Chapter 55 Malnutrition
Malnutrition: Causes, Impacts, and Management
Author:
Dr. Cierra Stevenson
Focus:
An in-depth overview of malnutrition, including both undernutrition and overnutrition, and their implications for health.
Review Topics
Nutrition Standards for Health Promotion and Maintenance:
DRIs based on age, gender, and life stage serve as a nutrition guide for more than 40 nutrients that provide basis for food
Common Diets:
Nutrition Assessment:
Nutrition Screening:
Anthropometric Measurements
Definition: Standard measurements that are crucial for assessing body composition and growth patterns across demographics.
Key Measurements:
Height & Weight: Basic metrics are utilized for calculating the Body Mass Index (BMI) to classify underweight, normal, overweight, and obese individuals.
Body Circumferences: Specific measurements such as waist, hip, and mid-upper arm circumferences help gauge fat distribution and overall health risks.
Skinfold Thickness: This method estimates subcutaneous fat to assess body fat percentage using calipers, with sites including triceps, abdominal, and thigh measurements.
Body Proportions: Ratios, particularly waist-to-hip ratio (WHR), provide insight into the risk of cardiovascular diseases.
Body Surface Area: Total body surface is calculated by height and weight, often used for determining appropriate drug dosages in clinical settings.
Malnutrition Impact
Key Points:
Lack of Nutrients: Inadequate intake of essential nutrients leads to a range of health issues from immune dysfunction to impaired cognitive abilities.
Health Impact: Malnutrition can affect individuals regardless of their weight status (underweight, overweight, or obese) and can lead to chronic diseases.
Systemic Impact: Malnutrition has widespread effects on all organ systems, resulting in complications such as heart disease, diabetes, and compromised immune systems.
Undernutrition Diagnostic Criteria
Main Indicators:
Calorie Deficit: Significant shortage of caloric intake compared to needs.
Muscle Loss: Measured through assessments like handgrip strength.
Weight Loss: Unintentional weight loss that raises clinical concern.
Grip Strength: Important indicator of muscle strength and overall health.
Diagnosis: Requires the presence of at least two specific indicators to confirm undernutrition or malnutrition diagnosis.
Protein-Energy Malnutrition
Conditions:
Marasmus: Characterized by severe calorie and protein deficiency leading to significant weight loss and muscle wasting. serum proteins are often preserved
Kwashiorkor: Usually results from diets low in protein despite adequate calorie intake, leading to symptoms such as edema and fatty liver.
can be life-threatening if left untreated.
Marasmic-Kwashiorkor: A condition that represents a combination of protein and calorie deficiency, posing significant health risks.
extreme weight loss, muscle wasting, edema and significant nutritional deficits
Characteristics of Marasmus and Kwashiorkor
Marasmus: Patients present as extremely thin, with severe muscle wasting and visible ribs; often exhibit severe nutritional deficiencies affecting growth and development.
Kwashiorkor: Characterized by edema (swelling) and a distended abdomen, changes in skin and hair, and an often deceptively normal weight.
Treatment and Complications
Kwashiorkor Treatment:
Gradual reintroduction of protein, fluid management to reverse edema, and close monitoring for electrolyte imbalances.
Complications: Can lead to immune dysfunction, hepatomegaly (enlarged liver), and severe skin conditions (dermatitis) increased risk of infections.
Marasmus Treatment:
Focus on careful caloric refeeding to restore weight and muscle mass, with regular monitoring for complications like dehydration and electrolyte imbalances.
complication: severe dehydration, electrolyte imbalance, hypothermia, and bradycardia
can lead to growth stunt and delayed developing
Physical Risk Factors for Undernutrition
Chronic Conditions: Various chronic diseases such as cancer and diabetes can significantly affect nutrient absorption and metabolism, leading to malnutrition.
Oral Health Issues: Dental problems can lead to decreased appetite and food intake, increasing the risk of malnutrition in older adults.
