Nutritional Problems

1. Nutritional Problems Lewis, S., Dirksen, S., Heitkemper,M., Bucher, L. & Camera,I.(2011). Medical Surgical NursinG. St Louis, MO:Mosby

2. Learning Objectives Explain the essential components of a nutritionally good diet and their importance to health maintenance. Describe and analyze the common etiologic factors, clinical manifestations, and nursing and collaborative management of malnutrition. Explain the indications for use, complications, and nursing management of enteral nutrition. Identify the types of feeding tubes and related nursing management, inclusive of collaborative care. Define and evaluate using the clinical reasoning process the indications, complications, and nursing management related to parenteral nutrition.   Compare and analyze the etiologic factors, clinical manifestations, and nursing management of eating disorders.

3. Nutrition- Carbohydrates • The process by which the body uses food for energy, growth, and maintenance of body tissues • Essential components: carbohydrates, fats, proteins, vitamins, and minerals • Average adult needs 20-35 calories per kilogram of weight/day • Carbohydrates = primary energy source: 45-60% of total caloric intake: protein sparing ingredient • SIMPLE • Monosacharides = glucose and fructose [honey & fruit] • Disacharides = complex; sucrose, maltose, lactose [sugar & milk] COMPLEX : starches [cereal, potatoes, legumes]

4. Carbohydrate

5. Carbohydrates • 14 grams of dietary fiber from fruits, vegetables, and whole grains per 1000 calories/day • Healthy bowels and prevents constipation • Choose food with little or no added sugar or caloric sweeteners

6. Nutrition - Fats • Fats- 1 gram = 9 calories • Stored in the adipose tissue of the abdominal cavity • Major source of energy • Act as insulation, reduces body heat loss • Padding and protection for vital organs in abdomen • Carriers of essential fatty acids and fat soluble vitamins • Slow digestion = satiety; delays hunger • 36% of daily caloric intake in America= CONCERN Should be 20 to less than 35%

7. Fat Trio

8. Trans fatty acid

9. Trans fats banned in NYC and Boston: Major food Sourcesoftrans fat

10. Cardiac Concerns Avoid Artery Clogging Trans fat = use vegetable oil

11. Trans fat and nursing education!

12. Trans fats

13. Nutrition - Proteins • Average adult needs = 20-35 calories per kilogram/day • Proteins should provide 15 -20% of caloric intake • Proteins = tissue, body regulatory function, energy Proteins are complex nitrogenous organic compounds: • Amino acids are the fundamental unit of structure • 22 amino acids: 9 essential complete proteins • Availability depends on diet alone • and non-essential/incomplete proteins

14. Protein Sources Complete Proteins Incomplete Proteins • Milk and milk products • Eggs • Fish • Meats • poultry • Grains • Legumes • Nuts • seeds

15. Protein Wasting in Dehydration

16. Vitamins • Organic compounds required in small amounts for metabolism • Catalysts for enzyme reactions that facilitate metabolism of carbohydrates, fats, and proteins • Two categories = fat or water soluble • Fat soluble: A, D, E, K • Water soluble: B1, B6, Cobalamin B12, C, Folate (folic acid)

17. Major Minerals and Trace Elements Major Minerals Trace Elements • Calcium • Chloride • Magnesium • Phosphorus • Potassium • Sodium • sulfur • Chromium • Copper • Fluoride • Iodine [fish/shellfish] • Manganese • Molybdenum-chocolate • Selenium • zinc

18. Malnutrition

19. Conditions that increase the risk for malnutrition • Dementia, depression • Socioeconomic factors- food insecurity • Chronic alcoholism • Excessive dieting to lose weight, eating disorders • Swallowing disorders • Decreased ability to do ADLs, decreased mobility • drugs: corticosteroids, antibiotics • Stressors: burns, trauma, fever, wounds • No oral intake or IV solutions for 10 days- 5 days geri • Malabsorption syndrome

20. Types of Malnutrition • Protein-calorie: most common form • Marasmus: generalized loss of body fat and muscle from protein and carbohydrate deficiency • Kwashiorkor: stress [GI obstruction, surgery, cancer, malabsorption, infectious disease] and protein deficiency • S/S appear well nourished = low serum protein levels Malnutrition Lab value: prealbumin levels drop – normal = 20 low < 5

21. Starvation • 97% of calories are from fat and protein is conserved • Fat stores used up in 4 – 6 weeks • Body proteins in internal organs and plasma are used; then rapidly decrease • Causes liver dysfunction and loss of liver mass • Causes shift in body fluids from the vascular fluid to the interstitial spaces = edema in face and legs • Skin appears dry and wrinkled • Failure of the sodium potassium pump (20- 50% of all ingested calories) as energy is needed / cells engorge • Death will be rapid : CA patients on chemo • Nursing measure; encourage eating!

