LEWIS, S., DIRKSEN, S., HEITKEMPER,M., BUCHER, L. & CAMERA,I.(2011). MEDICAL SURGICAL

NURSING. ST LOUIS, MO:MOSBY

Nutritional Problems

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.

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]

Carbohydrate

Carbohydrates

14 grams of dietary fiber from fruits, vegetables, and whole grains per 1000 calories/day

Healthy bowels and prevents constipationChoose food with little or no added sugar or

caloric sweeteners

Nutrition - Fats

Fats- 1 gram = 9 caloriesStored in the adipose tissue of the abdominal

cavityMajor source of energyAct as insulation, reduces body heat lossPadding and protection for vital organs in

abdomenCarriers of essential fatty acids and fat soluble

vitaminsSlow digestion = satiety; delays hunger36% of daily caloric intake in America= CONCERN

Should be 20 to less than 35%

Fat Trio

Trans fatty acid

Trans fats banned in NYC and Boston: Major food Sources of trans fat

Cardiac Concerns Avoid Artery Clogging Trans fat = use vegetable oil

Trans fat and nursing education!

Trans fats

Nutrition - Proteins

Average adult needs = 20-35 calories per kilogram/day

Proteins should provide 15 -20% of caloric intakeProteins = tissue, body regulatory function, energyProteins are complex nitrogenous organic compounds:Amino acids are the fundamental unit of structure22 amino acids: 9 essential complete proteins

Availability depends on diet aloneand non-essential/incomplete proteins

Complete ProteinsComplete Proteins Incomplete ProteinsIncomplete Proteins

Milk and milk products

EggsFishMeatspoultry

GrainsLegumesNutsseeds

Protein Sources

Protein Wasting in Dehydration

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 solubleFat soluble: A, D, E, KWater soluble: B1, B6, Cobalamin B12, C,

Folate (folic acid)

Major MineralsMajor Minerals Trace ElementsTrace Elements

CalciumChlorideMagnesiumPhosphorusPotassiumSodiumsulfur

ChromiumCopper FluorideIodine [fish/shellfish]ManganeseMolybdenum-

chocolateSeleniumzinc

Major Minerals and Trace Elements

Malnutrition

Conditions that increase the risk for malnutrition

Dementia, depressionSocioeconomic factors- food insecurityChronic alcoholismExcessive dieting to lose weight, eating disordersSwallowing disordersDecreased ability to do ADLs, decreased mobilitydrugs: corticosteroids, antibioticsStressors: burns, trauma, fever, woundsNo oral intake or IV solutions for 10 days- 5 days

geriMalabsorption syndrome

Types of Malnutrition

Protein-calorie: most common formMarasmus: 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

Starvation

97% of calories are from fat and protein is conserved

Fat stores used up in 4 – 6 weeksBody 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!

FeverIncreases 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

ANOREXIA NERVOSAANOREXIA NERVOSA BULEMIA NERVOSABULEMIA NERVOSA

Self-imposed wt lossMiddle-upper

class/whiteDeliberate starvationFear of wt gains/s = Hair loss,

sensitivity to cold, dry skin, constipation, elevated BUN, low K, body wasting and malnutrion

Binge and purgeWhiteLaxative/drug/

exercise abuseAnxiety, affective

disorders, conceal problem

s/s = dental problems, broken blood vessels in eyes, macerated knuckles

Eating Disorders

Clinical Manifestations of malnutrition

Muscles wasted and flabbyWeaknessIrritability/ confusionFatigueDelayed recovery and wound healingIncreased susceptibility to infectionRisk increases for anemiaLab analysis:Low serum prealbumin and lymphocyte

countElevated potassium and liver enzymes

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

Interventions to prevent malnutrition

A key intervention is daily weight/ same time q day

Daily calorie countFrequent small mealsOral nutrition supplementsEnteral nutrition [tube feeding]Parenteral nutrition [PN] - procalamineTotal parenteral nutrition [TPN]

fat emulsion, dextrose, amino acids

Refeeding Syndrome

Can occur any time a malnourished patient is started on aggressive nutritional support

s/s: fluid retention, electrolyte imbalancesHypophosphatemia is the hallmark s/s dysrhythmias, respiratory arrest,

neurologic disturbances

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?

