Transcript for:
Understanding Nutrition, Undernutrition, and Obesity

anorexia Loss of appetite for food. anorexia nervosa Eating disorder of self-induced starvation resulting from a fear of fatness, even though the patient is underweight. bariatrics Branch of medicine that manages patients with obesity and its related diseases. binge eating disorder Eating disorder that involves eating in binges with a feeling of loss of control over the eating behavior. body mass index (BMI) Measure of nutritional status that does not depend on frame size; indirectly estimates total fat stores within the body by the relationship of weight to height. body surface area (BSA) Calculated estimate of a person’s total body surface area reflecting physiologic and metabolic processes including heat exchange, blood volume, and size of vital organs. Used as an indicator for appropriate dosage calculation, especially for anticancer agents. bolus feeding Method of tube feeding that involves intermittent feeding of a specified amount of enteral product at specified times during a 24-hour period, typically every 4 hours. bulimia nervosa Eating disorder characterized by episodes of binge eating in which the patient ingests a large amount of food in a short time, followed by purging behavior, such as self-induced vomiting or excessive use of laxatives and diuretics. cachexia Extreme body wasting and malnutrition that develop from an imbalance between food intake and energy use. continuous feeding Method of tube feeding in which small amounts of enteral product are continuously infused (by gravity drip or by a pump or controller device) over a specified time. cyclic feeding Method of tube feeding similar to continuous feeding (see definition of continuous feeding) except the infusion is stopped for a specified time in each 24-hour period (“down time”); the down time typically occurs in the morning to allow bathing, treatments, and other activities. dietary reference intakes (DRIs) Nutritional guide developed by the Institute of Medicine of the National Academies that provides a scientific basis for food guidelines in the United States and Canada. dumping syndrome Vasomotor symptoms that typically occur within 30 minutes after eating, including vertigo, tachycardia, syncope, sweating, pallor/ash gray skin, and palpitations. enterostomal feeding tube Tube used for patients who need long-term enteral feeding. food allergy Reaction to a food (or multiple foods), rooted in the immune system, that can cause a life-threatening complication such as anaphylaxis. food intolerance Inability to tolerate a food (or multiple foods), rooted in the gastrointestinal system when a food cannot be properly broken down. gastric bypass Type of gastric restriction surgery in which gastric resection is combined with malabsorption surgery. The patient’s stomach, duodenum, and part of the jejunum are bypassed so that fewer calories can be absorbed. Also known as a Roux-en-Y gastric bypass, or RNYGB. gastrostomy Stoma created from the abdominal wall into the stomach. jejunostomy Surgical creation of an opening between the jejunum and surface of the abdominal wall. knee height caliper Device that uses the distance between the patient’s patella and heel to estimate height. kwashiorkor Lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low. lactose intolerance Type of food intolerance when a patient has an inadequate amount of lactase enzyme, which converts lactose into absorbable glucose. malnutrition Deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. marasmus Calorie malnutrition in which body fat and protein are wasted and serum proteins are often preserved. medical nutrition supplements Enteral products (e.g., Ensure, Boost) taken by patients who cannot or do not consume enough nutrients in their usual diet. nasoduodenal tube (NDT) Tube inserted through a nostril and into the small intestine. nasoenteric tube (NET) Feeding tube inserted nasally and then advanced into the gastrointestinal tract. nasogastric (NG) tube Tube inserted through a nostril and into the stomach for liquid feeding or for withdrawing gastric contents. nutrition screening Assessment of nutrition status that includes inspection, measured height and weight, weight history, usual eating habits, ability to chew and swallow, and any recent changes in appetite or food intake. obesity Increase in body weight at least 20% above the upper limit of the normal range for ideal body weight, with an excess amount of body fat; in an adult, a body mass index greater than 30. Subdivided into Class I, II, or III. overweight Increase in body weight for height compared with a reference standard (e.g., the Metropolitan Life height and weight tables) or 10% greater than ideal body weight. However, the weights listed in such tables may not reflect excess body fat, which in an adult is a body mass index of 25 to 29.9. panniculectomy Surgical removal of the abdominal apron (panniculus). percutaneous endoscopic gastrostomy (PEG) Stoma created from the abdominal wall into the stomach for insertion of a short feeding tube. protein-energy undernutrition (PEU) Nutritional disorder that may present in three forms: marasmus, kwashiorkor, and marasmic-kwashiorkor. Also called protein-calorie malnutrition. refeeding syndrome Life-threatening metabolic complication that can occur when nutrition is restarted for a patient who is in a starvation state. skinfold measurements Estimation of body fat, usually calculated through measurement of the triceps and subscapular skinfolds with a special caliper. starvation Complete lack of nutrients. total parenteral nutrition (TPN) Provision of intensive nutritional support for an extended time; delivered to the patient through access to central veins, usually the subclavian or internal jugular veins. undernutrition State of wasting, stunting, and being underweight. http://evolve.elsevier.com/Iggy/ Priority and Interrelated Concepts The priority concept for this chapter is: • Nutrition The interrelated concept for this chapter is: • Fluid and Electrolyte Balance The Nutrition concept exemplars for this chapter are Undernutrition and Obesity. To function well, the body needs adequate nutrition to grow; maintain temperature, approximate respirations, and cardiac output; and facilitate muscle strength, protein synthesis, and storage and metabolism. In healthy adults, most energy supplied by carbohydrates, protein, and fat undergoes digestion and is absorbed from the GI tract. The relationship between energy used and energy stored is referred to as energy balance. Weight is gained when food intake is more than energy used, and weight loss occurs when energy used is more than intake. The body attempts to meet its calorie requirements even if it is at the expense of protein needs; when calorie intake is insufficient, body proteins are used for energy. Influenced by personal preference, demographic location, cultural norms, spiritual observations, financial feasibility, and availability of nutritional sources, nutrition status varies for each patient. Further influencing factors include age, height, weight, gender, speed of metabolism, influence of exercise or activity, medications taken, substances used (e.g., alcohol or illicit drugs), and types of fluids consumed. The estimated energy requirement (EER) ranges from 1600 to 3200 calories per day for healthy adults; age, sex, height, weight, and level of activity are considered when a personalized eating plan is created (U.S. Department of Agriculture, 2023; U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). The caloric requirement may decrease if a patient needs to lose weight or increase if the patient needs to gain weight or promote healing. BOX 52.1 2020–2025 Dietary Guidelines for Americans • Follow a healthy eating pattern at every life stage. • Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations. • Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits. • Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages. From U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary Guidelines for Americans 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf. General Nutrition Recommendations for Health Promotion/Disease Prevention Current attention on nutrition is focused on health promotion and the prevention of disease by healthy eating and exercise. Dietary reference intakes (DRIs) based on age, gender, and life stage serve as a nutrition guide for more than 40 nutrients and provide a scientific basis for food guidelines in the United States and Canada (National Academies of Sciences, Engineering, & Medicine, n.d.). In the United States, the Dietary Guidelines for Americans are revised by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (USDHHS) every 5 years. Examples of the 2020-2025 Guidelines (9th edition) are listed in Box 52.1. “Start Simple with MyPlate” is an initiative that reminds users about building healthy eating habits into a lifestyle (U.S. Department of Agriculture, 2022) (Fig. 52.1). This pictorial demonstrates how to build a healthy plate of food, consisting of the right proportions of fruits, vegetables, grains, proteins, and dairy products. Canada publishes Canada’s Food Guide (Government of Canada, 2023), a similar visual reference. Common Diets Given the variance in people’s preferences, place of residence, availability of foods, financial means, cultural or spiritual observations, and financial circumstances, there is not a specific “typical (or common) diet.” Some people consume a highly nutrient-rich diet and remain adequately hydrated with water. Others eat excess foods heavy in fats or carbohydrates and choose to drink soda or juice on a regular basis, which can lead to obesity. Others do not have adequate access to nutrient-dense food and hydration and may experience undernutrition. Individuals with obesity or undernutrition both experience malnutrition in different ways, as the state of malnutrition occurs on a continuum. In ideal circumstances, patients should consume a diet containing complex carbohydrates, lean proteins, and monounsaturated or polyunsaturated fats that also contains necessary vitamins and minerals. The specific foods you recommend to patients to meet their nutritional needs depends on the variances mentioned earlier. FIG. 52.1 The U.S. Department of Agriculture MyPlate. From U.S. Department of Agriculture, 2023, www.ChooseMyPlate.gov; https://www.myplate.gov/eat-healthy/what-is-myplate; https://myplate-prod.azureedge.us/sites/default/files/2022-01/SSwMP%20Mini-Poster_English_Final2022.pdf. Symbol of Choose My Plate.gov shows a plate divided into four quarters, marked (increasing in portion size) as fruits, proteins, grains, and vegetables. A bowl next to the plate is labeled diary, with a fork kept next to the plate. Some adults follow vegetarian diet patterns for health, environmental, religious, cultural, or spiritual reasons (Box 52.2). People who eat a vegan diet can develop anemia as a result of a vitamin B12 deficiency. Teach people who are vegans to include a daily source of vitamin B12 in their diets, such as a fortified breakfast cereal, fortified soy beverage, or meat substitute. Refer those interested in vegetarianism to www.eatright.org, which contains many credible resources regarding vegetarian health (Academy of Nutrition and Dietetics, 2023). Patient-Centered Care: Culture and Spirituality Food Preferences Many adults have specific food preferences based on their ethnicity or race. Health teaching about nutrition should incorporate any cultural preferences voiced by the patient. Never assume what a patient’s preferences will be. Always ask the patient when providing care. Food Sensitivities Some adults have food allergies or intolerances. A true food allergy differs from a food intolerance in the sense that an allergy to a food can cause life-threatening complications such as anaphylaxis. A food allergy is rooted in the immune system. The most common food allergies are nuts, peanuts, and shellfish (Rogers, 2023). A food intolerance involves the gastrointestinal system and occurs when the system cannot properly break down food (American Academy of Allergy, Asthma, and Immunology, 2023). An example of a food allergy is shellfish, which can cause coughing; edema (face, lips, tongue, throat); shortness of breath; or anaphylaxis in certain patients. An example of a food intolerance is lactose intolerance, in which a patient has an inadequate amount of the lactase enzyme, which converts lactose into absorbable glucose. Ingesting a milk product causes bloating, diarrhea, abdominal discomfort, and flatulence. When taking a history, ask patients specifically what kind of reaction they have to certain foods; document and plan care accordingly. BOX 52.2 Vegetarian Types Lacto-vegetarian—allows dairya; avoids meat, poultry, seafood, eggs, and foods that contain those items Ovo-vegetarian—allows eggs; avoids meat, poultry, seafood, and dairy a Lacto-ovo vegetarian—allows eggs and dairy a ; avoids meat, poultry, seafood Pescatarian—allows fish; avoids meat, poultry, dairy,a eggs Vegan—consumes a plant-based diet only; avoids meat, poultry, seafood, dairy,a eggs, and foods that contain those items. (NOTE: Some people who eat a vegan diet also avoid honey.) a Dairy = milk, cheese, yogurt, butter, etc. Patient-Centered Care: Older Adult Health Preventing Constipation The USDA (2022) recommends that older adults consume plenty of water and fiber to prevent or manage constipation. In addition to water, beverage choices can include unsweetened fruit or vegetable juice, low-fat or fat-free milk, or fortified soy beverages. Nutrition Assessment Nutrition status reflects the balance between nutrient requirements and intake. Evaluation of nutritional status is an important part of total patient assessment and includes: • Review of the nutritional history • Food and fluid intake record • Notation of access to appropriate sources of nutrition • Laboratory data • Food-drug interactions • Health history and physical assessment • Anthropometric measurements • Psychosocial assessment Monitor the nutrition status of a patient during hospitalization as an important part of your initial assessment. Collaborate with the interprofessional health care team to identify patients at risk for nutritional problems. Initial Nutrition Screening The Joint Commission Patient Care Standards require that a nutrition screening occur within 24 hours of the patient’s hospital admission, with a full nutritional assessment for patients identified as being at risk (The Joint Commission, 2022). The initial screening includes inspection, measured height and weight, weight history, usual eating habits, ability to chew and swallow, and any recent changes in appetite or food intake. The Full MNA® Form (Mini Nutritional Assessment) (Fig. 52.2) is a helpful and brief screening tool that can assist in identifying older adults who are malnourished or at risk for undernutrition. An even shorter version—the MNA®, which refers to the Mini Nutritional Assessment–Short Form (formerly the MNA®-SF) (Nestle Nutrition Institute, n.d.)