22. Increases need for calories due to the increase in the bodies metabolic rate [BMR] • 1 degree = raises BMR 7%! • Thus without an increase in calories = a significant problem • Monitor serum protein levels: prealbumin is best Fever

23. Eating Disorders ANOREXIA NERVOSA BULEMIA NERVOSA • Self-imposed wt loss • Middle-upper class/white • Deliberate starvation • Fear of wt gain • s/s = Hair loss, sensitivity to cold, dry skin, constipation, elevated BUN, low K, body wasting and malnutrion • Binge and purge • White • Laxative/drug/exercise abuse • Anxiety, affective disorders, conceal problem • s/s = dental problems, broken blood vessels in eyes, macerated knuckles

24. Clinical Manifestations of malnutrition • Muscles wasted and flabby • Weakness • Irritability/ confusion • Fatigue • Delayed recovery and wound healing • Increased susceptibility to infection • Risk increases for anemia Lab analysis: • Low serum prealbumin and lymphocyte count • Elevated potassium and liver enzymes

25. Nursing Management/ Malnutrition • Nutritional screening: to determine need for a more thorough nutrition assessment • BMI = weight[kg] x height [squared in m] • Nursing Dx • Imbalanced nutrition • Self –care deficit • Constipation or diarrhea • Fluid volume deficit • Risk for impaired skin integrity • Non-compliance • Activity intolerance

26. Interventions to prevent malnutrition • A key intervention is daily weight/ same time q day • Daily calorie count • Frequent small meals • Oral nutrition supplements • Enteral nutrition [tube feeding] • Parenteral nutrition [PN] - procalamine • Total parenteral nutrition [TPN] fat emulsion, dextrose, amino acids

27. Refeeding Syndrome • Can occur any time a malnourished patient is started on aggressive nutritional support • s/s: fluid retention, electrolyte imbalances • Hypophosphatemia is the hallmark • s/s dysrhythmias, respiratory arrest, neurologic disturbances

28. NCLEX Question • A client receiving chemotherapy is experiencing persistent nausea and occasional vomiting. Based on these symptoms, which interventions should the nurse add to this client’s plan of care? • Change the clients diet to full liquid • Offer small amounts of food frequently* • Administer 4 mg zofran IV 1h prior to chemo* • Encourage liquid consumption throughout the day* • Serve a big meal prior to chemo • Offer foods that are mild smelling or odorless*

29. Nutrition Assessment for supplemental feedings • Functional GI tract: • Yes = enteral nutrition • Long term = gastrostomy or jejunostomy tube • Short term = nasogastric tube NO = parenteral nutrition (PN) Short term = peripheral (PN) – procalamine Long term = central PN (TPN) Note- always keep TPN refrigerated until use. Change bag, line, and filter every 24 h Never connect another line into TPN!!!!!

30. Indications for Tube Feedings • Anorexia patients • Orofacial fractures • Head and neck CA • Neurological or psychological conditions that prevent oral intake • Extensive burns • Chemotherapy • Enteral nutrition is Safer than parenteral nutrition

31. Nasogastric Tubes • Small diameter, soft and flexible • Radiopaque to assess position with X-ray • Smaller than standard decompression NG tube • Assess for patency as easily clogged, flush regularly, *flush following medication administration • Administer meds one at a time • Crush and mix all meds with water/sterile water is best * Flush after checking residual

32. Gastrostomy and Jejunostomy

33. Long Term Enteral Nutrition Percutaneous endoscopic gastrostomy (PEG) • Always check placement before using • Assess for return of bowel sounds before using- usually within 24 h of placement (water can be given within 2 h of placement) • Usually attached to a feeding pump for continuous feeding

34. Nursing Management of Feeding Tubes • Check placement before each feeding and medication • Continuous: start at a low rate and increase gradually for 24-48h to minimize side effects • Assess for bowel sounds before feeding. > or = 30ml syringe • Use liquid medications if possible/ crush pills thoroughly, give one at a time, dissolve in H2O (sterile water is best) • First stop enteral feeding - flush with 15ml prior to giving medication and after • Dilute viscous liquid medication • Elevate HOB 30 – 45 degrees: and for 30- 60 min p • Discard feedings after 8 h. Change tubing q 24 h • Check residuals volumes and gastric emptying, flush p check

35. Complications of Tube Feedings • Aspiration – too much feeding, too large a residual- delayed gastric emptying • Diarrhea- poor tolerance, too rapid, too cold (give at room temperature), fiber content too low • Abdominal distention – too much, too fast, or obstruction • Hyperglycemia – too high calorie for tolerance • Constipation or impaction: to prevent - give water to at regular intervals • Dehydration: from diarrhea, vomiting, too little H2O • Residual > 500 ml = hold next feeding for 1 h and recheck; always reinstill aspirate ( if no other adverse s/s such as nausea, abdominal distention) and flush!

