hey guys Woodruff here um so when it comes to nutritional disorders this lecture is going to start um by it's the long lecture broken up into smaller parts we're going to start by talking about malnutrition how we diagnose that what's the big deal um some Medical Treatments and nursing interventions I'll have some separate videos on intro and parenteral nutrition and then I'll have separate videos on Obesity and probably bariatric surgery as well as metabolic syndrome so hopefully this is helpful um we've talked you know if you're at my school um you know we've talked through a lot of disease processes that are affected by nutrition we've talked about um this a lot of diseases that can lead to nutritional issues or nutritional deficits but we're going to kind of get down to the uh the Nitty Gritty when it comes to a lot of this stuff so first let's talk about what malnutrition is so most of the time if you think malnutrition you probably imagine someone who's like really skinny hasn't eaten in a long time stuff like that and you know it definitely many times can be that but a malnutrition is actually where there's a deficit like so not enough in excess so too much or some sort of imbalance of nutrients so it's not necessarily always that you don't have enough um and so if you want to think of malnutrition just bad nutrition or poor nutrition um it can be poor because you don't have enough it can be poor because you have too much or it can be poor because there's some sort of imbalance um so really the thing I want to hit home here is that you patient doesn't have to be thin to be malnourished um it's a common misconception like you could look at an obese overweight patient and be like and they could skip a few meals they'll be fine but they could already be malnourished just because someone is obese overweight doesn't mean that they're nourished well um so it's definitely something to work on as a nurse to really look at like okay what can I look at to see that a patient is actually nourished or not um like I said patient can be overweight underweight but just think of it like the nutrients that are getting in your body regardless of how much you're actually eating are not sufficient to support the body so you're deficient or missing something that you need to support body functions um so who's at risk for malnutrition um so there's a few different considerations some of them of course are more environmental so thinking about those that may be malnourished maybe those that just don't have the money or the resources in order to get the food that they need to nourish them even some people that can afford food may not be able to afford food that provides them with the nourishment that their body needs um also those that are sick um recently had surgery or some sort of injury or hospitalization and specifically the things that you want to think about like you know because I mean a lot of people are in the hospital but not all of them are at risk for malnutrition issues specifically anyone with infection especially if we're looking at things like sepsis puts you at high risk for malnutrition people with wounds they have higher needs because of the wound issue in general or they're going to need certain nutrients and more nutrients to support them people with Burns same kind of situation where they have like the demand is greater than the supply even if they are eating okay fractures like we just went over and anyone who's immobilized is going to be more at risk to be malnourished and then of course those with absorption absorption issues so like people with GI disorders which we're about to get into um so people with like Crohn's or that had gastric bypass past surgery with crohn's you know we'll talk about this more later but they can have an inflammation in their small intestine which is where you absorb your nutrients so if I'm having inflammation there there's no there's not no but there's less ability to absorb the nutrients that I need or with gastric bypass we literally Bypass or take out part of the intestine where you need to absorb nutrients so if there's less there less opportunities for absorption and then also those with incomplete diet you know especially if you have history of substance abuse a lot of times as a result of sometimes the medications and the effects of the medications or the substances that they're using they have a higher chance of not getting the nutrients they need so let's do a practice before we get into what does malnutrition actually look like some of these may not surprise you some of these may but let's look for each of these are these a good indicator of malnutrition now I mean you could look at anything and eventually turn around maybe and say hey this has something to do with malnutrition or could lead to malnutrition let's look big picture here and see which of these might be good indicators so the first one is a hemoglobin of 8.1 so when you think hemoglobin you may not think nutrition but what you want to consider here is is that what does it take in order to make red blood cells and therefore hemoglobin it takes vitamins nutrients if you remember like almost uh like all of a lot of your blood cells especially your red blood cells they're made out of different vitamins and nutrients and if you don't have those so this is why like we know when we talked about iron deficient anemia it was