—is also available for use in the clinical setting. Another tool that is available is the Adult Malnutrition Screening and Nutrition Intervention (Fig. 52.3). Box 52.3 Best Practice for Patient Safety and Quality Care Nutrition Screening Assessment General • Does the patient have conditions that cause nutrient loss (e.g., malabsorption syndromes, wounds, prolonged diarrhea) • Does the patient have conditions that increase the need for nutrients (e.g., fever, burns, injury) • Has the patient been NPO for 3 days or more? • Is the patient receiving a modified diet or a diet restricted in one or more nutrients? • Is the patient being enterally or parenterally fed? • Does the patient describe food allergies, lactose intolerance, or limited food preferences? • Has the patient experienced a recent unexplained weight loss? • Is the patient on drug therapy, including prescription, over-the-counter, or herbal/natural products? Gastrointestinal • Does the patient have glossitis, stomatitis, or esophagitis? • Does the patient have difficulty chewing or swallowing or have poor dentition? • Does the patient have a partial or total GI obstruction? • Does the patient report nausea, indigestion, vomiting, diarrhea, or constipation? • Does the patient have an ostomy? Cardiovascular • Does the patient have ascites or edema? • Is the patient able to perform ADLs? • Does the patient have heart failure? Genitourinary • Is fluid intake about equal to fluid output? • Is the patient hemodialyzed or peritoneally dialyzed? Respiratory • Is the patient receiving oxygen or on mechanical ventilatory support? • Does the patient have chronic obstructive pulmonary disease (COPD) or asthma? Integumentary • Does the patient have abnormal skin, nail, or hair changes? • Does the patient have rashes or dermatitis? • Does the patient have dry or pale mucous membranes or decreased skin turgor? • Does the patient have pressure injuries? Musculoskeletal • Does the patient have cachexia? Modified Courtesy Ross Products Division, Abbott Laboratories, Columbus, OH. See Box 52.3 for examples of questions to consider as part of the initial assessment. FIG. 52.2 Full MNA® Form (Mini Nutritional Assessment). Société des Produits Nestlé S.A., Vevey, Switzerland, Trademark Owners. A specimen of Mini Nutritional Assessment by Nestle Nutrition Institute shows the following details: Personal information of patient. Screening involving five questions regarding food intake, weight loss, mobility, instance of psychological stress, and body mass index followed by a screening score (12-14 points, normal nutritional status; 8-11 points, at risk of malnutrition; and 0-7 points, malnourished). Assessment includes record for way of living, intake of prescribe drugs, pressure sores or skin ulcers, daily number of full meals, protein consumption markers, servings of fruit or vegetables, fluid intake, mode of feeding, self view of nutritional status, patient's health status as compared to other people, mid-arm circumference, and calf circumference. FIG. 52.3 AdultMalnutritionScreeningandNutritionInterventionPathway. FromNestleHealthScience.Copyright©2019.https://www.nestlemedicalhub.com/sites/site.prod.nestlemedicalhub.com/files/2020-04/Adult%20Malnutrition%20Screening%20and%20Intervention%20PATHWAY_122019%20FINAL.pdf. A chart for adult malnutrition screening and nutrition intervention pathway for nutrition screening of patients within 24 hours of hospital admission conducted by R N using validated nutrition screening tool that is age appropriate. The chart shows various steps starting from nutrition screening indication with (or at-risk of) malnutrition and ending at Documented Nutrition Care Plan in Medical Record. Anthropometric Measurements Anthropometric measurements are noninvasive methods of evaluating nutrition status. These measurements include obtaining height and weight and assessment of body mass index (BMI). You may delegate the task of obtaining height and weight to assistive personnel (AP) under your supervision, as this is within their scope. Be sure to instruct the AP to follow up with measurements as soon as this activity is completed, as this information affects the plan of care. Obtaining accurate measurements is important because patients tend to overestimate height and underestimate weight. Measurements taken days or weeks later may indicate an early change in nutrition status. Follow agency policy or the primary health care provider’s orders for frequency of measurement. Measure and weigh patients with the same scale and with the same amount of clothing (without shoes) each time. A sliding-blade knee height caliper, which uses the distance between the patient’s patella and heel to estimate height, can be used for those who cannot stand. It is especially useful for patients who have knee or hip contractures. The type of scale used depends on the patient’s ability to stand or sit; wheelchair scales or bed scales can be used for nonambulatory individuals. When using a bed scale, document the number of sheets, pillows, and blankets on the bed at the time of measurement. Lines, devices, and equipment should be lifted off the bed when the measurement is taking place. Normal weights for adult men and women are available from several reference standards, such as the Metropolitan Life tables. Online calculators are also available to calculate ideal body weight. An unintentional weight loss of 5% in a month or 10% over a 6-month period significantly affects nutrition status and should be evaluated. Nursing Safety Priority Action Alert Obtain weight at the same time each day, if possible, preferably before breakfast. Conditions such as heart failure and renal disease cause weight gain; dehydration and conditions such as cancer cause weight loss. Weight is the most reliable indicator of fluid gain or loss! Assessment of body fat is usually calculated by the registered dietitian nutritionist (RDN) if in a hospital setting or by a fitness trainer or physical therapist in the community setting. The body mass index (BMI) indirectly estimates total fat stores within the body by the relationship of weight to height (Table 52.1). For this reason, obtaining an accurate height is as important as an accurate weight. Online calculators can perform this computation, which divides a patient’s weight in kilograms by the square of height in meters. The least risk for malnutrition is associated with scores between 18.5 and 24.9. BMIs above and below these values are associated with increased health risks (CDC, 2022a). Limitations of BMI calculations include (Harvard T.H. Chan School of Public Health, 2023b; Simpson, 2021): • Indirect and imperfect measurements, as it does not distinguish between body fat and lean body mass • Inability to accurately predict body fat in older adults • Inability to account for sex assigned at birth and racial differences (e.g., women usually have more body fat than men; people of Asian ethnicity usually have more body fat than people of other races [Harvard T.H. Chan School of Public Health, 2023a]) Patient-Centered Care: Older Adult Health Eating Habits Body weight and BMI usually increase throughout adulthood until about 60 years of age. As some adults get older, they often become less hungry and eat less, even if they are healthy. Others continue usual eating patterns and are at higher risk for obesity—especially older adult females (CDC, 2022a). Do not assume that an older adult automatically eats less; personalize the nutritional assessment to accurately assess eating patterns for every patient. NCLEX Examination Challenge 52.1 Health Promotion and Maintenance An older adult is admitted to the hospital. The client’s height is 5 feet, 8 inches (1.73 m), and weight is 272 lb (123.4 kg). The nurse calculates the client’s current body mass index (BMI) as _______. Fill in the blank. Round your answer to the nearest whole number. Body surface area (BSA) is an estimate of a patient’s total body surface area. It reflects multiple physiologic and metabolic processes (Flint & Hall, 2022). BSA can be used as an indicator for appropriate dosage calculation for medication and IV administration, especially for anticancer agents, and to estimate the degree of severity in patients who have been significantly burned (Eaton & Lyman, 2022; Flint & Hall, 2022). BSA is calculated in meters squared, combining a patient’s weight and height and reflecting an estimate of their total surface (outside body layer) area (Eaton & Lyman, 2022). If a patient has a BSA of 3 m2, it means that the patient’s skin surface could be placed into a 3-meter × 3-meter box. TABLE 52.1 Body Mass Index (BMI) Ranges BMI Weight Status Below 18.5 Underweight 18.5–24.9 Normal or healthy weight 25.0–29.9 Overweight 30.0 and above Obese From Centers for Disease Control and Prevention (CDC). (2022b). Defining adult overweight & obesity. https://www.cdc.gov/obesity/basics/adult-defining.html. Calculate BSA by the Mosteller formula, which takes the square root of the height in centimeters, multiplied by the weight in kilograms, divided by 3600. The average BSA is 1.9 m2 for males and 1.6 m2 for females (Omni, 2022). Be aware that accurate calculation of weight is imperative, as height is unlikely to change significantly, but weight is variable. Skinfold measurements estimate body fat. The triceps and subscapular skinfolds are most commonly measured with a special caliper. Both are compared with standard measurements and recorded as percentiles. The midarm circumference (MAC) and calf circumference (CC) are needed if the full MNA® or the MNA® tool is used. Place a flexible tape around the upper arm (or calf) at the midpoint; wrap gently to avoid compressing the tissue, and record the findings in centimeters in the electronic health record. Nutrition Concept Exemplar: Undernutrition Pathophysiology Review Undernutrition is a multinutrient problem. If a patient does not, or cannot, consume calories and protein, intake of healthy nutrients is compromised. Inadequate nutrient intake can also result when an adult is admitted to the hospital or long-term care facility. For example, decreased staffing may not allow time for patients who need to be fed, especially older adults, who may eat slowly. Many diagnostic tests, surgery, trauma, and unexpected medical complications require a period of NPO in which nutrients are not being consumed or cause anorexia (loss of appetite). See Box 52.4 for common complications of undernutrition and Table 52.2 for common signs and symptoms of nutrient deficiencies. See Box 52.5 for concerns when assessing undernutrition in the older adult. Box 52.4 Common Complications of Undernutrition Cardiovascular • Reduced cardiac output Endocrine • Cold intolerance Gastrointestinal • Anorexia • Diarrhea • Impaired protein synthesis • Malabsorption • Vomiting • Weight loss Immunologic • Susceptibility to infectious disease Integumentary • Dry, flaky skin • Various types of dermatitis • Poor wound healing Musculoskeletal • Cachexia • Decreased activity tolerance • Decreased muscle mass • Impaired functional ability Neurologic • Weakness Psychiatric • Substance misuse Respiratory • Reduced vital capacity Patient-Centered Care: Culture and Spirituality Meals in the Health Care Setting In some cases, undernutrition results when meals provided in the health care setting differ from what the patient usually eats. Be sure to identify specific food preferences that the patient can eat and enjoy that are in keeping with personal cultural practices. Etiology and Genetic Risk The etiology of undernutrition is multifactorial and dependent on the specific type of undernutrition experienced. Protein-energy undernutrition (PEU), formerly protein-calorie malnutrition (PCM), has two common forms (Morley, 2022): • Marasmus: A calorie malnutrition in which body fat and protein are wasted. Serum proteins are often preserved. • Kwashiorkor: A lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low. Starvation, a complete lack of nutrients, is an acute and severe form of PEU, which usually occurs when food is unavailable (e.g., during a time of famine or exposure to the elements) (Morley, 2022). Unrecognized or untreated PEU can lead to dysfunction or disability and increased morbidity and mortality. TABLE 52.2 Signs and Symptoms of Nutrient Deficiencies Sign/Symptom Potential Nutrient