Nutritional Problems

OVERVIEW AND ASSESSMENT

Nutrition Overview

Knowledge of nutrients and the basic principles of nutrition are important in the role of patient teaching for disease prevention and health promotion. The principles also help to provide an understanding and background to diseases affected by a person’s nutritional status. The basic food groups and their placement on a plate help to serve as a guide to basic, healthy nutrition.

Key Principles

Nutrients, including carbohydrates, fats, proteins, vitamins, and minerals, have specific functions within the body. They work together to provide energy, regulate metabolic processes, and synthesize tissues.
Nutrition influences all body systems favorably and unfavorably. Examples of unfavorable effects include the link between cholesterol and heart disease or salt intake and high blood pressure (BP). Favorable effects are many, such as the association of fiber intake with improved GI function and the role of folic acid in preventing neural tube defects.
Nutritional needs vary in response to metabolic changes, age, sex, growth periods, stress (trauma, disease, pregnancy, lactation), and physical condition.
Nutritional supplements may be needed depending on disease states, dietary intake, and other factors.
The types of foods eaten and eating patterns are developed during a lifetime and are determined by psychosocial, cultural, religious, and economic influences.
The nurse works with the registered dietitian to promote optimum nutrition for each patient.

MyPlate and the Dietary Guidelines for Americans

Dietary guidelines were first developed in 1958 and were based on four basic food groups: grains, vegetables and fruits, meat, and milk. In 2010 the Department of Health and Human Services and U.S. Department of Agriculture (USDA) Dietary Guidelines for Americans were restructured and divided the four basic food groups into five food groups, which now consist of grains, fruits, vegetables, protein, and dairy. Although the guidelines have been reformatted, it still holds true that a well-balanced diet consists of foods from each of these groups and is composed of foods low in fat, cholesterol, and sodium and high in fiber (www.dietαryguidelines. gov). See Chapter 3, page 26, for more specific information about the guidelines.
In response to growing scientific knowledge regarding the linkage of diet and disease, the USDA developed the MyPlate Plan (see Figure 20-1). It reflects making food choices for a healthy lifestyle and includes basic information on how to build a healthy plate by cutting back on foods high in solid fats, added sugars, and salt; eating the right amount of calories; and being physically active.

Nutritional Assessment

Nutrition assessment is an ongoing process designed to identify a person’s nutritional status and the significance on the person’s well-being. Although there are many methods and tools for assessing nutritional status, there is no universal method or “gold standard.” Indeed, multiple factors must be evaluated and considered to determine risk for or degree of malnutrition. One such factor is determining nutritional intake.

Figure 20-1. MyPlate illustrates healthy eating. (U.S. Department of Agriculture.)

There are many methods to assess the type and amount of food consumed, including a 24-hour recall of foods eaten, a food diary kept by the patient for several days, and a food frequency questionnaire that reflects food-intake patterns. In addition to these specific tools, the following information is useful to determine nutritional patterns and status.

Key History Points

General background information—name, age, sex, family composition, socioeconomic status, occupation.
General health status and any chronic conditions, including diabetes and associated dietary restrictions.
Cultural and religious factors influencing dietary patterns.
Family history of diseases, including diabetes and obesity.
Current medications, over-the-counter products, and herbal supplements.
Food habits.
- Typical daily intake, including meal frequency, meal timing, meal location.
- Snacking patterns.
- Food intolerance or dislikes.
- Nutritional supplements, including vitamins, minerals, fortified beverages, and foods.
- Alcohol consumption.
- Use of specific diets or dietary restrictions.
Food purchase and preparation.
- Who purchases and prepares food and where food is purchased.
- Facilities for food storage and preparation.
- Factors influencing the types of food purchased.
Nutritionally related problems.
- General well-being, energy level.
- Weight change during the past 6 months.
- Difficulty chewing or swallowing, use of dentures.
- Change in sense of taste or smell.
- Eructation, flatulence, nausea, vomiting, diarrhea, constipation, or abdominal pain or swelling in relation to food intake.
- Bowel habits.

