Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Focus on Malnutrition (Relates to Chapter 40, “Nursing Management: Nutritional Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Malnutrition Deficit, excess, or imbalance in essential components of balanced diet Other terms—undernutrition and overnutrition Undernutrition Poor nourishment due to inadequate diet or disease Overnutrition Ingestion of more food than required Malnutrition can refer to alterations in macronutrients (carbohydrates, proteins, and fat) or micronutrients (electrolytes, minerals, and vitamins). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Undernutrition Most prevalent in countries lacking adequate food sources and education Does exist in United States Usually found in lower socioeconomic class or in those with chronic or acute illness Common in hospitalized patient (31% to 33%) 2% to 38% prevalence in elderly long-term care residents Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Protein-Calorie Malnutrition (PCM) Most common form of undernutrition Primary versus secondary Primary—poor eating habits Ingesting food deficient in protein, vitamins, and minerals Secondary—alteration or defect in ingestion, digestion, absorption, or metabolism Due to GI obstruction, surgical procedures, cancer, malabsorption syndromes, drugs, infectious diseases PCM may also be due to the ingestion of foods deficient in protein. In addition to decreased quantities of protein, the diet is generally low in necessary vitamins and minerals. Most malnourished ill patients have combined (both primary and secondary) PCM. Secondary malnutrition is also referred to as “disease-related” malnutrition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Marasmus Results from concomitant deficiency in caloric and protein intake Generalized loss of muscle and body fat Appear emaciated but have normal serum protein levels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Kwashiorkor Deficiency of protein intake Associated with edema, low serum protein levels May appear well nourished, but have low protein levels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Starvation process Initially, body uses carbohydrate stores from liver and muscle to meet metabolic needs. Stores are minimal and may be depleted in 18 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Starvation process (cont’d) Once stores are depleted, protein is converted to glucose for energy. Gluconeogenesis occurs. Formation of glucose by liver Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Starvation process (cont’d) Allows metabolic processes to continue Negative nitrogen balance In 5 to 9 days, fat is mobilized to supply energy. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Starvation process (cont’d) Prolonged starvation: 97% of calories from fat and protein are conserved Fat stores used in 4 to 6 weeks, depends on amount available Once fat stores are used, body proteins (from internal organs and plasma) are no longer spared. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Liver function impaired Protein synthesis diminished Plasma oncotic pressure ↓ Shift from vascular space into interstitial Albumin leaks into interstitial space. Edema presents. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology Skin is dry and wrinkled. Na+/K+ pump fails—deficiency in calories and proteins Liver loses mass, becomes infiltrated with fat. Diet of protein and other constituents must be initiated, or death will occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Causes Socioeconomic status Cultural influences Psychologic disorders Medical conditions Medical treatments Individuals and families may utilize “safety net programs,” including food assistance programs, housing and energy subsidies, and in-kind contributions from relatives, friends, food pantries, or charitable organizations to help them obtain food. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Malnutrition Sick persons have increased nutritional needs. Not an uncommon consequence of Illness Surgery Injury Hospitalization Fever increases basal metabolic rate, leading to protein depletion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Malabsorption Syndrome Impaired absorption of nutrients from the GI tract May result from ↓ enzymes Drug side effects ↓ bowel surface area Many drugs may have undesirable GI side effects, as well as alter normal digestive and absorptive processes. For example, antibiotics change the normal flora of the intestines, decreasing the body’s ability to synthesize biotin. Example of cause may be inflammation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Incomplete Diets Vitamin deficiencies are rare in developed countries. Usually found in Alcoholics Drug abusers Chronically ill Those with poor dietary practices For example, resection of the terminal ileum poses a risk for deficiencies of fat-soluble vitamins. After a gastrectomy, patients require cobalamin supplementation. Followers of fad diets or poorly planned vegetarian diets are also at risk. Clinical manifestations of vitamin imbalances are most commonly exhibited as neurologic manifestations. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations Obvious clinical signs of inadequate protein/calorie intake apparent in Skin Eyes Mouth Muscles CNS The most obvious clinical signs on physical examination are apparent in the skin (dry and scaly skin, brittle nails, rashes, hair loss), mouth (crusting and ulceration, changes in tongue), muscles (decreased mass and weakness), and CNS (mental changes such as confusion, irritability). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations Muscles wasted and flabby Delayed wound healing More susceptible to infection Humoral and cell-mediated immunity deficient ↓ in leukocytes in peripheral blood Phagocytosis altered Anemia A detailed listing of the clinical manifestations of malnutrition is available in a table on the website for this chapter at http://evolve.elsevier.com/Lewis/medsurg. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies History/physical examination Food history for past week Height Weight Vital signs Physical examination Table 40-8 summarizes the assessment and findings for the patient with malnutrition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies Laboratory studies Serum albumin Prealbumin Serum transferrin Visceral proteins C-reactive protein Electrolyte levels Complete blood count RBC, Hb, lymphocyte count In the absence of marked fluid loss, such as from hemorrhage or burns, the serum albumin value lags behind actual protein changes by more than 2 weeks and therefore is not a good indicator of acute changes in nutritional status. Prealbumin, a protein synthesized by the liver, has a half-life of 2 days and is a better indicator of recent or current nutritional status. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies Anthropometric measurements Skinfold thickness—various sites Midarm circumference Compared with standard for healthy persons Training and practice are required to perform these measurements accurately and reliably. To provide information on the patient’s nutritional status in response to treatment, serial measurements are needed. The sites most reflective of body fat are those over the biceps and the triceps, below the scapula, above the iliac crest, and over the upper thigh. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Assessment Changes in weight Diet history Minimum data set Medications Laboratory test results Physical examination Anthropometric measurements Common admission assessment criteria used to determine nutrition risk include history of weight loss, prior intake before admission, if patient is on nutrition support, chewing/swallowing issues, and skin breakdown. In older adults, the Mini-Nutritional Assessment (MNA) is used (available at www.mna-elderly.com/forms/mini/mna_mini_english.pdf). In long-term care, the Minimum Data Set (MDS) form is used to obtain information about a person’s nutritional status. A loss of 10 pounds during a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment, especially in the older adult. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Malnutrition Fig. 40-2. Patient with malnutrition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnoses Imbalanced nutrition: Less than body requirements Self-care deficit (feeding) Constipation or diarrhea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnoses Deficient fluid volume Risk for impaired skin integrity Noncompliance Activity intolerance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Planning Achieve weight gain. Consume specified number of calories per day. Have no adverse consequences related to malnutrition or nutritional therapies. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Teach/reinforce good eating habits. Assess nutritional state and other health problems. Record daily weights and I & O. Recommendations for good nutrition are presented in Table 40-10. When fever is present, the metabolic rate is increased and nitrogen loss is accelerated. Despite the return of body temperature to normal, the rates of protein breakdown and resynthesis may be accelerated for several weeks. Teach the patient and caregiver the importance of good nutrition and the rationale for recording the daily weight, intake, and output. To obtain an accurate weight, weigh the patient at the same time each day, on the same scale, with the same type or amount of clothing, and preferably with the bladder recently emptied. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Daily calorie count High-protein, high-calorie foods Multiple, small feedings Supplements Appetite stimulants Diet diary Dietitian consult Discharge instructions The protein and calorie intake required in the malnourished patient depends on the cause of the malnutrition, the treatment being employed, and other stressors affecting the patient. Table 40-11 gives examples of high-calorie, high-protein foods. If the patient is unable to consume enough nutrition with a high-calorie, high-protein diet, oral liquid nutrition supplements can be added. Some patients may benefit from appetite stimulants such as megestrol acetate (Megace) or dronabinol (Marinol) to improve nutritional intake. Unless the patient and the caregiver can be convinced of the necessity for dietary change and have the resources to change, it is likely that no long-term benefits will be achieved. Find ways in which the patient can become actively involved in the recovery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluation Patient will Achieve and maintain optimal body weight Consume well-balanced diet Experience no adverse outcomes related to malnutrition Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gerontologic Considerations Older adults at risk Physiologic changes Oral cavity Digestion/motility Endocrine system Musculoskeletal system Vision and hearing Older hospitalized adults with malnutrition are more likely to have poor wound healing and to develop pressure ulcers, infections, decreased muscle strength, postoperative complications, and increased morbidity and mortality. With the exception of calories, older adults do not have different requirements for specific nutrients compared with middle-aged adults. Generally, caloric intake should decrease with age because of the progressive loss of lean body mass and a decrease in basal metabolic rate. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 27-year-old woman comes into the clinic with fatigue. She has lost 10 pounds in the past 2 months. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study She is a graduate student working on her dissertation. History of Crohn’s disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Claims she is unable to watch her diet because she “doesn’t have time to think about that” In addition to fatigue, she reports having diarrhea and no appetite. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What nutrients is she likely deficient in? What dietary recommendations can be made? How can you help her monitor her diet without added stress? Fluids, electrolytes, fat She should begin a high-fat, high-protein diet. Provide her with a list of foods that she should try to eat. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.