Nutritional Problems LEWIS, S., DIRKSEN, S., HEITKEMPER,M., BUCHER, L. & CAMERA,I.(2011). MEDICAL SURGICAL NURSING.
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Transcript Nutritional Problems LEWIS, S., DIRKSEN, S., HEITKEMPER,M., BUCHER, L. & CAMERA,I.(2011). MEDICAL SURGICAL NURSING.
Nutritional Problems
LEWIS, S., DIRKSEN, S., HEITKEMPER,M.,
BUCHER, L. & CAMERA,I.(2011). MEDICAL
SURGICAL NURSING. ST LOUIS, MO:MOSBY
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 constipation
Choose food with little or no added sugar or caloric
sweeteners
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%
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 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
Protein Sources
Complete Proteins
Incomplete Proteins
Milk and milk products
Grains
Eggs
Legumes
Fish
Nuts
Meats
seeds
poultry
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 soluble
Fat soluble: A, D, E, K
Water soluble: B1, B6, Cobalamin B12, C, Folate
(folic acid)
Major Minerals and Trace Elements
Major Minerals
Trace Elements
Calcium
Chromium
Chloride
Copper
Magnesium
Fluoride
Phosphorus
Potassium
Sodium
sulfur
Iodine [fish/shellfish]
Manganese
Molybdenum-chocolate
Selenium
zinc
Malnutrition
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
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
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!
Fever
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
Eating Disorders
ANOREXIA NERVOSA
BULEMIA NERVOSA
Self-imposed wt loss
Middle-upper
Binge and purge
White
Laxative/drug/exercise
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
abuse
Anxiety, affective
disorders, conceal
problem
s/s = dental problems,
broken blood vessels in
eyes, macerated knuckles
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
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 count
Frequent small meals
Oral nutrition supplements
Enteral nutrition [tube feeding]
Parenteral nutrition [PN] - procalamine
Total 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 imbalances
Hypophosphatemia 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 liquid
2. 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 chemo
6. 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) – 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!!!!!
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
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
Gastrostomy and Jejunostomy
Long Term Enteral Nutrition
Percutaneous endoscopic gastrostomy (PEG)
Always check placement before using
Assess for return of bowel sounds before usingusually 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 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
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!
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 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
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
Indications for
Parenteral
Nutrition
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
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
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
Complications of Parenteral Nutrition
Risk for Infection: fungus, gram pos and neg bacteria
Metabolic 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 MD
Mechanical 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 peripherally
Chest X-ray to detect change in pulmonary status
Antibiotics 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 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