74 Providing nutritional support

Adequate nutrition is necessary to meet the body’s demands in order to maintain normal body composition and function. A patient’s nutritional status may be affected by disease or injury state (i.e., cancer or trauma), physical factors (e.g., poor dentition or mobility), social factors (e.g., isolation, lack of financial resources), or psychological factors (e.g., mental illness). In addition, cultural beliefs (e.g., vegetarian diet) and age (e.g., older adults with cognitive impairment causing them to forget to eat) may influence overall nutrition intake.

Hospitalized patients are at high risk for developing protein-energy malnutrition. Studies have shown that 40%-50% of hospitalized surgical patients have insufficient nutrient intake. According to the Institute for Healthcare Improvement (ihi.org), more than 91% of patients transferred from acute care to subacute care are either malnourished or at risk of malnutrition. Malnutrition is associated with impaired wound healing, pressure ulcers, infections, and increased hospital stays and associated costs. Individuals admitted with unintentional weight loss and maintained on intravenous (IV) dextrose/electrolyte solutions alone or with poor oral intake for more than 3 consecutive days should be considered and evaluated for nutritional support.

When individuals are well-nourished, there are no defined time frames during which they can be without water or food before addressing artificial replacement. The best markers to use for initiation of water and food in well-nourished people are magnitude of the injury/insult to the body and amount of time the individual will be unable to resume normal oral intake.

Health care setting

Acute care

Assessment

Dietary history

A dietary history is compiled to reveal adequacy of usual and recent food intake. Based on the information obtained, the nurse may identify the need to consult with a registered dietitian for additional interventions. Be alert to excesses or deficiencies of nutrients and any special eating patterns (e.g., various types of vegetarian or prescribed diets), use of fad diets, and excessive supplementation. The patient’s perception of and actual intake may differ; therefore, include family, significant others, or caregiver when obtaining a dietary history. Include in the care plan anything that impairs adequate selection, preparation, ingestion, digestion, absorption, or excretion of nutrients as follows:

• Food allergies, food aversions, and use of nutritional supplements (prescribed or over-the-counter).

• Any alternative therapies such as use of herbs or other “natural” supplements.

• Any over-the-counter medications.

• Recent unplanned weight loss or gain.

• Chewing or swallowing difficulties. Include questions related to dental care, such as dentures (note presence of dentures; ask about fit of dentures or other problems), missing teeth, no teeth, and/or loose teeth.

• Nausea, vomiting, or pain with eating.

• Altered pattern of elimination (e.g., constipation, diarrhea).

• Chronic disease affecting utilization of nutrients (e.g., malabsorption, pancreatitis, diabetes mellitus).

• Surgical resection; disease of the gut or accessory organs of digestion (i.e., pancreas, liver, gallbladder).

• Currently pregnant or lactating.

• Use of medications (e.g., laxatives, antacids, antibiotics, antineoplastic drugs) or alcohol. Long-term use of drugs may affect appetite, digestion, or utilization or excretion of nutrients.

Physical assessment

Most physical findings are not specific to a particular nutritional deficiency. Compare current assessment findings with past assessments, especially related to the following.

• Loss of muscle and adipose tissue.

• Assess fit of clothing, rings, and watches.

• Be aware that assessment of obese patients or individuals who have an excess of fluid accumulation due to body edema may be difficult.

• Look for temporal wasting in individuals who have ascites or other forms of body edema.

• Work and muscle endurance.

• Assess ability to maintain activities of daily living.

• Query patient regarding recent changes in mobility and/or activities.

• Muscle weakness may reflect several different deficiencies that may require additional evaluation and tests:

Selenium

Vitamin D

Potassium

Magnesium

• Changes in hair, skin, or neuromuscular function.

• Excessive bruising or bleeding may reflect vitamin K deficiency.

• Biotin deficiency may appear as alopecia or seborrheic dermatitis.

• Scaly dermatitis may reflect essential fatty acid deficiency.

• Zinc deficiency may present as sores at edges of mouth, palms of hands, and soles of feet with peeling of skin along with brittle nails.

• Hypocalcemia may be accompanied by dry, scaling skin; brittle nails; and/or dry hair.

