Adult Health 2- Concept of Care for Pt. with Malnutrtion
To function well the body needs adequate nutrition to maintain:
growth, temp, approximate respirations and cardiac output, facilitate muscle strength, metabolism
Adult energy supply: protein, carbs, fat
Weight gained when food intake > energy used
Weight loss when food intake < energy used
1600-3200 calories/day for healthy adults
HEALTH PROMOTION/DISEASE PREVENTION
Dietary reference intake (DRIs)= based on age, gender, and lifestage serve as nutrition guide and provide scientific basis for food guidelines in the US
Ex: Food pyramid
“Start Simple with MyPlate” reminds users about building healthy eating habits into a lifestyle
COMMON DIETS
No “typical” diet
Obesity: High carb, fat, sugar
Under: inadequate access to nutrient-rich foods and hydration
Malnutrition: occurs in both
Diet Variables:
preference, demographic location, cultural/spiritual norms, financial feasibility, availability of nutrtional sources
Health teaching about nutrition should include pt. cultural prefernces, always ask pt. preferences
Ideal diet: complex carbs, lean proteins, and monounsaturated or polyunsaturated fats
Vegetarian/vegan
Lacto-vegetarian: allows dairy, avoids meats. poultry, seafood, eggs
Ovo vegetarian: allows eggs, avoid meat, poultry, seafood, and dairy
Lacto-ovo vegetarian: allow eggs and dairy, avoid meat, poultry, seafood
Pescatarian: allows fish, avoid meat, polutry, dairy, and eggs
Vegan: consume a plate-based diet only
often anemic r/t B12 deficiency→ recommend B12 supplement or B12 fortified foods
Food sensitivities
Allergy= comes from immune system,
most common: tree nuts, peanuts, shellfish
Can cause edema in (face, lips, tongue, throat), SOB, anaphylaxis LIFE THREATENING
Intolerance: involves GI system, cannot properly break down food
ex: lactose intolerance (pt has inadequate amount of lactase enzyme)
causes bloating, diarrhea, abdominal discomfort, flatulence
When taking history, ask patients specifically what kind of reaction they have to foods
ASSESSMENT
Evaluation of nutritional status:
Review of nutrition history
Food and fluid intake record
Acess to appropriate sources of nutrition
Lab data
Food-drug interaction
Health history and physical assessment
Anthropometric measurements
Psychosocial assessment
Initial Nutrition Screening
Per The Joint Commission: should be done within 24 hours of a patient’s hospital admission
Initial screen:
Inspection→ look at patient (bony prominence, skin folds)
Height and Weight→ measure
Weight history
Eating habits→ unusual?
Issues with eating/swallowing→ aspiration risk?
Appetite
MNA (Mini Nutritional Asssessment)-SF (Short Form)
screening tool to see if older adult pt. is at risk for undernourishment or malnutrition
ANTHROPOMETRIC MEASUREMENTS
= noninvasive ways to evaluate nutrition status
Height
stand up scale
Weight
use the same scale, same time of day, same clothes, NO shoes
Zero out a bed scale before weighing a patient, document pillows and blankets on the bed during weight
UAP can measure a patients height and weight
BMI (Body mass index)= estimates total fat stores within the body by the relationship of weight to height
Below 18.5→ underweight
18.5-24.9→ normal
25-29.9→ overweight
>30 →obese
BSA (Body Surface Area)= estimate of pt. total body surface area
can be used for appropriate dose calc for meds
use to measure severity in pt. with burns
Skinfold measurement= estimate body fat
tricep and subscapular folds most commonly measures
UNDERNUTRITION: PATHO REVIEW
Occurs in long term care facility or long hospital stays
not enough staff to feed pts who need fed (LTC)
diagnostic tests, NPO, surgery, trauma (hospital)
Protein-energy undernutrition (PEU); also known as protein-calorie malnutrition (PCM)
Acute PEU vs Chronic PEU
Acute: was adequately nourished before event (trauma, hospital stay, etc) now experiencing acute starvation
Chronic: occur in those wh have a chronic health condition (cancer, CKD)
Marasmus= calorie malnutrition
body fat and protein wasting
Kwashiorkor= Lack of protein with adequate calories
looks swollen
Starvation= complete lack of nutrients
occur when food is unavailable
increase morbidity and mortality
EATING DISORDERS
Anorexia Nervosa= self induced state of starvation resulting from fear of fatness
Body dysmorphic disorder= obsessive condition in which patients spend an abnormal amount of time attempting to reach what they consider to be body perfection
Bulimia Nervosa= episode of binge eating and episode of purging (vomit, diuretic, laxative)
Binge Eating Disorder= episode of eating excessive amounts of food, no purge
involves feeling of loss of control over eating behavior
COMPLICATIONS OF UNDERNUTRITION
Cardiac
decrease output (lose heart muscle mass), hypotension, bradycardia
Endocrine
change: insulin, thyroid hormone, sex hormone
slow metabolism, delay growth, change in female cycle (lose period)
GI
not consistently using GI system→ gastric motility slows, stop making gastric enzymes
