Hospital Nutrition: Defining Nutrition Risk and Feeding Patients

Unfolding Case

Sandy Arnold

Sandy is a 21-year-old downhill skier who is training for international competition. She has been hospitalized for the last 7 days after a skiing accident in which she sustained multiple fractures and internal injuries. She is intubated, a nasoduodenal (ND) feeding tube is placed, and the enteral nutrition order is written for 2200 mL/day of a standard formula that provides 1.0 cal/mL to be given over 18 hours. She has no medical history, is 5 ft 8 in, and weighed 130 pounds upon admission.

Check Your Knowledge

True	False
□	□	1	Adult malnutrition may be related to starvation (e.g., social or environmental related), chronic disease, or acute illness or injury.
□	□	2	One of the criteria for the diagnosis of severe malnutrition in a patient with chronic illness is a weight loss of >5% in the previous 6 months.
□	□	3	Patient tolerance is improved when oral intake progresses slowly after surgery from a clear liquid diet to regular food.
□	□	4	Osmolality is a primary consideration in selecting an appropriate enteral formula.
□	□	5	The terms fiber and residue are synonymous.
□	□	6	The patient’s ability to digest nutrients is a primary consideration when deciding the type of enteral formula to use.
□	□	7	A continuous drip delivered by a pump is recommended for administering tube feedings to patients who are critically ill.
□	□	8	Parenteral nutrition can be infused through a peripheral or central vein.
□	□	9	The biggest source of calories in parenteral nutrition infusions is protein.
□	□	10	Coloring tube-feeding formulas with food dye helps to prevent aspiration.

Learning Objectives

Upon completion of this chapter, you will be able to

1 Modify a menu to an altered consistency diet (e.g., clear liquid diet, pureed diet, mechanically altered diet).

2 Give examples of therapeutic diets and their uses.

3 Compare polymeric enteral formulas with hydrolyzed formulas.

4 Choose the most appropriate enteral formula for a given patient.

5 Discuss the advantages and disadvantages of various enteral nutrition delivery methods.

6 Propose interventions to combat various nutrition-related problems that may occur with enteral nutrition.

7 Explain the potential benefits of using enteral nutrition over parenteral nutrition when enteral nutrition is not contraindicated.

8 List indications for using parenteral nutrition.

9 Discuss the components of parenteral nutrition and the usual concentration of macronutrients provided.

The primary focus of clinical nutrition is to prevent or treat malnutrition. The first step in the process is to identify patients with, or at risk for, malnutrition via a nutrition screen (see Chapter 1). A nutrition assessment follows along with classification of the degree of malnutrition and implementation of a nutrition care plan. The nurse facilitates the nutrition care process by sharing assessment data; facilitating nutrition therapy interventions; reinforcing nutrition education; monitoring the patient’s intake, weight, and function; and communicating findings so that the plan can be revised as needed. The nurse plays a critical role in combatting malnutrition.

This chapter begins with the etiology and characteristics of malnutrition and leads to options for “feeding” patients, including oral diets, nutritional supplements, enteral nutrition, and parenteral nutrition.

HOSPITAL MALNUTRITION

The prevalence of malnutrition among hospitalized adults is estimated at 30% to 50% (Jensen, Compher, Sullivan, & Mullin, 2013); however, only 3.2% of these patients are discharged with the diagnosis of malnutrition (Corkins et al., 2014). This discrepancy may be explained in part by the failure to identify patients with malnutrition and the lack of a universally agreed upon definition of malnutrition. It is well recognized that malnutrition is associated with numerous adverse outcomes, including an increased risk of pressure ulcers, impaired wound healing, immune suppression, increased rate of infection, muscle wasting, prolonged hospital stay, higher readmission rates, higher health-care costs, and increased mortality (Barker, Gout, & Crowe, 2011). The deleterious effect of malnutrition not only affects virtually all organ systems but it can also impair cognitive ability, leaving patients unable to make independent, informed consent when they are in a severely compromised nutritional state (Russo, Gupta, & Merriman, 2016). Timely identification and treatment of malnutrition is critical to improving patient outcomes (Field & Hand, 2015).

Diagnosis of Malnutrition

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) includes diagnosis codes for adult protein calorie malnutrition for billing and research purposes. However, the lack of a universally accepted set of signs and symptoms for defining and classifying the severity of malnutrition results in widespread confusion and potential misdiagnosis (White, Guenter, Jensen, Malone, & Schofield, 2012).