Medication Effects: Wellbutrin.
unintended weight loss
decreased appetite
poor dentition and dry mouth
Digestive problems: constipation and other digestive issues affecting nutrition
Failure to Thrive: A progressive decline in physical and nutritional health often seen in vulnerable populations, particularly among children and the elderly.
Chronic Disease-Related Malnutrition
Key diseases include:
Alcohol Use Disorder: Depletes essential nutrients and affects metabolism.
HIV/AIDS: Increases metabolic demands and hampers nutrient absorption.
COPD: Increases energy expenditure and complicates nutritional intake.
Chronic Kidney Disease: Impairs dietary protein and electrolyte balance, alters metabolisms
Acute Disease-Related Malnutrition
Major Events:
Trauma: Leads to increased metabolic demand and can result in rapid weight loss and nutrient depletion.
Burns: Result in significant nutrient loss and increased nutritional needs due to healing processes.
Sepsis: Triggers rapid metabolic changes, leads to nutrient depletion, and can affect multiple organ systems.
illness: requires an increase in cal and protein need
Common Complications of Undernutrition
Metabolic Changes: Malnutrition can lead to cachexia, a syndrome characterized by severe weight loss and muscle wasting due to chronic illness.
Physical Deterioration: Weight loss can reduce cardiac output and overall physical performance.and can result in weakness and lethargy
Skin and Temperature Changes: Poor wound healing and even hypothermia may occur, signifying compromised health status.
Severe Outcome: Malnutrition can be life-threatening if not promptly addressed with appropriate interventions.
Eating Disorders
Anorexia Nervosa: Characterized by self-induced starvation due to an intense fear of weight gain, resulting in severe weight loss and health complications.
Bulimia Nervosa: Binge eating followed by purging can lead to severe electrolyte imbalances and medical complications.
Binge Eating Disorder: Involves excessive eating without subsequent compensatory behaviors, often leading to obesity and related health issues.
Health Promotion and Maintenance
Malnutrition in Hospitalized Patients:
Up to 5% diagnosed during hospital stays due to various factors.
Discuss statistics on outpatient settings and long-term care facilities concerning malnutrition prevalence and intervention strategies.
Undernutrition Assessment Guide
Medical History Assessment: Focus on recent weight changes, appetite shifts, and medications affecting nutrition along with chronic health conditions.
Psychosocial History Assessment: Understanding access to food resources, financial ability to purchase nutritious foods, cultural preferences, and the patient's support system is vital.
Physical Assessment
external body assessment
Hair checking for alopecia, which can indicate zinc deficiency
skin: observe for edema, which can indicate a protein deficiency
nails check for abnormalities
musculoskeletal (muscle weakness, bone abnormalities)
neurological: lethargy
internal system
oral cavity: swollen/bleeding gums, lack of vitamin C
Blood status: check for anemia (iron, B12, folic acid, copper, vitamin E)
cardiac function: monitor for dysrhythmias and signs of MAG/calcium deficiency.
measurement
anthropometric measurements
food and fluid intake records
3-day cal intake assessment:
laboratory assessment
Complete Blood Count Parameters
hemoglobin (HGB) and Hematocrit (HCT) abnormalities indicate
low HCB suggests anemia, recent hemorrhage or hemodilution from fluid retention
Low HCT indicates anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis
elevated HCB and HCT
Protein Status Markers
Key protein measurements include:
serum albumin: nutritional status (2wks)
thyroxine-binding prealbumin for national status to monitor nutritional status
transferrin: iron transport
other
cholesterol levels: indicates malnutrition, sepsis, liver diseases, anemia, in stage cancer
total lymphocyte count: indicates what our immune system is doing
Total Enteral nutrition
inadequate for TEN
inadequate oral intake
advanced age complication
cancer therapy side effects
neuromuscular swallowing disorders
neurological conditions (stroke, severe head trauma, advanced MS)
Disorders requiring TEN
hemodynamic instability
diffuse peritonitis
intestinal obstruction
acute or chronic pancreatitis
Discontinuation
TEN should be discontinued when the pt regains adequate ability to meet nutritional needs through oral intake.
