Ch. 52 Flashcards
optimal nutrition
- obtained from a varied diet (veggies, fruits, dairy, grains, protein, liquids)
- desired amounts should be balanced (3 meals a day)
undernutrition
less than desired amounts of nutrients
what does undernutrition limit?
work capacity
immune system
mental activity
malnutrition
deficiencies, excesses, or imbalances in a person’s intake of nutrients
- includes undernutrition and obesity (both experience malnutrition but in different ways
overnutrition
excess nutrient and energy intake over time
excessive amounts of nutrient supplements over time
produces harmful gross body weight
protein-calorie/energy undernutrition: 3 forms
marasmus
kwashiorkor
starvation
marasmus calorie malnutrition
calorie malnutrition in which body fat and protein are wasted and serum proteins are often reserved
- not enough calories, protein, or fats
- low energy level
kwashiorkor
lack of protein quantity in presence of adequate calories, normal body weight
- low protein, normal calories, normal energy
starvation
complete lack of nutrients, most severe type of PEU
- see bones sticking out/protruding (not typically seen in the US)
physical risk factors for undernutrition
- chronic conditions/illnesses (COPD, emphysema, renal deficiency dialysis patients: SOB, low energy)
- constipation
- decreased appetite
- dentition drugs: N/V side effects from chemo
- dry mouth (side effect of medications)
- FTT: (patient must have 3/5 sx: unintentional weight loss, fatigue, weakness, low physical activity level, pain(?))
- impaired eyesight/teeth
- pain- acute or persistent
- weight loss
psychosocial risk factors for undernutrition
- inability to prepare meals due to functional decline, fatigue, memory
- depression
- decrease in enjoyment of meals
- income (ability to afford food)
- loneliness
- transportation access
examples of malnutrition problems (sx)
- poor wound healing
- dry, flaking skin and dermatitis
- lethargy
- cachexia
- weakness
- decreased muscle mass and cardiac output
- weight loss
- protein catabolism exceeds protein intake and synthesis
laboratory assessment of nutrition
- hemoglobin
- hematocrit
- serum albumin, thyroxine-binding pre-albumin
- transferrin
- cholesterol
- total lymphocyte count
(undernutrition: all values will be lower)
planning and implementation: how to improve nutrition
- meal management: who cooks/shops, #meals/day
- nutrition supplements: ensure shakes
- drug therapy: multi-vitamins, drugs that stimulate appetite
- total enteral nutrition (TEN)
drug therapy to improve nutrition
drugs to stimulate appetite
- periactin
- megace
total enteral nutrition is for patients who
- can eat but cannot maintain adequate nutrition by oral intake of food alone
- have permanent neuromuscular impairment and cannot swallow
- patients who do not have neuromuscular impairment but are critically ill and cannot eat because of their condition
total enteral nutrition can be administered through
- a nasoenteric tube (short term: <4 weeks)
- enterostomal feeding tubes (long term: months-years)
nasoenteric tubes examples
- nasogastric tubes (NG)
- nasoduodenal tube (NDT)
- nasojejunal tube (NJT)
enterostomal feeding tubes examples
a gastrostomy is performed to place either
- percutaneous endoscopic gastrostomy (PEG)
- dual-access gastrostomy-jejunostomy (PEG/J)
types of tube feedings
bolus feeding
continuous feeding
cyclic feeding
bolus feeding
- intermittent feedings at set intervals, ie. 1 can (240mL) over 4 hours
- only attached to pump during feedings
continuous feeding
- going 24/7, never stopped
- patient is hooked up to feeding- pump goes with them wherever they go
cyclic feeding
- stop it for a specific amount of time per order, ie stop from 6 AM- 12PM.
- only attached to pump during feedings
what is the priority for TEN?
patient safety
what is the most common problem with TEN?
clogged tube
- prevent with flushes: sterile water flush before and esp after giving a med
complications of TEN
- clogged tube* (#1)
- refeeding syndrome
- tube misplacement, dislodgement (only secured with tiny piece of tape)
- abdominal distention with N/V
- fluid and electrolyte imbalance with diarrhea: fluid overload- new crackles, peripheral edema; daily electrolyte and glucose levels ordered by provider
- aspiration risk: never put patient supine- HOB elevated at least 30°; shut tube feedings off if patient has to be in a supine position for prolonged time
parenteral nutrition types
peripheral parenteral nutrition (PPN)
total parenteral nutrition (TPN)
peripheral parenteral nutrition (PPN)
like TPN, but that can go through peripheral line instead of central
total parental nutrition (TPN)
does not use GI tract, uses IV route through a central line such as a PICC
- goes through vein in the arm
- osmolarity 1400 (normal is 300- this is why we do central vein insert)
nasogastric tubes (NG)
- can be used for drainage (ie post-op)
- can be used to infuse tube feedings (ie TEN)
- inserted into nose to esophagus to stomach
nasoduodenal tube (NDT) & nasojejunal tube
- nose, esophagus, small intestine
percutaneous endoscopic gastrostomy (PEG) tube
- inserted surgically into the abdomen
- feeding bag and pump connected to PEG tube
- patients can go home with PEG tubes
- could be in for months-years
- make sure it does not clog
complications of parenteral nutrition
- fluid imbalances: fluid volume overload/excess
- electrolyte imbalances
- infection at IV insertion site
what percentage of adults are overweight?