Recognizing the need to standardize how malnutrition is defined and classified, the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition proposed a standardized approach for defining malnutrition in the adult hospitalized patient (White et al., 2012). The etiology-based approach involves assessing the patient for the presence of inflammation, which is a potent contributor to disease related malnutrition (Fig. 14.1) (Malone & Hamilton, 2013). Although there is not one single criteria to confirm the presence of inflammation, a variety of lab values and clinical symptoms may be used, such as low serum albumin, elevated C-reactive protein, high blood glucose, altered white blood
cell count, fever, and infection (Malone & Hamilton, 2013). The etiology-based definitions of malnutrition are

Starvation-related, which occurs when food is not available due to environmental or social circumstances. It usually develops slowly and may be caused by abuse, neglect, famine, poverty, or disordered eating (Skipper, 2012).
Chronic disease-related, which may occur in patients with diseases such as congestive heart failure or chronic obstructive pulmonary disease. A mild to moderate degree of inflammation impedes appetite, intake, or nutrient utilization.
Acute disease or injury-related, which may occur in patients with critical illness, multitrauma, or major infection due to a marked inflammatory response. These patients may be adequately nourished upon admission but are at high risk for malnutrition due to the nature of their illness.

Figure 14.1 ▶ Etiology-based malnutrition definitions.

Six characteristics have been proposed for diagnosing and classifying the degree of malnutrition (Table 14.1). Malnutrition is diagnosed when a patient demonstrates two or more characteristics and is classified as severe or nonsevere (moderate) based on specific thresholds and/or descriptions for each etiology of malnutrition. Table 14.2 illustrates the interpretation of weight loss.

Nutrition Therapy for Malnutrition

Nutrition intervention is well documented to improve key clinical outcomes (Tappenden et al., 2013). Numerous studies, mostly in patients 65 years of age and older, show specific nutrition interventions have the potential to substantially lower complication rates, length of hospital stay, readmission rates, cost of care, and, in some cases, mortality (Cawood, Elia, & Stratton, 2012; Somanchi, Tao, & Mullin, 2011). Actual nutrient requirements are affected by the underlying etiology of malnutrition. For instance, the nutrition prescription for a patient whose malnutrition is caused by cirrhosis will differ from malnutrition caused by major burns.
Nutrition intervention strategies include oral diets, supplements, enteral nutrition, and/or parenteral nutrition. Often, a combination of nutrition therapies is needed to meet increased nutritional needs (Russo et al., 2016).

Table 14.1 Characteristics to Assess for Malnutrition

Malnutrition Characteristics	How Obtained	Potential Problems
Weight loss over time	Actual or stated measurement upon admission Weight history	Fluid overload or dehydration will skew admission weights. Usual weight may be unknown or difficult for the patient or caregiver to recall.
Inadequate food and nutrition intake compared with requirements	History obtained from the patient or caregiver Meal consumption documentation	If indirect calorimetry is not available, calorie needs are estimated by using predictive equations which are less valid.
Loss of muscle mass	Physical assessment of various muscles, such as quadriceps, trapezius, deltoid	Requires experience and training
Loss of fat mass	Physical assessment of subcutaneous fat, such as the orbital region, upper arm, and thoracic regions	Requires experience and training
Fluid accumulation	Physical exam for the presence of local or generalized fluid retention, such as in the lower and upper extremities, face and eyes, and scrotal area	Fluid accumulation may be caused by other conditions such as congestive heart failure or chronic kidney disease.
Measurably diminished hand grip strength	Measured by a dynamometer	Requires experience and training Diseases such as rheumatoid arthritis, dementia, and neuromuscular diseases may limit validity of measure.
*Source:* Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in practice. Nutrition in Clinical Practice, 28, 639-650.

Although timely implementation of a nutrition care plan is clinically important, it is often delayed (Russo et al., 2016). For instance, patients may be nothing by mouth (NPO) for extended periods of time due to medical diagnostic tests or procedures. Patients with poor intake due to changes in mental status may be candidates for enteral nutrition, but it may not be implemented in the hope of quick improvement in mentation. These and other scenarios leave a gap between what is recommended and what is actually implemented. Efforts should be made to monitor “holds” on oral diets or enteral nutrition for procedures and to ensure that enteral or parenteral formulas are infused at the prescribed rate to maximize benefits (Tappenden et al., 2013).