a lack of iron in the diet or people we talk about vitamin B12 deficiency can lead to anemia as well um so with that being said in other words think of it this way like you need certain supplies in order to make blood cells and so a lot of times when people aren't nourished well they're going to stop making as many blood cells because they don't have the supplies they need in order to make the blood cells so believe it or not a hemoglobin of 8.1 is actually a good indicator of malnutrition it's not good but it's a good indicator of malnutrition um next hemoglobin A1c 12 so hmm for this one you know you can go back and forth and say well you know I thought you said that you know just because someone's overweight doesn't necessarily mean they're malnourished but having a chronic disease like diabetes um and um having a hemoglobin A1c that that's that is that high is a good indicator of um poor glucose control and with poor glucose control um there's definitely a higher risk for malnutrition so one of the things that we do want to look at and again it's not that I can look at a hemoglobin of 12 and say oh my goodness this person eats too much they don't have a good diet I cannot from that number alone just like with the hemoglobin I cannot say oh it has to be from their diet it could be something else but um really what I want you to think of when you're looking at this is which of these Labs could I could I utilize as a part of building a profile to see if someone might be at risk or have malnutrition I mean hemoglobin A1c is another lab we can use I'm because it can tell us how some how well someone's doing again so someone could have a high hemoglobin A1c and maybe they're taking their meds their diet is good but there's maybe there's an absorption issue with their insulin or their other meds or there's something that's not working so there is that to consider but with the high hemoglobin A1c there's usually some sort of malnutrition or other issue going on um and if nothing else the patient has a very high risk for other things that could put up at risk for malnutrition but anyway that's I know that's not the question so I'm gonna try not to make a story I know it's so hard uh anyway potassium 3.2 so this one most students would be like bam this is it I know this one um but this one I'm actually going to say nope so I'm having a low potassium that's a electrolyte balance where electrolytes and nutrition are very different things so it's not to say we're going to check electrolytes um and oddly enough you're actually going to see patients that have bad malnutrition usually have a high potassium it's not usually low but it's not to say that you know if someone's potassium's low that it couldn't possibly be a sign but it'd be more of a stretch so think of these as more of electrolytes now when you start to have a lot of issues with severe malnutrition dehydration again potassium can get off it usually gets high but it's not usually low so so far we just have the hemoglobin A1c in the regular hemoglobin if you said potassium 3.2 um you know I could definitely see where we might get it just to look for it but that potassium of 3.2 Itself by itself is not a good indicator of malnutrition um hair loss so this is a more of a um actual like a visual or assessment finding that I would look for as a nurse and this is a good indicator of malnutrition when I say good indicator I sound so happy about it but what I mean by that is is that if you're losing your hair it's it can be one of the common things it's connected to is malnutrition um next one moodiness and irritability so for this one you know I'm thinking about that hangry person who doesn't have enough glucose or that hypoglycemia kind of patient that can kind of get hangry and not the happiest person in the world so this is also a good indicator of malnutrition so we have the hemoglobin hemoglobin A1c hair loss and moodiness creatinine 1.9 so a creatinine is a measure of kidney function it's a good measure of kidney function but the kidney function being worsened elevated Etc because a normal is 0.6 to 1.2 ish this is not necessarily directly connected with malnutrition now if this was liver function it's possible because the liver is more closely associated with the nutritional status then the kidneys are but usually we don't think elevated creatinine malnutrition BMI 17. so for this you would have to know what a normal BMI is and we usually like I want to say it's something like 18.5 to 24.5 ish is normal so anything below that is actually considered underweight so 17 would be underweight so this is another measure that we can use it's a body mass index and it gives us a general idea that based on someone's height and weight do they have the body mass that they probably need to sustain them so it's not a perfect measure but we can use it and this could use be used as a indicator for malnutrition so the answers are the hemoglobin hemoglobin A1c hair loss moodiness irritability and the BMI of 17. so let's look more at oh well actually let's look at some assessments first just kidding so this is a picture of someone who may have some um you know malnourishment the the word that we would use for someone who has kind of this sunken an appearance where you can see a lot of their skin and bones would be what we call cachexiers to check cachexia I've heard it said both ways I usually say