1. Gastrointestinal System – Part IX Malnutrition: Undernutrition & Obesity
Mrs. April Page MSN ARNP FNPC
Gulf Coast State College
NUR1213c Intermediate Adult Care

2. Lesson Objectives
Describe the causes, pathophysiology, classifications, and morbid complications associated with obesity and management strategies for treating obesity.
Identify risk factors and prevention methods associated with obesity.
Identify the complications of bariatric or other gastric surgical procedures and their prevention and management.
Describe the home health care needs of the patient who has had bariatric or other gastric surgical procedures.

3. Introduction
Classifications of Body Weight

4. Classifications Of Body Weight (cont.)
Degree a person has excess adipose tissue in terms of being overweight and obese
Body mass index (BMI)
Used to classify body weight
Correlates with total body adiposity

5. Classifications Of Body Weight
Body mass index
Calculated by weight in kilograms divided by height in meters squared
Increased waist circumference correlates with abdominal adiposity

6. Lesson Objective One
Describe the causes, pathophysiology, classifications, and morbid complications associated with obesity and management strategies for treating obesity.

7. Obesity Obesity is body mass indices (BMI) above 30 mg/m2
66% of all adults are overweight or obese
Obesity-related mortality rates are 30% greater for every gain of 5 kg/m2 of body mass beyond a BMI of 25 kg/m2
Increased risk for disease, disorders, low self- esteem, impaired body image, depression, and diminished quality of life
See Table 60-3, page 1247

8. Epidemiology Prevalence Effects of long-term obesity
Obesity has reached epidemic levels
14.5% of adults have class 2 obesity or higher
6.4% of adults have class 3 obesity
Effects of long-term obesity
Marked decrease in life expectancy
Linked to numerous chronic health conditions

9. Pathophysiology
Regulation of body weight is a complex interplay between appetite and energy expenditure
Basal metabolic rate
Adipokines
Leptin
Satiety
Environmental factors
Behavioral factors

10. Obesity Management Laboratory testing Diagnostic testing
Identification of secondary causes and risk factors
Specific tests are selected based on history and physical exam
Diagnostic testing
CT, MRI, fluoroscopy, and plain radiograph tables have weight limits

11. Obesity Management Lifestyle modifications Pharmacotherapy
Bariatric surgery

12. Obesity Management (Cont’d)
Treatment (cont’d)
Physical activity
Important for all adults
Long-term goals of 30 minutes of moderate-intensity exercise on most days of the week
Behavioral therapy
Self-monitoring via food logs, stimulus control, social support
Cognitive restructuring

13. Medications 3 medications available for long-term treatment Orlistat
Lorcaserin
Phentermine/topiramate

14. Surgical Management Bariatric surgery types Complications
Restrictive procedures
Malabsorptive procedures
Combination procedures
Complications
90-day mortality rate after bariatric surgery was 0.11%
30-day mortality rate was 0.09%

15. Surgical Management (Cont’d)
Short-term life-threatening complications
Pulmonary embolism, infection, and anastomosis leak
Long-term complications and side effects
Band slippage, obstruction, hernia
Esophageal erosion, ulcers, acid reflux
Vitamin deficiency, osteoporosis, anemia, and dumping syndrome

16. Lesson Objective Two
Identify risk factors and prevention methods associated with obesity.

17. Risk Factors for Obesity
Genetics
Diet
Family Lifestyle
Physical Inactivity
Medical Problems
Social and Economic Issues
Age
Smoking cessation
Lack of Sleep

18. Risk Factors for Obesity
Drug Therapy
Corticosteroids
Estrogens and certain progestin's
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Antihypertensive
Antidepressants and other psychoactive drugs
Antiepileptic drugs
Certain oral antidiabetic agents

19. Prevention Methods: Obesity
Improve diet
Eat five to six servings of fruits and vegetables daily.
Choose whole grain foods such as brown rice and whole wheat bread
Avoid highly processed foods
Weigh and measure food
Eat less calories than you burn
Avoid foods high in "energy density"

20. Prevention Methods: Obesity (cont.)
Increase physical activity
30 minutes 3-5 per week/then daily
Sweat
Make opportunities stairs vs elevator

21. Lesson Objective Three
Identify the complications of bariatric or other gastric surgical procedures and their prevention and management.