Table 14.2 Interpretation of Weight Loss by Malnutrition Etiology

Etiology of Malnutrition	Moderate Malnutrition	Severe Malnutrition
Starvation or chronic disease	5%/1 month 7.5%/3 months 10%/6 months 20%/1 year	>5%/1 month >7.5%/3 months >10%/6 months >20%/1 year
Acute disease or injury	1-2%/1 week 5%/1 month 7.5%/3 months	>2%/1 week >5%/1 month >7.5%/3 months
*Source:* Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in practice. Nutrition in Clinical Practice, 28, 639-650.

FEEDING HOSPITAL PATIENTS

The goal of nutrition intervention for all hospitalized patients, whether or not they have been diagnosed with malnutrition, is to provide sufficient calories and nutrients to meet the patient’s estimated needs in a form the patient can tolerate and utilize. Feeding strategies are presented in the following text.

Oral Diets

Oral diets are the easiest and most preferred method of providing nutrition. In most facilities, patients choose what they want to eat from a menu representing the diet ordered by the physician. Oral diets may be categorized as “regular,” modified consistency, or therapeutic. Often, combination diets are ordered, such as a pureed low-sodium diet or a high-protein, soft diet. The actual foods allowed on a diet vary among institutions and the diet manual used.

Private and government regulatory agencies stipulate meal timing, frequency, and nutritional content and require that hospital menus be supervised by a qualified dietitian. Many hospital food service departments offer a room service, cook-to-order menu. Compared to more traditional food service menus, a restaurant-style service gives patients greater control over what and when they eat, provides more menu choices, improves food quality and service temperatures, reduces food waste, and improves patient satisfaction (Fitzpatrick, 2010).

A study by van Bokhorst-de van der Schueren, Roosemalen, Weijs, and Languis (2012) found that although meals provided adequate amounts of calories and protein, most patients do not consume complete meals: 61% of patients consumed <90% of their calorie requirement and 75% consumed <90% of their protein requirement. Appetite may be impaired by fear, pain, or anxiety. Hospital food may be refused because it is unfamiliar, tasteless (e.g., cooked without salt), inappropriate in texture (e.g., pureed meat), religiously or culturally unacceptable, or served at times when the patient is unaccustomed to eating. Inadequate liquid diets may not be advanced to a solid food diet in a timely manner. Patients may underestimate the importance of nutrition in their recovery process. Giving the right food to the patient is one thing; getting the patient to eat (most of it) is another. See Box 14.1 for suggestions on how to promote an adequate intake.

BOX 14.1 Promoting an Adequate Intake

Attention to details can make a big difference in the patient’s acceptance of hospital food.

Let the patient select his or her own menu whenever possible. This gives the patient a greater sense of control, increases the likelihood that the food will be consumed, and may prompt the patient to ask questions about the particular diet or provide information about his or her personal food and nutrition history.
Offer patients who do not like menu selections the daily “standby” or choices as alternatives. Be aware that “hospital food” is frequently used as a vehicle for patients to vent anger and frustration over their loss of control.
Be aggressive about diet progressions. Keep in mind that advancing the diet as quickly as possible allows the patient to meet nutritional requirements sooner and increases patient satisfaction.
Set the stage for a pleasant meal. Be sure trays are delivered promptly to ensure foods are at the proper temperatures. Adjust the lighting and make sure the patient is in an appropriate sitting position. Screen the patient from offensive sights and remove unpleasant odors from the room. Encourage family to visit at mealtime, if appropriate. Offer mouth care to improve appetite, if appropriate.
Be positive. Refrain from negative comments about the food. Also be aware of what your body language is saying to the patient. A frown or raised eyebrows can speak volumes.
Provide assistance when necessary. Encourage the patient to self-feed to the greatest extent possible. Some patients may benefit from minor help such as opening milk cartons or buttering bread; others may need to be completely fed. Monitor the patient’s ability to self-feed and adjust the intensity of help accordingly.
Gently motivate the patient to eat. Sometimes, encouragement is all that is needed to get the patient to eat. For other patients, motivation comes from being made aware of the importance of food in the recovery process. Thinking of food as part of treatment instead of a social function may improve intake even when appetite is compromised.
Identify eating problems. Patients who feel full quickly should be encouraged to eat the most nutritious items first (meat, milk) and save the less dense items for last (juice, soup, coffee). Patients who have difficulty chewing benefit from a mechanical soft diet. Determine if the patient would accept between-meal supplements and a bedtime snack to help maximize intake.

