Nutrition: Less Than Body Requirements Lecture Notes

Learning Objectives for Imbalanced Nutrition

• Risk Factor Identification: Identify risk factors and clinical signs associated with undernourishment.

• Causality and Pathology: Explain the underlying causes of undernourishment and the nursing care required for associated disorders.

• Nursing Role in Treatment: Identify and discuss the specific role of the nurse in treating patients whose nutritional intake provides less than body requirements.

• Intervention Strategies: Describe nursing interventions designed to manage patients with imbalanced nutrition.

• Alternate Nutritional Therapies: Discuss various types of nutrition therapy available as alternatives to standard oral intake.

• Situational Anorexia: Discuss nursing care specifically for patients experiencing situational anorexia.

• Pharmacology: Describe pharmacological therapies and corresponding nursing interventions for patients suffering from nausea, vomiting, or cachexia.

• Prevention of Complications: Describe nursing interventions utilized to prevent complications in patients receiving enteral and parenteral nutrition.

Basic Facts and Impact of Malnutrition

What is malnutrition? ​

An imbalance between the nutrients the body needs and the nutrients it gets. ​

Inadequate or unbalanced diet​

Problems with digestion or absorption​

Certain medical conditions​

Celiac disease, cystic fibrosis-trouble with absorbing nutrients due to the pancreas being affected, lactose intolerance, iron deficiency is the most common form.​

​Includes under and over nutrition​

Can be a short or long period of time, malnourishment increases likelihood of getting sick.​

​Treat symptoms and underlying cause​

10% of older adults in the community do not eat enough (2023)​

​Under nutrition occurs more often in people who are very poor, such as homeless, and in those who have psychiatric disorders.​

​Drinking too much alcohol can cause under nutrition.​

​Malnutrition can increase the cost of treating a disease during a hospital stay.​

​Micronutrition-vitamins and minerals​

​Macronutrition- proteins, carbs, fats-body breaks down tissues to fuel itself, immune system shuts down first​

​Malnutrition increases morbidity and mortality in acute and chronic diseasesFactors Influencing Food Choices and Undernutrition

• Determinants of Food Choice:

  • Economic Factors: Availability of money.

  • Personal Preferences: Individual likes and dislikes.

  • Accessibility: Food availability and choice within shops.

  • Time Constraints: Work patterns and the time available for food preparation.

  • Skills: Individual cooking skills.

  • Psychological Factors: Emotions and the presence of temptation.

  • Social Factors: Family traditions and cultural influences.

• Factors Specifically Affecting Undernutrition:

  • Physiological and Physical Factors: Changes in the body's internal processing.

  • Developmental Considerations: Age-related nutritional needs and changes.

  • Biological Sex: Differences in metabolic rates and requirements.

  • Health Status: Current state of health or presence of disease.

  • Substance Abuse: Alcohol abuse specifically interferes with nutrition.

  • Medications: Side effects or interactions affecting appetite and absorption.

Causes and Risk Factors of Undernutrition

• Primary Causes:

  • Lack of physical or financial access to food.

  • Disorders interfering with the intake, metabolism, or absorption of nutrients. HIV, cancer, DM, anorexia nervosa, depresison, vomitting diarrhea

  • Conditions that significantly increase the body's metabolic demand and need for calories. burns, surgery, infection, high fever, hyperthyroidism, demanding exercise

  • Symptoms of malnutrition: Fatigue, dizziness, weight loss and decreased immune response. If left untreated, malnutrition can lead to impaired mental functioning, physical disbaility

• Specific Risk Factors:

  • Body Mass Index (BMI): A \text{BMI} < 18.5.

  • Anorexia: Loss of appetite or disordered eating.

  • Psychosocial Factors: Mental health and social isolation.

  • Sensory Impairment: Impaired sense of smell or taste.

  • Physical Difficulties: Difficulty chewing or swallowing (dysphagia).

  • Gastrointestinal (GI) Health: Chronic GI conditions.

  • Economic Barriers: Financial reasons preventing food purchase.

  • Socioeconomic Status: General medical and socioeconomic factors.