Deficiency Hair Alopecia Zinc Easy to remove Protein Lackluster hair Protein “Corkscrew” hair Vitamin C Decreased pigmentation Protein Eyes Dryness of conjunctiva Vitamin A Corneal vascularization Riboflavin Keratomalacia Vitamin A Bitot spots (keratin buildup in the conjunctiva) Vitamin A GI Tract Nausea, vomiting Pyridoxine Diarrhea Zinc, niacin Stomatitis Pyridoxine, riboflavin, iron Cheilosis Pyridoxine, iron Glossitis Pyridoxine, zinc, niacin, folic acid, vitamin B12 Magenta tongue Vitamin A, riboflavin Swollen, bleeding gums Vitamin C Fissured tongue Niacin Hepatomegaly Protein Skin Dry and scaling Vitamin A Petechiae/ecchymoses Vitamin C Follicular hyperkeratosis Vitamin A Nasolabial seborrhea Niacin Bilateral dermatitis Niacin Musculoskeletal Subcutaneous fat loss Calories Muscle wastage Calories, protein Edema Protein Osteomalacia, bone pain, rickets Vitamin D Hematologic Anemia Vitamin B12, iron, folic acid, copper, vitamin E Leukopenia, neutropenia Copper Low prothrombin time, prolonged clotting time Vitamin K, manganese Neurologic Disorientation Niacin, thiamine Confabulation Thiamine Neuropathy Thiamine, pyridoxine, chromium Paresthesia Thiamine, pyridoxine, vitamin B12 Cardiovascular Heart failure, cardiomegaly, tachycardia Thiamine Cardiomyopathy Selenium Cardiac dysrhythmias Magnesium Courtesy Ross Products Division, Abbott Laboratories, Columbus, OH. Box 52.5 Assessing the Older Adult for Undernutrition Ask the older adult about signs or symptoms that could indicate undernutrition. Physical Concerns • Chronic conditions/illnesses • Constipation • Decreased appetite • Dentition—poor dental health; poor-fitting dentures; lack of teeth or dentures • Drugs—prescription and OTC drugs that may impair taste or appetite • Dry mouth • “Failure to thrive” (a combination of three of five symptoms, including weakness, slow walking speed, low physical activity, unintentional weight loss, exhaustion) • Impaired eyesight • Pain that is acute or persistent • Weight loss Psychosocial Concerns • Inability to prepare meals due to functional decline, fatigue, knowledge deficit, memory • Decrease in enjoyment of meals • Depression • Income (ability to afford food) • Loneliness • Proximity to sources of nutrient-dense foods (e.g., grocery store) • Transportation access to get to sources of nutrient-dense foods Acute PEU may develop in patients who were adequately nourished before hospitalization but experience starvation while in a catabolic state from infection, stress, or injury. Chronic PEU can occur in those who have a chronic health condition such as cancer, end-stage kidney or liver disease, or chronic neurologic disease. Eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder are psychiatric diagnoses with causative agents of psychiatric origin. These conditions can lead to a state of undernutrition. Anorexia nervosa is a self-induced state of starvation resulting from a fear of fatness, even though the patient is underweight. This condition is often accompanied by a psychiatric diagnosis of body dysmorphic disorder (BDD). BDD is an obsessive-compulsive condition in which patients spend an abnormal amount of time attempting to reach what they consider to be body perfection. In the case of a patient with anorexia nervosa, perfection is found in being thin. The condition affects the patient’s ability to carry out normal ADLs and significantly impacts quality of life (Phillips, 2022; Perkins, 2019). If this condition is suspected, collaborate with the primary health care provider to determine whether a psychiatric consultation is needed. Bulimia nervosa is characterized by episodes of binge eating in which the patient ingests a large amount of food in a short time. The binge eating is followed by some form of purging behavior, such as self-induced vomiting or excessive use of laxatives and diuretics. If not treated, death can result from starvation, infection, or suicide. Binge eating disorder is a separate psychiatric diagnosis from bulimia nervosa. It resembles bulimia nervosa in terms of binge-eating episodes, and it involves a feeling of loss of control over the eating behavior (Office on Women’s Health, 2022); however, it is not accompanied by purging. Again, collaborate with the primary health care provider if this condition is suspected. Further information about eating disorders can be found in mental health nursing textbooks. Incidence and Prevalence Globally, there are about 462 million people who are underweight (World Health Organization, 2021). Data are difficult to collect regarding patients who are malnourished, as they are seen in a variety of settings for multiple concerns, many of which are perceived to be unrelated to nutrition. Patient-Centered Care: Older Adult Health Protein-Energy Undernutrition Older adults are most at risk for poor nutrition, especially PEU. Risk factors include physiologic changes of aging, environmental factors, and health problems. See Box 52.5, Assessing the Older Adult for Undernutrition, which lists some of the major factors for which you will assess. If psychosocial concerns are present, collaborate with mental health or social work professionals who can assist. Chapter 4 discusses nutrition for older adults in more detail. Interprofessional Collaboration Care of Older Adults at Risk for Undernutrition For older adults with undernutrition or at risk for undernutrition, assess for psychosocial concerns that can impact their desire or ability to consume nutrient-rich foods. If any of these concerns is rooted in mental health, such as depression or loneliness, collaborate with a mental health professional, such as a counselor or psychiatric–mental health nurse practitioner, who can work with the patient to enhance emotional well-being. If the concerns are economic or access-related, collaborate with the case manager or social worker, who can help identify ways to facilitate better access to sources of nutrition. According to the Interprofessional Education Collaborative (IPEC) Expert Panel’s Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care (IPEC, 2016; Slusser et al., 2019). Health Promotion/Disease Prevention It is estimated that 50% to 71% of older adult patients are malnourished before hospital admission (Bellanti et al., 2022; Ritchie & Yukawa, 2023). It is also thought that one-third of nourished older adults who are admitted will develop some degree of malnutrition during hospitalization (Bellanti et al., 2022). Status of nutrition may vary based on prehospitalization status, intake during a current illness or injury, and accurate assessment and intervention of health care professionals. Malnourishment can increase the length of the patient’s stay and contribute to the rate of readmission. Nurses can have a significant impact on a patient’s length of stay when adequately advocating for the patient’s nutritional status. (See the Systems Thinking/Quality Improvement box.) Interprofessional Collaboration The Patient With Undernutrition For patients with undernutrition, consult with a registered dietitian nutritionist (RDN), who can assist with meeting nutritional needs while the patient is hospitalized, as well as help with planning for continued nutritional health after discharge. According to the Interprofessional Education Collaborative (IPEC) Expert Panel’s Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care (IPEC, 2016; Slusser et al., 2019). Systems Thinking/Quality Improvement An Interprofessional Focus on Preventing Readmissions for Patients at High Risk for Malnutrition Reflecting on the fact that malnutrition affects one in three hospitalized patients, the authors of this study desired to put an evidence-based protocol in place to improve patient outcomes and avoid reduced reimbursement associated with 30-day malnutrition-related readmissions. Nurses, the clinical manager of nutritional services, physicians, care coordination staff, physical therapists, quality staff, and informatics experts were tasked together as an interprofessional team to address high hospital readmission rates due to patient malnourishment. After a comprehensive review of evidence was accomplished, the team developed the evidence-based Malnutrition Readmission Prevention Protocol, which identifies three stages of risk for malnutrition. The protocol was used first in one facility and then implemented across a hospital system. Informatics specialists worked to create automatic alerts within the electronic health record to flag health care professionals to use the protocol. Using this tool, patients were identified for inpatient management of nutritional supplementation, and then referral to a registered dietitian nutritionist (RDN) was made. The RDN coordinated availability of 30-day supplementation to be used in the home environment following discharge. An important part of protocol use was involving the patient (and caregiver, as appropriate) in conversations regarding inpatient and outpatient nutritional management. Follow-up calls were made by care management nurses; home visits were conducted by paramedics; and primary care providers were notified to coordinate care after discharge. Over a 5-year period, readmissions due to malnutrition decreased from 42% to 13.3%. Commentary: Implications for Practice and Research Coordinating an effort in which all professions involved in patient care had input into the protocol well before implementation facilitated a collaborative effort created with best practice and favorable patient outcomes in mind. Using the protocol together and meeting the patient’s nutritional needs in the inpatient and outpatient settings greatly decreased the readmission rate related to malnutrition. Working together facilitates better outcomes when all stakeholders, including the patient and caregiver, are involved in care processes and planning. Beckett, C., & Walsh, S. (2019). The malnutrition readmission prevention protocol. American Journal of Nursing, 119(12):60−64. Interprofessional Collaborative Care Care for the patient with undernutrition takes place in a variety of settings, such as the home, the community, and in the hospital setting if more comprehensive management is needed. Recognize Cues: Assessment History See Box 52.3 to complete the initial history. For older adults, also see Box 52.5, Assessing the Older Adult for Undernutrition. Keep in mind that an unintentional weight loss of 5% in 30 days, or 10% over a 6-month period, significantly affects nutrition status and should be further evaluated. In collaboration with the registered dietitian nutritionist (RDN), also obtain information about the patient’s: • Usual daily food intake and timing of eating • Food preferences (including cultural considerations) • Eating behaviors/patterns • Change in appetite • Recent weight changes • Economic status that may influence access to, or purchase of, food A full nutrition history usually includes a 24-hour recall of food intake and the frequency with which foods are consumed. The adequacy of the diet can be evaluated by comparing the amount and types of foods consumed daily with the established standards. The registered dietitian nutritionist (RDN) then provides a more detailed analysis of nutritional intake. Be aware that patients who live in food deserts (i.e., urban areas where fresh, healthy food is in low supply or unaffordable) may have difficulty obtaining food that is densely nutritious. Patient-Centered Care: Health Equity Access to Nutritional and Activity Resources The Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) (2023) are working to promote good nutrition, regular physical activity, and a healthy weight for everyone. When collecting a nutritional history, ask whether patients feel they can regularly identify, obtain, and afford nutritious foods. Also ask whether they have access to physical areas where they can be active, such as local parks. Collect information that identifies the knowledge patients have about healthy eating and movement and that helps to determine which teaching will be most beneficial. As needed, refer patients who can benefit from nutritional support to local organizations that can assist with resources and education. Nursing Safety Priority Action Alert Assess for difficulty or pain with chewing or swallowing. Unrecognized dysphagia is a common problem among older adults and can cause undernutrition, dehydration, and aspiration pneumonia. See Chapter 46 for more information. Physical Assessment/Signs and Symptoms Assess for signs and symptoms of various nutrient deficiencies (see Table 52.2). Inspect hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems. Examine the condition of the skin, including any reddened or open areas. Anthropometric measurements may also be obtained. Monitor all food and fluid intake. A three-day caloric intake may be collected and then calculated by the registered dietitian nutritionist (RDN). Delegate this activity to assistive personnel (AP) under your ongoing supervision, and direct AP to report the intake and output values back after obtaining them. Ask AP to report any signs of choking while the patient eats. Document the presence of mouth pain, difficulty chewing, nausea, vomiting, heartburn, or any other symptoms of discomfort with eating. Psychosocial Assessment The psychosocial history provides information about the patient’s economic status, occupation, educational level, ethnicity/race, living and cooking arrangements, and emotional status. Determine whether financial resources are adequate for providing the necessary food. If resources are inadequate, the social worker or case manager may refer the patient and caregiver to available community services. Laboratory Assessment Interpret laboratory data