Administering TEN: feeding Tube options
Nasoenteric tube (NET)
used for less than 4-6 wks (provides short-term feeding)
suitable for temporary nutritional support
insertion through the nose to the stomach or small intestine
Types: NGT, NDT, NJT
Nasogastric tube (NGT)
most common short-term feeding tube
passed through the nose directly into the stomach
regular assessment of placement required
preferred option when stomach function is normal
Nasoduodenal/nasojejunal
nasoduodenal: passes from nose through stomach to duodenum
nasojejunal: extends further into the jejunum portion of small intestine
used when gastric feeding is contraindicated
good for pt with gastroparesis
reduces risk of aspiration in high-risk pt Elevates HOB 30 degrees
Administering TEN: feeding Tube options 2
percutaneous endoscopic gastrostomy (PEG): placed with the aid of an endoscope. common long-term feeding solution for extended (>4wks). surgically or endoscopically inserted into the stomach
Low-profile gastrostomy device: an alternative to standard PEG tube, also known as a skin-level gastrostomy tube, a more discreet option for long-term use
Jejunostomy tubes: beneficial for pt with high aspiration risk
types of feedings
Bolus feeding: intermittent feedings administered approximately every 4 hrs
continuous feeding
formula is admitted at a constant rate over 24 hr period using specialized infusion pumps to ensure precise flowrates
method provides consistent nutrient delivery and is generally better tolerated in acute care settings
65 cc per hr
30 cc of flushes every 2 hrs
lowers aspiration risk
Cyclic feeding
includes planned breaks in the feeding schedule, typically stooping for 6 hrs or longer within each 24-hr period
clamp break time delivered overnight
complications related to TEN
Tube occlusion= immediate intervention
most common mechanical complication, typically caused by improper flushing or med admin
refeeding syndrome
serious metabolic complications occurring when nutrition is restarted in malnourished pt
monitor new onset of confusion or seizures
assess for shallow respirations
increased muscle weakness
metabolic alterations
during starvation, the body breaks down proteins and fats for energy instead of carbs, leading to muscle wasting
dumping syndrome: gastronomy, gallbladder removal
dumping syndrome is a complication of enteral feeding where the stomach empties too quickly after a meal
N/V/D managed by slowing down feeding
residue shows if the pt is tolerating the feeding
other complications: include aspiration risk, diarrhea, electrolyte imbalances, and tube displacement
regularly assess for these issues
administering parenteral nutrition
partial parenteral nutrition
administered via peripheral IV or PICC line into a large vein
suitable for pt who can eat but can’t meet nutritional needs orally. 7-10 days
isotonic solutions 10% dextrose 5% amino acids
Total parenteral nutrition (TPN) central line only
administered via PICC, subclavian, or internal; jugular catheter
provides complete intensive nutritional support (needs to be on a pump)
Hypertonic solution: 10% dextrose or higher
change the feeding bag and tubing every 24 to 48 hrs
administer insulin as prescribed
TPN solution is temporarily unavailable, 10% dextrose/water (D10W) or 20% dextrose with water can be administered until TPN solution is obtained
monitor for fluid and electrolyte imbalances
monitor pt site for infection or infiltration
nursing considerations
maintain sterile technique
use strict aseptic technique for all line manipulations, dressing changes, and tubing changes to prevent central line-associated bloodstream infections (CLABSI)
change DRESSING on the central line every 48 to 72 hr
change IV TUBING every 24 hrs
lipids should not hang longer than 12 hrs
check vital signs every 4 hrs
monitor vital signs- check temp, HR, BP, RR every 4 hrs
check blood work- monitor electrolytes, high blood glucose, liver function tests, and CBC as ordered. report abnormal values immediately
manage infusion; verify pump settings, maintain ordered flow rate, and monitor fluids balance (don’t stop abruptly to prevent valve hypoglycemia)
maintain accurate fluid balance records including all parenteral nutrition, medications, oral intake, and output. (notify the provider of weight gain greater than 1 Kg/day)
complications of use
infection and sepsis
fever or elevated WBC count. can be a result of catheter contamination during insertion, contaminated solutions, or long-term indwelling catheters
metabolic complications
include hyperglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration from hyperosmolar diuresis, and fluid overload (weight gain> 1kg/day), edema
refeeding syndrome
fluid and electrolyte imbalances (k, Mg, Po4) when transitioning from a catabolic to an anabolic state (seen in a starvation state).
