Nutrition in Patient Care



Nutrition in Patient Care



image http://evolve.elsevier.com/Grodner/foundations/ image Nutrition Concepts Online



Role in Wellness


The first three parts of this text discuss basic nutrition as it relates to wellness. Part 4, “Overview of Medical Nutrition Therapy,” provides information for nursing professionals on how nutrition pertains to the physiologic stresses of disease states.


Although Hippocrates made the link between nutrition and disease almost 3000 years ago, the modern medical community has just recently made the same discovery. The tremendous advances of medical technology are fundamentally important if the recipient is malnourished or is at nutritional risk. Nutritional risk is the potential to become malnourished because of primary (inadequate intake of nutrients) or secondary (caused by disease or iatrogenic affects) factors. Capacity for recovery from illness or disease depends on nutritional status. Poor nutritional status delays or prevents recovery, whereas good nutritional status promotes healing and recovery. It is therefore important to determine the nutritional status of those undergoing medical treatment or cure.


Sometimes dietary modifications are required to allow the body to heal, adjust to physical disability, prepare for diagnostic tests, or prepare for surgical procedures. Nutrition therapy may involve changes in dietary intake to liquefied or pureed foods, tube feeding, or intravenous (IV) nourishment. This chapter discusses promotion of wellness through typical progressive hospital diets, enteral formulas, and parenteral nutrition.


Because wellness is the goal of caring for patients, the physical, intellectual, social, emotional, and spiritual dimensions of health are applicable to the issues of this chapter. The physical health dimension is affected because dietary alterations may affect overall nutritional status; careful nursing supervision can ensure adequate nutrient intake. The intellectual dimension is tested because nurses and caregivers are in the tricky position of observing patient eating patterns and then assessing whether problems are caused by illness or food availability. Nurses need the intellectual skills to determine when to alert the clinical dietitian. The emotional health dimension can be challenged if the loss of symbolic foods, particularly if modifications are long term or permanent, stresses emotional health. Nurses can be sensitive to this aspect of dietary modification and help patients to create new symbols to replace the old. The social health dimension may be altered when patients are served meals in their rooms. Feelings of isolation may deprive mealtimes of their function of social relatedness. The spiritual health dimension is affected because some foods have spiritual or religious significance to individuals, such as bread and wine used for Communion or matzoh used during the Jewish holiday of Passover. When such foods are not permitted because of enteral problems, individuals should consult their spiritual or religious advisors.



Nutrition and Illness


Nurses are usually the first health care workers with whom the hospitalized patient comes into contact. By using information from nursing assessments, they are in a good position to identify patients in need of nutritional services. Furthermore, hospital size or staffing may necessitate nursing staff to perform some basic nutrition screening, nutrition assessment, and nutrition education.


When more in-depth knowledge of aspects of nutritional care beyond basic nutrition interventions are needed; this care is provided by registered dietitians (RDs). They conduct nutritional assessments, provide nutrition therapy, and serve as a valuable resource for the nursing staff. Nutrition therapy (also called medical nutrition therapy) is the provision of nutrient, dietary, and nutrition education needs based on a comprehensive nutritional assessment to treat an illness, injury or condition. Occasionally, RDs may be assisted by dietetic technicians when taking diet histories, collecting information for nutritional screenings and assessments, and working directly with patients who are having problems with foods.


Modern health care settings—acute care hospitals—can play havoc with patients’ nutritional status. During their hospitalization, patients admitted in good nutritional status encounter several elements—psychologic and physiologic—that can potentially put them at nutritional risk. If patients are admitted in compromised nutrition status, as many are, risks are even greater and of more consequence.



imageHospital Setting


Imagine you have been taken to a place where, after answering a multitude of questions about your insurance, financial status, and durable power of attorney (a legal document in which a competent adult authorizes another competent adult to make decisions for him/her in the event of incapacitation), you are whisked off to a sterile-looking room that you must share with a stranger. In this room your clothes are replaced with a thin, flimsy gown that won’t close in the back. You answer more questions about your medical history from the nurse who admits you. Once he or she finishes, a resident/intern comes into your room to ask many of the same questions and conduct a physical examination (Figure 14-1).