1.Change the clients diet to full liquid2.Offer small amounts of food frequently*3.Administer 4 mg zofran IV 1h prior to chemo*4.Encourage liquid consumption throughout the

day*5.Serve a big meal prior to chemo6.Offer foods that are mild smelling or odorless*

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) – procalamineLong term = central PN (TPN) Note- always keep TPN refrigerated until

use. Change bag, line, and filter every 24 hNever connect another line into TPN!!!!!

Indications for Tube Feedings

Anorexia patientsOrofacial fracturesHead and neck CANeurological or psychological conditions that

prevent oral intakeExtensive burnsChemotherapyEnteral nutrition is Safer than parenteral

nutrition

Nasogastric Tubes

Small diameter, soft and flexibleRadiopaque to assess position with X-raySmaller than standard decompression NG tubeAssess 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

Gastrostomy and Jejunostomy

Long Term Enteral Nutrition

Percutaneous endoscopic gastrostomy (PEG)Always check placement before usingAssess 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

Nursing Management of Feeding Tubes

Check placement before each feeding and medicationContinuous: start at a low rate and increase gradually for

24-48h to minimize side effectsAssess 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 afterDilute viscous liquid medicationElevate HOB 30 – 45 degrees: and for 30- 60 min pDiscard feedings after 8 h. Change tubing q 24 hCheck residuals volumes and gastric emptying, flush p

check

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 toleranceConstipation or impaction: to prevent - give water to

at regular intervalsDehydration: from diarrhea, vomiting, too little H2OResidual > 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!

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

Nursing Diagnosis

Risk for aspirationCheck residual q4-6h for first 24h, then q 8 hoursHold tube feedings if residual is > 500 and

reassessElevate HOB 30-45 degrees during feedings and 30-60 min after feedingsAssess for gastric retention symptoms: sensation

of fullness, nausea, vomitingDiscontinue feedings 30-60 min before laying

patient supine

Gerontologic Considerations

More vulnerable to complications:More vulnerable to fluid and electrolyte

imbalancesDecreased perception of thirst Impaired cognition; ability to manage home careMore susceptible to hyperglycemiaMore susceptible to fluid overload due to poor

cardiac (CHF) or decreased renal functionDecreased ability to tolerate large fluid volumes

of feedingsIncreased risk for aspiration

Indications for Parenteral Nutrition

Chronic severe diarrhea or vomiting

Complicated surgery or trauma

GI obstructionGI anomalies or fistulasIntractable diarrheaSevere anorexia nervosaSevere malabsorptionShort bowel syndrome

Peripheral Parenteral Nutrition (PPN)

IV with large veinProcalamine: protein and caloriesShort term therapy nutritional supportTends 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

Total Parenteral Nutrition (TPN)

Hypertonic solution (vesicant) = glucose, crystalline amino acids, fat emulsion, minerals, vitamins

Adjusted per individual by MD every dayContains, Na, K, Cl, Mg, Ca, Phosphate and trace

elements as per pt needsOnly administered through a central line or PICC If need to wait for another bag of solution use 5-

10% dextrose IVNever D/C suddenly; taperMonitor blood glucose q 6h

Complications of Parenteral Nutrition

Risk for Infection: fungus, gram pos and neg bacteriaMetabolic problems: hyperglycemia, hypoglycemia, prerenal azotemia

(presence of nitrogen, urea, in the blood), essential fatty acid deficiency

electrolyte imbalances, mineral deficiencies, hyperlipidemia

= why TPN is reformulated every day by MDMechanical problems: During insertion = air embolus, pneumothorax,

hemorrhage Dislodgement Thrombus of vein Phlebitis

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 peripherallyChest X-ray to detect change in pulmonary

statusAntibiotics if indicated

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

Nursing management of parenteral nutrition: Review

Assess VS q 4-8h and siteDaily weightKeep refrigerated until use- never add other

solutions to lineChange line, filter, and solution q 24hMake sure MD writes script for next dayIf not available hang 10% dextroseBS check q 6hMonitor for S/S of infection of site and of line (CA

pts)labs: glucose, electrolytes, urea nitrogen, CBC,

hepatic enzyme studies