Eating confuses belly→ bloating, constipation, malabsorption
Immune
lose WBC function→ impaired immunity, increase infection risk
Integumentary
thin, fragile skin, hair loss, delayed wound healing,
Musculoskeletal
muscle wasting, decrease bond density, fractures, imparied mobility
Neurologic
brain fog, congnitive slowing, confusion, dizziness
Psychiatric
depression, poor concentration, inc risk for substance abuse and suicide
Respiratory
resp muscle weaken (can’t get good breath in/out) reduced vital capacity
risk for pneumonia
PHYSICAL RISK FACTOR FOR UNDERNUTRITION
Chronic conditions/illnesses
Constipation
Decreased appetite
Dentition
poor dental health, poor fit dentrures, lack of teeth/dentures
Drugs
prescription or OTC may impair taste or appetite
Dry mouth
“Failure to thrive”
Weakness, slow walking speed, low physical activity, unintentional weight loss, exhaustion (3/5)
Impaired eyesight
Pain that is acute or persistent
Weight loss
PSYCHOSOCIAL RISK FACTOR FOR UNDERNUTRITION
ability to prepare meals
decrease enjoyment of meals
depression
income→ cannot afford food
loneliness
proximity to food sources
transportation access
HEALTH PROMOTION AND WELLNESS
50-71% of older adults are malnourished before hospital admission
advocate for pt. nutirtional status
poor nutrition can increase pt. length of stay and contribute to the rate of readmission
Incidence and Prevalence
462 million people worldwide are underweight
ASSESSMENT
History
usual food intake/timing
Ex: does pt. eat breakfast in morning?
preference
cultural/spiritual consideration
behavior/patterns
appetite
weight changes
economic status
ability to buy nutritious food
Have pt. use a food diary, if pt ate a snack write down why they ate it
Physical Assessment
assess hair, eyes (dry), oral cavity, nails, skin (dry, wounds), musculoskeletal (weak, brittle bones), neurologic systems
3-day caloric intake→ done by RDN
Anthropometric measurement
Food and fluid intake
document s/s of discomfort with eating (pain, N/V, heartburn)
Psychosocial
Economic status
financial status
SNAP: food security and consistency
Occupation
ex: nightshift may eat odd hours
Education
health literacy may effect the way they read food lables
Ethnicity/race
cultural food preference
cooking arrangement
do they have a kitchen? ability to cook? dependent on others to cook for them?
emotional status
Labs
Cholesterol: low
H&H: low
low in iron, folic acid, B12→ low Hgb→ anemic
Albumin: can be low r/t low protein
Prealbumin: GOLD STANDARD FOR MALNUTRITION
best indicator for most recent food intake and what nutrients get from that
low in acute malnutrition
Transferrin
plasma protein
decreased with protein deficiency and impaired iron transport
PLANNING: IMPROVING NUTRTION
Meal Management: high calorie, nutrient rich foods
follow recommendation for patient (ex: 6 small meals instead of 3 large; soft foods for pt. with dental problems)
Nutrition Supplement
use if pt. cannot take in enough nutrients in food
ex: Ensure, Sustacal, Carnation, Glucerna (DM)
Drug Therapy
multivitamins, zinc, iron preparations
Iron causes constipation→ stool softener
Zinc cause N/V→ antiemetics
Total enteral nutrition (TEN)
used if patient cannot achieve nutrition via oral intake
can eat but not maintain adequate nutrition
ex: older adult, cancer pt.
Check for advanced directive→ may state pt. does not want artificial feeding and hydration
permanent neuromuscular impairment who cannot swallow
ex: severe head trauma, brain attack, advanced MS
cannot eat because of condition
RDN makes recommendation for pt. HCP places order for TEN
Administering TEN:
Nasoenteric tube (NET)
used short term
Nasogastric tube (NG)
feedings/meds, stomach decompression
Nasodudenal tube (NDT)
use if gastric emptying is delayed or if pt. is aspiration risk
Nasojejunal tube (NJT)
use if pt. is high aspiration risk
Enterostomal feeding tubes
used long term
Gastrostomy performed
Percutaneous endoscopic gastrostomy (PEG)
more common
Dual-access gastrostomy-jejunostomy (PEG/J)
bypass stomach (GI disease, upper GI obstruction, abnormal GI emptying)
dual access: feed through jejunum, decompress through stomach
Types of Tube Feedings
Bolus= intermittent feeding of a specified amount of enteral product at set intervals during 24h period, typically Q4h
manual or infusion
Continous= similar to IV, small amounts are continously infused (gravity or pump) over specific time
Cycilic= same as bolus except infusion is stopped for a specified time in each 24h period, usualy 6h or longer “down time”
Tube Care and Maintenance
Placement verified by x-ray
DON’T give anything until placement is verified
if questioning placement→ X-ray
Secure→ tape
Skin→ s/s infection (gastrostomy or jejunostomy)
Residual check
document residual Q6h, unhook from feed, empty syringe and pull back (till resistance) to see what is left
<200mL normal
200-500mL use clinical judgement
>500mL stop feedings and call provider
Is patient tolerating?
