MALNUTRITION

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 MALNUTRITION

• undernutrition or overnutrition r/t

deficient or excess energy or
nitrogen stores, possibly due to
altered dietary intake
 PROTEIN -ENERGY
MALNUTRITION
• need for protein is not met by dietary intake
• syndromes:
 Kwashiorkor
 Marasmus
 Marasmic kwashiorkor
 “kwashiorkor-like malnutrition”
kwashiorkor marasmus

Marasmic KW
 PEM
• Primary – deficient food intake

– High-risk:

•  needs for growth, reproduction, milk

production

(infants, pregnant, lactating women), older

adults
 PEM
• Secondary- ass. with acute or
chronic disease that cause:
–  food intake
–  nutrient absorption
–  nutrient losses
–  nutrient requirements
• Obesity – caloric supply is adequate,
nutrient content is poor
 AGING
 loss of lean body mass impairment of
pulmonary, immune
 gain in body fat
function
& strength
 PEM- etiology
 acute or chronic disease
 socioeconomic
 physiologic changes in nutrient
absorption or requirement
 medical therapies
 inadequate food intake
 Multidisciplinary approach

• Health promotion
(client education)
• Health maintenance
(diet therapy)
• Health restoration
( retraining to swallow, TPN administration)
 manifestations
• hair loss, dull & dry hair
• skin dry & bruised
• brittle nails
• periodontal disease
• bleeding gums
• cheilosis
• anemic
Severe nutritional deficiencies

•  neuro reflexes, weakness

• edema

•  sensitivity to cold

• amenorrhea, impotence

• atrophied breasts

• delayed wound healing

 Abnormal values
• decreased:

 hgb, BUN
 crea, albumin
 total protein, transferrin
 prealbumin ( PAB)
 lymphocyte proliferation
 Medical
management
 management
• Client identification
( screen for nutritional problems)

• First level screening

*admission forms or simple questionnaires (weight
change, changes in dietary habits, GI problems)
 management

• comprehensive assessment

(medical hx, weight & diet hx,

anthropometric measures,
biochemical profile, PE)
 management

• define nutrition outcomes

(weight maintenance)
• define nutrient requirements

(energy needs can be determined with

formulas that estimate the basal
energy expenditure(BEE).
 management

• recommended DA for protein in healthy

people is 0.8g/kg/day.

• CHON needs of hospitalized client is 2x of

normal needs
 Route of feeding

• meal planning with dietician

• food supplements

• enteral or parenteral feedings

NURSING MANAGEMENT
 Nurse’s role

• history taking/ assessment

• improve nutritional intake

 choose from a menu

 assess individual preferences c/o dietitian

 Increase appetite
 create a pleasant environment at mealtime
 clear area of unsightly bedpans, urinals, suction
equipment, dressing supplies
 pain management
 regular exercise
 oral hygiene
 stimulate sense of taste, smell, sight
  social interaction

• encourage family to visit during

mealtimes
 Minimize sensory-perceptual
deficits

• corrective lenses if needed

• describe food & its location in the tray

• arrange food in clock-face pattern

• do not place foods on client’s blind side

 Minimize impact of
neuromuscular impairment

• OT referral

• allow adequate time for eating

• provide assistive devices

 Minimize impact of cognitive
impairment

 requires frequent cues & close supervision

 orient to the purpose of feeding

equipment
 several small meals for those with short
attention span
 Minimize fatigue

• plan rest periods

• help with meal set-up, open packages

• cut food
Swallowing assessment

• 4 steps:
– LOC

– gag reflex

– audible cough

– voluntary swallow
 Implement swallowing
techniques

 feeder clearly visible

 place food on unaffected side of mouth

 use of assistive feeding device

 massage throat on affected side

 hold head forward, hold breath before swallowing

 Implement swallowing
techniques
 know how to perform Heimlich maneuver
 TOTAL
ENTERAL
NUTRITION
 Tube feeding
• has impaired ingestion but normal
intestinal absorption
• c/i:
– complete intestinal obstruction
– severe ileus
– severe diarrhea
– malabsorption syndrome
 Tube feeding

• maintains & supports gut integrity & fxn

• prevent atrophy of GI mucosa

• based on nutrient needs, absorptive fxn of

the GIT, fluid status, level of stress
 classifications
• Standard

( intact protein, electrolyte, fiber)

• Predigested, semi-elemental

( hydrolyzed protein in the form of dipeptides,

tripeptides, amino acids, for clients with limited
digestive fxn)
 classifications

• Disease-specific formula

(enhances specific organ fxn for clients with

organ failure)
 Enteral feeding

• Intragastrically

( stomach)

• Duodenally or jejunally

( small intestine)
 Access depends on

• functional status of GIT

• risk for aspiration ( postpyloric feeding)

