This is Chapter 52, Care of Patients with Malnutrition, Undernutrition, and Obesity. The primary concept is nutrition, and the secondary concept is going to be fluid and electrolyte balance. There are several guides for good nutrition. First, the Dietary Reference Intakes, or DRIs.
This is a nutrition guide based on age, gender, and life stage. Dietary guidelines for American are drafted by the U.S. Department of Agriculture and the U.S.
Department of Health and Human Services. To start simple with my plate, it uses a pictorial demonstration of how to pretty much fill and build a healthy plate of food. And then the Canada Food Guide also provides visual reference.
First, it's important to understand that there's no typical diet that applies across the board. People may have diet preferences. Box 52.2 describes different vegetarian types of diets, and patients may complain of food sensitivities.
And this is different than a food allergy. A food allergy triggers the immune inflammatory response. For example, shellfish, they'll end up having edema. and that manifests in the face, lips, the throat, and the tongue. The airway would be a big area of concern.
And whereas intolerance basically just means that the GI tract is not able to break down whatever they're consuming. And that could, a couple of examples would be lactose and sometimes some raw vegetables. When we perform our nutrition assessment, we're going to ask them for nutrition history, it's a good idea to actually ask what their typical intake is over a couple of days.
If we can have them do a recall, if they can go all the way back seven days, that's great, but that's kind of hard to do. But if they can recall the last 72 hours, that's pretty good. So we want them to actually give us an idea of what their typical daily intake might be. We want to also assess if they have any difficulty in accessing proper nutrition. It sounds like a silly question to ask, but not everybody has the same resources.
Like in our case, if we get hungry or if we're lacking in certain foods, we'll just go down to HEB or order curbside. But if somebody is having some difficulty with transportation or resources to obtain good nutrition, that's important to kind of assess. We'll take a look at different labs to include fluid and electrolytes.
status, so electrolytes is very important. We would want to know potentially if there's any risk of iron deficiency anemia that could be related to diet, and then also albumin and prealbumin would be a couple of other things that we could assess lab-wise for nutrition assessment. We'll take a look at their medications and make sure that there's not any food-drug interactions that the patient is not already aware of. We'll complete a general health history and physical assessment and look specifically for any signs that would potentially indicate any nutritional deficits.
Our assessment may involve anthropometric measurements, which would basically be looking at adipose tissue using calipers. And then we would also include a psychosocial assessment relative to the nutritional status. As we discussed in class, per the Joint Commission, an initial nutritional screening must be done within the first 24 hours of a patient's hospital admission. The electronic health record will have the nutritional assessment form, whether it be the full mini or an even shorter form version of the mini nutritional assessment. There is also another tool, the adult malnutrition screening and nutrition intervention.
Box 52.3 in your text describes the different components of a nutritional screening assessment. Anthropometric measurements include height and weight to calculate the BMI, body surface area as well. And the difference between BMI and BSA, the first BMI is looking at the ratio of weight to height, and that's really to assess risk of health issues. Body surface area is looking at...
surface area, metabolic mass, and really that's used to calculate medication dosing. In addition, as we mentioned earlier, skin fold measurements could be included as well. Make sure that you're aware what the normal range is for body mass index. Let's talk about some undernutrition pathophysiology.
First, protein energy malnutrition, or PEM, formerly was called protein calorie malnutrition. And this includes merasmus, which is caloric malnutrition. Basically, the body fat and protein is wasted.
Quachicor is lack of protein quantity and quality. So the body weight here could be more normal. And then starvation is just overall severe. caloric deficiency.
Anorexia nervosa, bulimia nervosa, binge eating disorder. So anorexia is patients are not eating the content that they need. They're not receiving the nutrition they need.
And then bulimia and binge eating, they both have the binge eating component. The difference with bulimia nervosa is that there's purging that occurs. As we assess the older adult for nutrition, we're going to look at a variety of different things such as associated conditions and illnesses, problems with GI motility, which could increase the likelihood of constipation. What's their appetite like?
There's a natural decline as patients age. Is there a problem with dentition or poorly fitting dentures? Are they on any medications that impact?
motility or appetite? Are there any drugs that could potentially be interfered with by certain foods? Do they suffer from dry mouth?
Do they need oral hygiene, oral care? Are there any concerns with failure to thrive? Previously, this was a term that was typically only used for infants, and now they're used with older adults, which is basically, For the older adult, it means a failure to gain or maintain weight. Does your patient suffer from impaired eyesight that could impact their ability to feed themselves or to even prepare nutritious food? Are they suffering from any pain that's acute or persistent that also could impact their ability to eat?
And have they had any unplanned or unintentional weight loss? The psychosocial component would include a assessing whether or not your patient has the ability or inability to prepare meals because of a functional decline. Do they have problems with memory or are they too fatigued? Do they enjoy eating? Are they depressed?