Physical Examination and Anthropometrics

Perform a systematic physical examination, observing for a wide variety of physical findings associated with nutritional status.
- Listlessness, apathy.
- Poor muscle tone.
- Dull, brittle hair; hair may be thin or sparse, easily plucked.
- Rough, dry, and scaly skin or dermatitis.
- Cheilosis (fissures at angles of mouth).
- Stomatitis (inflammation of mouth).
- Inflammation and easy bleeding of gums.
- Glossitis (inflammation of tongue).
- Dental caries and poor dentition.
- Spoon-shaped, brittle, ridged nails.
- Skeletal deformities such as bowlegs.
Perform anthropometry, as indicated. (Anthropometry comes from the word anthropology and is the science that studies the size, weight, and proportions of the human body to determine body fat mass, lean mass, and nutritional status.) Types of anthropometric measurements include height and weight, skin-fold thickness, and circumferentialtests.
Height and weight are determined on patient admission and are later used as a baseline for comparisons in nutritional status.
- Weight should be measured using a consistent and reliable scale and at a consistent time.
- Unintended weight loss of more than 10% of body weight during 6 months is considered clinically significant and may be associated with physiologic abnormalities and increased morbidity and mortality.
Body mass index (BMI) is weight in kilograms divided by height in meters squared (see Table 20-1 on page 744).
- BMI of less than 18.5 is classified as underweight.
- BMI of 18.5 to 24.9 is classified as normal weight.
- BMI of 25 to 29.9 is classified as overweight.
- BMI of 30 to 39.9 is classified as obese.
- BMI greater than 40 is classified as extremely obese.
Metabolism is generally faster in younger people and for this reason, babies and children have higher energy requirement needs than adults. Requirement needs are based on many factors including age, gender, activity level, and disease state. Exact measurements of caloric requirements for infants can be obtained by using charts; these estimate the body surface area by height and weight and the standard basal metabolic rate for a given weight (see Appendix B).
Skin-fold thickness provides an estimate of body fat based on the amount of fat in subcutaneous tissue (see Figure 20-2 on page 744).
- Triceps skin-fold thickness:
  - At the midpoint of the nondominant upper arm (halfway between the tip of the shoulder and tip of the elbow), grasp skin and subcutaneous fat, pulling it away from the underlying muscle, and place the caliper jaws over the skin-fold flap.
  - Take the reading within 2 to 3 seconds and without using excessive pressure.
  - Repeat the reading twice and take an average of the three readings to increase accuracy.
- Subscapular skin-fold thickness: Grasp the skin and subcutaneous tissue just below the inferior border of the left scapula and measure with calipers, as noted.
Circumferential tests provide information on the amount of skeletal muscle and adipose tissue. Mid-upper arm circumference (MAC)—an indirect estimate of the body’s muscle mass:
- Place a tape measure around the midpoint of the nondominant upper arm and secure it snugly.
- To calculate, multiply the triceps skin fold by 3.14 and subtract the product from the MAC.
- Adult standards are 16.5 mm for women and 12.5 mm for men.

Table 20-1 Body Mass Index (BMI)^*

WEIGHT	5′	5′3″	5′6″	5′9″	6′	6′3″
140	27	25	23	21	19	18
150	29	27	24	22	20	19
160	31	28	26	24	22	20
170	33	30	28	25	23	21
180	35	32	29	27	25	23
190	37	34	31	28	26	24
200	39	36	32	30	27	25
210	41	37	34	31	29	26
220	43	39	36	33	30	28
230	45	41	37	34	31	29
240	47	43	39	36	33	30
250	49	44	40	37	34	31
^*Body mass index = weight (kg)/height (m²).

Figure 20-2. Anthropometric measurements. (A) Marking the midpoint of the upper arm; (B) obtaining the mid-upper arm circumference; (C) measuring triceps skin-fold thickness.