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FIG 14-1 A-D, Patients are interviewed by many health care professionals.

During a stay in the hospital, your eating habits are open to scrutiny, possibly provoking guilty feelings. You’re away from your own refrigerator, and meals are served on a schedule that may or may not coincide with your personal meal schedule. Although the food is prepared with the utmost care, it will be different from home cooking (just like any food eaten away from home). Depending on your diagnosis, the food is likely to be modified in texture, consistency, nutrients, or energy. When you’re waiting for meals to be served (you still haven’t gotten used to eating in bed), different hospital staff routinely enter your room to ask more questions, draw blood, take you elsewhere in the hospital for tests that may or may not be invasive, and ask you about your elimination habits and what you have eliminated, if anything.


Many patients who enter hospitals are miles away from their homes, family, and friends. Although no malfeasance is intended, little privacy is afforded hospital patients while they undergo tests and examinations that may provide them with critical information regarding their prognosis or life expectancy. During these trying times for patients and staff alike, food becomes very important, physiologically and psychologically, to patients because it is often one of the few familiar experiences encountered in a hospital setting (see the Personal Perspectives box, Sharing an Orange).



image Personal Perspectives


Sharing an Orange


Machines were whirling as I entered the cardiac intensive care unit to visit my husband Lenny’s grandmother. I didn’t know what to expect. Grandma Ethel was the most energetic older adult I ever knew. Eighty-six years old, still running her own gift shop, and always ready to go out with Lenny and me, until she had this heart attack.


Grandma Ethel was sitting upright in a chair with all kinds of wires attached to her body. She was pale but immediately her radiant smile spread across her face. She said, “Come and sit, have lunch with me,” as she invited me to share the hospital lunch that was on a tray in front of her. Now I certainly wasn’t going to eat any of her lunch, especially hospital food. But I was definitely needed. She wanted the soup, but with the wires and being somewhat weak, couldn’t get the lid off the Styrofoam cup. So I came to the rescue. Uncover the lid from the plate of soft chicken and mashed potatoes? Again I was handy. Open the juice container and decaffeinated coffee cup? Who knew I was so competent?


“Michele, here have the orange.” The orange was in a bowl surrounded by plastic wrap. I gently suggested she should have it because it was good for her. “No, I’m too full. Take it home . . . take it home for the boys [my sons; her great-grandsons] and take the brownie too!” I then realized that the real issue was not to feed Grandma Ethel’s body, but to let her soul feed us. Her soul needed to nourish us with her gift of a sweet orange and a rich brownie. And we were nourished.


Michele Grodner


Montclair, N.J.


Particularly with hospitalized toddlers and adolescents, food can become a battleground because of its emotional connotations (Figure 14-2). As you will see in this chapter and those following, food or alternative nourishment can mean the difference between a good or poor prognosis for many patients’ morbidity or mortality (see the Cultural Considerations box, Asking the Right Questions for Cultural Competence).


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FIG 14-2 Food provides emotional comfort as well as nutrition, especially for children. (Photo.com.)


Bed Rest


Occasionally, complete bed rest is prescribed as part of patients’ medical care, or patients may be unable to ambulate because of the severity of their illness or because they are “hooked up” to a multitude of necessary life-saving equipment at bedside. Although it is often necessary or unavoidable, complete bed rest can cause injurious effects on a patient’s body.1 Skin integrity may be compromised after just 24 hours of immobilization, and after 3 days of lying supine in bed, muscle tone, bone calcium, plasma volume, and gastric secretions diminish. In addition, glucose intolerance and shifts in body fluids and electrolytes may also occur. Nursing personnel can provide care that may help prevent or delay injurious effects of bed rest by frequently turning patients and stimulating the skin and underlying muscles by providing skin care (e.g., applying skin lotion) and passive exercises for the extremities, respectively.



image Cultural Considerations


Asking the Right Questions for Cultural Competence


Health care professionals strive for cultural competence when providing care to patients in a variety of health care settings. By doing so, they provide truly comprehensive health care. Cultural competence involves understanding the attitudes and knowledge of each cultural group in relation to how foods protect health and maintain wellness.