71.6% of adults ages 20-74 are overweight
- 40% of those people are obese
what percentage of children/adolescents are overweight?
center for health statistics states 18.5% of children and adolescents age 2-19 years are obese
obesity: pathophysiology
- dysregulation of adipokines (from adipose tissue)
- overweight- BMI 25-29.9
- obesity- BMI of 30+
class I obesity
BMI of 30 to <35
class II obesity
BMI of 35 to <40
class III obesity
BMI of 40 or higher
- sometimes called extreme or severe obesity
obesity: etiology
- environmental factors: home life: soda, cake
- genetic factors/family
- behavioral factors: anxious, depressed
- diet: consuming high-fat, high-cholesterol diets
- physical inactivity: working in office or remote; technology, cars
- drug therapy
overweight definition
increase in body weight for height compared with standard, or up to 10% greater than ideal body weight
obesity defintion
excess amount of body fat when compared with lean body mass, at least 20% above upper limit of normal range for ideal body weight
morbid obesity
severe negative effect on health, usually more than 100% above ideal body weight
complications of obesity
- HTN
- hyperlipidemia
- CAD: risk for MI
- neuro: stroke
- peripheral artery disease
- metabolic syndrome (hyperlipidemia, HTN)
- obstructive sleep apnea
- obesity hypoventilation syndrome
- depression/mental health issues
- urinary incontinence
- cholelithiasis
- gout
- chronic back pain
- decreased wound healing
- early ostoearthritis
obesity assessment: history
- appetite (what do you normally eat in a day)
- attitude towards food
- presence of any chronic diseases
- drugs taken (prescribed and OTC, including herbals)
- physical activity/ functional ability: walk, ride bike, joint pain
- family history of obesity
- what forms of weight loss have been tried in the past, results: weight watchers, did it work
obesity physical assessment
- height, weight, BMI
- waist, arm, calf circumference
- waist-to-hip ratio
- skin folds for reddened or open areas (abdominal or under breasts)
obesity psychosocial assessment
- emotional factors: anxiety, depression
- perception of weight, weight reduction, health benefits, lifestyle changes
- support system
weight gain causes stress on vitals organs due to ___
weight gain, which stress vital organs, due to excessive intake of calories
nonsurgical management of obesity
- diet programs
- nutrition therapy
- exercise program
- drug therapy
- behavioral management
- complementary and alternative therapies
drug therapy for obesity management
- liraglutide: injection diabetic med; can be used for weight loss
- semaglutide: injection diabetic med; can be used for weight loss
- orlistat: works by patient has more bowel movements
- naltrexone- bupropion: weight loss side effect
- phentermine-topiramate: seizure med; can be used for weight loss
complementary and alternative therapies for obesity management
- acupuncture
- acupressure
- ayurvedic therapy hypnosis
surgical management of obesity
- liposuction
- bariatrics
liposuction
sucks the adipose tissue
- patient lost weight and now has flabs of skin, this would be done to suck out some of the “flabs”
bariatrics
branch of medicine that manages obesity and its related diseases:
- gastric restrictive,
- malabsorption,
- both
preoperative care for obesity surgery
- thorough psychologic assessment and testing required
- assessment of support systems and coping skills
- role of nurse: reinforce health teaching about lifelong changes after surgery
operative procedures for obesity: gastric restriction
allows for normal digestion without risk for nutrition deficiencies, both types decrease capacity/size for food
operative procedures for obesity: malabsorption surgeries
- gastric bypass
- roux-en-Y
postoperative care for obesity surgery
think all body systems
- airway management
- pain management
- patient and staff safety
- care of NG tube
- assess for anastomotic leaks
special considerations after bariatric surgery
- abdominal binder
- position
- monitor SaO2
- sequential compression hose and/or heparin
- assess skin
- absorbent padding
- remove urinary catheter within 24 hours
- assist patient OOB
- ambulation asap
- monitor for abdominal girth
- 6 small feedings and prevent dehydration
- observe for signs of dumping syndrome
dumping syndrome
happens within 30 minutes of eating a meal
- eating and rapidly going through system
- nausea, vomiting, diarrhea, tachycardia
- treatment: want to prevent: 6 small feedings instead of 3
what kind of diet helps the body function better?