Laboratory Tests

Serum albumin, prealbumin.
- Albumin is a protein made by the liver and is responsible for maintaining blood volume and serum electrolyte balance. The half-life of albumin is about 21 days. A decrease in nutritional status may result in a drop in albumin synthesis. However, in chronic malnutrition, serum albumin levels are typically normal or high.
- Prealbumin is also made by the liver and is a more sensitive but expensive test that measures more recent nutritional status. Its half-life is 2 to 3 days.
Hemoglobin—made by the liver; decreased amounts are related to iron-deficiency anemia or other defect in hemoglobin synthesis or dilution of the blood such as during pregnancy.
Serum transferrin—another transport protein made by the liver; responsible for binding iron to plasma and transporting it to the bone marrow. Reduced levels are found in catabolic states and some chronic diseases.
Twenty-four-hour urine creatinine—an increase in this measure indicates increased tissue breakdown.
Twenty-four-hour urine urea nitrogen or total urinary nitrogen—this test can be used to determine nitrogen balance.

General Procedures and Treatment Modalities

The inability to take nutrients through the oral route either totally or in part may require alternative means to enhance and maintain
nutritional status. Alternative methods of nutritional support include enteral feeding and parental nutrition. The decision as to which method is used will depend on many factors including the patient’s acuity and nutritional status.

Enteral Feeding

See Procedure Guidelines 20-1.

Administration of nutrients directly into the stomach, duodenum, or jejunum through a tube is more physiologically beneficial and cost-effective than parenteral feeding. Enteral feeding carries less risk of infection than parenteral feeding and maintains a functional GI tract by preventing mucosal atrophy and biliary and hepatic dysfunction. Enteral therapy is appropriate for patients with at least a minimally functional GI tract who cannot take adequate nutrition by mouth.

Enteral therapy has become utilized more frequently as more commercially available enteral formulas have been developed and long-term enteral feeding tubes have become safer and more easily inserted.

Clinical Indications

Increased metabolic needs and inability to take adequate oral diet—trauma, burns, cancer, sepsis.
Coma or mechanical ventilation.
Head/neck surgery.
Malabsorption.
Obstruction of esophagus or oropharynx.
Severe anorexia nervosa.
Dysphagia.

PROCEDURE GUIDELINES 20-1

Administration of Enteral (Tube) Feedings: Intermittent or Continuous

PROCEDURE

Nursing Action		Rationale
Preparatory phase
1.	Remove formula from refrigerator and allow to warm to room temperature. Check expiration date.	1.	Room temperature formula is less likely to cause intolerance; use prepared dietary formulas within 24 hours.
2.	Explain procedure to patient.	2.	Promotes patient trust and allays patient anxiety.
3.	Wash hands. Don gloves.	3.	Prevents bacterial contamination of formula.
4.	Protect patient from spillage.	4.	Protects exposed areas of skin and/or clothing from damage with formula.
5.	Shake formula container.	5.	Shaking eliminates separation of formula.
6.	Elevate head of bed 30 to 45 degrees.	6.	Prevents aspiration.
7.	Using the catheter-tipped syringe, inject 30 cc of air while listening with a stethoscope positioned at the epigastric area (for nasogastric [NG] tubes). For nasointestinal tubes, 20 mL of air may be injected, but auscultation site may be displaced laterally and inferiorly.	7.	Auscultation of a “whooshing” or bubbling sound assists in confirmation of proper tube placement. Should patient burp immediately after injection of air, suspect esophageal placement of tube.
8.	If NG tube is used, aspirate stomach contents to check gastric residual. Also observe the position of the tube in the nose or mouth to ensure proper placement.	8.	If residual gastric contents exceed 200 mL for intermittent tube feedings, hold feeding and notify health care provider. Residual should not be obtained with intestinal placement.
9.	If residual is within normal limits and stomach or intestinal placement has been confirmed, return gastric contents to stomach through syringe using gravity to assist flow. If residual is >200 mL, replace 200 mL and discard the rest. Flush tube with 30 mL of water. If there is a question about the tube placement, notify the health care provider and obtain an order for an x-ray.	9.	Returning gastric contents to stomach prevents acidbase and electrolyte imbalance.
Performance phase
1.	For intermittent or bolus tube feeding, attach barrel of catheter-tipped syringe to pinched-off feeding tube.	1.	Pinching off the feeding tube prevents air from entering the stomach and causing distention.
2.	Fill catheter-tipped syringe with formula and allow fluid to flow in by gravity.	2.	The rate of flow is regulated by raising or lowering the syringe.
3.	Pour additional formula into barrel of syringe when it is three-quarters empty.	3.	Prevents air from entering stomach.
4.	After administering the prescribed amount of formula, flush tubing with at least 30 cc of water.	4.	Prevents clogging of feeding tube.
5.	If using a gavage bag for intermittent feeding, fill bag with prescribed amount of feeding, purge feeding bag tubing of air, attach distal end to feeding tube, and regulate to run over at least 10-20 minutes.	5.	Prevents distention from air in stomach or too rapid administration.
6.	For continuous tube feeding, fill bag with 4 hours of tube feeding (or prepare ready-to-hang container), flush tubing, attach to volume control infuser according to manufacturer’s instructions, attach distal end to feeding tube, and start. Flush with 30-60 ml of water every 4 hours after first checking residual.	6.	Prevents bacterial contamination. Maintains tube patency.
7.	After intermittent feeding is completed, cover end of feeding tube with plug or clamp.	7.	Prevents leakage.
Follow-up phase
1.	Rinse equipment with warm water, and dry. Replace every 24 hours or per facility policy.	1.	Limits bacterial contamination.
2.	Maintain head of bed elevation for 30-60 minutes after feeding is completed. If continuous feeding, maintain head elevation continuously.	2.	Prevents aspiration.
3.	Document type and amount of feeding, amount of water given, and patient tolerance of procedure.	3.	Ensures continuity of care. Sensation of fullness, nausea, or vomiting may indicate intolerance.
4.	Monitor breath sounds, bowel sounds, gastric distention, diarrhea or constipation, intake and output, daily weight, and serum chemistry results.	4.	Evaluates for aspiration, effect on GI system, and therapeutic effect of feedings.