Shouldn’t be extra tube feed in stomach
s/s of intolerance: N/V, bloating
HOB
>30 degree when getting feed
Bolus: 30 degree when getting feed and 1 hour after
Change tubing Q24-48h to prevent infection, lable with date, time, initials
Complications of TEN
Priority is always safety
Obstructed (clogged) tube is most common problem
liquid med> pill or crush pill as much as possible before administration through tube
FLUSH tube before/after meds 30mL Q4h
Tube misplacement, dislodgement→ can cause aspiration and death
remove any tube expected to being dislodged
after initial placement, check residual BEFORE each intermittent feeding or drug administration, or Q6h
x-ray is most accurate
Abdominal distention and n/v
caused by overfeeding
check residual→ high residual= overfeeding
Fluid and electrolyte imbalance
fluid overload (too much feeding)
diarrhea and dehydration can occur
two most common electrolyte imbalance
Hyperkalemia and hyponatremia
Refeeding Syndrome= lifethreatening complication r/t fluid and electrolyte shifts during aggressive nutritional rehabilitation of the patient in a state of starvation
prevent by slowly introducing food
CARE COORDINATION AND TRANSITION MANAGEMENT
Home care management
financial resources to obtain nutritional supplement
Self-management education
teach pt about high-cal, high-protein diet and nutrition supplement
take stool softener with iron supplement (avoid constipation)
Healthcare Resources
home nutritional therapy team: HCP, RN, RDN, pharmacist, case manager/social worker
for patients going home with enteral or parenteral nutrition
OBESITY: PATHO REVIEW
dysregulation of adipokines
hormone that affect appetite and metabolism
Dysregulation causes appetite increase, overstimulation of autonomic nervous system, blood vessel inflammation, ventricular hypertrophy
waist circumference (WC) is a strong predictor for overall health
WC is stronger predictor for CAD than BMI
central obesity is risk factor for CAD, DMII, brain attack, sleep apnea, colon and breast cancers, early death
Overweght: BMI of 25-29
Obesity: BMI of 30 or more
Class I: BMI 30 to <35
Class II: BMI 35 to <40
Class III: BMI of 40 or higher
OBESITY FACTS
Etiology and Genetics
environmental, genetic, behavioral factors
consuming high-fat, high-cholesterol diets
obesity associated with significant amount of saturated fat, which increases LDL
trans fatty acids, saturated fats, and cholesterol→ higher risk for heart disease
monounsaturated and polyunsaturated fats are healthy fats
Physical inactivity
Drug therapy
ex: steroids, estrogens and progestins, NSAIDs, AntiHTNs, antidepressants
Incidence and Prevalence
Prevalence have doubled since 1980
One third of world’s population is classified as overweight or obese
leasing cause of preventable death
HEALTH PROMOTION AND WELLNESS
Healthy People 2030
reduce proportion of children, adolescent, and adult with obesity
teach importance of WT management and physical activity to improve health
Even 5% weight loss can decrease risk of CAD and DM
walk 20 minutes daily
ASSESSMENT
History
RESPECT: Rapport, Environment that is Safe and Private, Encourage realistic goals, provide Compassion, use Tact in conversation
Physical Assessment
HT and WT
BMI, skin folds, body surface area
Skin assessment
look in folds→ yeast infections or sores
Ask about: attitude towards food, appetite, presence of chronic illness, Drugs taken, ways they have tried to lose weight in the past
Psychosocial
emotional factors may prevent sucessful weight loss
PLANNING AND IMPLEMENTATION
Nonsurgical
Diet
1200-1800 calories/day with balanced carbs, protein, and fat
balanced diet (NO low carb diet, don’t want them to cut out important nutrient)
Nutrition Therapy
Evidence based, nutritionally balanced
Low risk and practical
Exercise Program
walk 20 minutes/day
Drug therapy
4 meds are FDA approved for overweight treatment
Cryolipolysis
“fat freezing”
freeze fat cells so they can’t get bigger
Behavioral Management
help change eating habits
Complementary and Integrative Health
Surgical management
Bariatrics
Surgical candidate:
repeated failure of nonsurgical itervention
BMI >40
BMI >35 with other health risk
Post OP
airway management is always postop priority
clear liquids introduced slowly if patient can tolerate water
full liquid diet follow tolerance of clear liquid
pureed food in a week (5tbsp food)
soft foods
8 week post op solid nutrient-dense foods
remind pt. to eat/drink slowly, and stop when they get feeling of fullness
High protein, low fat foods
CARE COORDINATION AND TRANSITION MANAGEMENT
Home care
surgery→ PT/OT
psychologist
make sure pt. continues healthy diet
physical activity should be doable
eat good balanced small meals (do not get undernourished)