Nutrition Exam 3

Characteristics to assess for malnutrition

-inability, unwillingness to eat (insufficient energy intake)
-moderate to sever weight loss (based on time frame and percent)
-loss of subcutaneous fat
-muscle wasting
-fluid accumulation
-functional status

Chronic Severe Malnutrition

5% over 1 month
7.5% over 3 months
10% over 6 months
20% over 1 year

Malnutrition Screening Tool

-only have to score 2
-Have you lost weight recently without trying? (+2 if yes)
-If yes, how much? (1-5 +1, 6-10 +2, 11-15 +3, Unsure +2)
-Have you been eating poorly because of a decreased appetite? (+2 if yes)

Nutrition related client outcomes

After short term goals are met, attention can expand to promoting healthy eating to reduce the risk of diet related chronic disease

Nursing Role in Nutrition

-nurses are often responsible for nutrition screening, integrate nutrition into nursing plans, and obtain assessment data that dietitians use in completing nutrition assessments
-dietitians may obtain much of their preliminary assessment data about clients from the nursing history and physical examinations (ex. skin integrity, problems chewing, swallowing, or self feeding, use of supplements and over the counter meds, and living situation)

BMI categories

≤18.5 underweight
18.5-24.9 Healthy weight
25-29.9 Overweight
30-34.9 Obesity class 1
35-39.9 Obesity class 2
≥40 Obesity class 3

BMI equation

weight/(height)^2

increasing adherence to supplements

Making liquids cold/cool can improve an older client’s adherence to taking liquid supplements

Indications for EN

-functioning GI tract (at least partially)
-PO intake is deemed unsafe, insufficient, or impossible

Standard formulas

-polymetric
-high protein
-high calorie
-fiber enriched

polymetric standard formula

-unaltered molecules of protein, carbohydrate, and fats
-best for those with no digestion or absorption deficits

Hydrolyzed formula

-monumetric
-predigested proteins (free aminos) and simple carbs
-small amounts oil or MCT oil
-used for patients who lack ability to digest or have small absorptive ability (inflammatory bowel disease, CF, and pancreatic disorders)
-contain little fiber (residue) and are better suited for patients that need bowel rest
-patients with feeding tubes in lower GI tract may benefit from these formulas

EN complications

-aspiration is the most serious potential complication
-GI complications include bleeding, bloating, constipation, diarrhea, heartburn, incontinence, nausea, vomiting, and stomach pain
-before stopping EN/Changing formula due to GI complications, make sure to check tube placement, tube obstruction, and fluid balance

EN and medication

-medications should never be infused during TF administration (some drugs are ineffective if added to EN formula)
-should flush the tube with 15-30 mL of water before and after med is given
-some drugs require tube feed to be held 1-2 hours before and after administration

indications for PN

-malabsorption (GI is unable to absorb)
-Prolonged ileus
-ischemia/thrombosis
-intestinal fistula
-short Gut syndrome
-small or large bowel obstruction, pseudo obstruction

Central Parenteral Nutrition

-parenteral nutrition delivered through a central vein (usually superior vena cava, goes directly to heart)
-the larger central vein allows a larger catheter to deliver higher concentrations of nutrition with higher calories
-delivered via a central venous catheter into a large high flow vein

PN carbohydrate concentration

over 10% requires central access
blood glucose is closely monitored

PN interruption

-can lead to hypoglycemia
-if interrupted for any reason, IVF is likely hung (usually D5W) to maintain blood glucose levels

PN complications

-refeeding syndrome= caused by aggressive feeding of a malnourished patient and characterized by a drop in K+, Mag, Phos
-hypoglycemia if interrupted
-infection

PN transitioning

-taper down volume and components as either oral diet or tube feeds are increased
-d/c when 50% or more of nutrition is being provided by another source

Gene-Environment interaction for obesity

in people with a genetic predisposition to obesity, the severity of the disease is largely determined by lifestyle and environmental conditions