What about resources? Do they have the means to afford food? Do they suffer from potential from loneliness? What impact their interest or ability to eat? And tying back to resources and ability to secure good nutrient-dense foods, and do they need assistance with transportation, or could they potentially benefit from something like Meals on Wheels?
With the goals of health promotion and disease prevention relative to undernutrition, know that a very large percentage of older adults are malnourished before they even come to the hospital. One-third of those are going to develop some sort of malnutrition during the hospitalization. I mentioned during earlier conversations that we've gotten better in early nutrition compared to when I started my nursing career in the early 90s. So we have gotten better, but this is always something that we need to put at our forefront.
Good nutrition is so important with healing overall. We need to be an advocate for the nutrition status. The incidence and prevalence of malnourished are estimated to be 462 million worldwide.
The history for relative to undernutrition, we do want them to describe to us what their usual food intake is and what the timing of those meals are. What are their food preferences? What are their patterns?
Have they had a change in appetite or any unintentional or unplanned weight changes? And then again, their resources and economic status that could influence their ability to obtain good nutritious food. We want to look for any potential signs and symptoms of undernutrition.
Looking at their hair, is it vibrant? Is it full? Are the eyes bright?
Look at the oral cavity in their nails, the skin. Is it nice and supple? Do the nails look brittle? Musculoskeletal, are they well-developed? Do they look well-nourished?
Neurologically, are they functioning pretty well? Are they alert and oriented? We'll complete those anthropometric measurements and determine whether or not they have.
Add a subcutaneous fat and look for also for lean. lean muscle. We're going to assess the food and fluid intake that they describe and hopefully they were able to do for us and we'll partner with a registered dietitian to perform caloric intakes.
This is where we really need to educate our CNAs to try to estimate very accurately or as accurately as possible how much of the tray the patients are consuming. This is going to sound repetitive because it is the psychosocial assessment. This is just for undernutrition. So we're looking at all the things that we would for a general nutrition status, their economic status as it would impact potentially their ability to secure food. We would look at their occupation and their education level.
It would actually help us understand or have an appreciation for their understanding and whether or not they put emphasis on good nutrition. How do they define good nutrition? Knowing their ethnicity and race would help us potentially start looking at their food preferences.
In some instances, there might be foods that they absolutely will not eat. What are their living and cooking arrangements like? What's their emotional status?
And again, financial resources for their ability to secure food. Labs are going to sound very similar. We'll look at hemoglobin and hematocrit and also transferrin for potential health.
iron metabolism or iron deficiencies. For overall general nutrition status, we'll look at prealbumin, albumin, and thyroxine-binding prealbumin. We can also look at cholesterol. Our analysis and hypothesis might be weight loss due to inability to access, ingest, or digest food or to absorb the nutrients.
As far as our plan for an undernourished patient, the goal is going to be improving nutrition overall, and that could include meal management. It could include a variety of different things. If they're struggling because they're fatigued, then maybe the right answer might be is to get with dietary to select choice foods that are not going to make it very difficult for them, or they're going to be tired and chewing and make things easier for them to eat. We might have to cut meals short, like multiple small meals versus large regular-sized meals. They may or may not need nutritional supplementation.
Again, the dieticians can determine that. A lot of patients in hospitals get supplements. That's not unusual at all.
Drug therapies can include a variety of different things. If it's a motility issue, we might give medications to help propel peristalsis and get the gut moving a little bit easier. In some instances, if there are nauseous, for example, we might have to give some anti-emetics to try to get that under control.
We also, pharmacy does this, but we'd also want to know whether or not there's any potential drug-food interactions. And then if, for some reason, they need additional nutrition, we might have to initiate enteral nutrition. In the previous slide, I meant total parenteral nutrition.
So talking about total enteral nutrition, the way that we would deliver that is going to be either using a gastric tube or an enteral ostomy-feedy tube. So the gastric tube could be inserted via the nose, which would be a nasogastric tube. If patients, when you do your complex II, are intubated, we typically do not insert NG tubes. A lot of the times we'll just go via the mouth, so that'll be an OG tube. A nasojejunal tube just goes, it goes down the same path except it's allowed to kind of float down into the jejunum a little bit further than the stomach.
An enteral ostromal feeding tube or gastrostomy, which is also called a PEG, is done under sedation. That's a surgical procedure and this is inserted for long-term enteral nutrition, whereas a gastric tube is considered a short-term. Different types of enteral tube feeding, the different approaches would be bolus feeding, which is something that kind of mimics more the way we're used to being fed or eating.
