Chapter 60

Care of Patients with

Malnutrition:
Undernutrition and
Obesity

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 Concepts
 The priority concept for this chapter is
 NUTRITION
 The interrelated concept for this chapter is
 FLUID AND ELECTROLYTE BALANCE

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Nutrition Standards for Health Promotion
and Maintenance
 Dietary Reference Intakes (DRIs)
 Dietary Guidelines for Americans
 Canada Food Guide
 Eating Well with Canada’s Food Guide
 USDA MyPlate
 Vegetarian diets
 Cultural awareness

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 MyPlate

From U.S. Department of Agriculture, 2017, www.choosemyplate.gov

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 Nutrition Assessment
 Review of nutrition history
 Food and fluid intake record
 Laboratory data
 Food-drug interactions

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 Initial Nutrition Screening
 Should be done within 24 hours of a patient’s
hospital admission
 MNA

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 Anthropometric Measurements
 Height
 Weight
 BMI
 Skinfold measurements

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Nutrition Concept Exemplar: Malnutrition
 Protein-energy malnutrition (PEM); also known
as protein-calorie malnutrition (PCM)
 Marasmus
 Kwashiorkor
 Marasmic-kwashiorkor

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 Malnutrition problem examples
 Protein catabolism exceeds protein intake and
synthesis
 Weight loss
 Decreased muscle mass and cardiac output
 Weakness
 Cachexia
 Lethargy
 Dry, flaking skin and dermatitis
 Poor wound healing
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 Situations linked to malnutrition
 Poverty
 Lack of education
 Substance abuse
 Decline in functional ability
 Infectious disease
 Medical treatments (e.g., chemotherapy)

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 Eating Disorders
 Anorexia nervosa
 Bulimia nervosa

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Health Promotion and Maintenance
 Advocate for client’s nutrition status

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 Assessment: Noticing
 History
 Full medical history
 IADLs
 Usual food intake
 Eating behaviors
 Change in appetite, weight
 Food preferences (meals, culture, snacks, etc.)

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 Physical Assessment/
Signs and Symptoms
 Hair, eyes, oral cavity, nails, skin, MS, and
neurologic systems
 Anthropometric measurements
 Food and fluid intake

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 Psychosocial Assessment
 Economic status
 Occupation
 Education level
 Gender orientation
 Ethnicity/rate
 Living and cooking arrangements
 Mental status

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 Laboratory Assessment
 Hemoglobin and hematocrit
 Serum albumin, thyroxine-binding prealbumin,
transferrin
 Cholesterol levels
 Total lymphocyte count

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 Analysis: Interpreting
 Weight loss due to inability to ingest or digest
food or absorb nutrients

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 Planning and Implementation:
Responding
 Improving nutrition
 Meal management
 Nutrition supplements
 Drug therapy
 Total enteral nutrition (TEN)

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Administering Total Enteral Nutrition
 Nasoenteric tube (NET)—short term
 Nasogastric tube (NG)
 Nasoduodenal tube (NDT)
 Enterostomal tubes—long term
 Gastrostomy performed; percutaneous endoscopic
gastrostomy (PEG) or dual-access gastrostomy-
jejunostomy (PEG/J) placed
 Low-profile gastrostomy device (LPGD)

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 Complications of TEN
 Priority is always patient safety.
 Clogged tube is the most common problem.
 Refeeding syndrome
 Tube misplacement, dislodgement
 Abdominal distention with nausea, vomiting
 Fluid and electrolyte imbalance with diarrhea

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 Administering Parenteral Nutrition
 Partial parenteral nutrition
 Total parenteral nutrition (TPN)

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 Care Coordination and
Transition Management
 Patients may be cared for in acute care,
transitional care, nursing home, or own home.
 Home Care Management
 Self-Education Management
 Health Care Resources

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 Evaluation: Reflecting
 Consumes available nutrients to meet metabolic
demands for maintaining weight and total protein
 Adequately hydrated

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Nutrition Concept Exemplar: Obesity
 Overweight versus obesity versus morbid
obesity
 Adipokines—affect appetite, fat metabolism
 Complications include cardiovascular,
respiratory, and musculoskeletal concerns
 Causes are environmental, genetic, and
behavioral.

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Health Promotion and Maintenance
 Healthy People 2020
 Weight management and exercise importance
 Even a 5% weight loss can decrease risk of
CAD and DM.

