Transcript Focus on Malnutrition

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.