36. Nursing Diagnosis • Imbalanced nutrition less than body requirements related to . . . Assess: weight/ height, Hct, muscle tone, food intake, hydration, bowel sounds, diarrhea, follow protocol Collaborate with the dietician • Risk for aspiration related to . . . Prevention: HOB elevated, check residuals, assess tube placement, leave HOB elevated for 30-60 min p feeding Assess for sensation of fullness, nausea, vomiting because these are signs of gastric retention

37. Nursing Diagnosis • Risk for aspiration Check residual q4-6h for first 24h, then q 8 hours Hold tube feedings if residual is > 500 and reassess Elevate HOB 30-45 degrees during feedings and 30-60 min after feedings Assess for gastric retention symptoms: sensation of fullness, nausea, vomiting Discontinue feedings 30-60 min before laying patient supine

38. Gerontologic Considerations More vulnerable to complications: • More vulnerable to fluid and electrolyte imbalances • Decreased perception of thirst • Impaired cognition; ability to manage home care • More susceptible to hyperglycemia • More susceptible to fluid overload due to poor cardiac (CHF) or decreased renal function • Decreased ability to tolerate large fluid volumes of feedings • Increased risk for aspiration

39. Chronic severe diarrhea or vomiting • Complicated surgery or trauma • GI obstruction • GI anomalies or fistulas • Intractable diarrhea • Severe anorexia nervosa • Severe malabsorption • Short bowel syndrome Indications for Parenteral Nutrition

40. Peripheral Parenteral Nutrition (PPN) • IV with large vein • Procalamine: protein and calories • Short term therapy nutritional support • Tends to easily burn vein (vesicant) = assess vein for redness, pain, irritation, and thrombophlebitis • Can cause fluid overload • Monitor for jugular vein distention, elevated B/P, crackles during lung auscultation, SOB

41. Total Parenteral Nutrition (TPN) • Hypertonic solution (vesicant) = glucose, crystalline amino acids, fat emulsion, minerals, vitamins • Adjusted per individual by MD every day • Contains, Na, K, Cl, Mg, Ca, Phosphate and trace elements as per pt needs • Only administered through a central line or PICC • If need to wait for another bag of solution use 5-10% dextrose IV • Never D/C suddenly; taper • Monitor blood glucose q 6h

42. Complications of Parenteral Nutrition Risk for Infection: fungus, gram pos and neg bacteria Metabolic problems: • hyperglycemia, hypoglycemia, prerenalazotemia (presence of nitrogen, urea, in the blood), essential fatty acid deficiency • electrolyteimbalances, mineral deficiencies, hyperlipidemia = why TPN is reformulated every day by MD Mechanical problems: During insertion = air embolus, pneumothorax, hemorrhage Dislodgement Thrombus of vein Phlebitis

43. Catheter Related Infection • Assess site for : erythema, tenderness, exudate • Assess systemic: fever, chills, nausea, vomiting, malaise Patient has s/s = • Culture blood and tip of catheter: 2 blood cultures - from catheter and peripherally • Chest X-ray to detect change in pulmonary status • Antibiotics if indicated

44. Nursing Diagnosis • Risk for infection related to central line placement . . • monitor for s/s of infection, assess and document site findings q 4-8h Infection severity: fever, malaise, blood culture colonization, wound/ feeding culture colonization, WBC elevation (cancer patients may be difficult to assess due to poor immune response/low WBCs) Infection control: maintain an aseptic environment: sterile dressing changes, change tubing and filter q 24h Check lab values for s/s of infection: high WBC and increased neutrophil count

45. Nursing management of parenteral nutrition: Review • Assess VS q 4-8h and site • Daily weight • Keep refrigerated until use- never add other solutions to line • Change line, filter, and solution q 24h • Make sure MD writes script for next day • If not available hang 10% dextrose • BS check q 6h • Monitor for S/S of infection of site and of line (CA pts) • labs: glucose, electrolytes, urea nitrogen, CBC, hepatic enzyme studies