• The Vicious Cycle:

  • Undernutrition leads to increased energy needs and decreased immunity.

  • This increases the risk of infectious diseases.

  • Infectious diseases, in turn, exacerbate undernutrition.

Physical Assessment and Nutritional Screening

• Nutritional Screening Tools:

  • Mini-Nutritional Assessment (MNA): A validated tool for screening. detect older adults at risk for malnutrition before changes in albumin levels and BMI

  • $24$-hour Recall: Patient recounts everything consumed in the previous day.

  • Calorie Counts: Direct observation and recording of caloric intake.

  • Signs for undernourishment​

    Marked weight loss/ loss of adipose tissue​

    Generalized weakness and fatigue​

    Increased susceptibility to infection​

    Delayed wound healing​

    Inability to stay warm​

    Diarrhea ​

    Loss of appetite​

    Irritability & apathy​

    Physical assessment - Physical assessment s/s usually isn’t seen until the condition is further advanced.​

    Dysphagia- difficulty swallowing or inability to swallow. Increase risk for aspiration.​

    Aspiration- misdirection of oropharyngeal secretions/gastric contents into the larynx and lower respiratory tract. ​

    Labs​

    Albumin - indicator of pt nutritional status a few weeks prior, chronic nutrition problems. Malnutrition and various diseases can cause this to decrease. Overhydration can lower it, dehydration can cause a high level.​

    Prealbumin - short-term nutritional status detect daily changes in protein status and good marker in malnutrition.​

    Transferrin- iron-transporting protein, not always most accurate indicator.​

    Total lymphocyte count- immune status directly affected by impaired nutrition​

    Blood glucose, cholesterol, triglycerides are all additional information. ​

    Creatinine- body’s muscle mass, a reduction can indicate severe malnutrition. Breakdown of muscle issue produces creatinine, low levels can equal low muscle mass

• Nutrition Metabolic Pathophysiology Spectrum:

  • Failure to thrive, anorexia, cachexia, and nausea/vomiting.

  • Altered taste sensations and $NPO$ (nil per os) status.

  • Environmental/Social factors: Poverty, alcohol misuse, and chronic illness.

  • Alternative nutrition methods: Total Parenteral Nutrition ($TPN$), Peripheral Parenteral Nutrition ($PPN$), and tube feeding.

Clinical Syndromes: Failure to Thrive, Anorexia, and Cachexia

• Failure to Thrive (FTT):

  • Typically seen in older adults who were once active but have become socially withdrawn, lonely, bored, and depressed.

  • Criteria: Weight loss of > 5\% of baseline, decreased appetite, poor nutrition, and inactivity.

  • Associated Conditions: Dehydration, impaired immune function, and decreased cholesterol levels.

  • Signs/Symptoms: Impaired physical function, malnutrition, depression, and cognitive impairment.

  • Lab Findings: $\downarrow$ albumin and $\downarrow$ cholesterol.

• Systemic Effects of Anorexia:

  • Brain: Changes in chemistry and bad memory.

  • Hair: Becomes thinning and brittle.

  • Muscle: Aches, pains, and potential paralysis.

  • Skin: Becomes yellow and dry.

  • Kidneys: Risk of acute kidney failure.

  • Intestines: Constipation and bloating.

  • Bone: Development of osteoporosis.

• Cachexia:

  • Charaterized by loss of muscle mass with or without the loss of fat.

  • Signs/Symptoms: Weakness, weight loss, muscle and fat depletion.

  • Diagnostic Markers: Unintentional loss of > 5\% body weight in $6$ to $12$ months. \text{BMI} < 20 for those under $65$ years or \text{BMI} < 22 for those over $65$ years. Body fat percentage of < 10\%.

  • Management: Treat the underlying cause; focus on improving symptoms and quality of life.

Pharmacological Management

• Cachexia and Consumption Medications:

  • Corticosteroids: Used to decrease inflammation, help prevent nausea and vomiting ($N\&amp;V$), and increase appetite.

  • Megestrol acetate (Megace): A progestin used as an appetite stimulant.