It is difficult to know all of the specific cultural food practices of diverse groups in North America. The use of the Cultural Nutritional Assessment Guide, presented here, is essential as part of a patient’s health history. The information obtained from the patient or family member by health care professionals ensures cultural competent practice.



Cultural Nutritional Assessment Guide




• What nutritional factors are influenced by the client’s cultural background? What is the meaning of food and eating to the client?


• With whom does the client usually eat? What types of foods are eaten? What is the timing and sequencing of meals?


• What does the client define as food? What does the client believe comprises a “healthy” versus an “unhealthy” diet?


• Who shops for food? Where are groceries purchased (e.g., special markets or ethnic grocery stores)? Who prepares the client’s meals?


• How are foods prepared at home—type of food preparation, cooking oils used, length of time foods are cooked (especially vegetables), amount and type of seasonings added to various foods during preparation?


• Has the client chosen a particular nutritional practice such as vegetarianism or abstinence from alcohol or fermented beverages?


• Do religious beliefs and practices influence the client’s diet (e.g., type, amount, preparation, or delineation of acceptable food combinations [e.g., kosher diets])? Does the client abstain from certain foods at regular intervals, on specific dates determined by the religious calendar, or at other times?


If the client’s religion mandates or encourages fasting, what does the term fast mean (e.g., refraining from certain types or quantities of foods, eating only during certain times of the day)? For what period of time is the client expected to fast?



Cultural Nutritional Assessment Guide from Andrews M, Boyle J: Transcultural concepts in nursing care, ed 4, Philadelphia, 2002, Lippincott Williams & Wilkins.



Malnutrition


Many patients admitted to hospitals are at nutritional risk, whereas other may develop malnutrition during their hospitalization.2 These patients may be experiencing hypermetabolism or have physiologic stress from injury or illness that increases nutritional needs, further increasing nutritional risk. Additionally, nutritional needs may be further compromised because of, for example, periodic need for an empty gut for laboratory testing or diagnostic procedures. Likely problems may develop from hospital routine causing inadequate nourishment in some cases, including the following:3



Each ill or injured patient is a unique person and needs individual treatment and care.3 Nursing personnel can be a fundamental factor in prevention of malnutrition by paying particular attention to patients’ diet orders, recognizing potential risk when patients have had nothing but clear or full-liquid diets for more than 24 hours, and contacting the RD to evaluate patients’ nutritional risk.



Nutrition Intervention


The tremendous advances of medical technology are fundamentally unimportant if the recipient is malnourished or is at nutritional risk. Most patients entering the health care system are prone to have nutrition problems and will have special nutritional needs depending on their injury or illness. Patients at nutritional risk need to be identified so high-quality nutrition care can be provided.4 Poor nutritional status may lead to complications that may lead to increased morbidity and mortality, length of stay, and cost of care.5 For nutrition intervention to be efficacious and successful, a systematic, logical strategy is necessary. The nutritional care process provides such an approach (Box 14-1).



BOX 14-1   American Dietetic Association’s Nutrition Care Process



Definition of the American Dietetic Association’s Nutrition Care Process (NCP)


Providing nutrition care employing the American Dietetic Associations’s (ADA’s) NCP starts when a patient is recognized as being at nutritional risk and requiring additional support to attain or maintain positive nutritional status. The NCP is defined “as a systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care.” It is composed of the following four separate but interrelated and associated steps:



Each stage builds upon the preceding one, but the process is not necessarily linear. Figure 14-3 provides a visual illustration of the model.


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FIG 14-3 Nutrition Care Process and model. (Redrawn from Lacey K, Pritchett E: Nutrition Care Process and model: ADA adopts road map to quality care and outcomes management, J Am Diet Assoc 103(8):1062, 2003, with permission from the American Dietetic Association.)



