Obesity/malnutrition

what does leptin do

• tells parts of body that you’re full

• decreases w weight loss so feel constantly hungry

what is anorexia

loss of appetite

what is anorexia nervosa

eating disorder or self induced starvation resulting from a fear of being fat even though the patient is underweight

Brain gut axis

serotonin?

• 95% of serotonin in body is in the gut

• to increase serotonin you ness tryptophan- from turkey, cheese, eggs, nuts, seeds, salmon, and whole grains

• more serotonin = a healthier stomach

what do diet sodas cause

• metabolic syndrome and belly fat

preventing constipation in older adults

• consume plenty of water and fiber to prevent or manage constipation

• other beverage choices can include: unsweetened fruit or veggies juice, low fat or fat free milk, or fortified soy beverages

action alert for weight

• measure at the same time each day preferably before breakfast

• HF and renal disease cause weight gain

• dehydration and cancer cause weight loss

• weight is the most reliable indicator of fluid gain or loss

What is BMI

• divides pts weight in kgs by the square of the height in meters

• many limitations

• judgmental terms like morbid obesity

what is BSA

• body surface area

• used for appropriate med dosages and IV titration

• sq root of height in cm x weight in kg/3600

• used in peds

what are skinfold measurements

• measures triceps and subscapcular skinfolds

• can use midarm or midcalf circumference measurements

older adults and body weight & BMI

• weight and BMI increase through adulthood until 60yo

• often become less hungry, eat less, even if they are healthy

• others continue usual eating patterns and are at higher risk for obesity, esp older females

• do not assume that an older adult automatically eats less

• personalize nutritional assessment to accurateley assess eating patterns for every pt

BMI ranges

• underweight: <18.5

• normal: 18.5-24.9

• overweight: 25-29.9

• obesity: 30 or >

assessing older adult for undernutrition physical concerns

• chronic conditions/illness

• constipation

• decreased appetite

• poor dentition

• drugs: prescription and OTC can impair taste and appetite

• Failure to thrive

• impaired eyesight

• pain that is acute or persistent

• weight loss

what is failure to thrive

combo of 3-5 symptoms:

• weakness

• slow walking speed

• low physical activity

• Unintentional weight loss

• exhaustion

assessing older adult for undernutrition psychosocial concerns

• inability to prepare meals due to fx decline, fatigue, knowledge deficit, memory

• decrease enjoyment of meals

• depression

• income (ability to afford food)

• loneliness

• proximity to sources of nutrient dense foods

• transportation access to get to sources of nutrient dense foods

protein energy malnutrition

• marasmus

• kwashiorkor

• starvation

what is marasmus

• calorie malnutrition in which body fat and protein are wasted serum protein is preserved

what is kwashiorkor

• lack of protein quantity and quality w adequate calories

• common in children

what is starvation

complete lack of nutrients

what to do for the pt w undernutrition?

consult with?

help do what?

• consult a RD who can assist meeting nutritional needs while the pt is hospitalized as well as help w planning for continuous nutritional health after discharge

• using complementary abilities of other team members optimizes health and pt care

common eating disorders

• anorexia nervosa

• bulimia

• binge eating disorder

what is important to watch for w pts w eating disorder

• LABS- this is what kills them

• esp K+ for anorexia pt’s

• put them on heart monitor and watch K

Complications of undernutrition

• reduced CO

• cold intolerance

• anorexia

• diarrhea

• impaired protein synthesis

• malabsorptions

• vomiting

• weight loss

• susceptible to disease

• dry flaky skin

• variou types of dermatitis

• poor wound healing

• cachexia

• decreased activity tolerance

• decreased muscle mass

• impaired function ability

• weakness

• substance misuse

• reduced vital capacity in lungs

meals in healthcare system

elderly?

• undernutrition can result when meals provided by the hospital are different than what the pt usually eats

• identify specific food preferences that the pt can eat and enjoy that are in keeping w personal cultural practices

action alert dysphagia

• assess for difficulty or pain w chewing or swallowing

• unrecognized dysphagia is common in older adults and can cause undernutrition, dehydration, and aspiration pneumonia

promoting nutrition intake environment

• remove bedpans, urinals, and emesis basins from the environment

• eliminate or decrease offensive odors as much as possible

• decrease environmental distractions

• admin pain meds or antiemetics at least 1 hrs before mealtime

promoting nutrition intake comfort

• allow the pt to toilet before mealtime

• provide moth care before mealtime

• ensure eyeglasses and hearing aids are in place during meals

• remind assistive personnel to have pt sit in chair if possible during mealtime

promoting nutrition intake function

• ensure that meals are visually appealing, appetizing, and at apropriate temps

• if needed, open cartons and packages and cut up food

• observe during meals for food intake and document percentage consumed

• encourage self feeding

• eliminate or minimize interruptions during mealtime for nonurgent procedures or rounds

tx for eating disorders

• meal management

• nutritional supplements: can be full of sugar, encourage smoothies

• total enteral nutrition

• drug therapy

TPN

what is it?