carefully with regard to the total patient; focusing on an isolated value may yield an inaccurate conclusion. In general, laboratory values that may be decreased in the presence of undernourishment include (Pagana et al., 2022): • Cholesterol • Hemoglobin • Hematocrit • Serum albumin • Thyroxine-binding prealbumin (PAB) • Transferrin Analyze Cues and Prioritize Hypothesis: Analysis The priority collaborative problem for the patient with undernutrition is: 1. Weight loss due to inability to access, ingest, or digest food or absorb nutrients Generate Solutions and Take Actions: Planning and Implementation Improving Nutrition Planning: Expected Outcomes The patient with undernutrition is expected to have nutrients available to meet the patient’s metabolic needs. Interventions The preferred route for food intake is orally through the GI tract because it enhances the immune system and is safer, easier, less expensive, and more enjoyable. Meal Management Following the primary health care provider’s and RDN’s recommendation, provide high-calorie, nutrient-rich foods (e.g., milkshakes, cheese, and supplement drinks such as Boost or Ensure). A feeding schedule of six small meals may be tolerated better than three large ones. A pureed or dental soft diet may be easier for those who have problems chewing or do not have teeth. Follow recommendations in Box 52.6 to provide a more enjoyable and productive eating experience for patients with undernutrition. Nutritional Supplementation If the patient cannot take in enough nutrients in food, fortified medical nutrition supplements (MNS) (e.g., Ensure, Sustacal, Carnation Instant Breakfast [also available as a lactose-free supplement]) may be given, especially to older adults. For patients with liver and renal disease or diabetes, special products that meet these needs are available (e.g., Glucerna for patients with diabetes). Box 52.6 Best Practice for Patient Safety and Quality Care Promoting Nutrition Intake Environment • Remove bedpans, urinals, and emesis basins from the environment. • Eliminate or decrease offensive odors as much as possible. • Decrease environmental distractions as much as possible. • Administer pain medication and/or antiemetics for nausea at least 1 hour before mealtime. Comfort • Allow the patient to toilet before mealtime. • Provide mouth care before mealtime. • Ensure that eyeglasses and hearing aids are in place, if appropriate, during meals. • Remind assistive personnel (AP) to have the patient sit in a chair, if possible, at mealtime. Function • Ensure that meals are visually appealing, appetizing, and at appropriate temperatures. • If needed, open cartons and packages and cut up food. • Observe during meals for food intake, and document the percentage consumed. • Encourage self-feeding (if able), or feed the patient slowly (delegate to AP, if desired). • Eliminate or minimize interruptions during mealtime for nonurgent procedures or rounds. Nutrition supplements are supplied as liquid formulas, powders, soups, coffee, and puddings in a variety of flavors. Examples include Duocal for carbohydrates and fats, and Beneprotein for protein. Follow the primary health care provider’s prescription for nutritional supplementation. Drug Therapy Multivitamins, zinc, and an iron preparation are often ordered to treat or prevent anemia in patients who are malnourished. Monitor the patient’s hemoglobin and hematocrit levels for efficacy of treatment, and assess for side effects. For example, iron can cause constipation, and zinc can cause nausea and vomiting. Total Enteral Nutrition If a patient cannot achieve adequate nutrition via oral intake, total enteral nutrition (TEN) may be needed. Enteral tube feedings may be necessary to supplement oral intake or to provide total nutrition. Patients likely to receive TEN can be divided into three groups: • Those who can eat but cannot maintain adequate nutrition by oral intake of food alone • Those with permanent neuromuscular impairment who cannot swallow • Those who do not have permanent neuromuscular impairment but cannot eat because of their condition Patients in the first group are often older adults or patients receiving cancer treatment. In some cases, artificial nutrition and hydration may not be desired. Check for advance directives stating whether the patient desires artificial nutrition and hydration if certain conditions exist. If advance directives are not in place, yet the patient has a designated durable power of attorney, that individual can make health-related decisions when the patient is unable to do so. Legal and ethical questions often arise when patients do not have advance directives, are unable to make their wishes known, and do not have a designated durable power of attorney. The decision to feed or not to feed is complex, and there is no clear right or wrong answer. See the Legal/Ethical Considerations box for more information. Legal/Ethical Considerations Ethics Committees and Feeding Decisions about legal/ethical situations regarding feeding benefit from the involvement of interprofessional ethics committees in health care facilities. When clinicians are making decisions about the desirability of tube feedings for patients who cannot express their own wishes and who do not have an advance directive in place, the focus should be on achieving consensus by: • Reviewing what is known about tube feedings, especially their risks and benefits • Reviewing the medical facts about the patient • Investigating any available evidence that would help understand the patient’s wishes • Obtaining the input of all stakeholders in the situation • Delaying any action until consensus is achieved Those in the second group of patients likely to receive TEN usually have permanent swallowing problems due to a condition such as brain attack, severe head trauma, or advanced multiple sclerosis. These patients require some type of feeding tube for delivery of the enteral product on a long-term basis. Patients in the third group receive enteral nutrition for as long as their illness lasts. The feeding is discontinued when the patient’s condition improves and oral intake can resume. A therapeutic combination of carbohydrates, fat, vitamins, minerals, and trace elements is available in liquid form. A prescription from the health care provider is required for enteral nutrition, but the RDN usually makes the recommendation and computes the amount and type of product needed for each patient. NCLEX Examination Challenge 52.2 Safe and Effective Care Environment A client with terminal cancer who is comatose has a durable power of attorney but no advance directive. When total enteral nutrition (TEN) is prescribed, which nursing action would be appropriate? A. Contact the durable power of attorney. B. Begin administration of TEN immediately. C. Consult the interprofessional ethics committee. D. Ask the health care provider whether to start nutritional therapy. FIG. 52.4 Nasoduodenal tube. From Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder, J. [2011]. Pharmacology and the nursing process [6th ed.]. St. Louis: Mosby. Methods of administering total enteral nutrition TEN is administered as a “tube feeding” through a nasoenteric or enterostomal tube. It can be used in the patient’s home or any health care setting. A nasoenteric tube (NET) is a feeding tube inserted nasally and then advanced into the GI tract, such as a Dobbhoff tube. Commonly used NETs include the nasogastric (NG) tube, the smaller (small-bore) nasoduodenal tube (NDT) (Fig. 52.4), and the nasojejunal tube (NJT), which is used less often. All of these types of tubes are used for less than 4 weeks to provide short-term feeding. Enterostomal feeding tubes are used for patients who need long-term enteral feeding. The surgeon directly accesses the GI tract using various surgical, endoscopic, and laparoscopic techniques. Under sedation, a gastrostomy—a stoma created from the abdominal wall into the stomach—is created. Then a percutaneous endoscopic gastrostomy (PEG) or dual-access gastrostomy-jejunostomy (PEG/J) tube (Fig. 52.5) is placed. A jejunostomy is used for long-term feedings when it is desirable to bypass the stomach, such as with gastric disease, upper GI obstruction, and abnormal gastric or duodenal emptying. This can be accomplished via a direct percutaneous endoscopic jejunostomy (DPEJ) (see Fig. 52.5) (DeLegge, 2021). Tube feedings are administered by bolus feeding, continuous feeding, or cyclic feeding. Bolus feeding is an intermittent feeding of a specified amount of enteral product at set intervals during a 24-hour period, typically every 4 hours. This method can be accomplished manually or by infusion through a mechanical pump or controller device. Continuous feeding is similar to IV therapy in that small amounts are continuously infused (by gravity drip or a pump or controller device) over a specified time. Cyclic feeding is the same as continuous feeding except that the infusion is stopped for a specified time in each 24-hour period, usually 6 hours or longer (“down time”). Down time typically occurs in the morning to allow bathing, treatments, and other activities. Follow the health care provider’s prescription for type, rate, and method of tube feeding, as well as the amount of additional water (“free water”) needed. If the patient can swallow small amounts of food, the patient may also eat orally while the tube is in place. FIG. 52.5 Percutaneous endoscopic gastrostomy (PEG), dual-access gastrostomy-jejunostomy (PEG/J) tube, and direct percutaneous endoscopic jejunostomy (DPEJ). Redrawn from Zhu, Y., Shi, L., Tang, H., & Tao, G. [2012]. Current considerations of direct percutaneous endoscopic jejunostomy. Canadian Journal of Gastroenterology 26[2], 92–96. Set of the three illustrations depict three types of enterostomal feeding tubes as follows: • On the left, P E G is depicted as a single lumen tube with gastric port inserted in the fundus of stomach. • At the center P E G or J is shows as a two-port tubing as jejunal port and gastric port, with free end inserted in the fundus. • On the right, D P E J is depicted as tubing is inserted in duodenum, with tube having two ports as suction port and feeding port. The nurse is responsible for the care and maintenance of the feeding tube and the enteral feeding. See Box 52.7. Nursing Safety Priority Action Alert If a gastrostomy or jejunostomy tube cannot be moved while you are performing your regular assessment, notify the health care provider immediately because the retention disk may be embedded in the tissue. Cover the site with a dry, sterile dressing and change the dressing at least once a day. Complications of total enteral nutrition The nursing priority for care of a patient receiving TEN is safety, which includes preventing, assessing, and managing complications associated with tube feeding. Some complications of therapy result from the type of tube used to administer the feeding, and others result from the enteral product itself. The most common problem is the development of an obstructed (“clogged”) tube. Use the information in Box 52.8 to address this concern (Drummond Hayes & Drummond Hayes, 2018). Patients receiving TEN are at risk for several other complications, including refeeding syndrome; tube misplacement and dislodgment; abdominal distention and nausea/vomiting; and problems with fluid and electrolyte balance, often associated with diarrhea. These problems can be prevented if the patient is monitored carefully and complications are detected early. Tube misplacement and dislodgment Misplacement or dislodgment of the tube can cause aspiration and possible death. Immediately remove any tube that you suspect is dislodged! An x-ray is the most accurate confirmation method and should always be done on initial tube insertion. If a larger bore NG tube is used, after the initial placement is confirmed, check gastric residual before each intermittent feeding or drug administration, or at least every 6 hours during feeding (Hodin & Bordeianou, 2023). Do not rely on traditional methods for checking tube placement such as auscultation; pH testing of GI contents; testing of biochemical markers, such as bilirubin, trypsin, or pepsin; or assessment for carbon dioxide using capnometry. Once x-ray confirmation has been made, mark the tube exit point as a baseline for visual reevaluation of placement at each assessment. Nursing Safety Priority Action Alert If enteral tubes are misplaced or become dislodged, the patient is likely to aspirate. Aspiration pneumonia is a life-threatening complication associated with TEN, especially for older adults. Observe for fever and signs of dehydration, such as dry mucous membranes and decreased urinary output. Auscultate lungs every 4 to 8 hours to check for diminishing breath sounds, especially in lower lobes. Patients may become short of breath and report chest discomfort. If a chest x-ray confirms this diagnosis, treatment with antibiotics is started. Abdominal distention and nausea/vomiting Abdominal distention, nausea, and vomiting during tube feeding are often caused by overfeeding. To prevent overfeeding, check gastric residual volumes every 6 hours, depending on agency policy and patient assessment. If residual feeding is obtained, check with the health care provider for the appropriate intervention (usually to slow or stop the feeding for a time) or consult the American Society of Parenteral and Enteral Nutrition (ASPEN) (2023) best practice recommendations (ASPEN, 2023). Follow agency policy regarding holding feeding if necessary. After a period of rest, the feeding can be restarted, usually at a lower flow rate. Fluid and electrolyte imbalances Patients receiving enteral nutrition therapy, especially