  • Cannabinoids: Includes Dronabinol (Marinol) and nabilone (Cesamet).

  • Antiemetics: metoclopramide, Compazine, and Phenergan.

• Classification of Anti-Emetic Agents:

  • OTC Agents: Antacids, diphenhydramine, peppermint, and ginger.

  • Anticholinergics/Antihistamines: Scopolamine patch, hydroxyzine, and meclizine. Side effects ($SE$) include drowsiness, dry mouth, and hypersensitive reactions.

  • Serotonin Receptor Antagonists: Suffix "-setron" (e.g., ondansetron). $SE$ include headache ($HA$), injection-site reactions, dizziness, and dysrhythmias.

  • Prokinetic Agents: metoclopramide.

  • Phenothiazines: Prochlorperazine and promethazine. $SE$ include sedation, dry eyes, and photosensitivity.

  • Dexamethasone: A corticosteroid used specifically for delayed post-surgical nausea and vomiting.

Assessment of Nausea and Vomiting (OPQRSTUV)

• O – Onset: When did the symptoms start?

• P – Provoking/Palliating: What makes it worse or better?

• Q – Quality: What does it feel like (e.g., queasy, dry heaving)?

• R – Region/Radiation: Where is the sensation concentrated?

• S – Severity: On a scale of $1$ to $10$, how bad is it?

• T – Treatment: What has been tried to treat it?

• U – Understanding: What does the patient think is causing it?

• V – Values: What are the patient's goals and preferences regarding treatment?

Altered Sensations and Lifestyle Factors

• Sensory Impairments:

  • Xerostomia: Dry mouth, common in advanced age.

  • Medications: Can cause dry mouth, salty or bitter tastes, and altered/decreased taste perception.

  • Vision/Smell: Alterations in these senses can decrease the desire for food.

  • Dysgeusia- disgusting oral taste or altered taste sensation.​

    Hypogeusia- reduction in all 4 taste modalities​

    Ageusia- no taste​

    Phantogeusia- spontaneous, altered often metallic taste in the mouth that is typically drug related.

• Alcohol Misuse:

  • Alcohol is energy-rich but nutritionally poor.

  • It is addictive and causes damage to the stomach and intestines.

  • It inhibits the breakdown and absorption of nutrients, leading to significant deficiencies.

Enteral Nutrition (Tube Feeding)

• Overview:

  • Oral consumption is always the best option; oral formula supplements can be used between meals.

  • When oral intake is insufficient, enteral nutrition (feeding via the GI tract) is the next step.

• Delivery Methods:

  • Short-term (< 4 weeks):

    • Nasogastric ($NG$) tubes.

    • NGT are short term or less than 4 weeks of therapy. Inserted in the nose and down to the stomach. Can be pulled out easily. ​

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      Risk for aspiration of TF into the lungs. Pt not a candidate for this route: dysfunctional gag reflex, high risk of aspiration, gastric stasis, gastroesophageal reflux, nasal injuries, and cannot tolerate HOB elevated, total or partial gastrectomy (gastric bypass). Never placed in patients with maxillofacial surgery, basilar skull fractures/facial trauma, or uncontrolled coagulation abnormalities. Use cautiously if inserted w/ esophageal varices r/t increase risk of bleeding.​

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      NG tubes can be used for multiple purposes, can have large bore for decompression/suction contents from the stomach, or can be smaller and used for feedings. Small bore cannot be used to aspirate contents, large bore could be used for aspiration or feedings. NG tubes for decompression will be discussed in 211, will focus on the NGT for feedings. Salem sump pump tube is typically for decompression, but may be seen as a tube for feeds if it was in place for decompression & then switched to feed.​

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      NGT for feeds is smaller, more flexible, less trauma, and increase pt comfort. Also called a Dobbhoff. Tube is typically placed with a thin wire down the middle to help guide it and maintain some stiffness to the tube. Once in place, the wire is pulled out. NGT can stop in the stomach or can pass into the jejunum nasojejunal tube, or nasoduodenal. These are placed for patients that have an increased risk of aspiration or delayed gastric emptying. Weighted tip to help it stay in place.​

