ch 15 malnutrition

Malnutrition

• Bad Nutrition

• Not eating enough, Not eating enough of the right things, Unable to use the food that one does eat, etc.

• Highest rates among Black, elderly, and poor communities

• Estimated to affect 20-50% of all adult hospitalized patients

Diagnosis of malnutrition - ASPEN guidelines

• Requires 2/6 of these:

  • Inadequate calorie intake - categorized by %

  • Unintentional weight loss

  • Loss of muscle mass

  • Loss of subcutaneous fat

  • Localized or generalized fluid accumulation that may mask weight loss

    • harder to use bc it's more difficult to rule out other causes

  • Diminished functional status as measured by handgrip strength

    • Harder to use bc the device used (dynamometer) isnt found everywhere

Malnutrition is classified as _______________

Severe or Non-Severe (moderate)

process of classifying malnutrition

• No inflammation present → starvation related (purely just inadequate caloric intake)

• Chronic disease related → mild/moderate inflammation

• Acute disease or injury related → significant inflammation

  • trauma pts, burn pts, anyone with a significant wound

Nursing nutrition screen must be conducted within ___ hours after admission to a hospital or other health-care facility

24

Malnutrition Screening Tool (MST)

• asks only three questions:

  • Have you lost weight without trying?

  • If yes, how much weight have you lost?

  • Have you been eating poorly because of a decreased appetite?

nutritional protocol for malnutrition

• Nursing nutrition screen must be conducted within 24 hours after admission to a hospital or other health-care facility

• Based on MST

• At-risk clients are referred to a dietitian within 48hrs

• RD must see all admitted clients within 4-5 days per JCOH and continue follow up throughout hospital stay

nutritional assessment for malnutrition

• continuous

• specific for nutrition problems

• includes adequate calories and protein

  • Needs vary per person

  • may require alternate means of nutrition if unable to consume at least 50% of their goals

normal protein needs

1.2-1.5 grams/kg daily

ill/hospitalized patients protein needs

1.5-2.0 grams/kg daily

Alternate nutrition should start by day ___ if the diet can't be advanced, or sooner (day ____) for poor nutritional status/ICU admission

5 ; 2 or 3

underweight BMI

<18.5

healthy weight BMI

18.5 - 24.9

overweight BMI

25 - 29.9

obese BMI

≥30

Percentage of weight loss

(Amount of weight lost ÷ starting body weight) x 100%

Pts may still be malnourished if they meet the other 2 criteria even if they don’t have, what is considered, “significant” _________

weight loss

Moderate malnutrition from starvation or chronic disease

• 5% per month

• 7.5% per 3 months

• 10% per 6 months

• 20% per year

Moderate malnutrition from acute disease or injury

• 1%–2% per week

• 5% per month

• 7.5% per 3 months

Severe malnutrition from starvation or chronic disease

• >5% per month

• >7.5% per 3 months

• >10% per 6 months

• >20% per year

Severe malnutrition from acute disease or injury

• >2% per week

• >5% per month

• >7.5% per 3 months

Dietary Intake

• Need to know:

  • How many kcals pt needs per day

    • Estimated energy needs

  • How many kcals pt has been consuming

    • Usual eating pattern vs. changed eating pattern

    • Intakes at home vs. Intakes in hospital

      • Expressed as a %

malnutrition - potential physical findings

• Loss of subq fat (eye socket, upper arm, thoracic regions)

• Loss of muscle mass (quads, traps, shoulder muscles)

• Localized or generalized fluid retention in the lower and upper extremities, face and eyes, and/or scrotal area

• Diminished handgrip strength

malnutrition - laboratory data findings

• No universally agreed upon biochemical indicators to diagnose

• possibly albumin but it is neither specific, reliable, nor sensitive enough to be an indicator

  • low levels could be malnutrition OR in inflammation which is too general

  • may be used but still assess the patient—are they eating their meals, do they have other inflammatory diseases, etc.?

Oral diets may be categorized as

• “Regular”

• Modified consistency

• Therapeutic

• Combined diets

  • Pureed, Low-sodium diet

  • High-protein, Soft diet

  • DM, Renal diet

Regular diet

• Used to achieve or maintain optimal nutritional status

• Adjusted to meet age-specific needs throughout the life cycle

• The nurse has the authority to advance the diet as tolerated (DAT)

Modified Consistency Diets

• Clear liquids

  • commonly used in preparation for GI procedures

  • not used postop because they do not provide adequate nutrition or protein

• Traditionally, ordered as the first postoperative meal

  • early resumption of oral feeding after major surgery, including GI surgery, reduces postop complications, length of stay, and mortality.

Modified Consistency Diets - Mechanically altered diets

Contain foods that are chopped, ground, pureed, liquid, or soft

Modified Consistency Diets - Dysphagia diets

• National Dysphagia Diet (NDD)

• International Dysphagia Diet Standardization Initiative (IDDSI)

Modified Consistency Diets - Therapeutic diets

• More restricted than a regular diet

• Used for the purpose of preventing or treating disease or illness

  • Diabetic

  • 2 gm Na+ (separate flashcard)

  • Cardiac (separate flashcard)

  • Renal (separate flashcard)

  • Gluten Free

  • Fiber Restricted

2 gm Na+ diet

• Sodium limit may be set at 1500-2000 mg/day

• Indications:

  • HTN, CHF

  • Acute and chronic renal disease

  • Liver disease

cardiac diet

• Limited in saturated fats (less than 7%–10% total calories), trans fats, and sodium (less than 2300 mg/day)

• Encourages whole grains, fruits, veggies, unsaturated fats, and appropriate calories to attain/maintain healthy weight

• Indications:

  • High LDL cholesterol

  • Prevention or treatment of CVD

renal diet

• Slightly lower in protein

• Sodium, potassium, and phosphorus levels adjusted depending on the stage (usually lowered)

• Emphasizes heart-healthy fats

• Adequate in calories

• Indications:

  • Stages 1-4 CKD

Modified Consistency Diets - Oral nutritional supplements (ONS)

• Used for inadequate intake or to treat malnutrition

• Provide calories, protein, and micronutrients to help limit weight loss and promote recovery of lost lean body mass

• Categories include:

  • clear liquid drinks

  • milk-based drinks

  • prepared liquid supplements

  • specially prepared foods

  • bariatric meal replacements

    • Low carb, low fat, high protein