So we would, the nutritional medicine folks would calculate how many milliliters of the tube feeding that the patient would require over 24 hours. and it would be divided by whatever number of boluses is determined needs to occur so if we're trying to train the person and get them back into feeling fullness and feeling hunger it might be maybe four or six feedings across the board so we'll basically Use a cath tip syringe, and we can go ahead and just bolus the tube feeding in. A continuous would be we hook up the tube feeding to a tube feeding pump, and it's a continuous flow 24-7.
And cyclic would be a combination of the two. Some complications with enteral nutrition is the tubes getting clogged. That's probably the most common problem. It's good practice to... irrigate the tubes every so often.
Some facilities will have protocols in place where it's they're at least irrigated once every shift, which means every 12 hours or once every 24 hours. If we're going to be administering medications via the same tube, it's good practice to make sure that we also again flush very liberally. You do not want to be the person that clogs these tubes up. Safety is is the utmost. So we'll talk a little bit about well during your clinical check off in your lab.
You guys did go over the importance of securing the NG tubes and making sure that you annotate how far in the tubes were inserted so that you could determine whether or not it has migrated in or out. So we want to monitor and document for any potential tube misplacement or dislodgement. We'll assess patients for nausea, vomiting, We don't want them vomiting while they're on tube feedings.
And we'll also assess the abdomen to include, make sure that they're not getting distended. Typically, we'll check for residual. And protocols will be written specific for your patient as far as whether we're going to, if they have a large volume of residual, whether or not we return it all or return a portion.
These patients... are going to be at risk for fluid and electrolyte imbalances, so we will probably be checking laps pretty cyclically. We need to be very careful when somebody's extremely malnourished and we resume feeding.
We could potentially, if we get a little too aggressive, we could potentially kick them into a metabolic complication that could be potentially life-threatening, where dangerous fluid and electrolyte shifts occur. Parental nutrition could be delivered a couple of different ways. First, peripheral parental nutrition or PPN can be administered via a PIC. Total parental nutrition or TPN has to be administered via a traditional central line. With both we have special precautions.
Both, as we mentioned in class, are at high risk for developing infections so we do not allow these bags to hang for more than 24 hours. It is a nurse-to-nurse, an RN-to-RN confirmation. There's double checks.
Whenever you receive the bag, you check it your first time, and then right before you hang the bag, you have to make sure that everything is exactly as it's ordered. Frequently what will happen is the clinical pharmacist may change the formula day-to-day depending on the patient's labs, and as the patient gets better, we always use a new fresh primary tube. With the new bag, it's always nice if you can separate a port from the central line or the PIC to be used for PPN only or TPN only and nothing else. Lipids could be potentially part of the TPN or PPN bag, or they could be brought up by pharmacy separately.
As we prepare these patients to go either home or their next facility, or if they're going to be going to a rehab or an LTAC, We want to make sure that we communicate any challenges with nutrition if they're eating. We want to make sure that we coach the patients and families on food choices. And if they're going home, maybe the case management needs to hook them up if they're having difficulty obtaining food or they don't have the resources to hook them up to appropriate entities that can help. them receive good nutritious food such as I mentioned before meals on wheels might be one option. If we did it right our evaluation will reveal that the patient was able to consume all available nutrients, they met their metabolic demands, they're maintaining their weight, definitely not losing weight, and they're obtaining their required protein intake and also just as important that they're maintaining adequate hydration.
The pathophysiology of obesity is actually not that simple. Obesity could be related to a chemical imbalance, including adipokines that are out of whack. These hormones are supposed to work to affect appetite and fat metabolism.
The definition of overweight is a body mass index of 25 to 29. Obesity is defined of a BMI of 30 or greater. And then you can read the different classes of obesity below. There are some environmental, genetic, and behavioral factors associated with obesity. Environmental, looking at what is available for them to eat.
What do other people around them eat? What were they raised eating? Are they used to consuming a high-fat diet?
The genetic components are obesity can run in families, and unfortunately, children of obese... Parents tend to be at higher risk of them, they themselves becoming obese. Are there some psychosocial issues that are driving the eating patterns where they're overeating and causing that obesity or being related to that obesity? Are they consuming high fat, high cholesterol diets? Is this also associated with physical inactivity?
We spoke a little bit in a different class about how technology has kind of made it more difficult to understand the effects of eating too much. made lifestyles a little bit differently. When I grew up, there were no cell phones, there was no gaming.
And so our gaming was actually outside. It was, we were constantly running around all day. And that has just changed.
Today, people are sitting at home and they can game for hours on end. Then there's also some medications that unfortunately, one of the downsides could be is unintended weight gain. Incidence and prevalence of obesity, unfortunately, has doubled since 1980. One-third of the world's population is classified as overweight or obese.
That's very, very concerning. Children also, that's actually reached epidemic proportions. And it's a leading cause of preventable death.