GASTROSTOMY OR JEJUNOSTOMY CARE

Nursing Action			Rationale
Performance phase
1.	Special care of ostomy tube insertion site should include:		1.
	a.	Cleaning around tube with prescribed cleansing solution every shift and as needed.		a.	Prevent peristomal infection.
	b.	Applying sterile 4” × 4” gauze pad and taping in place.		b.	Collects any drainage.
	c.	Applying skin barrier should peristomal skin become excoriated.		c.	Prevent breakdown of peristomal tissue.
	d.	Taping of tube to skin or skin barrier with hypoallergenic tape.		d.	Anchor and secure tube.
Evidence Base Bankhead, R., Boullata, J., Brantley, S., et al. (2009). A.S.P.E.N. enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition, 33(2), 122-167.

Sites of Tube Insertion

Short-Term Nutritional Support (<30 days)

Nasogastric (NG) feeding—tubes are passed through the nose or mouth (orogastric) into the stomach and secured in place.
- Tube placement must be verified by x-ray before use. Aspiration of contents for pH or auscultation of air injected through tube has been shown to be of limited value. New techniques that are available include colorimetric carbon dioxide detectors and electronic capnographics, both of which measure end-tidal carbon dioxide to determine if the tube has gone into the trachea.
- If there is a question about tube placement in the respiratory tract, the tube should be removed.
Nasoenteric feeding (ie, nasoduodenal or nasojejunal)—tube is passed through the nose into duodenum or jejunum and secured in place. X-ray is usually needed to verify correct tube placement.

Long-Term Nutritional Support (>30 days)

Gastrostomy—insertion of a tube surgically, radiologically, or by a percutaneous endoscopic procedure into the stomach.
Gastrostomy button—small device inserted through gastrostomy stoma to allow for long-term feeding with minimal effect on body image.
Jejunostomy—insertion of a tube directly into the jejunum either surgically or by a percutaneous endoscopic procedure. Jejunostomy feedings are generally by continuous infusion using a feeding pump.