manifests as respiratory depression, confusion, seizures, weakness, arrhythmias, fluid retention, and acidosis
obesity as malnutrition
types of obesity
a chronic condition characterized by excess body fat, including
general overweight (BMI 25-29)
obesity (BMI 30 or greater)
central obesity (excessive abdominal fat distribution
Obesity classes
class 1: BMI 30 to <35
class 2 : BMI 35 to <40
class 3: BMI 40 or higher extreme obesity
metabolic impact
features dysregulation of adipokines leading to inflammation, insulin resistance, and altered metabolism throughout the body
obesity complications
cardiovascular: CAD, hypertension, hyperlipidemia
endocrine: diabetes, hormonal imbalances,
GI: fatty liver, reflux
musculoskeletal: joint pain, osteoarthritis
Respiratory: sleep apnea, SOB
etiology and genetic risk for obesity
drug therapy mechanism:
behavioral factors: physical inactivity, sedentary lifestyle, stress-related eating, consuming high-fat, high-cholesterol diets
environmental factors
genetic factors: family history, metabolism genes, and inherited traits, HX: depression, diabetes, stroke, joint/bone conditions, gallstones, stress, HTN, HLD
health promotion and maintenance
national health objective (table 55.7)
Healthy People 2020 and 2030 initiatives emphasize prevention and health promotion through lifestyle modifications and regular health screenings (weight management and exercise)
physical activity guidelines
start with walking 20 min daily- this simple activity can improve cardiovascular health, manage weight, and reduce stress
weight management benefits
even a modest 5% reduction in body weight can significantly decrease the risk of coronary artery disease and DM
role model effects
healthcare providers who demonstrate commitment to healthy behaviors are more likely to be viewed as credible sources of health education by their patients
RESPECT: Obesity Assessment History
Rapports
economic status
usual intake: diet pattern
culture
medication
family history
previous attempts
economic status
eating behaviors
chronic conditions
activity level
developmental level
physical assessment
basic anthropometric measurements
height, weight, BMI calculations
Body circumference measurements
waist, arm, and calf circumferences; waist-to-hip radio t
skin assessment
evaluate skinfold thickness and examine skin conditions, particularly in fold areas
interventions for obesity
reduced-cal diet
behavior modification
physical activity
OTC med: Orlistat (Alli) helps with fat absorption limitation
prescription medications
orlistat
inhibits the digestion of fats by blocking gastric and pancreatic lipases.
adverse effects: oily rectal discharge, flatulence, and reduced absorption of vitamins
psyllium( Metamucil), a bulk-forming laxative, can increase fat absorption and decrease GI side effects
side effect: Gas, bloating
precautions; difficulty swallowing, bowel obstruction
nursing implication: educate on mixing with adequate fluid; monitor bowel habits
pts should take a multivitamin to prevent deficiencies
lorcaserin
phentermine-topiramate
suppresses appetite and induces satiety.