cachexia but um again I'm probably saying it wrong like I say um I would say I probably I would probably if I had to guess it I'd probably say I say about 23 of words incorrectly um and 23 is not it's like one like probably my fourth least favorite number so that says a lot that I'm saying 23rd um just in case you're wondering um and if you're confused so am I but anyway um so priority assessments we're going to do for a malnutrition patient are going to be assessing their Eden pattern Eden Eden apparently I need to be making sure I'm okay maybe it's because today is Easter when I'm recording this um my eating patterns maybe I've been having some strange eating patterns today anyway eating patterns or diets are going to be important things to assess for because we want to see kind of where they're like what are all the factors that could contribute to my malnutrition or where are they at like um we want to with malnutrition we always want to get to the bottom of the cause so if the cause is in their eating pattern or debt we definitely want to know assess their BMI or weight we'll see that more on the next slide a skin hair and nails because like you can see below they can have dry skin brittle nails hair loss we're going to assess for muscle strength or assess for weakness because a lot of times this is also going to be a common symptom of malnutrition and then also mental status because like I said it gets to the point where your brain doesn't have the nutrients it needs to be able to do things and they can have confusion irritability you know also like I said kind of like that hypoglycemia picture I'm not saying they're going to be hypoglycemic it just depends on the cost but I just mean it looks like that kind of patient so then what do we do for labs and Diagnostics so we need to do a very thorough history and assessment but then we're going to take a look at their CBC specifically looking at what we call the H or hemoglobin and hematocrit I would know these numbers it's great to put them if you if you're like our school we give note cards for certain classes you can definitely use a note card for this um so H H um so yes especially like I said with that hemoglobin you can have less cells because you don't have the supply so that might be lower the hematocrit could be low as well we're also going to check for protein levels and this has a lot to do with the liver's role in nutrition that the liver makes albumin in order to um pretty much it albumin is a plasma protein and the way that I explain albumin is it's a protein whose main job is to keep fluid where it's supposed to be in the body when you're malnourished you're not going to be making as much albumin and as a result of that um fluid goes where it's not supposed to go in your body so we can check an albumin level I will say this this is that like a lot of times students get hung up on albumin levels like if you look at most patients in the hospital their albumin level is going to be low but we don't necessarily like we like in albumins and medication we can give to so sometimes you know I know when I first started I thought oh if my albumin's low I'm going to give of albumin but it's not actually how it works we we use um like if I called a doctor and said hey here um you know I need some album in my albumin slow they would probably laugh at me because that's not what we do for low albumin we really look at their nourishment and making sure that as a whole that they're getting what they need a better more specific measure because albumin is it lives like how many albumin that you have you know it cycles and it's one of those things that can vary in stuff throughout the day or with time so a better measure is what's called pre albumin and pre-albumin tells us how many baby albumen are being made so in other words it tells us more like what's in the factory so if I have like if valbumin is a sign of poor nutrition then pre-albumin I don't know why this sounds so weird pre-albumin if that's uh what do you call it if that's how many are being made pre-albumin is a better measure because it tells me how how much I'm making versus how much I have right now um so maybe you could kind of compare it to uh what do you call it um um albumin is like how much money you have in the bank right now but pre-albuements how much that you're going to be bringing in soon so you know a better measure of how you're doing financially might not be how much money you have in the bank but how much you're going to be bringing in so pre-albumin is a better measure overall of nutrition and I love that my brain works in a special place sometimes I wonder um where my brain gets these analogies because I'm not very I'm not a very like intelligent person and I don't like you know sit around and think about intelligent things all the time but sometimes these weird things just come to me but anyway um so moving on uh like I said we will check the serum electrolytes we'll probably check the potassium like I said we would expect it to be higher and then the liver function testing and there's different numbers there's AST and ALT we'll talk about them more when we get to the biliary disorders but just know in general if it's less than 36 you're in a good range um and then like we talked about for uh the body mass index or over you know this is something a lot of doctors use now it's not the best measure