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      Verify placement: after initial insertion, before beginning a feeding/meds, at regular intervals. Verification ensures the tube is in the correct position to prevent complications. Verification can be completed with an X-ray to confirm placement which is the most commonly seen after insertion. Once secured and verified, numbers will be visible on NG t that will be documented and that will allow verification of placement. Can also aspirate stomach contents out and measure the pH and perform a visual assessment. Feedings have to be turned off for 1 hour prior to this technique, can be less helpful for continuous feeds. Small bore more likely to collapse when negative pressure is applied so may not be the best indicator or able to be performed at al. Can also be placed during EGD. If placement is ever in doubt, utilize x-ray for placement. Auscultation is not considered best practice.

    • Nasoduodenal or Nasojejunal tubes ($ND$/$NJ$) used for patients with increased aspiration risk or delayed gastric emptying.

    • Dobbhoff: A small-bore feeding tube.

  • Long-term:

    • Gastrostomy ($G$-tube): Tube placed directly into the stomach, such as a $PEG$ (Percutaneous Endoscopic Gastrostomy).

    • Jejunostomy ($J$-tube): Tube placed directly into the jejunum.

Gastrostomy is preferred route because going into the stomach the GE sphincter is still intact, decreasing the risk for regurgitation and aspiration than with NG tube feeds.​

​Gastrostomy can be placed by a GI physician or surgeon called a PEG (percutaneous endoscopic gastrostomy). Can be placed surgically through an open or laparoscopic method, not as common. PEG is typically used, general anesthesia not required.​

If tube is dislodged within 24hours a temporary tube (foley catheter) should be placed in the track to prevent closure. ​

(GJ) Jejunostomy is an alternative to PEG with patients that may have gastric problems.​

​There is also a low-profile gastrostomy tube used mostly for children or patients living an active lifestyle. Only has a button or plug on the outside instead of a short segment of tubing like with a PEG.​

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Tubes are changed out q3-6 months for balloon G tube, and 6-12 months non-balloon G tube. Wait 6wks-3months post-op before changing out tube.​

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The site should be kept clean and dry for the first few days and then after the patient can shower. Important to educate cleaning around PEG insertion.

• Placement Verification: Must verify placement prior to any use via X-ray (golden standard), measurement of tube length, or checking $pH$ of aspirate.

• Feeding Schedules:

  • Continuous: Slow administration via pump over $24$ hours.

  • Intermittent: Administration via pump or gravity, often coinciding with regular mealtimes.

  • Cyclic: Continuous feeding typically delivered overnight only, allowing the patient to attempt oral eating during the day.

• Formula Types:

  • Standard: Contains whole proteins, carbohydrates, and fats; requires normal digestion and absorption.

  • Hydrolyzed: Proteins and nutrients are in simple forms; requires little to no digestion; used for impaired GI function.

Nursing Management of Enteral Nutrition

• Medication Administration via Feeding Tube:

  • Give each medication separately.

  • Flush the tube with $15$ to $30\,mL$ of water before, between, and after meds.

  • Crush tablets and mix with $15$ to $30\,mL$ of water.

  • Safety Note: Stop enteral nutrition ($EN$) for $30$ minutes before administration and restart $30$ minutes after (gastric only) to allow for absorption and emptying.

  • Document all flush volumes in Intake and Output ($I\&amp;O$).

  • HOB 30-45 degrees to prevent aspiration and facilitate proper digestion during enteral feeding.

  • secure tube

• Complications to Monitor:

  • Aspiration and tube dislodgement.

  • Refeeding Syndrome: A potentially fatal shift in fluids and electrolytes.

  • Fluid imbalances and tube clogging.

  • Insertion site infection and Dumping Syndrome.

  • Feeding intolerance.

Parenteral Nutrition ($PN$)

• Indications: Nutritional support via IV when oral or enteral intake is inadequate or expected to be inadequate over a $7$ to $14$ day span.

• Total Parenteral Nutrition ($TPN$):

  • Highly concentrated, HYPERTONIC nutrient solution (high protein and dextrose).

  • Must be administered via a central line.

