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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 longterm care residents Protein-Calorie Malnutrition (PCM) Most common form of under nutrition Primary versus secondary Primary—poor Ingesting eating habits food deficient in protein, vitamins, minerals Secondary—alteration or defect in ingestion, digestion, absorption, or metabolism Due to GI obstruction, surgical procedures, cancer, malabsorption syndromes, drugs, infectious diseases Kwashiorkor how to pronounce https://www.youtube.com/watch?v=hLrCuBSKtJU Deficiency of protein intake superimposed by catabolic stress event such as Symptoms Change is skin color Fatigue D Loss of muscle mass GI obstruction Surgery Cancer Edema Mal-absorption syndrome Failure to grow or Infectious disease irritability May appear well nourished, have low protein levels Could be taking in enough calories gain weight 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 (1st 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 (2nd Stage) Within 5 to 9 days, fat is mobilized to supply energy Etiology and Pathophysiology Starvation process 2nd Stage cont. cont. Prolonged starvation: 97% of calories from fat and protein are consumed Fat stores used in 4 to 6 weeks, depends on amount available 3rd 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 Poorly planned vegetarian diets Anorexia Bulimia Alcoholics Drug abusers Fad diet followers What other types of diets/conditions can be missing necessary nutrients? 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?? Diagnostic Studies 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)? Nursing Assessment Health status Diet history Medical history Medications Family history Laboratory test results Changes in weight Physical examination Anthropometric measurements History/physical examination Food history for past week Height Weight VS Physical examination What do we include in PA? Planning/Goals Achieve weight gain. Consume specified number of calories per day? Consume specific amount of Fluid/liquids-proteincarbs-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 http://www.nutrition.gov/life-stages/seniors 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. http://www.ncbi.nlm.nih.gov/pubmed/17468550 Questions 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. 2. Which assessment findings support a risk for malnutrition? What further assessment-evaluation-questions are necessary to care for this patient. 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.