Transcript File - Brittany Wrasman`s Portfolio

Malnutrition Associated With
Chronic Disease
KNH 411
Brittany Wrasman
December 3, 2013
What is Malnutrition?
• Defined by the International Dietetics and
Nutrition Terminology as:
▫ “Inadequate intake of protein and/or
energy over prolonged periods of time
resulting in loss of fat stores and/or muscle
wasting including starvation-related
malnutrition, chronic disease-related
malnutrition, and acute disease or injury
related malnutrition.”
Diagnosis of Adult Malnutrition in
Clinical Setting
Nutritional Risk
Identified
(compromised
intake or loss of
body mass)
Inflammation
Present?
No
Yes (mild to
moderate degree)
Yes (marked
inflammatory
response)
Starvation-Related
Malnutrition
Chronic DiseaseRelated
Malnutrition
Acute Disease or
Injury-Related
Malnutrition
Laboratory Values Used to Confirm
Inflammation
• Positive Acute-Phase Proteins
▫
▫
▫
▫
Fibronectin
C-reactive protein
Ceruloplasmin
Serum amyloid
• Visceral Proteins
▫ Albumin
▫ Prealbumin
Changes in Metabolism in Response to
Starvation
•
•
•
•
•
Decrease in overall energy need.
Metabolic rate decreases 20-25 kcal/kg/day
Energy from fat storage >90% of kcal
Energy from protein <10% for gluconeogenesis
Hormone adaptation preserves protein stores.
Patient Description
• Harry Campbell, 68 y.o., Male
• Height: 6’3”
• Current Weight: 156 lbs.; BMI: 19.6 kg/m2
▫ UBW: 220 lbs.
▫ %UBW: 70.9%
▫ % Weight Change: 29.1%
• Admitted to acute care for possible dehydration,
weight loss, generalized weakness, and
malnutrition.
• Ordered a mechanical soft diet and started on
I.V. fluids.
Patient’s Diagnosis
• Chronic-Disease Related Malnutrition
▫ Supported by:
 Patient’s energy intake of <75% of estimated energy
requirements for >1 month.
 Patient’s 29.1% weight change in the past 2 years.
 Patient’s decrease muscle tone and loss of lean mass in his
quadriceps and gastrocnemius.
 Lab results indicating inflammation:
 Elevated C-reactive protein level of 2.4 mg/dL
 Low albumin (1.8 g/dL) and pre-albumin (9 mg/dL) levels
Support of Dehydration
•
•
•
•
•
•
•
Patient feels lethargic
Skin turgor: TENT
Receiving only 360 mL of fluid orally
High Sodium and Chloride levels
Low Potassium Levels
Elevated BUN and Creatinine Serum levels
Slightly elevated specific gravity in urinalysis
Braden Score
• A Braden scale is used score a patient’s level of risk
for developing pressure ulcers.
• The Braden Scale measures six risk factors:
▫
▫
▫
▫
▫
▫
Sensory pressure
Moisture
Activity
Mobility
Nutrition
Friction/shear,
• Scored on a scale of 1-4 (1 for low level of
functioning and 4 for the highest level or no
impairment).
• Total scores range from 6-23 (friction/shear is
scored with values of 1-3, only).
Nutrition
•
•
•
•
EER: 1,850-2,050 kcal/day
EPR: 106-142 grams
Fluid Requirements: 1,850- 2,050 mL/day
Usual Dietary Intake:
▫ ~582 calories/day
▫ 30 grams PRO
• Ordered a mechanical soft diet upon admission
• Intake % of meals: <5%; sips of liquid
• Intake/Output
▫ Intake: P.O.= 360 mL; I.V.= 2,160 mL
▫ Output: 1,444 mL
▫ Net I/O= +1,076 mL
Usual Dietary Intake
Nutrition Diagnoses
• Malnutrition (NI-5.2)
• Unintended Weight Loss (NC-3.2)
• Inadequate Energy Intake (NI-1.2)
Malnutrition (NI-5.2)
▫ Malnutrition related to chronic disease (squamous
cell carcinoma of tongue) as evidenced by patient’s
unintentional weight loss of 29.1% of his usual
body weight in the past 1-2 years, patient’s
insufficient energy intake over the past several
months, patient’s lack of appetite, patient’s
decreased muscle tone and loss of lean mass in his
quadriceps and gastrocnemius, and patient’s
prealbumin level of 9 mg/dL.
