound healing Hypertension Hyperlipidemia, cardiovascular disease DM 2 and insulin resistance with hyperinsulinemia DJD, osteoarthritis, gout Respiratory problems, sleep apnea Gallbladder disease and non-alcoholic fatty liver Delayed wound healing Stroke Cancer (breast, endometrial) Depression (social stigmatization, discrimination bullying) Urinary stress incontinence Chronic back pain Venous stasis GERD
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Obesity Psychosocial Issues
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Poor body image, self-esteem and body consciousness Social stigma: prejudice (thought of lazy, stupid), discrimination (lower salary, less chance of promotion, unemployment, poverty, isolation, difficulty finding clothes)
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Obesity management
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Goal is to change eating behavior Diet diaries Frank discussion on eating habits Realistic goals Obesity epidemic in the USA Reach a plateau (days to weeks) Weight is lost only when energy expended is greater than calorie intake Daily weights are not recommended Diet Therapy Exercise and physical activity Behavior Modification Support Groups Combination Therapies Drug therapy Bariatric Surgery
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Drug therapy
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appetite suppressing nutritent-absorption blockers
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Appetite suppressing
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noradrenergic- serotonergic (Belviq)
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Nutrient-absorption blockers
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Orlistat (Xenical)
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Obesity management (interventions)
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Several small meals a day increases metabolic rate Evaluation of other medical conditions Need special bed, trapeze, B/P cuffs, bedside commodes, bedpans, etc Prevent respiratory infections Prevention of thrombophlebitis Care of skinfolds
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Bariatric Surgery
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Gastrointestinal surgeries directed at limiting food intake or producing malabsorption
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Bariatric Surgery
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drastically limits gastric capacity produces rapid gastric emptying
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Goals of bariatric surgery
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Experience long-term weight loss Improvement in obesity-related co-morbidities Integrate healthy practices into daily routines Improve self-image Monitor/prevent adverse side-effects of surgical therapy
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Types of Bariatric Surgery
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Restrictive Combined restrictive/malabsorptive Mainly malabsorptive
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Restrictive (gastric restriction)
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What type of surgery? adjustable gastric banding (AGB) Limits gastric capacity. Patient may accommodate to _________
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Combined restrictive/malabsorptive
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What type of surgery? gastric bypass (GBP). Gastric pouch +- 30ml, no pyloric sphincter Documented post-op resolution of Type 2 DM
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Mainly malabsorptive
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bilio-pancreatic diversion with or without "duodenal switch". No bile, no pancreatic enzymes
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Complications of bariatric surgery
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Dumping syndrome Small bowel obstruction Iron deficiency anemia Calcium, vit.B12 deficiency Diarrhea
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Nursing Care after bariatric surgery
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NG tube intra and post-op HOB elevated 35-40 degrees (regurgitation) Monitor re-sedation (stores anesthesia in fat tissue) Monitor fluid and electrolytes (vomiting, diarrhea) Crush meds for first 6 weeks Eat slowly Diet high in proteins and low in CHOs
