Focus on Malnutrition Heather Rawls RN MS

Evaluate Concept map  Now that we have reviewed nutrition lets look more closely at part of our concept map.  We will be discussing Attributes  Sub concepts  Mal-nutrition is a definite negative consequence.  As we go forward we will discuss the interrelated concepts.

Malnutrition  Deficit, excess, or imbalance in essential components of balanced diet  Other terms—under nutrition and over nutrition  Under nutrition  Poor nourishment due to inadequate diet or disease  Over nutrition  Ingestion of more food than required

Patient with Malnutrition (under nutrition)

Under Nutrition  Most prevalent in countries lacking adequate food sources and education  Does exist in United States in the same way it does in underdeveloped countries ◦ Usually found in lower socioeconomic class or those with chronic or acute illness  Common in hospitalized patient (30% to 55%) Wow!!  23% to 85% prevalence in elderly long- term care residents

Protein-Calorie Malnutrition (PCM)  Most common form of under nutrition  Primary versus secondary  Primary—poor eating habits  Ingesting food deficient in protein, vitamins, minerals  Secondary—alteration or defect in ingestion, digestion, absorption, or metabolism  Due to GI obstruction, surgical procedures, cancer, mal- absorption syndromes, drugs, infectious diseases

Kwashiorkor how to pronounce  Deficiency of protein intake superimposed by catabolic stress event such as  GI obstruction  Surgery  Cancer  Mal-absorption syndrome  Infectious disease  May appear well nourished, have low protein levels  Could be taking in enough calories  Symptoms  Change is skin color  Fatigue  D  Loss of muscle mass  Edema  Failure to grow or gain weight  irritability

Marasmus  Results from concurrent deficiency in caloric and protein intake  Generalized loss of muscle and body fat  Appear emaciated but have normal serum protein levels  If condition continues, damage will occur to major organs such as Heart, lungs & kidneys.  Children will not grow.  If happens during 6 to 18 months – permeant brain damage will occur  Does this occur in the US??

Etiology and Pathophysiology  Starvation process  (1 st Stage)  Initially body uses carbohydrate stores from liver and muscle to meet metabolic needs.  Glycogen stores are minimal and may be depleted in 18 hours  Once stores depleted, protein from skeletal muscle is converted to glucose for energy Gluconeogenesis occurs  Formation of glucose by liver from fats  Allows metabolic processes to continue  Pt may have a negative nitrogen balance  (2 nd Stage)  Within 5 to 9 days, fat is mobilized to supply energy

Etiology and Pathophysiology  Starvation process cont.  2 nd Stage cont.  Prolonged starvation: 97% of calories from fat and protein are consumed  Fat stores used in 4 to 6 weeks, depends on amount available  3 rd Stage  Once fat stores are used, body proteins (from internal organs and plasma) are no longer spared. This is termed Visceral Proteins. They are used until organ failure occurs.

Etiology and Pathophysiology ◦ Liver function impaired ◦ Protein synthesis diminished ◦ Plasma oncotic pressure ↓  Shift from vascular space into the ? ◦ What happens to Albumin? ◦ What do we see as a result?

Malnutrition  Sick pts have increased nutritional needs  Not an uncommon consequence of  Illness  Surgery  Injury  Hospitalization  Question: Does fever increase basal metabolic rate?  What is the result?

Incomplete Diets  How rare or common are vitamin deficiencies in developed countries?  Usually found in  Alcoholics  Drug abusers  Fad diet followers  What other types of diets/conditions can be missing necessary nutrients? Poorly planned vegetarian diets Anorexia Bulimia

Clinical Manifestations  Obvious clinical signs of inadequate protein/calorie intake apparent in  Skin  Eyes  Mouth What other area may present obvious signs ? Muscles CNS

Clinical Manifestations  Muscle wasting  Delayed wound healing  More susceptible to infection  Humoral and cell mediated immunity deficient  ↓ in leukocytes in peripheral blood  Phagocytosis altered (meaning what)  What about Anemia??

 Laboratory studies  Serum albumin (3.5-5g/dL)  Pre-albumin ( ↓ 19.5 mg/dL)  Serum transferrin  Electrolyte levels  Complete blood count  RBC  Hgb  lymphocyte count  Liver enzymes  Serum levels of vitamins Diagnostic Studies

 Anthropometric measurements  Skinfold thickness—various sites  Midarm circumference  Compared with standard for healthy persons (is there a difference)? Diagnostic Studies

Nursing Assessment  Health status  Medical history  Family history  Changes in weight  Diet history  Medications  Laboratory test results  Physical examination  Anthropometric measurements

 Food history for past week  Height  Weight  VS  Physical examination  What do we include in PA? History/physical examination

Planning/Goals  Achieve weight gain.  Consume specified number of calories per day?  Consume specific amount of Fluid/liquids-protein- carbs-fats-vitamins-minerals necessary.  Have no adverse consequences related to malnutrition or nutrition therapies  Avoid/ Monitor for refeeding syndrome.  Can be fatal  Introduction of excess protein and calories can overload enzymatic and physiologic function  Introduce nutrients slowly and monitor & monitor medical & metabolic status closely.

Nursing Implementation  Caloric count & dietary needs pt specific  High-protein, high-calorie foods  What food need to be eliminated?  What alternative food(s) can supply nutrition?  Multiple, small feedings  Supplements  Appetite stimulants  Diet diary (How can we approach this?)  Dietitian consult  Discharge instructions  Patient-family-caregiver questions

Evaluation  Patient will  Achieve and maintain optimum body weight by X amt of time  Consume well-balanced diet by end of shift  Experience no adverse outcomes related to malnutrition during this shift  Be realistic with your goals!!

Gerontology Considerations  Are older adults at risk ? Why?  Physiologic changes  Oral cavity-dentures  Digestion/motility  Endocrine system  Vision and hearing (sensory)  Dysphagia  What other considerations can you think of? Musculoskeletal--Mobility Psychological-Dementia-confusion How about Isolation??— Access Socioeconomics Culture-Family

Gerontological Considerations Nursing Assessment/ Intervention Age related change may present in-tolerance to foods triggering mal-digestion-abdominal discomfort- bloating diarrhea and mal-absorption thus malnutrition. The nurse must obtain an in depth history if this is a reoccurring condition and it is suspected Food allergies culprits can trigger over-activity of the immune system, which can at times even be life threatening. 

A 88 -year-old male is admitted for dehydration. Upon assessment, it is noted that he has dry mucous membranes, weakness, slow unstable gait, and a poor appetite. He has lost 15 lbs. in the last 2 weeks. He wears dentures. 1.Which assessment findings support a risk for malnutrition? 2.What further assessment-evaluation-questions are necessary to care for this patient. Questions

The patient is admitted to the acute care unit. The nurse reviews his admission laboratory results. Why? Which result supports a diagnosis of malnutrition? A.Serum albumin 3.5 g/dL B.Hematocrit 37% C.Hemoglobin 12 g/dL D.Prealbumin 13 mg/dL

You have assessed that the patients dentures are loose. Which dietary item should be removed from the patient’s nutritional tray? Why? A.Applesauce B.Scrambled eggs C.Toast with butter D.Granola cereal

References Potter, P., Perry, A., Stockert, P., & Hall, A. (2013). Fundamentals of Nursing, 8th Edition.