Traditional Approach to obesity

-losing 5-10% of body weight
-1-2 lbs lost per week until goal weight is reached
-loss of 500-1000 cal/day either through diet or exercise

lifestyle approach for weight loss

-diet modifications
-exercise
-behavior modification

Weight loss diet modifications

-low CHO diets
-Low fat diets
-dairy should be low fat version
-lean meats
-balanced diet by myplate
-Approximately 50% carbohydrates, 30% fats, and 20% protein- intakes within the ranges recommended by the DRIs

Diet modifications bottom line

-low calorie diets produce weight loss regardless of which macronutrients they emphasize
-when total calories are the same, the macronutrient distributions of the diet do not affect the amount of weight loss over time
-individualized by patients needs

Behavior change ideas

Change the environment
Eat wisely
Shop smart
Practice healthy habits
Stress reduction

Anorexia Diagnostic criteria

-Restriction of energy intake leading to a significantly low body weight
-Intense fear of gaining weight or becoming “fat”
-Disturbance in the way which one’s body weight or shape is experienced or undue influence of weight on self evaluation

Severity based off BMI

Mild ≥ 17
Moderate 16-16.9
Severe 15-15.99
Extreme < 15

Anorexia restricting type

individuals who lose weight is primarily through dieting, fasting, and/or excessive exercise in the last 3 months

Anorexia binge/purge type

within the last 3 months, the individual has engaged in recurrent episodes of binge eating and/or purging behavior

Bulimia Diagnostic Criteria

-Recurrent episodes of binge eating
-Eating in a discrete period of time an amount of food that is larger that may typically eaten
-A sense of loss of control overeating
-Recurrent Inappropriate compensatory behaviors to prevent weight gain
-Laxative, diuretics, vomiting
-Binge/purges occur on average at least once a weak for 3 month
-Self evaluation is unduly influenced by body shape and weight
-The disturbance does not occur exclusively during episodes of AN

Bulimia severity based off frequency of compensatory behavior per week

Mild 1-3
Moderate 4-7
Severe 8-13
Extreme >14

Pica

an eating disorder, frequent in children, in which non-nutritional objects are eaten persistently

-persistent eating of nonnutritive, nonfood substances

Refeeding Syndrome

Shift from fat metabolism (during starvation) to CHO metabolism
Increase glucose intake → increase insulin release
Increase in cellular uptake of Phos, K+, Mg+, H2O, and protein synthesis
Increase cellular utilization of thiamin
Hypophosphatemia→ ATP depletion
HypoMg and HypoK→ cardiac arrhythmias

Nutritional Considerations for ED treatment

The RD will evaluate the starting calorie level appropriate for each individual
Calories are not usually discussed with patient
Strategies for Bulimia and Anorexia

The stress response

-The body’s attempt to promote healing and resolve inflammation when homeostasis is disrupted
-Intensity of the stress response depends to some extent on the cause and/or severity of the initial injury

feeding Critically ill patients

-Considered after the patient is hemodynamically stable
-Within 24-48 hours usually
-May not be at the goal, but nutrition should be started, by end of first week goal should be met
-Usually require EN (tube feeding)
-Initiate EN within 24-48 hours; increase to goal over the 1st week of ICU stay

BMI less than 30

25-30 kcal/kg actual body weight

BMI 30-50

11-14 kcal/kg actual body weight

BMI over 50

22-25 kcal/kg ideal body weight

Critically ill protein needs

-Range from 1.2-2.5 g/kg depending on BMI
-Proteins are vital to determining outcomes, especially in the obese population
-Sometimes diet is hypocaloric but hyperprotein

oral diets for critically ill

-Oral diets are provided as soon as possible
-The goal of nutrition therapy is to maximize and intake and preserve lean body mass
-High calorie, high protein diet

ARDS nutrition

Primary goal is to not overfeed

negative nitrogen balance

- If more nitrogen is lost than given, the patient is considered to be catabolic or “in negative nitrogen balance
-Physical or emotional stress, starvation, Fever, Wasting diseases, Burns
-the body will break down its own muscle to meet its most basic, life-sustaining needs (prevents immune fxn)

weight gain

-unreliable indicator of improvement for unintentional weight loss related to malnutrition
-Edema, an indicator of malnutrition, can increase weight and falsely suggest an improvement in nutritional status

When malnutrition screening should be completed

The Joint commission mandates that screening must be completed in 24 hours upon patient admission to the hospital