  • Used for extended periods of intensive support.

  • Monitor blood glucose levels regularly to prevent hyperglycemia and ensure proper metabolic response.

• Peripheral Parenteral Nutrition ($PPN$):

  • Less concentrated, isotonic solution.

  • Short-term use (less than $2$ weeks).

  • Administered via a peripheral vein carries an increased risk of thrombophlebitis.

  • can tolerate some PO feeding

• Complications of PN include, those with having a central line (pneumothorax, thromboembolism/air embolism), infection & sepsis, hyper/hypoglycemia, fluid, electrolyte and acid-base imbalances, phlebitis, hyperlipidemia, liver/gallbladder disease.​

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  Hyperglycemia is the most common complication of TPN. Q4-6h CBGs should be instituted. Usually the patient will have sliding scale insulin orders to cover the CBGs. Hypoglycemia is likely to occur with abrupt cessation of TPN. ​

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  Assess serum protein & electrolytes for imbalance. Sodium: patients receiving TPN may have hyponatremia. In most instances, the serum sodium reflects excess body water or maybe a true body sodium deficit. Water restriction is usually indicated. Nurse should evaluate changes in weight and intakes and outputs. Cellular fluid shifts relate to electrolyte imbalances.​

  Hypercalcemia /hypocalcemia-inverse phos. imbalance​

  Hyponatremia​

  Hypokalemia/hyperkalemia​

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  The primary cause of the metabolic response to refeeding is the shift from stored body fat to carbohydrate as the primary fuel source. Serum insulin levels rise, causing intracellular movement of electrolytes for use in metabolism.​

  The best advice when initiating nutritional support is to "start low and go slow". ​

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  Gradually discontinued to allow pt to adjust to decreased levels of glucose​

  When abruptly stopped:​

  Dextrose (10% or 20%) given at same rate for 1-2 hours to prevent rebound hypoglycemia

• Nursing Management of $PN$:

  • Always use an infusion pump.

  • Dedicated Line: Lumen/line must be dedicated only to $PN$.

  • Never add medications directly to the $PN$ bag or line it is administered in its own line.

  • Monitoring: Check blood glucose levels, daily weights, and liver/renal function.

  • Safety: Use a micron filter; requires two RN verification before hanging; discard bag after $24$ hours.

  • Storage: Store under refrigeration; remove $60$ minutes before hanging.

  • Discontinuation: Must be discontinued gradually to prevent hypoglycemia.

Questions & Discussion

• Question 1: Regarding a low-profile gastrostomy device vs. a nasal tube.

  • Correct Statement: "The device is usually comfortable for children."

• Question 2: Regarding types of enteral nutrition (EN) formulas.

  • Correct Statement: "Standard formula contains whole protein."

• Question 3: Regarding home administration of cyclic enteral feedings.

  • Correct Actions: "Set the feeding up before you go to bed" and "Weigh yourself daily."

• Question 4: Nursing interventions for bolus enteral feedings for malnutrition.

  • Correct Actions: Verify bowel sounds, flush with warm water, and administer at room temperature.

• Question 5: Interventions for intermittent enteral feeding.

  • Correct Actions: Discard equipment after $24$ hours and place unused open formula in the refrigerator.

• Question 6: Planning care for peripheral parenteral nutrition ($PPN$).

  • Correct Actions: Examine weight loss trends, review prealbumin findings, add a micron filter to tubing, and use an IV infusion pump.

• Question 7: Information about fat emulsion (lipids) in $PN$.

  • Correct Points: Concentration can be up to $30\%$, solution has a milky appearance, check for soybean oil allergies, and it prevents essential fatty acid deficiency.

• Question 8: Medication compatibility with $TPN$.

  • Correct Statement: "Regular insulin can be added to the TPN solution."

• Question 9: Addressing a layer of fat floating in a lipid emulsion bag.

  • Action: Return the bag to the pharmacy.

• Question 10: Action when the next bag of $TPN$ is not available for a central line.

  • Action: Administer $10\%$ or $20\%$ dextrose in water ($D20W$) IV until the next bag arrives to prevent hypoglycemia.