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 Assessment: Noticing
 History—use acronym RESPECT
 Economic status
 Usual food intake, appetite
 Eating behaviors, attitude towards food
 Culture
 Chronic diseases
 Drugs (including herbs, OTC)
 Activity
 Family history
 Developmental level

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 Physical Assessment:
Signs and Symptoms
 Height, weight, BMI
 Waist, arm, calf circumferences
 Waist-to-hip ratio
 Skin

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 Psychosocial Assessment
 Emotional factors
 Perception of weight, weight reduction, health
benefits, lifestyle changes

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 Analysis: Interpreting
 Weight gain due to excessive intake of calories

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 Planning and Implementation:
Responding
 Improving nutrition
 Nonsurgical management (including behavioral
management)
 Surgical management
• Bariatrics
 Preoperative care
 Operative procedures
 Postoperative care

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 Operative Procedures
 Gastric restriction

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 Operative Procedures (Cont.)
 Roux-en-Y
 Also called malabsorption surgery or gastric
bypass

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 Considerations After
Bariatric Surgery
 Airway management
 Patient and staff safety (special equipment,
etc.)
 Pressure between skinfolds
 Reintroduction of nutrition

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 Special Considerations After
Bariatric Surgery
 Abdominal binder
 Position in semi-Fowler’s
 SaO2 monitoring
 Sequential compression hose and/or heparin
 Skin assessment
 Absorbent padding
 Removal of urinary catheter within 24 hours

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 Special Considerations After
Bariatric Surgery (Cont.)
 Assist patient out of bed.
 Ambulate as soon as possible.
 Monitor abdominal girth daily.
 6 small feedings, prevent dehydration
 Observe for signs of dumping syndrome.

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 Care Coordination and
Transition Management
 Home Care Management
 Self-Management Education
 Health Care Resources

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 Case Study
An 88-year old male has been admitted for dehydration.
Upon assessment, dry mucous membranes, generalized
weakness, difficulty ambulating, and very little appetite are
noted by the nurse. His weight is down from 112 to 98
pounds over the past 3 month. His dentures are loose and
poor fitting.

1. Which assessment findings support a risk for

malnutrition?
2. Which assessment findings support failure to thrive?

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 Case Study (Cont.)
The patient is admitted to the hospital. The nurse reviews
the patient’s admission laboratory results.

Which result supports a diagnosis of malnutrition?

A. Hematocrit 37%
B. Hemoglobin 12 g/dL
C. Prealbumin 13 mg/dL
D. Serum albumin 3.5 g/dL

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 Case Study (Cont.)
On assessment, the patient is noted to have conjunctival
xerosis, dry skin, follicular hyperkeratosis, and a bright
magenta (purple) tongue.

Which vitamin deficiency does the nurse suspect?

A. Vitamin A
B. Vitamin C
C. Vitamin D
D. Vitamin K

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 Case Study (Cont.)
Which dietary item should be removed from the
patient’s nutritional tray?

A. Applesauce
B. Granola cereal
C. Scrambled eggs
D. Toast with butter

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 Case Study (Cont.)
The patient is ordered daily multiple vitamins with zinc and
iron supplements. Which nursing interventions promote oral
nutrition intake? (Select all that apply.)

A. Delegating a UAP to feed the patient

B. Providing mouth care before each meal
C. Placing a small-bore nasoduodenal tube
D. Assisting the patient to sit up in a chair
E. Ordering foods that the patient likes to eat

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 Chapter 60

Audience Response System Questions

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Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
 Question 1
What possible complication does the nurse
observe for when administering total parenteral
nutrition (TPN)?

A. Infection
B. Dehydration
C. Hyperglycemia
D. Electrolyte imbalance

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 Question 2
An older adult with anemia requests help with
menu choices. What type of food will the nurse
encourage the patient to eat?

A. Prunes
B. Oranges
C. Skim milk
D. Wheat bread

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 Question 3
The nurse is caring for a patient who is preparing
for bariatric surgery. What is the appropriate
nursing response when the patient states, “I am
afraid this surgery won’t work”?

A. “Are you afraid you will stay overweight for

life?”
B. “This surgery always works. It will be fine.”
C. “Tell me what concerns you most.”
D. “We will postpone the surgery until you
decide how you feel.”
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