The concern would be, of course, the comorbidities that are associated with obesity. There are initiatives to try to promote. health and to prevent disease. Healthy People 2030, for example, identifies public health priorities to help people and organizations and communities across the United States improve health and well-being overall. We want to promote weight management and physical activity to help prevent some of the complications associated with obesity and promote that even a 5% weight loss can decrease.
the risk of coronary artery disease and diabetes. We want to promote and encourage walking at least 20 minutes daily. When obtaining their history relative to nutritional status and obesity, we want to use the acronym RESPECT that was created by The Ohio State University.
First, create a rapport with the patient in an environment that is safe. Ensure and procure their privacy. protect their privacy, and encourage them to set realistic goals, then provide CS compassion and use tact in conversation.
We want to assess their appetite as they describe it on a typical day, typical week. What is their overall attitude towards food? Are they using it for comfort? Do they eat primarily when they're stressed?
Do they eat all the time? Do they even think about, or do they only eat once a week? when they're hungry or do they feel hungry all the time?
Do they have any chronic diseases that would potentially impact their nutritional status overall? Again, we're going to look at their drugs, their medications, including herbal preparations and anything over the counter. What is their functional ability, their physical activity, their overall?
Do they have a familial history of obesity as we described previously? That's very important. there can be an increased risk overall have they tried to lose weight in the past what has been tried has anything been successful how long was it successful the assessment approach is going to be similar for obesity than it was for under nutrition we're going to look at height weight anthropometric measurements we're going to look at the skin and skin fold areas And the same thing with psychosocialist assessment. We're going to look at their circumstances overall, any emotional factors that could be tied into potentially overeating.
What's their perception of their nutritional status? Do they even perceive it as a problem? Our overall hypothesis and analysis, nutritional status is greater than requirements or obesity. Weight gain, which is going to stress all the vital organs because of the excessive intake of calories.
The goals are going to include improving nutrition. Non-surgical management is going to include tying them into diet programs. We're going to partner with nutritional therapy. We're probably going to promote an exercise program.
There could be drug therapy involved. such as a GLP-1 agonist or Ozempic. There could also be medications to blunt the feeling of hunger. Other strategies might be cryolipolysis, which would basically be something like cool sculpting. If the overeating is because of a psychosocial component, then behavioral management has to occur or should occur.
Another option might be an oral superabsorbent hydrogel. So the patient takes the capsules, and then when they eat, the multiple capsules then kind of mix with the food, and they take up to maybe like a fourth of the stomach volume, so it makes the patient feel fuller. And additional complementary or integrative health strategies. On the surgical management side, this would include bariatric surgery.
These are big surgeries, and they carry some substantial risk. The illustration on the left shows a gastric banding. It's called a gastric restriction.
With gastric restriction, it still allows normal digestion to occur. So the patient just has a small pouch so they feel fuller quicker. But this particular approach doesn't necessarily risk nutritional deficiencies.
On the right-hand side, this is the most common bariatric surgery that is done in the United States. It's commonly called a gastric bypass. It's a Roux-en-Y. In this particular procedure, the patient's stomach, duodenum, and part of the jejunum are bypassed so fewer calories can be absorbed.
Unfortunately, this also ends up in malabsorption problems. So post-op management and home health management for patients that have bariatric surgery is pretty extensive. They're going to have several follow-ups. If they had a Roux-en-Y, they're going to have to have supplements, nutrition supplements.
The post-op patients will start with pureed foods and then they'll slowly work their way up to solid foods, to soft foods and then solid foods. We need to teach those patients to look for signs and symptoms of dumping syndrome. which basically means the food's getting into the small intestine way too quick.
It's being dumped into the small intestine. So the signs and symptoms could be tachycardia, nausea, diarrhea, and abdominal cramping. So we need to make sure that they are aware of those potential symptoms. They'll need to structure multiple small meals instead of large, or even they won't be able to tolerate regular-sized meals. Overall, in general, and this...
doesn't necessarily limit just to patients that have had bariatric surgery. But overall, we do want to make sure that these patients are tied in with a registered dietitian and that they're receiving the counseling to get a good diet plan going. There are community resources to include Overeaters Anonymous. If they were able to do the surgery laparoscopically, They won't necessarily have these big wounds that they'll have to care, but they do have to take care of the cannulation sites and watch for any potential signs and symptoms of infection.
Additional resources, if they did have surgery, there's an American Society for Metabolic and Bariatric Surgery. There could be local support groups as well. If we met our goals in our evaluation, we'll find that the patient was consuming appropriate nutrient-dense foods that met and not overwhelmed. their metabolic demands and that they did not overeat and then more importantly that they remained free from infection if they had bariatric surgery that concludes this chapter