Unintended Weight Loss (NC-3.2)
▫ Unintended weight loss related to client’s inability
to consume sufficient energy as evidenced by a
29.1% weight change within the last two years,
client’s decreased appetite over the last several
months, patient’s decreased muscle tone and loss
of lean mass in his quadriceps and gastrocnemius,
and patient’s partial glossectomy 5 years ago.
Inadequate Energy Intake (NI-1.2)
▫ Inadequate energy intake related to patient’s
decreased ability to consume sufficient energy as
evidenced by patient’s 29.1% weight change within
the last two years, client’s decreased appetite over
the last several months, patient’s failure to
consume estimated needs from diet, and patient’s
partial glossectomy 5 years ago.
Intervention
• Enteral Nutrition
▫ 1500 mL Isosource HN




1,800 kcal
80 g protein
240 g carbohydrate
58.5 g fat
▫ Goal rate= 63 cc/hr
▫ Start: 32 cc/hr, increasing by 10 cc every 3 hours until
goal is reached.
▫ After tolerance is established, bolus feeds (250 cc),
6x’s/day will be initiated.
▫ Once this is tolerated, bolus feeds (375 cc), 4 x’s/day will
be implemented.
Monitoring/Evaluation
• Sufficiency of nutrient intake: intake/output
• Hydration Status
▫ Electroyltes, BUN, creatinine
• Electrolyte Balance
▫ Magnesium, phosphorus, calcium
•
•
•
•
Weight
Bowel Function
Blood Glucose
Nitrogen Balance
Questions?
References
2014 ICD-10-CM diagnosis codes E40-E46: Malnutrition. (n.d.). Retrieved from
http://www.icd10data.com/ICD10CM/Codes/E00-E89/E40-E46
Academy of Nutrition and Dietetics (2013). Pocket guide for international dietetics & nutrition
terminology (IDNT) reference manual: Standardized language for the nutrition care process.
Chicago, Ill: Academy of Nutrition and Dietetics.
Dixon, M. (2012). Caring~Web: Education and support for caregivers of stroke survivors. Retrieved
from http://caringweb.utoledo.edu/softdiet.html
Hamilton, C., & Boyce, V. (2013). Addressing malnutrition in hospitalized adults. Journal of Parenteral
and Enteral Nutrition, 1-8. Retrieved from
http://malnutrition.andjrnl.org/Content/articles/Hamilton-Addressing.pdf
Jensen, G., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, A., Grijalba, R., & Waitzberg, D. (2010). Adult
starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical
practice setting from the International Consensus Guideline Committee. Clinical Nutrition, 29(2),
151-153. doi:10.1016/j.clnu.2009.11.010
Mahan, L. K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy.
Philadelphia: Saunders.
Marcason, W. (2012). Malnutrition: Where do we stand in acute care? Journal of the Academy of
Nutrition and Dietetics, 200. Retrieved from http://malnutrition.andjrnl.org/Content/articles/4Malnutrition_where.pdf
References Cont.
Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study approach. Stamford,
Connecticut: Cengage Learning.
Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and pathophysiology
(2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Nestle Nutrition. (n.d.) Your source chart: Product reference guide. U.S. National Library of Medicine
(2013). 2012AB Braden Scale source information. Retrieved from
http://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/
U.S. National Library of Medicine (2011). Dehydration: MedlinePlus Medical Encyclopedia. Retrieved
from http://www.nlm.nih.gov/medlineplus/ency/article/000982.htm
USDA (2013). SuperTracker. Retrieved from
https://www.supertracker.usda.gov/foodtracker.aspx?CatgoryID=-1&FoodDescription=Ensure+Plus
Sonora Quest Laboratories (2013). Understanding the Complete Blood Count. Retrieved from
http://www.sonoraquest.com/test-information/understanding-the-complete-blood-countcbc/?AspxAutoDetectCookieSupport=1
White, J., Guenter, P., Jensen, G., Malone, A., Schofield, M., The Academy Malnutrition Work Group,
The A.S.P.E.N. Malnutrition Task Force, & The A.S.P.E.N. Board of Directors (2012). Consensus
statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral
Nutrition: Characteristics recommended for the identification and documentation of adult
malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
Retrieved from http://malnutrition.andjrnl.org/Content/articles/1-Consensus_Statement.pdf