care of TPN

•  IV (PICC lines, central lines, and Midlines - not peripheral) when a patient cannot effectively use the GI tract for nutrition

• CARE

  • No medications goes into the TPN bag

  • Check TPN solution with orders, 2nd nurse verify

  • Monitor IV pump for accurate rate

  • If TPN runs out, administer D10W or D20 W until available

  • Do not increase rate, if administer dose late

  • Daily weights, Monitor I&O

  • Monitor glucose and electrolytes daily (2 most common electrolyte imbalances are K+, NA . Monitor labs frequently)

  • Administer insulin as ordered

  • Assess IV site

  • Change tubing every 24 hours

  • Change the dressing every 48 hours for a gauze dressing change and 7 days for a transparent dressing change.

TEN

what is it?

care for TEN/tube feeding

• Tube placed into the stomach or jejunum, peg tube

• CARE

  • NG tubes can be used less than 4 weeks w bolus or cyclic feedings

  • blood glucose management bc high in sugar

  • HOB should be 30 degrees during feeding and 1 hr after the feeding for bolus, continuously maintain semi-fowlers for pts receiving continuous: to prevent aspiration

  • Check residuals before administering meds & PER FACILITY

  • Daily weight, I&O

  • X-ray confirmation

  • Change tubing and feeding 24-48 hrs

  • Labs: BUN, electrolytes, Hct, prealbumin, & glucose

  • Obstructed (clogged) tube most common problem

  • Flush tube with 30 ml of water every 4 hrs, before & after administration of meds, and after interruption of TEN

  • Ensure correct prescribed rate (ml/hr)

TUbe care feeding and maintenance

• NG: use soft flexible small bore feeding tube

• if gastrostomy or jejunostomy tube is usesd assess insertion site for signs of infection and excoriation, rotate tube 360 degrees each day and check in and out play of about 1/4 inch

• document residual vol Q6h by aspirating stomach contents into syringe

• for continuous cyclic feeding: add only 4hrs of product to the bag at a time to prevent bacteria growth, closed system is preferred and each set should be used no longer than 24hrs

• label cans w date and time opened, cover and keep refrigerated, discard unused open cans after 24hrs

ACTION ALERT

enteral tubes and aspiration

• if enteral tubes are misplaced or become dislodged the pt is likely to aspirate

• life threatening comp w ten esp w older adults

• observer for fever and signs of dehydration (dry mucus membranes, decreased urinary output)

• auscultate lungs q4-8hrs to check for decrease breath sounds esp in lower lobes

• pts may become sob and report chest discomfort

• if xray confirms, tx w antibiotics is started

ACTION ALERT

gastrostomy or jejunostomy

• if a gastrostomy or jejunostomy tube cannot be moved while performing regular assessment, notify hcp immediately bc the retention disk may be embedded in the tissue

• cover site w a dry, sterile dressing and change the dressing at least once a day

Maintaining a feeding tube w occlusion

• risk for occlusion: delivering multiple meds w out flushing inbetween, not flushing before and after overall med admin, using longer tubes, and small diameter tubes

• consult w pharmacist to be sure meds are compatible w nutrition formula and can be cleared from the tube w appropriate flushing

• collab w HCP to use liquid meds instead of crushed ones when possible unless liquid form causes diarrhea

• do not mix drugs w the deeding product before giving, crush tablets as finely as possible and dissolve in warm water (+ for unclogging)

• flush tube w 30ml water using at least a 30ml syringe to prevent tube rupture at least Q4hr, before and after med admin, after interruption of enteral nutrition

• if tubing becomes clogged: use 30ml of water applying gentle pressure w 50ml piston syringe

• as final attempt to unclog, enzyme declogging kits or devices can be used by experiences nurse

• if unclogging is unsuccessful replacement of tube recommended

CRITICAL RESCUE

Refeeding syndrome

• life threatening comp r/t fluid and electrolyte shifts during aggressive nutritional rehab in the pt w starvation