22. Nursing Process: The Care of the Patient With Gastric Surgery—Assessment
Patient and family knowledge
Nutritional status
Abdominal assessment
Postoperatively assess for potential complications

23. Nursing Process: The Care of the Patient With Gastric Surgery—Diagnoses
Anxiety
Pain
Deficient knowledge
Imbalanced nutrition

24. Collaborative Problems and Potential Complications
Hemorrhage
Dietary deficiencies
Bile reflux
Dumping syndrome

25. Nursing Process: The Care of the Patient With Gastric Surgery—Planning
Major goals include reduced anxiety, increased knowledge, optimal nutrition, management of complications that can interfere with nutrition, relief of pain, avoidance of hemorrhage and steatorrhea, and enhanced self-care skills at home

26. Interventions Provide interventions to reduce anxiety Pain
Administer analgesics as prescribed so patient may perform pulmonary care, leg exercises, and ambulation activities
Position in Fowler’s position
Maintain function of NG tube
Patient education
Individualized nutritional care and support

27. Care and Prevention of Complications
Gastric retention
May require reinstatement of NPO and Ng suction; use low-pressure suction
Bile reflux
Agents that bind with bile acid: cholestyramine
Malabsorption of vitamins and minerals
Supplementation of iron and other nutrients
Parenteral administration of vitamin B12 because of a lack of intrinsic factor

28. Care and Prevention of Complications
Dumping syndrome
Caused by rapid passage of food into the jejunum and drawing of fluid into the jejunum caused by hypertonic intestinal contents
Causes vasomotor and GI symptoms with reactive hypoglycemia
Avoid fluid with meals
Avoid high carbohydrate and sugar intake
Steatorrhea
Reduce fat intake and administer loperamide

29. Lesson Objective Four
Describe the home health care needs of the patient who has had bariatric or other gastric surgical procedures.

30. Dietary Self-Management
To delay stomach emptying and dumping syndrome, assume low Fowler’s position after meals; lie down for 20 to 30 minutes
Take antispasmodics as prescribed
Avoid fluid with meals
Meals should contain more dry items than liquid items

31. Dietary Self-Management (cont.)
Eat fat as tolerated but keep carbohydrate intake low and avoid concentrated carbohydrates
Eat small, frequent meals
Take dietary supplements as prescribed; vitamins, medium-chain triglycerides, and B12 injections
See chart 60-7, page 1252

32. Manifestation of Nutrient Deficiencies
SIGN/SYMPTOM
POTENTIAL NUTRIENT DEFICIENCY
Hair
Alopecia
Zinc
Easy to remove
Protein
Lackluster hair
“Corkscrew” hair
Vitamin C
Decreased pigmentation
Eyes
Xerosis of conjunctiva
Vitamin A
Corneal vascularization
Riboflavin
Keratomalacia
Bitot's spots

33. Manifestation of Nutrient Deficiencies (cont.)
SIGN/SYMPTOM
POTENTIAL NUTRIENT DEFICIENCY
Gastrointestinal 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

34. Manifestation of Nutrient Deficiencies (cont.)
SIGN/SYMPTOM
POTENTIAL NUTRIENT DEFICIENCY
Skin
Dry and scaling
Vitamin A
Petechiae/ecchymoses
Vitamin C
Follicular hyperkeratosis
Nasolabial seborrhea
Niacin
Bilateral dermatitis
Extremities
Subcutaneous fat loss
Calories
Muscle wastage
Calories, protein
Edema
Protein
Osteomalacia, bone pain, rickets
Vitamin D

35. Manifestation of Nutrient Deficiencies (cont.)
SIGN/SYMPTOM
POTENTIAL NUTRIENT DEFICIENCY
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

36. Manifestation of Nutrient Deficiencies (cont.)
SIGN/SYMPTOM
POTENTIAL NUTRIENT DEFICIENCY
Cardiovascular
Congestive heart failure, cardiomegaly, tachycardia
Thiamine
Cardiomyopathy
Selenium
Cardiac dysrhythmias
Magnesium
Table 60-2, page 1239, Iggy

37. The End
Chapter 60: Malnutrition: Undernutrition and Obesity