Step 2: Nutrition Diagnosis


Before nutrition intervention can take place, the nutrition problem(s) must be identified. This is accomplished with the nutrition diagnosis. Standardized language has been developed to make the nutrition diagnosis clear to other nutrition and health care professionals. When the nutrition problem has been identified, it is labeled with a specific, standardized diagnostic term. The nutrition diagnosis statement or PES statement is organized in three distinct parts: the problem (P), etiology of the problem (E), and signs and symptoms associated with the problem (S). Typically nutrition diagnoses fall into three categories or domains: intake, clinical, and behavioral-environmental.


Here is an example of how a nutrition diagnosis is written:





Step 3: Nutrition Intervention


Intervention begins once the nutritional diagnosis is identified. It is generally aimed at the etiology (E) of the nutrition diagnosis and is directed at reducing or eradicating effects of the signs and symptoms (S). Nutrition interventions are intended to modify a nutrition-related problem, and are comprised of two interconnected components: planning and implementation. Nutrition diagnoses are prioritized in the planning component, whereby implementation is the “action phase.” The plan is communicated and carried out, data continued to be collected, and the nutrition intervention is revised as necessary. Four categories or domains of nutrition intervention have been identified:




Step 4: Nutrition Monitoring and Evaluation


The point of the nutrition monitoring and evaluation step in the NCP is to measure improvement made by the patient in meeting nutrition care goals. Patients’ progress is examined by determining if the nutrition intervention is being executed and by providing evidence that the intervention is/is not altering the patients’ nutritional status. Nutrition monitoring and evaluation terms are organized into four categories or domains:



In summary, the Nutrition Care Process allows for continuous monitoring and evaluation of the patient. As the condition of the patient changes, plans or interventions change, and diagnoses and/or interventions change. Or if the patient does not respond to interventions, new interventions can be developed. Additionally, any/all nutrition interventions should be planned along with patients and/or their caregivers or significant others. For more detailed information regarding the Nutrition Care Process, please refer to the following references.




Screening


In long-term care, assessments must be completed on all residents within 14 days of admission. The Joint Commission (TJC) requires all patients admitted to a hospital to be screened within 48 hours of admission.6 “Nutrition screening is the process of identifying characteristics known to be associated with nutrition problems.”7 It is not possible, or necessary, to complete a full nutrition assessment on every patient. It is necessary, however, to have a system in place to quickly identify patients at risk for nutritional problems, such as malnutrition.7


Nutrition screening can be executed by registered dietitians, dietetic technicians, dietary managers, nurses, physicians, or other trained personnel. Whether or not RDs are engaged in performing nutrition screening, they are responsible for providing input into development of suitable screening parameters to make certain the screening process addresses the correct parameters.7 The nutrition screening process has the following characteristics:8



A referral process may be necessary to ensure a patient is referred to an RD, who will conduct the nutrition assessment, make nutritional diagnoses, and provide nutrition care.



Nutritional Assessment


The nutritional care process is often performed during a comprehensive nutritional assessment conducted by dietetic professionals, who work synergistically with nursing personnel to provide this essential component in medical care. A comprehensive nutritional assessment is a procedure conducted by dietetic professionals to determine appropriate medical nutrition therapy based on identified needs of the patient. This process uses data collected from several different sources to assess patients’ nutritional needs, often using the ABCD approach: Anthropometrics, Biochemical tests, Clinical observations, and Diet evaluation. Each part of this process is important because there is no one parameter that directly measures nutritional status or determines nutritional problems or needs. Thus a combination of these parameters must be used to interpret the overall nutrition picture presented by patients within the context of their personal, social, and economic backgrounds.*



Anthropometric assessment

Anthropometric measurements are determined by simple, noninvasive techniques that measure height and weight, the head, and skinfold thicknesses. Effectiveness of single anthropometric measurements is limited, but certain serial measurements can be useful to assess body composition changes or growth over time. Standardized techniques must be used to obtain valid and reliable measurements. Evaluation of anthropometric data involves comparison of data collected with predetermined reference limits or cutoff points that allow classification into one or more risk categories and, in some cases, identification of the type and severity of malnutrition.9 Discussion of various anthropometric measurements follows.