older adults and those with cardiac or renal problems, are at an increased risk for fluid imbalances. Some electrolyte imbalances can be avoided. For example, a patient with renal problems and existing high potassium levels may be given a special formula lower in potassium. Fluid imbalances associated with enteral nutrition are usually related to the body’s response to increased serum osmolarity, but fluid overload from too much tube feeding can also occur. If patients do not have normal renal and cardiac function, expansion of the plasma volume can lead to circulatory overload and pulmonary edema, especially in older adults. Assess for signs and symptoms, such as peripheral edema, sudden weight gain, crackles, dyspnea, increased blood pressure, and bounding pulse; report these to the health care provider. Box 52.7 Best Practice for Patient Safety and Quality Care Tube-Feeding Care and Maintenance • If nasogastric or nasoduodenal feeding is ordered, use a soft, flexible, small-bore feeding tube (smaller than 12 Fr). • Recognize that tubes with ports minimize contamination by eliminating the need to open the feeding system to administer drugs. • The initial placement of the tube should be confirmed by x-ray study even if another method of confirmation is available, such as electromagnetic feeding tube–placement device (ETPD). Evidence shows that radiographic confirmation is essential (Hodin & Bordeianou, 2023). • If correct tube placement is ever in question, a chest x-ray should again be performed. • Secure the tube with tape or a commercial attachment device after applying a skin protectant; change the tape regularly. • If a gastrostomy or jejunostomy tube is used, assess the insertion site for signs of infection or excoriation (e.g., excessive redness/hyperpigmentation, drainage). Rotate the tube 360 degrees each day, and check for in-and-out play of about ¼ inch (0.6 cm). • Check and document residual volume every 6 hours or per agency policy by aspirating stomach contents into a syringe. If residual feeding is obtained, check with the health care provider for the appropriate intervention (usually to slow or stop the feeding for a time), or consult the American Society of Parenteral and Enteral Nutrition’s best practice recommendations (ASPEN, 2023). • Check the feeding pump to ensure proper mechanical operation. • Ensure that the enteral product is infused at the ordered rate (mL/hr). • Change the feeding bag and tubing every 24 to 48 hours; label the bag with the date and time of the change with your initials. Use an irrigation set for no more than 24 hours. • For continuous or cyclic feeding, add only 4 hours of product to the bag at a time to prevent bacterial growth. A closed system is preferred, and each set should be used no longer than 24 hours. • Wear clean gloves when changing or opening the feeding system or adding product; wipe the lid of the formula can with clean gauze; wear sterile gloves when caring for patients who are critically ill or immunocompromised. • Label open cans with date and time opened; cover and keep refrigerated. Discard any unused open cans after 24 hours. • Do not use any color of food dye in formula because it can cause serious complications. • To prevent aspiration, keep the head of the bed elevated at least 30 degrees during the feeding and for at least 1 hour after the feeding for bolus feeding; continuously maintain the semi-Fowler’s position for patients receiving cyclic or continuous feeding. • Monitor laboratory values, especially blood urea nitrogen (BUN), serum electrolytes, hematocrit, prealbumin, and glucose. • Monitor for complications of tube feeding, especially diarrhea. • Monitor and document the patient’s weight and intake and output per the health care provider’s order or agency policy. Box 52.8 Best Practice for Patient Safety and Quality Care Maintaining a Patent Feeding Tube • Recognize that a tube occlusion is more easily prevented than corrected. • Specific risks for tube occlusion include delivering multiple medications without flushing between administration, not flushing before and after overall medication administration, using longer tubes, and using tubes of smaller diameter. • Consult with the pharmacist to be sure the prescribed medications are compatible with the enteral nutrition formula. • Consult with the pharmacist to confirm that medications and formula can be cleared from the tube with appropriate flushing. • Collaborate with the health care provider to use liquid medications instead of crushed tablets when possible, unless the liquid form of medication causes diarrhea. • Do not mix drugs with the feeding product before giving. Crush tablets as finely as possible and dissolve in warm water. (Check to see which tablets are safe to crush. For example, do not crush slow-acting [SA] or slow-release [SR] drugs.) • Flush the tube with 30 mL of water, using at least a 30-mL syringe to prevent tube rupture: • At least every 4 hours • Before and after medication administration • After any interruption of enteral nutrition • If the tube becomes clogged, use 30 mL of water for flushing, applying gentle pressure with a 50-mL piston syringe. • Do not instill a carbonated beverage or cranberry juice; these have an acidic pH that can worsen the occlusion by causing enteral nutrition formula proteins to precipitate in the tube. • Use warm water as the best choice for unclogging. • Attach a 30- or 60-mL piston syringe to the feeding tube; retract the plunger to facilitate dislodging the clog. Then fill the flush with warm water, reattach it to the tube, and attempt flushing. If continued resistance is experienced, move the plunger gently back and forth. Then clamp the tube to allow the warm water to penetrate the clog for about 20 minutes. • If water does not unclog the tube, an experienced nurse can use an activated pancreatic enzyme solution ordered by the health care provider, following agency policy. • As a final attempt, commercially available enzyme declogging kits or devices can be used by an experienced nurse, again following agency policy. • If unclogging is unsuccessful, replacement of the tube is recommended. Data from Boullata, J., Carrera, A., Harvey, L., et al. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15–103; Drummond Hayes, K., & Drummond Hayes, D. (2018). Best practices for unclogging feeding tubes in adults. Nursing2018, 48(6), 66; Guenter, P., & Lyman, B. (2021). Evidence-based strategies to prevent enteral nutrition complications: Follow these tips to keep your patients safe. American Nurse Journal, 16(6), 18–22; Jackson, K., & Tomlinson, S. (2021). Essential procedures: Acute care. Philadelphia, PA: Wolters Kluwer. Excessive diarrhea and/or dehydration may develop when hyperosmolar enteral preparations are delivered quickly and excessive water loss is experienced. A more iso-osmolar formula may be needed. If diarrhea continues, and especially if it has a very foul odor, evaluate for Clostridium difficile or other infectious organisms. Contamination can occur because of repeated and often faulty handling of the feeding solution and system. In some cases, diarrhea may follow the administration of multiple liquid medications, such as elixirs and suspensions that have a very high osmolarity. Examples include acetaminophen, furosemide, and phenytoin. Discuss this with the health care provider to determine whether the patient’s drug regimen can be changed to prevent diarrhea or if dilution is possible. The two most common electrolyte imbalances associated with enteral nutrition therapy are hyperkalemia and hyponatremia. Both of these conditions may be related to hyperglycemia-induced hyperosmolarity of the plasma and the resultant osmotic diuresis. Risks for disturbances in fluid and electrolyte balance are discussed in detail in Chapter 13. Refeeding syndrome Refeeding syndrome is a potentially life-threatening complication related to fluid and electrolyte shifts during aggressive nutritional rehabilitation of the patient in a state of starvation. Prevent this complication by carefully assessing and managing nutritional needs early before a patient is severely malnourished. Nursing Safety Priority Critical Rescue Recognize signs of refeeding syndrome, which include hypophosphatemia and hypokalemia noted in laboratory values, heart failure, peripheral edema, rhabdomyolysis, seizures, hemolysis, and respiratory insufficiency (Mehler, 2023). Respond by contacting the health care provider immediately. More information on fluid and electrolyte balance can be found in Chapter 13. Parenteral Nutrition When a patient cannot effectively use the GI tract for nutrition, either partial or total parenteral nutrition therapy may be needed. This form of nutrition is introduced into the veins and differs from standard IV therapy in that any or all nutrients (carbohydrates, proteins, fats, vitamins, minerals, electrolytes, and trace elements) can be given. Parenteral nutrition can be mixed by the pharmacist using compounded bags or delivered from a multichamber bag in which commercially premixed solutions are used (King, 2019). In a multichamber bag, dextrose, amino acids, electrolytes, and lipids are preloaded in separate chambers that are mixed together right before administration. The benefit of compounding is that mixtures can be highly personalized to each patient. However, a downfall is the rate of human error that can take place in the compounding, labeling, and administration processes (King, 2019). A benefit of the multichamber bag is that shelf life is 12 months or more (compared with a 7- to 9-day shelf life for individually compounded formulations). The downfall is lack of customization to the individual patient, as multichamber bags usually contain less protein and fewer electrolytes than personalized formulations (King, 2019). At the time of publication, the American Society for Parenteral and Enteral Nutrition (ASPEN) recommends using premixed formulations or multichamber bag solutions. Peripheral parenteral nutrition (PPN) Peripheral parenteral nutrition (PPN) is administered through a cannula or catheter in a large distal vein of the arm on a short-term basis. It is usually used for patients who can eat but are not able to take in enough nutrients to meet their needs. PPN is fat-based and does not contain all of the carbohydrates a patient needs, so it is not used on a long-term basis (Baiu & Spain, 2019). The patient must have adequate peripheral vein access and be able to tolerate large volumes of fluid to have this type of nutritional therapy. PPN has an osmolarity lower than conventional parenteral nutrition and must be administered in a high volume and/or with a high fat formulation to deliver adequate nutrients (Seres, 2021). Monitor for irritation at the site of the cannula or catheter insertion, as infusion of large volumes of PPN can be irritating to tissue. Nursing Safety Priority Critical Rescue Recognize that you must monitor patients receiving fat emulsions for fever, increased triglycerides, clotting problems, and multisystem organ failure, which may indicate fat overload syndrome, especially in patients who are critically ill. Respond to any of these signs and symptoms by discontinuing the IV fat emulsion infusion and reporting the changes to the health care provider immediately. Total parenteral nutrition When the patient requires intensive nutrition support for an extended time, the health care provider orders centrally administered total parenteral nutrition (TPN). TPN (Fig. 52.6) is delivered through a temporary central line inserted in the neck or chest, a long-term tunneled catheter or implanted part inserted in the chest, or via a PICC line (Baiu & Spain, 2019). (See Chapter 15 for care.) This type of nutrition is hypertonic and contains a high glucose content. FIG. 52.6 Total parenteral nutrition. TPN solutions are administered with an infusion pump. The osmolarity of the fluid and the concentrations of the specific components make controlled delivery essential. See Box 52.9 for appropriate nursing interventions. Patients receiving parenteral nutrition fluids are at risk for a wide variety of serious and potentially life-threatening complications. Complications may result from the solutions or from the peripheral or central venous catheter (see Chapter 15). The patient with cardiac or renal dysfunction can develop problems with fluid and electrolyte balance, including fluid overload, heart failure, and pulmonary edema. The health care provider usually requests frequent serum electrolyte levels to detect imbalances. Potassium and sodium imbalances are common, especially when insulin is also administered as part of the therapy. Calcium imbalances, particularly hypercalcemia, are associated with TPN. The risk for metabolic and electrolyte complications is reduced when the administration rate is carefully controlled and patients are closely observed. Monitor for any of these imbalances, and report any major changes or abnormalities to the health care provider immediately. Care Coordination and Transition Management The patient with undernutrition, once stabilized, can be cared for in an acute care hospital, transitional care unit, long-term care agency, or their home. Box 52.9 Best Practice for Patient Safety and Quality Care Care and Maintenance of Total Parenteral Nutrition • Follow the Infusion Nurses Society’s Infusion Therapy Standards of Practice (Gorski et al., 2021). • Check each bag of total parenteral nutrition (TPN) solution for accuracy by comparing it with the original prescription. • Administer insulin as ordered. • Monitor the IV pump for accuracy in delivering the ordered hourly rate. • If the TPN solution is temporarily unavailable, collaborate