because someone could have a height and weight and it can say they're like extremely obese you know like in a really bad place um but it really depends sometimes on the patient because everyone cares their weight in different places we'll talk more about that with obesity but this is something that a lot of doctors go by um and a measurement that's kind of seen widely around as accurate even though we are trying to move towards different scales these days like I said 18.5 to 24.9 I think I said 24.5 so 18.5 to 24.9 is normal 25 to 29.9 is overweight and anything greater than 30 is obese and I think when we I think greater than 40 is like extreme obesity when we get into obesity another thing you might want to assess is how well can they perform their activities of daily living because that kind of tells you about their weakness because like I can look at numbers all day long and I can be like oh yeah look these these Labs show that they're malnourished but how is their body and their ability to perform actions also telling us how they're doing so what's the big deal here with malnutrition the big deal is that um you know these people don't heal well so if they have wounds other things it's going to get a lot worse so kind of getting back to that hemoglobin A1c I mean if they already have a hemoglobin A1c that's that High um and then they're malnourished um they're they're not going to heal anything um it's going to be very hard to treat anything that's going on with them it also leads to pressure ulcers because remember malnutrition really affects the skin a lot the skin the hair the nails it also like I said puts you at increased risk for infection and it also because of the weakness and other things that can do with your muscle strength it can lead you to have a higher risk for falling and then mental status wise it can also lead to depression and dementias this is why you know I don't know if you've ever heard about people that go through really bad depressions and then find out it was like a vitamin B deficiency this is really a true thing where sometimes like if you are deficient in certain vitamins or malnourished in certain ways a lot of times it can show up as mental illness even though that seems crazy that's how much nutrition can have an effect on a person so Medical Treatments we're going to use is like I mentioned before we always want to find the cause like what's the deficit is it a um you know a diet thing um you know what what's going on is there some other disease process going on that's not being managed well like what's leading to the the deficit because again if the problem is is my diet need to change some with my diet if the problem is I have Crohn's disease and I have inflammation I need to treat that cause you know so again it just goes back to what is the issue um and um you know we do nutritional supporting counseling and a lot of times these patients are going to need enteral and parental feeding and when I say nutritional support and counseling you know as a nurse I do on a daily basis fill out a malnutrition screen on my patients to say like hey they're showing a risk or something related to being malnourished and I actually Lis Lisk list I cannot talk today I have a lisp because I'm trying to say list and I said Lisk so anyway I'm gonna stop um because I feel like I'm again becoming a doctor novel but what I was trying to say is there's a list with a bunch of different malnutrition risk factors and then I select which ones that the patient has vitamin and nutrient supplements as well for these patients depending on what they're deficient in and then making sure that they're hydrated and have adequate nutrition because a lot of times people that are malnourished may also be dehydrated and they may need medications to stimulate appetite and at least where I teach you don't have to know about these but there's a variety one that you'll probably see given in the hospital too that you'll probably see given one is going to be called what's known as Mega straw something like that Mega straw also known as megase and it's used sometimes in cancer patients or other people that are chronically ill that need to eat more so we use appetite stimulants we also use Marinol or drabinol which is um you know like the medical marijuana stuff and you know it's a controlled substance so when you give it you know you have to do the narcotic count and stuff like that also usually most often used for cancer patients but I've seen it used in other patients that have really chronic malnutrition issues maybe because of outside other disease processes um so we might get do stuff like that again you don't have to know those in depth but just know there are medications that exist that can increase your appetite there's also some more natural ones sometimes when we're treating a patient for certain conditions and we've talked a little bit about this but some patients that have other conditions like pneumonia they they might be on steroids and steroids are also an appetite stimulant and they treat the problem now we're not usually going to put someone on steroids to stimulate their appetite I've never heard of that but sometimes for some patients it's kind of like a it helps in both ways where it helps because it increases it helps treat their underlying disease process but also increases their appetite and last but not least