Types of Tubes

Large-bore NG polyurethane tube—size 12 to 18F, used very short term (eg, Salem Sump).
Small-bore NG tube—made of polyurethane, silicone, or polyvinyl chloride with a tungsten-weighted tip or nonweighted tip, size 8 to 12F and 30 to 36 inches (76 to 91.5 cm) long.
Nasointestinal tube—made of silicone, polyurethane, or polyvinyl chloride with tungsten-weighted tip or a nonweighted tip, size 8 to 12F and 40 to 60 inches (101.5 to 152.5 cm) long.
Gastrostomy tube—catheter made of silicone, polyurethane, polyvinyl chloride, or latex; a balloon on the distal end to stabilize tube may be used and ranges from 5 to 30 mL capacity, size 14 to 28F. Adults usually have 20F tubes and children usually start with 14F.
Gastrostomy button—silicone; ranging from 18 to 28F and 1 inch (2.5 cm) long; useful for person wanting minimal alteration in body image.
Jejunostomy tube—size ranging from 5 to 14F with or without a balloon (a balloon may obstruct lumen of jejunum). A plain red rubber catheter is occasionally used as a short-term jejunostomy tube and some gastrostomy tubes may be used for jejunostomy.

Delivery Systems for Feeding Solution

Intermittent or continuous infusion of feeding solution by gravity is accomplished by hanging container of feeding solution from an intravenous (IV) pole and adjusting delivery rate by flow regulator.
Continuous feeding by controller feeding pump allows uniform flow, particularly of viscous solutions.
Bolus feeding involves enteral formula poured into barrel of a large (60 mL) syringe attached to a feeding tube and allowed to infuse by gravity.

Community and Home Care Considerations

Teach patient and family:

Technique for administration of tube feeding outlined in Procedure Guidelines 20-1.
Signs and symptoms of potential complications.
Need to assess tube placement and residual before each feeding (for gastric feedings only).
Principles of medical asepsis, including careful handwashing, refrigeration of formula, cleaning of equipment with soap and water and thorough drying between feedings.
When the gastrostomy or jejunostomy tube insertion site is well healed, surrounding skin can be cleaned with soap and water.
Gauze dressing can be applied, as needed.
Leakage around tube or signs of peristomal skin irritation should be reported.

Parenteral Nutrition

See Procedure Guidelines 20-2, pages 750 to 751.

Parenteral nutrition is the introduction of nutrients, including amino acids, lipids, dextrose, vitamins, minerals, and water, through a venous access device (VAD) directly into the intravascular fluid to provide nutrients required for metabolic functioning of the body.

Clinical Indications

Patient cannot tolerate enteral nutrition due to:
- Paralytic ileus.
- Intestinal obstruction.
- Acute pancreatitis and enteral feedings not possible.
- Severe malabsorption.
- Persistent vomiting and jejunal route not possible.
- Enterocutaneous fistula and enteric feeding not possible.
- Inflammatory bowel disease.
- Short bowel syndrome.
Hypermetabolic states for which enteral therapy is either not possible or inadequate, such as burns, trauma, or sepsis.
In these situations, additional components are added to the enteral therapy or individualized solutions are developed to meet the nutritional needs of the patient.