imageHeight

Stature (height/length) is important in evaluating growth and nutritional status in children. In adults, height is needed for assessment of weight and body size. Height should be measured using a fixed measuring stick or tape on a true vertical, flat surface with no carpeting. If this is not available, the movable measuring arm on platform clinic scales may be used with reasonable accuracy, although it tends to produce lower measures.10 The patient should be measured standing as straight as possible, without shoes or head coverings, with the heels together, and looking straight ahead (Box 14-2).



BOX 14-2


Measuring Height




From Lee RD, Nieman DC: Nutritional assessment, ed 4, New York, 2007, McGraw-Hill.


Accurate heights are important in nutritional assessment. Many calculations used to determine energy requirements and needs are based on height and weight. Heights are not always available in the medical records of hospitalized patients. When heights are documented, it is often unclear whether they are reported by the patient or measured. Asking patients about their height does not always produce accurate information. On average when asked, people report being slightly taller than they actually are.11 Men overstate height more often than women (men—0.46 in. [1.22 cm]; women—0.68 in. [0.68 cm]), and the extent of overstating height increases as people age.11 If the height of a patient recorded in the medical record is not a measured height, it should be documented as a stated height.


When measuring infants and children (younger than 2 to 3 years) who cannot stand or others unable to stand erect without assistance, recumbent measures can be taken while the subject is lying down or reclining. A recumbent length table can be used. A recumbent length table or board has a fixed headboard, a movable footboard, and a permanent measuring tape along the side (Figure 14-4). To measure a patient, he or she should be placed supine on the board or table with shoulders and legs flat against the measuring board (table) and arms at the sides. The head should firmly touch the headboard while the line of vision is perpendicular to the board or table. Soles of the feet should be vertical, and the footboard should touch the bottom of the feet so that the soft tissue is compressed. Length can be recorded from the measure at the footboard. Two people are often needed to take an accurate measurement.10


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FIG 14-4 A recumbent length board used to take height measurements horizontally. (From Mahan LK, Escott-Stump S: Krause’s food & nutrition therapy, ed 12, St. Louis, 2009, Saunders.)

When the patient is comatose, critically ill, or unable to be moved for other reasons, taking a recumbent bed height may be possible (Box 14-3).12 Note that when compared with standing height, bed height is significantly greater by at least 2%.12



BOX 14-3


Measuring Recumbent Bed Height




Data from Gray D: Accuracy of recumbent height measurement, JPEN J Parenter Enteral Nutr 9:712-715, 1985.


A more accurate measurement for patients who cannot stand is knee height. Knee height is more accurate when measured in a recumbent rather than a sitting position.13,14 This measurement is minimally affected by aging. In older adults, knee height can be measured to estimate height by using the following formulas15:


Male height (cm)=64.19−(0.04×age)⋅[2.02×Knee height (cm)]


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Female height (cm)=84.88−(0.24×age)⋅[1.83×Knee height (cm)]


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The special calipers necessary for measuring knee height are available from Ross Laboratories in Columbus, Ohio.



imageWeight

When accurately measured, body weight is a simple, gross estimate of body composition. In fact, body weight is one of the most important measurements in assessing nutritional status and is used to predict energy expenditure.16 Beam scales with movable but nondetachable weights or accurate electronic scales are recommended to obtain accurate results. Spring scales are not recommended. If the patient is nonambulatory, wheelchair or bed scales should be used (Figure 14-5).10 Scales should be checked for accuracy periodically and recalibrated when necessary. Like heights, actual measured weights are more accurate than patients’ estimated weights because men slightly overreport their weight (men—0.66 lbs [0.30 kg]), and women report slightly less than it actually is (–3.06 lbs [–1.39 kg]).11


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FIG 14-5 If a patient is nonambulatory, a bed scale can be used to measure patient weight.