with the health care provider so that 10% dextrose/water (D10W) or 20% dextrose/water (D20W) can be administered until the TPN solution can be obtained. • If the TPN administration is not on time (“behind”), do not attempt to “catch up” by increasing the rate. • Monitor and document the patient’s weight daily or according to facility protocol. • Monitor serum electrolytes and glucose daily or per facility protocol. • Monitor for, report, and document complications, including problems with fluid and electrolyte balance. • Monitor and carefully record the patient’s intake and output. • Assess the patient’s IV site for signs of infection or infiltration (see Chapter 15). • Change the IV tubing every 24 hours or per facility protocol. • Change the dressing every 48 hours for a gauze dressing change and 7 days for a transparent dressing change (see Chapter 15). • Before administering TPN, have a second nurse check the prescription and solution to increase patient safety. Home Care Management The patient with undernutrition needs a variety of resources at home to continue consistent nutrition support. If food can be consumed orally, the case manager or other discharge planner can determine whether financial resources are available for nutritional supplements. If the hospital provides ambulatory nutrition counseling services, the patient may be scheduled for follow-up after discharge for assessment of weight gain. Self-Management Education The registered dietitian nutritionist (RDN) teaches the patient with undernutrition (and family, as indicated) about a high-calorie, high-protein diet and nutrition supplements. It is important for you, as the nurse, to: • Reinforce the importance of adhering to the ordered diet. • Review any drugs the patient may be taking. • Teach the importance of taking iron immediately before or during meals. • Caution the patient that iron tends to cause constipation. • Emphasize ways to prevent constipation, including adequate fiber intake, adequate fluids, and exercise. Health Care Resources The patient with undernutrition discharged to home on enteral or parenteral nutrition support needs the specialized services of a home nutritional therapy team. This team generally consists of the health care provider, nurse, registered dietitian nutritionist (RDN), pharmacist, and case manager or social worker. Several commercial companies supply these services to patients at home in addition to the feeding supplies and formulas and health teaching. Evaluate Outcomes: Evaluation Evaluate the care of the patient with undernutrition based on the identified priority patient problem. The primary expected outcome is that the patient consumes available nutrients to meet the metabolic demands for maintaining weight and total protein and has adequate hydration. Nutrition Concept Exemplar: Obesity Pathophysiology Review The pathophysiology of obesity is complex. Numerous chemicals in the body, including hormones known as adipokines, work together to affect appetite and fat metabolism. Dysregulation of these chemicals can result in conditions such as appetite increase, overstimulation of the autonomic nervous system, blood vessel inflammation, and ventricular hypertrophy. Complications of obesity can affect many organ systems (Box 52.10). The terms obesity and overweight are often used interchangeably, but they refer to different health problems. In both problems, the patient often has not consumed enough healthy nutrients to achieve adequate nutrition and has an abnormal or excessive amount of fat accumulation (World Health Organization, 2023). Overweight is reflected by a body mass index (BMI) of 25 to 29. Obesity is reflected by a BMI of 30 or above (CDC, 2022b). BOX 52.10 Common Complications of Obesity Cardiovascular • Coronary artery disease (CAD) • Hyperlipidemia • Hypertension • Peripheral artery disease (PAD) Endocrine • Insulin resistance • Metabolic syndrome • Type II diabetes Gastrointestinal • Cholelithiasis Genitourinary/Reproductive • Erectile dysfunction in men • Menstrual irregularities in women • Urinary incontinence Integumentary • Delayed wound healing • Susceptibility to infections Musculoskeletal • Chronic back and/or joint pain • Early onset of osteoarthritis Neurologic • Stroke Psychiatric • Depression Respiratory • Obesity hypoventilation syndrome • Obstructive sleep apnea Obesity is subdivided into three categories (CDC, 2022b): • Class I—BMI of 30 to <35 • Class II—BMI of 35 to <40 • Class III—BMI of 40 or higher (sometimes called “extreme” or “severe” obesity) The distribution of excess body fat rather than the degree of obesity has been used to predict increased health risks. The waist circumference (WC) is a stronger predictor of coronary artery disease (CAD) than is the BMI. A WC greater than 35 inches (89 cm) in women and greater than 40 inches (102 cm) in men indicates central obesity (National Heart, Lung, and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services, n.d.). Central obesity is a major risk factor for CAD, brain attack, type 2 diabetes, some cancers (e.g., colon, breast), sleep apnea, and early death. The waist-to-hip ratio (WHR) is also a predictor of CAD. This measure differentiates peripheral lower body obesity from central obesity. A WHR of 0.95 or greater in men (0.8 or greater in women) indicates android obesity with excess fat at the waist and abdomen. Etiology and Genetic Risk The causes of obesity involve complex interrelationships of many environmental, genetic, and behavioral factors. One of the most common causes of being overweight or obese is eating high-fat and high-cholesterol diets. Obesity is associated with diet when it contains a significant amount of saturated fat, which increases low-density lipoproteins (LDL, or LDL-C for low-density lipoproteins cholesterol). Trans fatty acids (TFAs), saturated fats, and cholesterol are linked to a higher risk for heart disease (Oteng & Kersten, 2020). By contrast, monounsaturated and polyunsaturated fats are healthy fats. Physical inactivity has been identified as another cause of overweight and obesity. The major barriers to increasing physical activity include lack of time, comfort level in a sedentary lifestyle, and decreased mobility due to health conditions. Drug therapy also contributes to obesity when prescribed medications cause weight gain when they are taken on a long-term basis. Examples include: • Corticosteroids • Estrogens and certain progestins • NSAIDs • Antihypertensives • Antidepressants and other psychoactive drugs • Antiepileptic drugs • Certain oral antidiabetic agents Patient-Centered Care: Genetics/Genomics Genetic Classifications of Obesity Evidence shows that genetic classifications of obesity can be (Loos & Yeo, 2022; Lin & Li, 2021): 1. Monogenic (caused by a single gene); 2. Syndromic (severe obesity associated with other phenotypes, including neurodevelopmental abnormalities such as Prader-Willi syndrome); 3. Oligogenic (due to the absence of a certain phenotype); or 4. Polygenic (caused by a cumulative effect of numerous genes whose effect is increased in the environment where weight gain is prominent) Polygenic obesity is most common. In any predisposition to obesity, environment (lifestyle) is also a strong influence. Encourage patients to focus on lifestyle modifications that are within their control, even if they believe genetics is the root cause of obesity. Incidence and Prevalence Worldwide, the prevalence of overweight and obesity has doubled since 1980 (Chooi et al., 2019). About one-third of the world’s population is now classified as overweight or obese (Chooi et al., 2019). This problem is a leading cause of preventable death. Health Promotion/Disease Prevention Obesity is a major public health problem and is associated with many complications, including death. As a result of this continuing concern, one of the Healthy People 2030 nutrition objectives is to reduce the proportion of adults with obesity (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). See Box 52.11 for more. In collaboration with the registered dietitian nutritionist (RDN), teach the importance of weight management and physical activity to improve health. Even a 5% weight loss can drastically decrease the risk for coronary artery disease (CAD) and diabetes mellitus. Teach patients that physical activity can be as simple as walking 20 minutes a day. Interprofessional Collaborative Care Care for the patient with obesity takes place in a variety of settings—from the home to the community to a hospital setting (if more comprehensive management or surgery is needed). Members of the interprofessional team who collaborate most closely to care for this patient include the primary health care provider, the surgeon (if surgery is required), the nurse, the social worker, and the registered dietitian nutritionist (RDN). For patients who experience psychological impact related to obesity, a psychologist or therapist will also have an important role in care. Box 52.11 Meeting Healthy People 2030 Select Objectives and Targets for Adults: Nutrition and Healthy Eating Increase consumption of these items in people aged 2 years and over: • Calcium • Dark green vegetables, red and orange vegetables, and beans and peas • Fruit • Potassium • Vegetables (overall vegetables) • Vitamin D • Whole grains Decrease consumption of these items in people aged 2 years and over: • Added sugars • Saturated fats • Sodium General: • Reduce household food insecurity and hunger Data from Office of Disease Prevention and Health Promotion. (2023). Healthy People 2023: Nutrition and healthy eating. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/nutrition-and-healthy-eating. NCLEX Examination Challenge 52.3 Health Promotion and Maintenance A client states, “I keep trying to lose weight, but I can’t because I am genetically obese.” Which nursing responses would be appropriate? Select all that apply. A. “Genes can contribute to obesity.” B. “Have you considered bariatric surgery?” C. “Let’s talk about your family history with weight.” D. “What are your feelings about increasing physical activity?” E. “It would be good for us to discuss your usual nutritional intake.” Recognize Cues: Assessment History Patients with obesity may be embarrassed or reluctant to talk about their weight or fear judgment because of the stigma that can be attached to this condition. Approach patients with obesity by using the acronym RESPECT, created by The Ohio State University (Aycock et al., 2017). Create a rapport with them in an environment that is safe. Ensure their safety and privacy, encourage them to set realistic goals (in the planning phase), provide compassion, and use tact in conversation. See Box 52.3 to complete the initial history. In collaboration with the registered dietitian nutritionist (RDN), also obtain the information as noted in the History section under the concept exemplar of Undernutrition. Additionally, ask about: • Appetite • Attitude toward food • Presence of any chronic diseases • Drugs taken (prescribed and over-the-counter [OTC], including herbal preparations) • Physical activity/functional ability • Family history of obesity • What forms of weight loss have been tried in the past and their results Physical Assessment/Signs and Symptoms Obtain an accurate height and weight measurement. Anthropometric measurements may also be obtained. Examine the skin for reddened or open areas. Lift skinfold areas, such as pendulous breasts and abdominal aprons (panniculus), to observe for Candida (yeast) (a condition called intertrigo) or other infections or lesions. Infection of the panniculus is referred to as panniculitis. Psychosocial Assessment Obtain a psychosocial history to determine the patient’s circumstances and emotional factors that might prevent successful weight loss or that might be worsened by intervention. Ask about the perception of current weight and weight reduction. Some patients do not view weight as a problem, which affects planning, treatment, and outcome. Ask patients questions about their health beliefs related to being overweight, such as: • What does food mean to you? • Do you want to lose weight? • What prevents you from losing weight? • What do you think will motivate you to lose weight? • How do you think you might benefit from losing weight? • Do you have a support system in place that will encourage you during weight loss? Some patients become very depressed regarding their weight and/or failure of weight loss efforts. If the patient reports depressed symptoms that have occurred consistently for more than 2 weeks that impact performing ADLs, referral to a mental health professional can be helpful. Analyze Cues and Prioritize Hypothesis: Analysis The priority collaborative problem for the patient with obesity is: 1. Weight gain, which stresses all vital organs due to excessive intake of calories Generate Solutions and Take Actions: Planning and Implementation If the patient with obesity is to be hospitalized, an appropriate bariatric care room is important in the provision of high-quality, patient-centered care whether nonsurgical or surgical management is planned. Ensure that the patient has the right room so that care can be maximized to the very best benefit. See Table 52.3 for criteria for these types of rooms. Improving Nutrition Planning: Expected Outcomes The patient with obesity is expected to return to a normal BMI while consuming dense nutrients that meet metabolic needs without overeating. Nonsurgical Management Weight loss may be accomplished by nutrition modification with or without the aid of drugs and in combination with a regular exercise program. Patients who may be candidates for surgical treatment include those who