Anthropometric data

Height:

Used to determine ideal weight and body mass index (BMI). If patient’s height is unavailable or impossible to measure, obtain an estimate from family or significant other.

Weight:

Used by many to determine nutritional status, but fluctuations may be a result of amputation, dehydration, diuresis, fluid retention (renal failure, edema, third spacing), fluid resuscitation, wound dressings, or clothing. (It is helpful to remember that 1 L of fluid equals approximately 2 lb or 1 kg.) More reliable information may be obtained by asking patient to recall usual weight, weight changes (gains and losses), and time frame in which these occurred. Unintentional loss in weight of greater than 10% over a 6-mo period is considered significant and may be associated with severe malnutrition. The greater the unintentional weight loss, the more predictive this weight loss may be of mortality.

BMI:

Used to evaluate the weight of adults. One calculation and one set of standards are applicable to both men and women:

BMI values of 19-25 are appropriate for 19-34 yr olds; whereas, BMI values of 21-27 are appropriate for individuals older than 35 yr. Obesity is defined as BMI greater than 27.5, with severe or morbid obesity greater than 40. A BMI of 16-18.5 is considered mild to moderate malnutrition; whereas BMI less than 16 indicates severe malnutrition. A BMI of less than 18.5 and more than 40 is associated with increased risk of adverse clinical outcomes; referral to a clinical dietitian should be considered. Height, weight, and BMI should be documented in the medical record.

Estimating nutritional requirements

Calorie estimation:

To prevent overfeeding, calculate the total calorie intake as follows:

Average nourished patient: 25 total calories per kg of body weight

Mildly stressed patient: 30 total calories per kg of body weight

Severely stressed patient: 35 total calories per kg of body weight

Morbidly obese patient: 18 total calories per kg of body weight

Protein requirements:

Usually 0.8-1.5 g/kg/24 hr. (Protein will be restricted if patient has hepatic or renal failure that is not being treated with dialysis.)

Carbohydrate (CHO) requirements:

Excess amounts of CHO are not utilized or tolerated. Overfeeding of CHO may lead to hyperglycemia, increased CO₂ production, hypophosphatemia, and fluid overload in short-term use or fatty liver syndrome in long-term use. Patients with diabetes will need to be counseled regarding how to count carbohydrates for appropriate glycemic control (see “Diabetes Mellitus,” p. 348).

Fat requirements:

Saturated fat intake should be limited, especially in patients with coronary artery disease (see p. 150).

Vitamin and essential trace mineral requirements:

In general, follow the recommended daily allowances (RDAs) to provide minimum quantities of vitamins, minerals, and essential fatty acids. For specific patients, supplement specific vitamins or minerals needed in increased amounts for existing disease states (e.g., pressure ulcers/wounds: zinc, vitamins A and C; chronic alcohol ingestion: thiamine, folate, vitamin B₁₂).

Fluid requirements:

Many factors affect fluid balance. Under usual circumstances an estimate of fluid needs can be made by providing 30-50 mL/kg body weight. Daily loss of water includes approximately 1400 mL in urine (60 mL/hr), 350 mL via respiration, 600 mL as evaporation through skin, and about 200 mL in feces. Fluid losses are 100-150 mL/day for each degree of temperature increase above 37° C. If loss by any of these routes is increased, fluid needs increase; if loss by any of these routes is impaired, fluid restriction may be necessary. Areas to include in the nursing assessment for fluid requirements are:

• Intake and output (I&O). Evaluate that neither one is in excess of the other and for decreases in urine output.

• Daily weights. Note: Rapid changes may represent problems with technique or equipment rather than actual changes in body weight. If sudden increases in weight occur, look for imbalances in I&O, occurrence of edema, and dilution of serum electrolytes.

• Presence or absence of edema.

• Large wounds, burns, or open abdomen.

• Skin turgor. This assessment may be helpful in younger patients, but is less useful in older adults due to normal changes in skin elasticity that occurs with aging.