a well-balanced diet
nutrition is influenced by
- personal preference
- age
- weight
- gender
- height
- demographics
- cultural norms
- finances
the focus of nutrition is on
health promotion and disease prevention
nutrition standards for health promotion and maintenance
- dietary guidelines for americans
- USDA myplate
- cultural awareness
- geriatric considerations
surveys of the changing food environment indicate:
- fast food restaurants are offering low-fat, health-conscious alternatives
- chain restaurants are developing new healthier menu items
- shoppers are using/reading FDA’s nutrition labeling
nutrition support settings
vary
- can be inpatient or outpatient
- health care team- nurse, registered dietician, and physician
- goal: to provide a balanced nutrition plan that the patient will agree and adhere to follow
nutrition care process model
- nutrition assessment
- nutrition diagnosis
- nutrition intervention
- nutrition monitoring and evaluation
nutrition assessment
- initial nutritional screening
- anthropometric measurements: ht, wt, BMI
- waist circumference, skin-fold measurements
anthropometric measurements: weight
- weigh patients at consistent times
- weigh patients without shoes in light indoor clothing
- ask about recent weight loss or gain
anthropometric measurements: height
- use fixed stick on wall or moveable measuring rod on platform clinic scale
anthropometric measurements: BMI
calculate based on height and weight
nutritional assessment: biochemical tests
serum and urine
- Serum Bun and electrolytes- evaluate renal function
- CBC: evaluates anemia
- Plasma proteins: Serum albumin and prealbumin-indicate protein status
- Protein metabolism
- Basic 24-hour urine tests
- Elevated levels may indicate excess breakdown of body tissue
- Total lymphocyte count-evaluates immune function
nutritional assessment: skeletal system integrity
status of bone integrity and possible osteoporosis
nutritional assessment: GI function
tests and procedures used to detect peptic ulcer disease
nutritional diagnosis involves
involves identification and labeling of nutrition problem
nutrition interventions
- food and nutrient delivery
- nutrition education and counseling
nutrition evaluation (at end of nursing process)
did interventions work?
nutrition assessment: history
usual daily food intake
food preferences
food allergies
eating behaviors
change in appetite
weight changes
activity level
nutrition assessment: physical assessment
head to toe process
- hair, eyes, mouth, tongue
- skin
- feet
psychosocial assessment of nutrition includes
- economic status
- occupation
- education level
- gender orientation
- ethnicity/race
- living and cooking arrangements
- mental status
BMI is calculated based on
height and weight
BMI: underweight
< 18.5
BMI: normal/healthy
18.5-24.9
complications of undernutrition
- weight loss
- impaired protein synthesis (cells aren’t making protein)
- decreased muscle mass, weakness
- decreased cardiac output
- lethargy
- dry flaking skin and dermatitis
- poor wound healing
total enteral nutrition
uses GI tract through oral or tube feedings
- goes through nose to stomach
how to confirm placement of nasoenteric tubes
chest x-ray to confirm in the stomach
- do NOT want in the lungs (aspiration)
feedings for nasoenteric tubes (TEN) are determined by and stored where?
determined by dietician: calculate type of tube, how many mL/hr and goal, ie start jevity at 15mL/hr with goal of 60mL/hr
- kept in the kitchen
- provider orders
how and when to flush nasoenteric tubes
- before and after every medication
- can use sterile water at room temp or tap water to flush
- flush on regular basis over a 24 hour period
how and why to check residual in nasoenteric tubes
- want to see if patient is absorbing whatever they are receiving
- should be a standing order of when to check, call HCP if greater than ___mL (determined by HCP)
- examples: 5mL-10mL is normal residual; 200-300mL is abnormal
refeeding syndrome
- life threatening complication r/t fluid and electrolyte shifts during refeeding process in severely malnourished patients
- not common
- s/sx of fluid overload: crackles, SOB, peripheral edema
- labs: hypokalemia, hypophosphatemia
- treatment: stop tube feedings, call HCP, replace electrolytes
TPN preparation/order/pump type
- pharmacy mixes up, physician orders- considered a medication
- will need to do 3 checks
- attached to regular IV pump
- goes through PICC, implanted port, tunneled lumen, triple lumen catheter, etc.
how often change bag and tubing for TPN and TEN?
change the bag and tubing every 24 hours
- for bacteria build up purposes
care of patient with TPN
- monitoring central line insertion complications: infection, redness, drainage, swelling
- change bag and tubing q24hr
- daily labs: glucose, electrolytes, BUN, creatinine
- daily weights: gaining weight
what happens if TPN bag runs out?
should have standing order of 5% dextrose, 10% dextrose until you get new bag of nutrition
- worried about hypoglycemia
malabsorption surgery: roux-en-Y gastric bypass
more invasive surgery where stomach, duodenum, and part of the jejunum are bypassed affecting absorption of nutrient
postoperative complications with bariatric surgery
CV/resp:
- airway management
- bed position: semi fowlers
- monitor resp rate and O2 sat
- clots: sequential compression stockings and anticoagulants
GI care post-op with bariatric surgery
- abdominal binder
- monitor and record abdominal girth
- care of NG tube
- assess for anastomotic leaks- common
- 6 small feedings, progression of diet, encourage fluids to prevent dehydration, vitamins/mineral supplements (multivitamins every day, zinc/iron possible)
- observe for signs of dumping syndrome
post-op care of bariatric surgery
GU: remove catheter within 24 hours
Skin: assess skin and folds, use absorbent padding
MS: assist patient out of bed
discharge teaching after bariatric surgery
- nutrition (think smaller stomach- eat less bc less room; healthier meals- dietician rec)
- drug therapy: vitamins (multivitamin)
- wound care
- activity level: normal activity without impact on incision
- s/sx to report: s/ of infection, N/V, diarrhea, fever
- follow-up care: bariatrics, physicians, support groups