Table 20-2 Complications of Enteral Feeding and Treatment

COMPLICATIONS	CAUSES	INTERVENTIONS
Tube displacement	Tube migration into esophagus	• Observe for eructation of air when injecting air to test for tube placement in stomach. • Aspirate gastric contents; if none is obtained, suspect esophagea l placement.
	Tube placement into respiratory tract	• Observe for gagging, dyspnea, inability to speak, coughing when tube insertion attempted. • Obtain chest x-ray^* • Withdraw tube and attempt reinsertion with patient’s head flexed forward.^*
Tube obstruction	Tube kinking	• Obtain chest x-ray to confirm and withdraw and reinsert new tube.^*
	Tube clogging	• Flush tube every 4 hours with 30 mL of water and after administration of intermittent feeding and medication administration. • Administer medications in liquid form if possible. Crush medications finely (if crushable). • Attempt to declog by administering water first. If unsuccessful, then administer pancreatic enzyme/bicarbonate mixture.
Aspiration	Patient lying flat	• Elevate HOB 30-45 degrees during continuous feedings or for 30-60 minutes after bolus feeds.
	Absent or depressed gag reflex	• Elevate HOB 30-45 degrees during continuous feedings or for 30-60 minutes after bolus feeds.
	Reflux	• Elevate HOB 30-45 degrees during continuous feedings or for 30-60 minutes after bolus feeds. • Administer proton pump inhibitor per MD’s orders.
	Improper tube placement	• Confirm proper placement with x-ray imaging. • Tape tube in place.
Vomiting	Tube migration into esophagus	• See interventions for tube displacement above.
	Decreased absorption	• Auscultate for decreased bowel sounds, observe for abdomina l distention. • Consider decreasing amount of tube feeding.^* • Consider administration on a continuous basis.^* • Consider placement of a small-bore, weighted-tip nasointestina l tube.^*
	Rapid rate of infusion	• Administer no faster than 200-300 mL during 10-20 minutes. • Consider administration on a continuous basis.^*
	Excessive infusion of air	• If giving a bolus feeding, pinch tubing off when refilling syringe with formula. • If giving continuous feeding, make certain bag does not empty before closing off tubing.
	Patient position	• Maintain patient at 30- to 45-degree angle of head elevation during and 30-60 minutes after feeding. If administering continuous feeding, maintain head elevation at all times.
	Nausea	• Anti-emetics.
	Obstruction	• Assess for distention and decreased bowel sounds; obtain x-ray.
	Constipation	• Assess for impaction and review frequency of bowel movements.
Diarrhea	Drug therapy	• Evaluate drug regimen for possible causes of drug-induced diarrhea from antibiotics, elixirs with high osmolarity, elixirs with sorbitol, magnesium-containing antacids.
	High osmolarity of formula	• Begin administration of formula at slow rate.^* • Consider continuous feeding rather than intermittent.^*
	Lactose intolerance	• Administer lactose-free formula. (Few commercial formulas contain lactose.)
	Bacterial contamination of formula	• Change administration set daily or per facility protocol. • Maintain strict medical asepsis, including careful handwashing before administration of formula. • Allow formula to hang no longer than 8 hours (unless it is a “readyto-hang” container that can hang for 24-48 hours).
	Rapid infusion rate	• Administer slowly; consider continuous rather than intermittent infusion.^*
	Fecal impaction	• Manually clear the impaction.
	Clostridium difficile	• Administer antibiotics.
Constipation	Lack of fiber	• Ensure that patient is not impacted and administer formula with fiber.^*
	Decreased fluid intake	• Increase intake of water.^*
	Drug therapy	• Evaluate drug regimen for possible cause, including aluminum-containing antacids or lack of stool softener.
Hyperglycemia	Diabetes Impaired metabolism	• Monitor serum glucose, assess for dehydration caused by hyperosmotic diuresis; observe for symptoms of hyperglycemia, including polyuria, polydipsia. • Administer insulin.^* • Observe for hypercapnia (increased respirations, elevated Pco₂).
Hypernatremia	Dehydration	• Assess for signs and symptoms of dehydration (I&O, daily weight, skin turgor, blood urea nitrogen, CVP, tachycardia, hypotension). • Rehydrate with extra water via the feeding tube or, if patient is severely hypernatremic, use IV route. • Rehydrate with D₅W or hypotonic saline solutions.^*
Hyponatremia	Overhydration Excessive sodium loss (diaphoresis, nasogastric suction)	• Observe for signs and symptoms of hypervolemia (shortness of breath, rales, I&O, daily weight, peripheral edema, elevated CVP). • Observe for signs and symptoms of hyponatremia (lethargy, headaches, mental status change, nausea, vomiting, abdomina l cramping). • Replace sodium, administer diuretics, or, depending on the cause of hypernatremia, restrict fluids.^*
Hyperkalemia	Metabolic acidosis/renal insufficiency	• Observe for signs and symptoms of hyperkalemia (dysrhythmias, nausea, diarrhea, muscle weakness). • Treat underlying cause. • Administer exchange resin, glucose, and insulin.^* • Choose lower potassium formula.
Hypokalemia	Diarrhea Refeeding syndrome	• See interventions for diarrhea. • If severe, replace potassium.^*
*Obtain orders from health care provider.
H₂, histamine; HOB, head of bed; I&O, intake & output; CVP, central venous pressure.

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Tags: Lippincott Manual of Nursing Practice

Jul 20, 2016 | Posted by drzezo in NURSING | Comments Off

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