have: TABLE 52.3 Criteria for a Bariatric Room Criterion Specifications Location Designation specifically for bariatric care Capacity Single patient Area Minimum clear floor area of 18 m2 Entry At least 60 inches (1500 mm) wide Clearance Minimum distance of 5 feet (1.5 m) between sides and foot of bed and wall Bedding Bariatric bed with low air loss mattress Handwashing station Mounted on wall; able to withstand downward static force of a predetermined maximum patient weight Toilet room Toilet with weight capacity of 1000 lb (453 kg) Toilet mounted to floor with at least 24 inches (61 cm) from wall to center of toilet line, and 3 feet, 8 inches (112 cm) of clear space on the opposite side of the toilet for wheelchair and caregiver access Grab bars on the side of the toilet that can withstand 1000 lb (453 kg) of downward force Bathing facilities Shower stall—4 feet × 5 feet (1.2 m × 1.5 m) with turning radius of 71 inches (1800 mm) (separate area from washing station and toilet room) Grab bars in the shower stall that support 1000 lb (453 kg) of downward force Handheld spray nozzles mounted on a side wall Enclosure for privacy Portable shower chair Patient lift system Built-in mechanical lift system that accommodates up to 1000 lb (453 kg) Airborne isolation room At least one airborne isolation room per bariatric unit should be available General Gowns of appropriate size Equipment of appropriate size (e.g., bedpans, blood pressure cuffs, antiembolus stockings, sequential compression devices, gait and transfer belts, stretchers) Furnishings of accommodative size (e.g., recliners, chairs) Data from Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, Bariatric Care and Rehabilitation Research Group, Faculty of Rehabilitation Medicine – University of Alberta, & Obesity Canada. (2022). Guidelines for the care of hospitalized patients with bariatric needs. https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-don-guidelines-for-hospitalized-patients-bariatric-needs.pdf; Dockrell, S., & Hurley, G. (2021). Moving and handling care of bariatric patients: A survey of clinical nurse managers. Journal of Research in Nursing, 26(3), 194-204; Lim, R. (2022). Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient. UpToDate. Retrieved May 23, 2023, from https://www.uptodate.com/contents/hospital-accreditation-accommodations-and-staffing-for-care-of-the-bariatric-surgical-patient • Repeated failure of nonsurgical interventions • A BMI equal to or greater than 40 • Weight more than 100% above ideal body weight Diet programs Diets for helping adults lose weight include fasting, very-low-calorie diets, nutritionally balanced diets, and unbalanced low-energy diets. Short-term fasting programs and very-low-calorie diets (usually 200 to 800 calories/day) require an initial cardiac evaluation and supervision by the interprofessional health care team. Neither diet is ideal due to risks involved and the likelihood of regaining weight after completion of the diet. Ketosis is a risk of short-term fasting. Nutritionally balanced diets generally provide about 1200 to 1800 calories/day with a conventional distribution of carbohydrate, protein, and fat. Vitamin and mineral supplements may be used. These diets adhere to conventional foods that are economical and easy to obtain. Unbalanced low-energy diets, such as the low-carbohydrate diet, restrict one or more nutrients. Protein and vegetables are encouraged, but certain carbohydrates and high-fat foods are not. Although results are mixed per health research, these diets are extremely popular. Nutrition therapy Nutrition recommendations for each patient are developed through close interaction among the patient, caregiver, primary health care provider, nurse, and registered dietitian nutritionist (RDN). The diet must meet the patient’s needs, habits, and lifestyle and should be realistic. At a minimum, the diet should: • Be evidence based • Be nutritionally balanced (see Diet Programs section) • Have a low risk-benefit ratio • Be practical and conducive to long-term success Calorie estimates are easily calculated. Resting metabolic rate is determined using a gender-specific formula that incorporates the appropriate activity factor. This figure reflects the total calories needed daily for maintaining current weight. To encourage a weight loss of 1 lb (0.45 kg) a week, the registered dietitian nutritionist (RDN) subtracts 500 calories each day. To encourage a weight loss of 2 lb (0.9 kg) a week, 1000 calories each day are subtracted. The amount of weight lost varies with the patient’s food intake, level of physical activity, and water losses. A reasonable expected outcome of 5% to 10% loss of body weight has been shown to improve glycemic control and reduce cholesterol and blood pressure. These benefits continue if the weight loss is sustained. Exercise program For most adults, adding physical activity to a healthy diet produces more weight loss than dieting alone. More of the weight lost is fat, which preserves lean body mass. An increase in exercise can reduce the waist circumference and the waist-to-hip ratio. Even a small loss of 5% to 10% of overall weight is beneficial to blood pressure and to cholesterol and glucose levels (Centers for Disease Control and Prevention, 2022c). Table 52.4 Common Examples of Drug Therapy Overweight and Obesity Treatment Drug Selected Nursing Implications Bupropion-naltrexone (combines the antidepressant bupropion with the opioid antagonist naltrexone) Patients with uncontrolled hypertension, seizures, anorexia nervosa, or bulimia nervosa or patients who are withdrawing from drugs or alcohol should not take this drug; this medication is contraindicated in these populations. Patients taking bupropion should not take this drug; cumulative doses can increase risks for side effects. Monitor for suicidal ideation; this can develop due to the antidepressant effect. Liraglutide (activates appetite regulation in the brain) Given by injection; ensure that patient knows how to properly administer this medication. Monitor ALT and AST; there is an increased risk for pancreatitis when taking this drug. Patients taking insulin should not take this drug; hypoglycemia can develop. Teach to report taking this drug to all health care providers; alpha1-adrenergic antagonists can increase or decrease the side effects of other drugs such as beta-blockers, calcium channel blockers, or medications used to treat erectile dysfunction. Orlistat (inhibits lipase; thus, fats are only partially digested and absorbed) Monitor liver enzymes; rare cases of liver injury have been reported. Teach to take a multivitamin daily; the body may not normally absorb enough vitamins found in foods due to the effect of the drug. Teach that loose stools, abdominal cramps, and nausea can occur unless fat intake is reduced to less than 30% of the daily intake; the drug mechanism facilitates GI symptoms since fats are only partially digested and absorbed. Phentermine-topiramate (combines short-term weight loss drug phentermine with seizure medication topiramate) Patients with glaucoma or hyperthyroidism should not take this medication; this medication can increase eye pressure and thyroid activity. Determine whether patient is pregnant or planning pregnancy; this medication can cause birth defects. (NOTE: Patient should also refrain from using this medication if breastfeeding). Semaglutide (increases resting metabolism and feeling of fullness; reduces appetite) Given by injection; ensure that patient knows how to properly administer this medication. Monitor ALT, AST, and thyroid panels; this medication can increase the risk for developing pancreatitis and (in rare cases) thyroid tumor. Setmelanotide (targets impaired MC4R pathway, the underlying hunger) Given by injection; ensure that patient knows how to properly administer this medication. Teach that sexual function may change while taking this medication; priapism, spontaneous penile erection, and changes in sexual arousal that occur without sexual activity are side effects. Teach to report any feelings of depression, mood changes, or suicidal thoughts; this medication can cause these symptoms. Recommend the patient have a full body skin examination before and during treatment; this medication can cause skin changes. Teach that increasing skin pigmentation and darkening of moles or nevi can occur; these are side effects associated with this medication. From the National Institute of Diabetes and Digestive and Kidney Disorders. (2021). Prescription medications to treat overweight and obesity. https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity. A minimum-level workout should be developed so that consistency can be achieved and maintained. Encourage walking 20 minutes a day and increasing the time as endurance increases. The activity may be performed all at once or divided over the course of the day. Drug therapy Four medications are FDA-approved for overweight and obesity treatment. The primary health care provider will work with the patient to determine which, if any, of these drugs are appropriate. See Table 52.4 for information about select types of drug therapy used for treatment of overweight and obesity. Cryolipolysis Cryolipolysis is a nonsurgical procedure also known as “fat freezing.” This procedure is used to reduce fat deposits in certain body areas (American Society for Dermatological Surgery, 2023). However, it is not meant for people with overweight and obesity; it is used primarily for removal of small amounts of excess fatty tissue that cannot be changed by diet or exercise (American Society for Dermatological Surgery, 2023). Redirect patients requesting cryolipolysis to the primary health care provider for further discussion. Behavioral management Behavioral management of obesity helps the patient change daily eating habits to lose weight. Self-monitoring techniques include keeping a journal of foods eaten (food diary), exercise or activity patterns, and emotional and situational factors. Stimulus control involves controlling the external cues that promote overeating. Reinforcement techniques are used to self-reward the behavior change. Cognitive restructuring involves modifying negative beliefs by learning positive coping self-statements. Counseling by health care professionals must continue before, during, and after treatment. The 12-step program offered by Overeaters Anonymous (www.oa.org) has helped many adults lose weight, especially those who eat compulsively. Oral superabsorbent hydrogel FDA-cleared to be a medical device instead of drug therapy, this type of treatment comes in the form of a small capsule taken orally with water before meals. The capsule disintegrates in the stomach and releases superabsorbent hydrogel particles that absorb water, which expand to take up 25% of total gastric volume (Anasari & Miras, 2022). The particles also absorb food, which contributes to fullness. They break down in the colon, release water that is reabsorbed into the body, and are then excreted in feces (Anasari & Miras, 2022). The average patient in a recent study of this type of treatment decreased daily intake by 300 calories and lost (and maintained the loss of) about 5% of total weight over a 6-month period (Greenway et al., 2019). Side effects include fullness, bloating, abdominal cramping, and flatulence (Gelesis, Inc., 2023). Complementary and integrative health Many complementary and integrative therapies have been tested and used for obesity. These modalities aim to suppress appetite and therefore limit food intake to lose weight: • Acupuncture • Acupressure • Ayurveda (a combination of holistic approaches) • Hypnosis Evidence about the effectiveness of each of these therapies varies. Encourage the patient to speak to the primary health care provider to determine whether any of these methods are recommended. Surgical Management Some patients seek to improve their appearance by reducing the amount of adipose tissue in selected areas of the body. A typical example of this type of surgery is liposuction, which can be done in a health care provider’s office or ambulatory surgery center. Although the patient’s appearance may improve, if weight gain continues, the fatty tissue will return. This procedure is not a solution for adults with obesity. Bariatrics is a branch of medicine that manages patients with obesity and its related diseases. Certain adults may be considered for this type of weight loss surgery. These include patients who: • Do not respond to traditional interventions • Have a body mass index (BMI) of 40 or greater • Have a BMI of 35 or greater, with other health risk factors Surgical procedures include gastric bypass, sleeve gastrectomy, adjustable gastric band, biliopancreatic diversion with duodenal switch (BPD/DS), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (American Society for Metabolic and Bariatric Surgery [ASMBS], 2023). Another procedure, gastrointestinal electrical stimulation (GES), involves the implantation of a vagal-blocking device (vBloc) into the abdomen (Anasari & Miras, 2022) that causes early satiety, and thus, reduced intake (Shikora et al., 2019). Depending on the procedure, the surgeon may choose to use a conventional open approach or perform minimally invasive surgery (MIS). Many patients have MIS via either the laparoscopic adjustable gastric band (LAGB) procedure or laparoscopic sleeve gastrectomy (LSG). Both procedures are classified as restrictive surgeries. The decision of whether the patient is a candidate for the MIS is based on weight, body build, history of abdominal surgery, and coexisting medical complications. With any surgical approach, patients must agree to modify their lifestyle and follow stringent