• s/s: hypophosphatemia, hypokalemia, hf, peripheral edema, rhabdomyolysis, seizures, hemolysis, resp insuff

• contact HCP immediately

CRITICAL RESCUE

fat emulsions

• monitor for fever, increased triglycerides, clotting problems, multisystem organ fialure which may indicate fat overload syndrome esp in pts who are critically ill

• respond to theres s/s by DC IV infusion and reporting changes to hcp immediately

Central obesity

what is it

increases risk for

measurements

• distribution of excess body fat in the abdominal area is strong risk fx for health (a strong risk/predictor of health)

• increases risk for cad, stroke, cancer, sleep apnea, type 2 dm, early death

• if more inches than a healthy range of waste circumference

healthy waist circumference

• women

  • 35 or <

• men

  • 40 or <

drugs that contribute to weight gain

• steroids

• estrogens

• hormones

• nsaids

• antihypertensives

• antidepressants

• antiepileptics

• oral antidiabetics

how to ask the pt if its ok to talk to them about elevated weight

respect

Rapport

Environment

Safe

Privacy

Encourage

Compassion

Tact

a _____ can decrease risk of CAD and t2DM

5-10% weight loss

cutting out sugary carbonated beverages can

other benefits?

• cause weight loss over time

• improve bloodsugar

• reduce the risk of heart disease

• improve dental health

non surgical management for obesity

• diet programs (use percentages not numbers for weight)

• nutrition therapy

• exercise program

• drug therapy (glp1)

• behavioral management

• complementary and integrative health

surgical management for obesity

• vertical banded gastroplasty

• gastric banding

• vertical sleeve gastroplasty

• biliopancreatic diversion w duodenal stitch

• roux-en-y gastric bypass

complication of bariatric surgery

increased n/v

ACTION ALERT

bariatric surgery and NGT

• some pts have to get ng tube esp after open procedures

• gastroplasty: NG tube drains both proximal pouch and distal pouch, closely monitor tube for patency, never reposition the tube because it can disrupt the suture line

• ng tube is removed the second day if pt passing gas

nutrition after bariatric surgery

• several weeks of pureed foods then solid good at week 8

• small meals and avoid high fat and sugar content

• takes 18-24mo for weight to stabilize

CV and resp care after bariatric surgery

• semifowlers to improve breathing and decrease risk for sleep apnea, pneumonia and atelectasis

• monitor o2 sats

• provide o2, bilevel or cpap or vipap ventilation per orders

• apply compression stocking and admin prophylactic anticoagulants to prevent clots

GI care after bariatric surgery

• abdominal binder to prevent dehiscence for open surgeries

• observe for dumping syndrome

• provide six small feedings (clear then full liquids as ordered) and plenty of fluids tp prevent dehydration, collab w rd

• measure abdominal girth daily

GU care after bariatric surgery

Musculoskeletal care after bariatric surgery

• remove catheter w in 24hrs after surgery to prevent uti

• collab w physical therapist for transfers or ambulation assistive devices

• encourage turning q2hrs using weight bearing overhead trapeze

skin care after bariatric surgery

• observe folds for redness/hyperpigmentation, excoriation, or breakdown and tx early

• use absorbent padding between folds to prevent pressure and skin breakdown

• ensure tubes and catheters are not causing pressure on skin

CRITICAL RESCUE

anastomotic leaks

• most serious complication and cause of death after gastric bypass

• s/s: increasing back, shoulder or abdominal pain, restlessness, unexplained tachycardia and oliguria

• contact surgeon immediately

what is dumping syndrome

• rapid emptying of gastric contents into small intestine

• s/s: tachycardia, abdominal cramping, distention, diarrhea, n/v, vertigo, sweating, pallor, palpitations

discharge teaching topics post bariatric surgery

• including vitamin and mineral supplements

• analgesics and antiemetic drugs

• cover wound during shower or bath

• avoiding lifting; activity progression

• signs and symptoms to report: Fever; excessive nausea or vomiting; epigastric, back, or shoulder pain; red, hot, or draining wound(s); pain, redness/hyperpigmentation, or swelling in legs; chest pain; difficulty breathing

• nutrition and exercise classes; follow-up visits with RD

genetic classifications of obesity

- monogenic: single gene
- syndromic: severe obesity associated w other phenotypes, including prader-willi syndrome
- oligoenic: absence of certain phenotype
- polygenic: cumulative effect of numerous genes whose effect is increased in the environment where weight gain is prominent (common)