adverse effects: headaches, dry mouth, constipation, nausea, and insomnia
contraindicated in pt with hyperthyroidism, glaucoma, taking MAO inhibitors
Take med early in the day to avoid insomnia
liraglutide
suppresses appetite and slow gastric emptying
adverse effects: N/V, hypoglycemia. avoid use for type 2 diabetes
naltrexone-bupropion
suppresses appetite and decreases cravings
adverse effects: constipation, nausea, and dry mouth
contraindicated in pt with uncontrolled hypertension, eating disorders, seizures, or taking MAO inhibitors
avoid high-fat meals to prevent increased drug concentrations
monitors for suicidal ideation due to bupropion’s antidepressant effects
surgical interventions: bariatric
preop care: the nurse’s primary role is to reinforce health education and prepare the patient for surgery
operative procedure
gastric restrictive: reduce stomach vol, so you eat less and get full faster
malabsorptive: interfering with nutrients in the Gi tract
some procedures combine both restrictive and malabsorptive elements
post op care
the type of postop care depends on the specific bariatric procedure performed
types of procedure
gastric banding
gastric banding is a reversible, less invasive bariatric procedure that involves placing an adjustable band around the upper stomach to create a small pouch, limiting food intake. regular follow-up and monitoring are essential for optimal results (restrictive)
Sleeve gastrectomy (not reversible)
a surgical procedure that removes approximately 80% of the stomach, creating a smaller, sleeve-shaped stomach to limit food intake
Roux-en Y bypass (for quick weightloss)
a combination procedure that both reduces stomach size and reroutes the small intestine to limits food intake and absorption
stomach, duodenum and part of the jejunum are bypassed so fewer cal are absorbed
most invasive, increase risk for post-up, increase the risk for malnutrition
dumping syndrome may be on supplements for the rest of their lives
post-bariatric surgery care
airway management: priority due to compromised airways
patient and staff safety
skin integrity: wound healing, pressure between skinfold
nutrition progression: start with clear liquids, then progress to full liquids, and pureed foods for 6 wks, then focus on regular nutrient-dense foods like lean proteins, fruits, vegetables, and whole grains
nutrient monitoring
regular lab tests are essential to monitor levels of key nutrients and electrolytes after bariatric surgery
B12, iron, calcium, vitamin D, and folic acid deficiency
special considerations after bariatric surgery
abdominal binder- provides supported compression after surgery,
semi-fowlers position 30 to 45 degrees
sao2 monitoring
compression Hose and heparin: use sequential compression devices and/or administer heparin to prevent DVT
skin assessment: signs of pressure, irritation breakdown, using padding
absorbent padding
urinary catheter removal: within 24 hrs of surgery
early mobilization as soon as possible to prevent DVT, gate belt
abdominal girth monitoring: internal bleeding, swelling, edema
frequent small feedings: provide the pt with 6 small, frequent feedings to prevent dehydration
dumping syndrome: observe for signs of dumping syndrome, including tachycardia, Nausea, diarrhea, and abdominal cramping (gastric bypass)
complications after bariatric surgery
anastomotic leak: frequent, serious complications of gastric bypass surgery that is a life-threatening emergency
monitor for signs like increasing back/shoulder/ abdominal pain, restlessness, tachycardia, and oliguria. notify the provider immediately
malabsorption/malnutrition
bariatric surgeries reduce stomach size or bypass parts of the intestines, leading to fewer nutrients being ingested and absorbed
common nutrient deficiencies include vitamin B12, vitamin D, thiamine, calcium, iron, and folate
dehydration
warn the pt that excessive thirst or concentrated urine can indicate dehydration, and the surgeon should be notified
work with the pt to establish goals for adequate daily fluid intake of at least 1.5 L
nursing actions
monitor the pt’s tolerance to increasing food and fluids
refer the clients for dietary management
encourage meals in a low-fowler’s position for 30 minutes after eating to delay stomach emptying and minimize dumping syndrome
client education
protein needs maybe 60-80g per day, depending on the ideal body weight
eat only nutrition-dense foods, avoid empty cal (colas and fruit juice drinks), and limit carb
take vitamin and mineral supplements for life.