Malnutrition Flashcards
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Results when the body’s need for protein &/or energy is not supplied in adequate quantity by dietary intake
e.g., kwashiorkor, marasmus, marasmic kwashiorkor
Protein-Energy Malnutrition (PEM)
> Can occur as a result of infection, stress, or injury
Could be chronic in pts that have cancer, end-stage kidney/liver dz or chronic neurologic dz
Etiology & Risk Factors
- What causes malnutrition?
> Decreased intake
> Decreased absorption
> Increased body needs
> Rx’s
Physical problems
Knowledge deficit
Malnutrition Assessment
i.e., MST, MUST, MNA, NRS, SGA
Assessment - History
- Conduct a culturally sensitive & relevant interview while avoiding stereotyping
- Routine physical or a problem-focused exam
- Collect medical, surgical, family, & social hx
- Pertinent q’s
> Appetite, food intake, weight changes, loss of appetite, & changes in bowel patterns
Physical Examination
- Inspection - Auscultation - Percussion - Palpation
Assessments & Clinical Manifestations
- Cardiac
- Pulmonary
- Immune
- Integumentary/wound healing
- Skeletal muscle
- GI/GU function
Diagnostic Labs
- Hgb/Hct
- Serum albumin
- Pre-albumin
- Transferrin
- TIBC
- Cholesterol
- Total Lymphocyte Count
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This lab value reflects nutritional status a few weeks before testing & is NOT the most sensitive protein study
Serum albumin
The thyroxine-binding pre-albumin, PAB, is a more sensitive indicator b/c it has a half-life of 2 days
Analysis - Nursing Diagnoses
- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Impaired Skin Integrity (r/t altered nutritional status)
- Risk for Infection (r/t malnutrition)
- Risk for Disturbed Body Image (r/t biophysical changes from weight loss)
Interventions
“The preferred route for feeding is through the GI tract because it enhances the immune system and is safer, easier, less expensive, and enjoyable”
> May need to consult w/RDN on these
- Ensure that the diet includes foods high in fiber content to prevent constipation
- Monitor & record intake for nutritional content & calories
- Weigh pt at appropriate intervals
- Encourage pt to wear properly fitted dentures &/or obtain dental care
- Determine pt’s ability to meet nutritional needs
- Provide appropriate info about nutritional needs & how to meet them
- Assist pt in receiving help from appropriate community nutritional programs, as needed
Management
Nutritional Supplements
> Ensure, Boost, Carnation Instant Breakfast
Rx Therapy
- Cyproheptadine - antihistamine ↑ appetite
- megestrol acetate - ↑ appetite
- metoclopramide - prokinetic
- dronabinol - (THC) - appetite stimulation in HIV/AIDS, chemo
- ondansetron - serotonin blockers - N/V assoc w/chemo
- Anticholinergics can help to reduce N/V
Special Nutritional Modalities
- TEN
- TPN (via CVC, PICC)
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- Is for those pts who can eat but cannot maintain adequate nutrition by oral intake of food alone
- Have permanent neuromuscular impairment & cannot swallow
> MS, ALS, Parkinson’s - Who do not have permanent neuromuscular impairment but are critically ill & cannot eat b/c of their condition
Total Enteral Nutrition (TEN)
Intercostal: Feeding Tubes
- Gastrostomy
- Percutaneous endoscopic gastrostomy
- Low-profile gastrostomy device (LPGD)
- Jejunostomy
Purposes of GI Intubation (aka NG tube placement)
> Decompress the stomach
Lavage the stomach
Diagnose GI disorders
> Administer rx’s & feeding
To treat an obstruction
To compress a bleeding site
To aspirate gastric contents for analysis
Administration of Tube Feedings
- Bolus feeding
- Continuous feeding
- Cyclic feeding
Enteral Nutrition - General nursing considerations
- Daily weights
- Assess for bowel sounds <feedings (assess & auscultate)
- Accurate I&O
- Initial glucose checks
- Label w/date & time started
- Pump tubing changed q24
- Administer feeding @ prescribed rate & method & according to pt tolerance
- Check residual prior to intermittent feedings & every 4-6 hrs during continuous feedings (or per facility policy)
- Admin water (typically 30mL) before & after each rx & each feeding, w/e the tube feeding is discontinued or interrupted
- Do not mix rx’s w/feedings
- Use a 30mL or larger syringe (change syringe daily)
- Maintain delivery system as req’d; to avoid bacterial contamination, do not hang more than 4 hrs of feeding in an open system
Reduce Risk for Aspiration
Elevate HOB of bed how much and for how long after feedings?