For accurate weights, patients should be clothed in their underwear or hospital gown. Weights should be measured at the same time of day and after voiding. The patient should stand still with the weight evenly distributed on both feet while weight is recorded to the nearest 0.1 kg, or 0.25 pound.10


As a nutritional screening tool, weights can be used to recognize changes that may be representative or suggestive of serious health problems. Magnitude and direction of weight change are more meaningful when dealing with sick or debilitated patients than standardized desirable weight references (see Table 14-1). Percent weight change is a useful nutrition index and may be computed as follows:


% Weight change=(Usual weight−Actual weight)÷Usual weight×100


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For example, Mrs. Welch is admitted to your unit. Her weight on admission is 120 pounds. During the admissions interview, she indicates that 3 months ago she weighed 135 pounds. Her percent weight change from usual weight is


(135−120)÷135×100=15÷135×100=0.11×100=11% Weight change


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Mrs. Welch’s (actual) weight is 11% less than her usual weight.


% Weight change from admission weight=(Usual weight−Actual weight)÷Admission weight×100


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For example, Mr. Tucker is a patient in the long-term care facility where you work. When he was admitted more than a year ago, he weighed 180 pounds. He has weighed 170 pounds for the past 6 months, but today you weigh Mr. Tucker and he weighs 165 pounds. His percent weight change from admission weight is


(170−165)÷180×100=5÷180×100=0.0278×100=2.78%, or 3% Weight change


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Mr. Tucker’s (actual) weight is 3% less than his admission weight.


%Weight change since nutrition intervention=(Usual weight−Actual weight)÷Preintervention weight×100


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For example, Mrs. Bussard was placed on a feeding tube because her weight has decreased from her usual weight of 130 pounds to 115 pounds. She has been on the feeding tube for 1 week, and when you weigh her today, she weighs 122 pounds. Her percent weight change since nutrition intervention is


(130−122)÷115×100=8÷115×100=0.067×100=6.96%, or 7% Weight change


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Mrs. Bussard’s weight has increased 7% since the tube feedings were initiated.


Care should be taken to identify patients with ascites, edema, or dehydration because their weight changes may be more a reflection of their fluid status than actual changes in body composition. If more than 1 pound is gained in a day’s time, it may be indicative of excess fluid. It is also important to examine any unplanned weight loss the patient might experience, as indicated in Table 14-1. Reported or measured percent weight losses of these magnitudes could be cause for alarm.



For older adult patients who cannot be weighed because of the severity of their medical condition, or if bed or chair scales are not available, Chumlea and colleagues17 have developed gender-specific equations used to predict body weight in people 60 to 90 years of age. The estimated weights are based on recumbent measures of arm circumference (AC), calf circumference (CC), subscapular skinfold (SSF), and knee height (KH).


Women: Weight (cm)=[0.98×AC (in cm)]+[1.27×CC (in cm)]+[0.4×SSF (in mm)]+[0.87×KH (in cm)] 62.35


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Men: Weight (cm)=[1.73×AC (in cm)]+[0.98×CC (in cm)]+[0.37×SSF (in mm)]+[1.16×KH (in cm)] 81.69


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Another challenge in obtaining weights occurs in patients who have missing body parts because of accidents or amputation. Figure 14-6 shows the approximate percent of body weight contributed by individual body segments so desirable weight can be calculated.


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FIG 14-6 Approximate body weight percentages.Rights were not granted to include this figure in electronic media. Please refer to the printed book. (Modified from Brunnstrom S: Clinical kinesiology, Philadelphia, 1962, FA Davis.) FA Davis 1962


Body mass index

Body mass index (BMI) is a ratio of weight to height and has been associated with overall mortality and nutritional risk.18,19 BMI does not determine body composition (lean body mass or adipose) but is a dependable gauge of total body fat, which is interrelated with risk of disease.20 While measurements are valid for men and women, BMI measurements do have limits:19,20



You can determine BMI by referring to Table 10-1 or by dividing weight in kilograms by height in squared meters using the following three steps:



The desired BMI range for healthy adults is 18.5 to 24.9 kg/m2, which reflects a healthy weight for height. Although at low risk for health problems, people with BMIs of 25 to 29.9 kg/m2 are approximately 20% above desirable levels. A BMI of less than 18.5 kg/m2 is classified as underweight (Table 14-2) and is associated with risk factors such as respiratory disease, tuberculosis, digestive disease, and some cancers.21





Biochemical assessment

Many routine blood and urine laboratory tests recorded in patients’ charts are useful in providing an objective assessment of nutritional status. However, care should be taken in interpreting test results for a number of reasons. First, there is no single test available for evaluating short-term response to medical nutritional therapy. Laboratory tests should be used in conjunction with anthropometric data, clinical data, and dietary intake assessments. Second, some tests may be inappropriate for certain patients; for example, serum albumin might not be useful in the evaluation of protein status in those patients with liver failure because this test assumes normal liver function. Third, laboratory tests conducted serially will give more accurate information than a single test. Although, serial measures can be obtained in long-term care settings, patients in acute care facilities are rarely hospitalized long enough to obtain serial measures. Therefore, it might be more appropriate to compare test results with known standards.


The most important biochemical parameters are visceral protein status and immune function. Visceral protein status is assessed through tests of serum albumin and prealbumin. (Visceral proteins include proteins other than muscle tissue, such as internal organs and blood.) Immune function is evaluated based on total lymphocyte count (TLC). The test results of these biochemical assessments provide useful information to determine the effects of nutritional factors or of medical conditions on the health status of patients (Table 14-3).



TABLE 14-3


BIOCHEMICAL PARAMETERS AND HOW THEY ARE TESTED





















SERUM PROTEIN FUNCTION COMMENTS

Maintains plasma oncotic pressure; carrier for small molecules Not sensitive or specific for acute protein malnutrition or response to nutrition therapy; affected by hydration status, disease state, clinical condition
Can be used as prognostic indicator of morbidity, mortality, and severity of illness

 Binds iron in plasma and transports to bone marrow Inversely correlated with body’s iron stores; elevated concentration often indicates early iron deficiency
Will decrease during acute illness
Verify with laboratory whether lab is direct measurement or calculated

 Carrier protein for thyroxin
Combined with retinol-binding protein, transports vitamin A		 Influenced less by intravascular fluid volume
Not affected as early or as significantly with liver disease (compared with albumin)
More likely to be a reflection of recent dietary intake than accurate indicator of nutritional status


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Adapted from (compiled from components in tables and text) Moore MC: Pocket Guide to Nutrition Assessment and Care, ed 6, St. Louis, 2009, Mosby Elsevier; Thompson CW: Laboratory assessment. In Charney P, Malone AM, editors: ADA Pocket Guide to Nutrition Assessment, ed 2, Chicago, 2009, American Dietetic Association; Lee RD, Nieman DC: Nutritional Assessment, ed 4, Boston, 2007, McGraw Hill.



Serum albumin

Serum albumin provides an assessment of visceral protein status. Normal values are within 3.5 to 5 g/dL. For nutritional analysis, values between 2.8 and 3.5 g/dL indicate compromised protein status; values less than 2.4 g/dL suggest possible kwashiorkor. This test is most useful when used to monitor long-term nutrition changes because normal values may still be found among patients who are recently malnourished. In addition, if patients are experiencing dehydration (hemoconcentration) or have received infusions of albumin, fresh frozen plasma, or whole-blood serum albumin, levels may appear normal. However, as a tool to assess long-term changes, the effects of dehydration and infusions would dissipate. Alternate causes of abnormally low values may be infection and other stressors (especially with poor protein intake), burns, trauma, congestive heart failure, fluid overload, and severe hepatic insufficiency.24,25




Clinical assessment

Clinical assessment incorporates data from several sources: medical history, social history, and physical examination. Many environmental factors can affect nutritional status. This information can be found by reviewing the patient’s medical record or through direct interview. Social or family factors may also affect nutrient intake or past or present medical conditions that influence nutrient use. Many physical signs and symptoms associated with malnutrition are also an integral part of assessing nutritional status.