Regular Diet

Regular diets are used to achieve or maintain optimal nutritional status in patients who do not have altered nutritional needs. No foods are excluded, and portion sizes are not limited on a normal diet. The nutritional value of the diet varies significantly with the actual foods chosen by the patient.

Regular diets are adjusted to meet age-specific needs throughout the life cycle. For instance, a regular diet for a child differs from that of an adult. Regular diets are also altered to meet specifications for vegetarian or kosher eating.

Sometimes, physicians order a diet as tolerated (DAT) on admission or after surgery. This order is interpreted according to the patient’s appetite and ability to eat and tolerate food. The nurse has the authority to advance the DAT.

Modified Consistency Diets

Modified consistency diets include clear liquid and mechanically altered diets (Table 14.3). A clear liquid diet is the most frequently ordered postoperative meal, based on the rationale that a gradual progression from a clear liquid diet to a regular diet is important for maximizing tolerance when
eating resumes. However, there is little scientific evidence to support this practice. In a randomized controlled trial of patients undergoing major gastrointestinal (GI) surgery, giving “normal food” on the first postoperative day did not increase morbidity or mortality; postop nausea occurs in approximately 20% of patients whether they are advanced first to clear liquids or to solid food (Lassen et al., 2008). A regular diet as the first meal has been shown to be well tolerated and provides more nutrition and greater patient satisfaction than a clear liquid diet (Warren, Bhalla, & Cresci, 2011).

Table 14.3 Characteristics of Modified Consistency Diets

Diet Characteristics	Foods Allowed	Indications
Clear liquid
A short-term, highly restrictive diet composed only of fluids or foods that are transparent and liquid at body temperature (e.g., gelatin). It requires minimal digestion and leaves a minimum of residue. Inadequate in calories and all nutrients except vitamin C if vitamin C-fortified juices are used.	Clear broth or bouillon Coffee, tea, and carbonated beverages, as allowed and as tolerated Fruit juices; clear (apple, cranberry, grape) and strained (orange, lemonade, grapefruit) Fruit ice made from clear fruit juice Gelatin Popsicles Sugar, honey, hard candy Commercially prepared clear liquid supplements	In preparation for bowel surgery or colonoscopy; acute gastrointestinal disorders; transitional feeding after parenteral nutrition Practice of using clear liquids as initial feeding after surgery may not be warranted.
Pureed diet
A diet composed of foods that are blended, whipped, or mashed to pudding-like consistency All foods should be smooth and free of lumps. Most foods can be liquefied by combining equal parts of solids and liquids; fruits and vegetables need less liquid. Broth, gravy, cream soups, cheese, tomato sauce, milk, and fruit juice are preferable to water for blenderizing due to their higher calorie and nutritional value. Liquids may be thickened to improve ease of swallowing.	All foods are allowed, but consistency is changed to liquid.	Used after oral or facial surgery; for wired jaws; chewing and swallowing problems
Mechanically altered diet
A regular diet modified in texture only; excludes most raw fruits and vegetables and foods containing seeds, nuts, and dried fruit Gravies, sauces, milk, and water are used to soften foods that are chopped, ground, mashed, or cooked soft. Sticky foods such as peanut butter are avoided.	Chopped or ground diet: milk; yogurt; pudding; cottage cheese; mashed, soft ripened fruit (peaches, pears, bananas); cooked, mashed soft vegetables (peas, carrots, yams); ground meats; soft casseroles; smooth cooked cereals; soft bitesized pasta; bread products made into a slurry with the addition of gravy or syrup	Used for patients who have limited chewing ability, such as patients who are edentulous, have ill-fitting dentures, or have undergone surgery to the head, neck, or mouth
Soft diet
A regular diet that features soft-textured foods that are easy to chew and swallow. Hard, sticky, dry, or crunchy foods are excluded.	Soft cooked vegetables; shredded lettuce; canned fruit; soft, peeled fresh fruit; well-moistened, thin sliced, tender, or ground meats, poultry, or fish; eggs; milk; yogurt; mashed potatoes; white rice; well-cooked pasta; well-moistened cereals without dried fruits or nuts	Used to limit gastrointestinal irritation and minimize gut activity for healing purposes Not intended for long-term use because it can cause constipation

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Nov 8, 2018 | Posted by drzezo in NURSING | Comments Off

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