Nutritional support modalities

Specialized nutritional support refers to provision of an artificial formulation of nutrients via oral, enteral, or parenteral route for the treatment or prevention of malnutrition. Oral supplements are the preferred route because they are less invasive, more natural, and less costly, whereas enteral nutrition is preferred over parenteral.

Types of feeding tubes:

Small-bore nasal tubes:

Defined as 12 French or smaller. Require abdominal x-ray examination for confirmation of placement. Composition may be polyurethane, silicone, or polyvinyl chloride. Location cannot be verified in the gastrointestinal (GI) tract when using auscultation after injecting an air bolus, asking patient to speak, or submerging the tube’s proximal tip into a glass of water. Usual length of tube is 36-55 inches and it may or may not require a stylet for insertion. The physician should determine whether the distal tip ends in the stomach or small intestine. Insertion by a nurse is determined by hospital policy. It also may be inserted by a physician using endoscopy or fluoroscopy-guided placement. Because of their diameter and composition, these tubes are easily dislocated proximally in the GI tract without any resultant external signs.

Large-bore nasal tubes:

Defined as larger than 12 French. Composition is either polyurethane or polyvinyl chloride. Usual length of tube is 36 inches. Stylet is not required for insertion. Insertion may be by a nurse. Placement is confirmed by withdrawal of gastric fluid or x-ray examination.

Gastrostomy tubes:

Exit stomach directly through abdominal wall and usually anchored with either a balloon or disc on the inside of the stomach. Usually they are 12 French or larger. Composition may be polyurethane, silicone, or rubber and may contain multiple ports, in addition to the main lumen, for insertion of air into the balloon and delivery of medications. Initially a physician in radiology, endoscopy, or surgery performs the insertion. If not placed during surgery (i.e., open laparotomy), the common term used to describe the tube is percutaneous endoscopically inserted gastrostomy (PEG). Reinsertion by a nurse is determined by hospital policy. Inadvertent removal of a tube in position for less than 6 wk should be considered a medical emergency and the health care provider should be contacted immediately.

Gastrostomy button:

Placed into a mature gastrostomy stoma. It fits into the stoma tract flush with the outer abdominal wall. The button contains an antireflux valve to prevent leakage, but gastric samples or residuals usually cannot be obtained via the button.

Jejunostomy tubes:

Placed by a physician either surgically or percutaneously (PEJ). Diameter is usually about 12-18 French. Anchoring the tube inside the jejunum presents a problem because a balloon larger than 5 mL might cause bowel obstruction. Confirmation of position requires x-ray examination with contrast. No residuals should be obtained from this tube. If the tube becomes displaced, the entry site into the jejunum will close down rapidly (approximately 20-30 min). Reinsertion by a nurse is determined by hospital policy, but it is not recommended without special training.

Gastrostomy-jejunostomy tubes:

Exit stomach directly through the abdominal wall with a small-bore jejunostomy tube placed through the main lumen of the gastrostomy and the distal tip positioned in the jejunum.

Feeding sites:

Stomach:

Simulates normal GI functions; may be used for bolus, intermittent, or continuous feedings; indicated for patients who have intact gag or cough reflexes.

Duodenum, jejunum:

Must be used for continuous feedings only to prevent dumping syndrome and diarrhea. Small-bore diameter tube is recommended.

Total parenteral nutrition

Total parenteral nutrition (TPN) provides some or all nutrients by the IV route. TPN is used to provide complete nutrition for patients who cannot receive enteral nutrition or to supplement nutritional needs of patients who are unable to absorb sufficient calories via the GI tract. TPN is more expensive than enteral nutrition and has the potential for developing severe complications more rapidly.

Parenteral solutions:

IV solutions are customized combinations of dextrose (CHO), amino acids (protein), IV fat emulsions (fat), electrolytes, vitamins, and trace metals.

CHOs:

Dextrose provides approximately 50%-60% of the total calories. Final compounded concentrations will range from 5%-70%. All final mixed solutions that are more than 12.5% dextrose must be administered via a central venous catheter. (If unsure or information is unavailable on the infusion container related to infusion route, consult with pharmacist or refer to hospital policy.) The more CHO delivered, the greater the potential for complications, which include fatty liver syndrome, increased CO₂ production, and hyperglycemia.

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