• estimated length of therapy

– temporary < 4 to 6 wks

– permanent > 4 to 6 wks)

 Short-term feeding
• NGT or nasoenteric feeding.
- 5F to 16F
- tip verified through abdominal XR
- smaller diameter tubes
(frequently flushed with water)
- small bore enteral feeding tubes
( polyurethane or silicon plastic)
 Long-term feeding

• gastrostomy & jejunostomy tubes

• most recent - Percutaneous Endoscopic Gastrostomy (peg)

or jejunostomy approach

- tubes can be placed surgically, endoscopically,

radiologically
 Enteral administration
• intermittent

• continuous – tube tip in small intestine

 Bolus – 300-500ml/day x 10-15min

 Intermittent – IP or syringe pump x 30-60min

 Continuous – IP x 24°, 50-150ml rate

NURSING CARE
 Interventions:
• prevent contamination of formula & delivery
system

*Strict handwashing

• Open delivery system – hang x 4 hrs, change set q

24 °
 Interventions:

• Closed delivery system – prefilled

container, hangtime 24to 48°
 Assess tube location

• auscultate
(inject air into tube)
• aspirate
(observe fluid removed)
• pH paper testing
• radiography
 Prevent aspiration

• HOB 45° x 1 hr pre,during,post

feeding
• monitor residual q 4°

(significant 150ml)
 Maintain enteral access

• caring for external site

• patency

• correct tube position

 Abdominal wall tubes
• CDW first 24° with mild soap & warm
water
 MEDICAL
MANAGEMENT –
parenteral
nutrition
 TPN

• introduction of nutrients, ( amino acids, lipids,

CHO, vitamins, minerals, & water) through a

venous access device (VAD) directly into the

intravascular fluid to provide nutrients required

for metabolic functioning of the body

 types

 Total nutrient admixture –through a

central vein, often into the SVC,for
those requiring parenteral
nutrition feeding for ≥7 days
 types
Peripheral parenteral nutrition –combines a
lesser concentrated glucose solution with
amino acids, vitamins, minerals, and lipids

-provides fewer calories

 Administer PN

• check expiration date, correct

ingredients, leaks or

tears,appearance of solution
 interventions
• monitor blood glucose level q 6° x 24°

• insulin drip if necessary

• observe for allergy – usually w/in 30min

• maintain vascular access – routine heparin

flush

• prevent infection

• CDW
 RS
DE
O R
DIS
IN G
A T
E
OBESITY
• over abundance of fat resulting in body weight of
> the average weight for the person’s age, height, sex
& body frame

• diagnosed using BMI( body build) and /or Body

surface area, and Basal Metabolic rates

• a BMI > 30% is considered obese.

 etiology

• environmental

• genetic

• socioeconomic

• ethnic disparities
 manifestations
• truncal obesity ( DM2)

• sleep & respiratory problems

• thrombosis
 MEDICAL
MANAGEMENT
• focus on client & caregiver safety

– oversized equipment

• larger BP cuffs

• oversized gowns
 Medical mgt

• diet ( -500 to 1000kcal : 1 to 2 lbs/wk)

• behavior modification

• exercise (lifestyle modification)

 medications

– Orlistat (prevents breakdown of dietary

fat )

– Sibutramine (meridia)- appetite

suppressant
 Surgical management

• for BMI > 40kg/m², or > 35 kg/m² with

comorbidity

• 2 approaches:

– Gastric restrictive

– malabsorptive
 Gastric restrictive
• stomach is reduced to a 2 oz
capacity
• gastroplasty
Gastric bypass
 Gastric bypass

• bypasses a segment of duodenum, thus

inducing malabsorption of nutrients &
dumping manifestations when
concentrated sugars are ingested

• avoid sweets
ANOREXIA
 ANOREXIA NERVOSA

• criteria for diagnosis:

 preoccupation with personal body weight &

appearance

 behaviors directed at thinness

 physical results of behavior

• need for psychiatric intervention

 Bulimia nervosa

• excessive eating & purging

• abuse of laxatives and diuretics

• “ a form of depressive illness”

 etiology

• sociocultural & environmental

( media, peer)
• family factors
( parental discord)
• biologic factors
( genetics, hormones)
anorexia
 manifestations

• dry skin, pallor,

bradycardia,
hypotension,
intolerance to
cold, constipation,
amenorrhea
 bulimia

• manifestations:

– erosion of tooth enamel

– throat irritation

– electrolyte imbalance
MEDICAL MANAGEMENT
 management

psychological & nutritional support

psychotherapy

hospitalization of severely malnourished

Enteral/ TPN
NURSING MANAGEMENT
 interventions
 comprehensive history
 help to select from food pyramid guide
 be supportive during mealtimes
 stay with the client to prevent her from purging
 accurate calorie count & weight monitoring
 emotional support
 help to  self-esteem