protocols to lose weight and keep the weight off. After successful bariatric surgery, many patients no longer have complications of obesity, such as diabetes mellitus, hypertension, depression, or sleep apnea. Preoperative care Preoperative care is similar to that for any patient undergoing abdominal surgery or laparoscopy (see Chapter 9). However, patients with obesity are at increased surgical risks of pulmonary and thromboembolitic complications, as well as death. Some surgeons require a specific amount of weight loss before bariatric surgery to minimize complications. Patients also have a thorough psychological assessment and testing to detect depression, substance abuse, or other mental health/behavioral health problems that could interfere with success after surgery. Cognitive ability, coping skills, development, motivation, expectations, and support systems are also assessed. Patients who are not alert and oriented or do not have sufficient strength and mobility are not considered for bariatric surgery. The primary role of the nurse is to reinforce health teaching in preparation for surgery. Most bariatric surgical centers provide educational sessions for groups of patients who plan to have the procedure. Operative procedures Gastric restriction surgeries, the easiest to perform, allow for normal digestion without the risk of nutrition deficiencies. In a banding procedure, the surgeon places an adjustable band to create a small proximal stomach pouch through a laparoscope (Fig. 52.7A–B). The band may or may not be inflatable. In the vertical sleeve gastroplasty (see Fig. 52.7C), about three-fourths of the stomach is removed, with the sleevelike remaining stomach having a much-reduced capacity. In the biliopancreatic diversion with duodenal switch (see Fig. 52.7D), a less common bariatric surgery, almost 80% of the stomach is removed. The remaining pouch is connected to the bottom of the small intestine (bypassing the upper portion). Therefore, most calories and nutrients are routed into the colon, where they are not absorbed (Phillips & Zieve, 2022). The most common bariatric surgery performed in the United States is the Roux-en-Y gastric bypass (RNYGB), which is often done as a robotic-assistive surgical procedure. Most commonly called a gastric bypass, this procedure results in quick weight loss, but it is more invasive with a higher risk for postoperative complications. In this procedure, gastric resection is combined with malabsorption surgery. The patient’s stomach, duodenum, and part of the jejunum are bypassed so that fewer calories can be absorbed (see Fig. 52.7E). Postoperative care Postoperative care depends on the type of surgery performed. Patients having one of the MIS procedures have less pain, scarring, and blood loss. They typically have a faster recovery time and a faster return to daily activities. However, even patients having MIS are considered to have had major abdominal surgery along with all its risks, and their care is planned accordingly. These patients may require less than 24 hours in the hospital; some may need 1 to 2 days. Patients with open procedures may need several days to recover. A major focus of postoperative care must be placed on patient and staff safety. Patients should be placed in a bariatric room (see Table 52.3). Always use additional personnel when moving the patient. Ensure that side rails are not touching the body because they can cause pressure injuries. Pressure between skinfolds and tubes and catheters can also cause skin breakdown. Monitor the skin in these areas, and keep the skin clean and dry. FIG. 52.7 Bariatric surgical procedures. (A) Vertical banded gastroplasty. (B) Gastric banding. (C) Vertical sleeve gastroplasty. (D) Biliopancreatic diversion with duodenal switch. (E) Roux-en-Y gastric bypass (RNYGB). From Silvestri, L., & Silvestri, A. [2020]. Saunders Comprehensive review for the NCLEX-RN examination [8th ed.]. St. Louis: Elsevier. Set of five illustrations marked A to E depict five types of bariatric procedures as follows: A) Vertical banded gastroplasty shows a polypropylene band with calibrated stoma at the center creating a pouch of 15 to 30 milliliters of capacity. B) Gastric banding shows an inflatable silicone band with a self-sealing reservoir at other end around fundus creating a pouch of capacity 15 to 30 milliliters. C) Vertical sleeve gastroplasty shows labels for gastric sleeve and pylorus. D) Biliopancreatic diversion with duodenal switch shows a part of jejunum attached to colon with a suture at ileum, creating a pouch capacity of 100 o 200 milliliters. E) Roux-en-Y gastric bypass shows end-to-side surgery with one end attached to stoma of proximal pouch of stomach and other at jejunum, creating a pouch capacity of 20 to 30 milliliters of capacity. Care of the patient who has undergone any type of bariatric surgery is similar to that of any patient having abdominal or laparoscopic surgery (see Chapter 9). The priority for postoperative care is airway management. Patients with short and thick necks often have compromised airways and need aggressive respiratory support—possibly mechanical ventilation in the critical care unit. In addition to the postoperative complications typically associated with abdominal and laparoscopic surgeries, patients who have undergone bariatric surgery are at risk for anastomotic leaks (a leak of digestive juices and partially digested food through an anastomosis). Implement measures to prevent complications as noted in Box 52.12. All patients experience some degree of pain, but it is usually less severe when MIS is performed. Patients may use patient-controlled analgesia (PCA) with morphine for up to the first 24 hours. All patients receive oral opioid analgesic agents (liquid form when possible) as prescribed after the PCA is discontinued. Acute pain management is discussed in detail in Chapter 6. Clear liquids are introduced slowly if the patient can tolerate water, and 1-ounce cups are used for each serving. A full liquid diet follows tolerance of the clear liquid diet; usually patients are discharged on full liquids. Pureed foods follow in about a week, with each meal consisting of about 5 tablespoons of food. Nursing Safety Priority Action Alert Some patients who undergo bariatric surgery have a nasogastric (NG) tube put in place, especially after open surgical procedures. In gastroplasty procedures, the NG tube drains both the proximal pouch and the distal stomach. Closely monitor the tube for patency. Never reposition the tube because its movement can disrupt the suture line! The NG tube is removed on the second day if the patient is passing flatus. After several weeks of pureed foods, soft foods are introduced. Around the eighth postoperative week, solid, nutrient-dense foods are incorporated. Remind the patient to eat and drink slowly, to consume only small meals, to stop eating before feeling full, to choose foods high in protein, and to avoid foods that are fatty or have high sugar content. Care Coordination and Transition Management Obesity can be a chronic, lifelong problem if weight loss is not accomplished. Diets, drug therapy, exercise, and behavioral modification can produce short-term weight losses with reasonable safety. However, many patients who do lose weight often regain it. Treatment of obesity should focus on the long-term reduction of health risks and problems associated with obesity, improvements in quality of life, and the promotion of a health-oriented lifestyle. Box 52.12 Best Practice for Patient Safety and Quality Care Care of the Patient After Bariatric Surgery Cardiovascular/Respiratory Care • Place the patient in semi-Fowler’s position to improve breathing and decrease risk for sleep apnea, pneumonia, or atelectasis. • Monitor oxygen saturation; provide oxygen, bilevel, or continuous positive airway pressure (BiPAP or CPAP) ventilation per orders. • Apply sequential compression stockings and administer prophylactic anticoagulant therapy as prescribed to prevent venous thromboembolisms, including pulmonary embolism (PE). Gastrointestinal Care • Apply an abdominal binder to prevent wound dehiscence for open surgical procedures. • Observe for signs and symptoms of dumping syndrome (caused by food entering the small intestine too quickly) after gastric bypass, such as tachycardia, nausea, diarrhea, and abdominal cramping. If this occurs, treatment ranges from dietary adjustments, to administration of antidiarrheal agents and/or acarbose depending on symptom severity, to surgical intervention. • Provide six small feedings (clear and then full liquids as ordered) and plenty of fluids to prevent dehydration in collaboration with the registered dietitian nutritionist (RDN). • Measure and record abdominal girth daily or as per orders. Genitourinary Care • Remove urinary catheter within 24 hours after surgery to prevent urinary tract infection. Integumentary Care • Observe skin areas and folds for redness/hyperpigmentation, excoriation, or breakdown, and treat these problems early. • Use absorbent padding between folds to prevent pressure areas and skin breakdown. • Ensure that tubes and catheters are not causing pressure on the skin. Musculoskeletal Care • Collaborate with the physical therapist for transfers or ambulation assistive devices, such as walkers. • Encourage and assist with turning every 2 hours, using an appropriate weight-bearing overhead trapeze. Nursing Safety Priority Critical Rescue Anastomotic leaks are the most common serious complication and cause of death after gastric bypass surgery. Recognize that you must monitor for symptoms of this life-threatening problem, which includes increasing back, shoulder, or abdominal pain; restlessness; and unexplained tachycardia and oliguria. If any of these findings is present, respond by contacting the surgeon immediately! Home Care Management In collaboration with the registered dietitian nutritionist (RDN), counsel the patient on a healthful eating pattern. The physical therapist or exercise physiologist recommends an appropriate exercise program. A psychologist may recommend cognitive restructuring approaches that help alter dysfunctional eating patterns. For patients who have surgery, additional discharge teaching is needed. Box 52.13 lists the important areas that should be reviewed. Patients are usually followed closely by the surgeon and registered dietitian nutritionist (RDN) for several years. Encourage patients to keep all appointments and to adhere to the treatment plan to ensure success. Plastic surgery, such as panniculectomy (removal of the abdominal apron, or panniculus), may be performed if needed after weight is stabilized, usually in about 18 to 24 months. Box 52.13 Patient and Family Education Discharge Teaching Topics for the Patient After Bariatric Surgery Nutrition: Diet progression, nutrient (including vitamin and mineral) supplements, hydration guidelines Drug therapy: Analgesics and antiemetic drugs, if needed; drugs for other health problems Wound care: Clean procedure for open or laparoscopic wounds; cover during shower or bath Activity level: Restrictions, such as avoiding lifting; activity progression; return to driving and work Signs and symptoms to report: Fever; excessive nausea or vomiting; epigastric, back, or shoulder pain; red, hot, or draining wound(s); pain, redness/hyperpigmentation, or swelling in legs; chest pain; difficulty breathing Follow-up care: Health care provider office or clinic visits, support groups and other community resources, counseling for patient (and caregiver, if needed) Continuing education: Nutrition and exercise classes; follow-up visits with registered dietitian nutritionist (RDN) For patients with Type 2 diabetes mellitus who have undergone bariatric surgery, shared medical appointments (SMAs) can be valuable (Reigel et al., 2021). This type of appointment involves a group of patients who have undergone the same surgery. The group meets periodically for an extended amount of time with the health care provider and interprofessional team for follow-up care. Group members have individual time with the health care provider and then interact with each other and other health care professionals in an effort to improve self-management following surgery (Reigel et al., 2021). Self-Care Management Remind patients to coordinate with their surgeon or primary health care provider to create a manageable and appropriate physical activity plan. For patients having nonsurgical management, emphasize the need to decrease overall fat intake and to avoid reliance on appetite-reducing drugs. Keeping a food journal that documents mood and events that take place with eating can be helpful to identify eating patterns. Teach patients who have had bariatric surgery that postsurgical bowel changes are common. Vitamin and mineral supplements are prescribed after surgery, especially vitamin D, B-complex vitamins, iron, and calcium, and adherence to this regimen is important for surgical success. Health Care Resources Provide the patient with a list of available community resources, such as Overeaters Anonymous (www.oa.org). For patients who have had or are contemplating surgery, the American Society for Metabolic and Bariatric Surgery (www.asmbs.org) may be helpful. Evaluate Outcomes: Evaluation Evaluate the care of the patient with obesity based on the identified priority patient problem. The primary expected outcome is that the patient consumes appropriate, nutrient-dense foods to meet metabolic demands without overeating. For surgical patients, an additional expected outcome is that the patient remains free of infection after bariatric surgery. Get Ready For The Next-Generation NCLEX® Examination! Essential Nursing Care Points