Features associated with nutritional deficiency may be considered through historical and clinical categories.24,25 Historical findings may include alcohol abuse, poverty, avoidance of specific food groups (e.g., fruits or vegetables), weight loss, drug use (or abuse), family history of inborn errors, and cigarette smoking. Clinical features are extensive, including surgery or wounds; blood loss; dull, dry, pluckable hair; fever; and bleeding gums. Findings may be organized by symptoms of the eyes, face, skin, muscles, tongue, and central nervous system. Table 14-4 provides additional data about historical and clinical features in relation to nutritional status.



Table 14-4


SIGNS THAT SUGGEST NUTRIENT IMBALANCE




















































































































































































































































AREA OF CONCERN POSSIBLE DEFICIENCY POSSIBLE EXCESS
Hair    
Dull, dry, brittle Pro  
Easily plucked (with no pain) Pro  
Hair loss Pro, Zn, biotin Vit A
Flag sign (loss of hair pigment in strips around head) Pro, Cu  
Head and Neck    
Bulging fontanel (infants)   Vit A
Headache   Vit A, D
Epistaxis (nosebleed) Vit K  
Thyroid enlargement Iodine  
Eyes    
Conjunctival and corneal xerosis (dryness) Vit A  
Pale conjunctiva Fe  
Blue sclerae Fe  
Corneal vascularization Vit B2  
Mouth    
Cheilosis or angular stomatitis (lesions at corners of mouth) Vit B2  
Glossitis (red, sore tongue) Niacin, folate, vit B12, and other B vit  
Gingivitis (inflamed gums) Vit C  
Hypogeusia, dysgeusia (poor sense of taste, distorted taste) Zn  
Dental caries Fluoride  
Mottling of teeth   Fluoride
Atrophy of papillae on tongue Fe, B vit  
Skin    
Dry, scaly Vit A, Zn, EFAs Vit A
Follicular hyperkeratosis (resembles gooseflesh) Vit A, EFAs, B vit  
Eczematous lesions Zn  
Petechiae, ecchymoses Vit C, K  
Nasolabial seborrhea (greasy, scaly areas between nose and lip) Niacin, vit B12, B6  
Darkening and peeling of skin in areas exposed to sun Niacin  
Poor wound healing Pro, Zn, vit C  
Nails    
Spoon-shaped nails Fe  
Brittle, fragile Pro  
Heart    
Enlargement, tachycardia, failure Vit B1  
Small heart Energy  
Sudden failure, death Se  
Arrhythmia Mg, K, Se  
Hypertension Ca, K  
Abdomen    
Hepatomegaly Pro Vit A
Ascites Pro  
Musculoskeletal Extremities    
Muscle wasting (especially temporal area) Energy  
Edema Pro, vit B1  
Calf tenderness Vit B1 or C, biotin, Se  
Beading of ribs, or “rachitic rosary” (child) Vit C, D  
Bone and joint tenderness Vit C, D, Ca, P  
Knock-knee, bowed legs, fragile bones Vit D, Ca, P, Cu  
Neurologic    
Paresthesias (pain and tingling or altered sensation in the extremities) Vit B1, B6, B12, biotin  
Weakness Vit C, B1, B6, B12, energy  
Ataxia, decreased position and vibratory senses Vit B1, B12  
Tremor Mg  
Decreased tendon reflexes Vit B1  
Confabulation, disorientation Vit B1, B12  
Drowsiness, lethargy Vit B1 Vit A, D
Depression Vit B1, biotin, B12  

Ca, Calcium; Cu, copper; EFAs, essential fatty acids; Fe, iron; K, potassium; Mg, magnesium; Na, sodium; P, phosphorus; Pro, protein; Se, selenium; Vit, vitamin(s); Zn, zinc.

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Feb 9, 2017 | Posted by in NURSING | Comments Off on Nutrition in Patient Care

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