> Monitor residual volumes
30-45°, @ least 1 hr
Complications of Total Enteral Nutrition (TEN)
- Refeeding syndrome
- Tube misplacement & dislodgement
- Abd distention, n/v/d
- Fluid & electrolyte imbalances
- Aspiration pneumonia
- Tube displacement/obstruction
- Nasopharyngeal irritation
- Hyperglycemia
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Is a life-threatening metabolic complication
> Occurs in pts that have been starving; they break down fat & protein for energy rather than carbs. This leads to muscle & cell loss in major organs like the heart, liver, & lungs
> Body loses electrolytes like potassium & phosphate into plasma; insulin secretion decreases; then process is restarted, insulin production resumes, & cells take up glucose & electrolyte from the bloodstream, which depletes serum lvls
This creates a severe electrolyte shift & can cause cardiovascular, respiratory, & neurological problems
Refeeding syndrome
Refeeding syndrome
> Shallow respirations, weakness, acute confusion, seizures, an inc in bleeding tendencies
- Bolus feedings can also result in __ __, which is a rapid distention of the jejunum when hypertonic solutions are given too fast
> Results in lightheadedness, dizziness, rapid HR, anxiety, n/v/d
dumping syndrome
Aspiration pneumonia can occur if the pt aspirates during the feed
Another complication is tube displacement or obstruction & hyperglycemia
Proper Tube Care
- Use appropriate dressing (i.e., Drain Sponge)
- Skin care, assessment, & documentation of area around the tube
- Manipulation of the stabilizing disk prevents skin breakdown
Potential Nursing Diagnoses (r/t TPN/TEN)
> Imbalanced nutrition
Risk for diarrhea
Risk for ineffective airway clearance
Risk for deficient fluid
> Risk for ineffective coping
Risk for ineffective therapeutic regimen management
Deficient knowledge
Risk for impaired skin integrity
Nursing Process - Planning Outcomes
> Major outcomes include attaining an optimal level of nutrition, preventing infection, maintaining skin integrity, enhancing coping skills, adjusting to changes in body image, acquiring knowledge of & skill in self-care, & preventing complications
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Needed when pts cannot effectively utilize the GI tract for nutrition either partial or TPN may improve nutritional status
> Diff from regular IV therapy in that it may include any & all nutrients (carbs, proteins, fats, vitamins, minerals, & trace elements)
Parenteral Nutrition
1L of D5W = 170 kcal > 500-700 kcal/per day
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- Requires catheter in a large distal vein, i.e., PICC
- May be able to eat but not able to take in needed nutrients; able to tolerate large volumes of fluid
- IV fat emulsions &/or amino acid dextrose solutions (separate or together)
> AADex considered more stable & may contain vitamins, minerals, electrolytes, trace elements
Partial Parenteral Nutrition
MUST INFUSE ON IV PUMPS
> Is usually needed for less than 13 days
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Must be administered to central veins via PICC, subclavian, or internal jugular veins
- Higher concentrations of dextrose & proteins (hyperosmotic) 3-6x blood
> Electrolytes, minerals, trace elements, & insulin may be added by pharmacy to base solutions r/t pt’s specific needs
Total Parenteral Nutrition (TPN)
MUST BE INFUSED VIA INFUSION PUMPS
! No TPN infused into peripheral circulation b/c it can damage blood cells & the endothelial lining of veins & decrease perfusion; ALWAYS into a central vein
Assessment
- Assist in identifying pts who are candidates for PN
- Nutrition status, hydration status, electrolytes
- S/S of hypoglycemia/hyperglycemia
> Monitor blood glucose - Assess for potential complications
> VS inc temperature every 4 hrs or according to facility policy
Collaborative Problems & Potential Complications
! Pneumothorax
! Clotted or displaced catheter
! Sepsis
! Hyperglycemia
! Rebound hypoglycemia
! Fluid overload
Nursing Management - Parenteral Therapy
- Administer parenteral nutrition
- Prevent complications
> Mechanical: pump/VAD issues
> Metabolic: refeeding or dumping syndromes
- Prevent infections
- Evaluation on nutritional interventions
Potential Nursing Diagnoses
- Imbalanced nutrition
- Risk for infection
- Risk for excess or deficient fluid
- Risk for immobility
- Risk of ineffective therapeutic regimen
Goals
Major goals may include attaining an optimal lvl of nutrition, absence of infection, adequate fluid volume, optimal lvl of activity, knowledge of self-care, & absence of complications