let's talk about um what we're going to do as the nurse My overall goals are going to be for this patient that they have good nutrition and that they're fluid in electrolytes are balanced I need to look for malnutrition in my assessment and like I said a lot of that is going to be the skin the hair the nails making sure that they are you know they're they're showing signs of improvement it's not that I'm going to sit there I need to measure their hair or do something crazy but just looking overall I'm at a patient to see what signs they're showing externally that they're being well nourished a lot of it's going to go back against that mental status to that confusion do they seem hangry and then also of course the labs the Diagnostics and things like that like a daily weight is going to be super important on these patients we might also do things like it's talking about here what's called a calorie count which is what I do is as the nurse my role in a calorie count a nutritionist usually orders it but they put like on their door this like piece of paper that says calorie count and I don't have to actually count their calories but I just have to write down every single thing that went into that patient's body and then the nutritionist calculates it and figures out like what they're intaking versus what they need and it's pretty cool the nutritionists in dietitians they have to work pretty hard like they can calculate some pretty gnarly stuff when it comes about a patient's nutrition like they can figure out like oh hey um this patient they're on these meds have this disease process here's how old they are here's all their functions of their organs you know this is how much nutrition they need they they have they're really the boss when it comes to the nutrition stuff and figure that stuff out really seamlessly it's pretty cool um if they are overweight or obese and they are in taking foods but not the right Foods than just Lifestyle Changes health promotion we'll talk more about that with obesity and we want to encourage nutrition whenever possible so with these patients it's like so important that we are trying to get them like you know just like you sit there and um as the nurse you might see in your meds like oh hey they have an insure that's due at nine o'clock I'm gonna go bring that in but it's not just about bringing it in it's encouraging them to drink it get them a flavor that they like um try to encourage like be there with them support a positive eating environment um so that they can want to eat so positive eating environment would mean like do not put their urinals and dirty stuff on buy their food try to get food that they like make sure that it's the least stressful environment that you can create whatever you have to do to set up a good environment good smells good taste and sounds and stuff like that in the environment can affect it and so trying to set up an environment that's going to make it comfortable and pleasant for them because it can make a big difference I don't know if you've ever had a time where you know you've been genuinely hungry but maybe there's something going on or something in your environment that just makes it where you're like yeah I don't even want to eat right now so um definitely want to set them up the best that you can and then checking on them so like I've before you know I'll give someone some pills with their insurer their boost or something like that if you don't know these are like protein supplements or protein shakes and then I'll leave it there I was like oh yeah try to finish this but I you know it's really so important to go back and check on them or um sometimes they might need help and they may not tell you so just taking those opportunities to try to encourage them to finish it and like sometimes it's even for me it's like hey I'm in the room like you know doing regular rounding hey have you have you drank any of this lately have you finished this um and encouraging those whenever possible for those that um don't like those particular drinks there are other formulas that we have in the hospital or sometimes we'll just mix in like for some patients with wounds we'll mix in powders and stuff into other drinks but whatever we need to do to make it taste good I've had some patients that just don't like the taste of this stuff I remember back when I was a tech working rehab I used to make some pretty exciting um little like smoothie milkshake things where I would take the ensure the Boost mix it with some chocolate ice cream and like I used to go to town and really try to get patients wanting to drink these things because a lot of times I just don't like the taste but we need these patients to gain weight so I would like mix it with I would take the booster the ensure and then mix it with like some ice cream or other things to try to like even get more calories in it and really try to support something that they can actually you know want to eat or drink so the the two nutrients that we really want to focus on as the nurse are going to be increased protein and increase calories that's going to be really what our focus is um but yeah that is the big picture for malnutrition but the next videos are going to be going deeper into what internal nutrition is and parenteral nutrition and what our role as the nurse is to manage those I hope this video helped see you for the next one