focus on malnutrition (relates to chapter 40, “nursing management: nutritional problems,” in the...

Focus onFocus onMalnutritionMalnutrition

(Relates to Chapter 40, “Nursing Management: Nutritional

Problems,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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MalnutritionMalnutrition

• Deficit, excess, or imbalance in essential components of balanced diet•Other terms—undernutrition and

overnutrition•Undernutrition

Poor nourishment due to inadequate diet or disease

•Overnutrition Ingestion of more food than required


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UndernutritionUndernutrition

• Most prevalent in countries lacking adequate food sources and education

• Does exist in United States•Usually found in lower socioeconomic

class or in those with chronic or acute illness

• Common in hospitalized patient (31% to 33%)

• 2% to 38% prevalence in elderly long-term care residents


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Protein-Calorie Malnutrition Protein-Calorie Malnutrition (PCM)(PCM)

• Most common form of undernutrition

• Primary versus secondary•Primary—poor eating habits

Ingesting food deficient in protein, vitamins, and minerals

• Secondary—alteration or defect in ingestion, digestion, absorption, or metabolism Due to GI obstruction, surgical

procedures, cancer, malabsorption syndromes, drugs, infectious diseasesCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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MarasmusMarasmus

•Results from concomitant deficiency in caloric and protein intake•Generalized loss of muscle

and body fat•Appear emaciated but have

normal serum protein levels


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KwashiorkorKwashiorkor

• Deficiency of protein intake • Associated with edema, low

serum protein levels• May appear well nourished, but

have low protein levels


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Etiology and Etiology and PathophysiologyPathophysiology

•Starvation process • Initially, body uses

carbohydrate stores from liver and muscle to meet metabolic needs.

•Stores are minimal and may be depleted in 18 hours.


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•Starvation process (cont’d)•Once stores are depleted,

protein is converted to glucose for energy.

•Gluconeogenesis occurs. Formation of glucose by liver


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•Starvation process (cont’d)•Allows metabolic processes

to continue•Negative nitrogen balance• In 5 to 9 days, fat is

mobilized to supply energy.


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Etiology and Etiology and PathophysiologyPathophysiology• Starvation process (cont’d)

•Prolonged starvation: 97% of calories from fat and protein are conserved

• Fat stores used in 4 to 6 weeks, depends on amount available

•Once fat stores are used, body proteins (from internal organs and plasma) are no longer spared.


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•Liver function impaired•Protein synthesis diminished•Plasma oncotic pressure ↓

Shift from vascular space into interstitial

•Albumin leaks into interstitial space. Edema presents.


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•Skin is dry and wrinkled.•Na+/K+ pump fails—deficiency

in calories and proteins•Liver loses mass, becomes

infiltrated with fat.•Diet of protein and other

constituents must be initiated, or death will occur.


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CausesCauses

•Socioeconomic status•Cultural influences•Psychologic disorders•Medical conditions•Medical treatments


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• Sick persons have increased nutritional needs.

• Not an uncommon consequence of• Illness• Surgery• Injury •Hospitalization

• Fever increases basal metabolic rate, leading to protein depletion.


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Malabsorption SyndromeMalabsorption Syndrome

• Impaired absorption of nutrients from the GI tract

•May result from•↓ enzymes•Drug side effects•↓ bowel surface area


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Incomplete DietsIncomplete Diets

•Vitamin deficiencies are rare in developed countries.

•Usually found in•Alcoholics•Drug abusers•Chronically ill•Those with poor dietary

practices


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Clinical ManifestationsClinical Manifestations

•Obvious clinical signs of inadequate protein/calorie intake apparent in•Skin•Eyes•Mouth•Muscles•CNS


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Clinical ManifestationsClinical Manifestations

•Muscles wasted and flabby•Delayed wound healing•More susceptible to infection•Humoral and cell-mediated

immunity deficient•↓ in leukocytes in peripheral

blood•Phagocytosis altered

•Anemia


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Diagnostic StudiesDiagnostic Studies

•History/physical examination•Food history for past week•Height•Weight•Vital signs•Physical examination


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•Laboratory studies•Serum albumin•Prealbumin•Serum transferrin•Visceral proteins•C-reactive protein•Electrolyte levels•Complete blood count

RBC, Hb, lymphocyte count


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•Anthropometric measurements•Skinfold thickness—various

sites•Midarm circumference•Compared with standard for

healthy persons


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Nursing AssessmentNursing Assessment

•Changes in weight•Diet history•Minimum data set•Medications•Laboratory test results•Physical examination•Anthropometric

measurements


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Fig. 40-2. Patient with malnutrition.

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Nursing DiagnosesNursing Diagnoses

• Imbalanced nutrition: Less than body requirements

•Self-care deficit (feeding)•Constipation or diarrhea


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Nursing DiagnosesNursing Diagnoses

•Deficient fluid volume•Risk for impaired skin

integrity•Noncompliance•Activity intolerance


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Planning Planning

•Achieve weight gain.•Consume specified number

of calories per day.•Have no adverse

consequences related to malnutrition or nutritional therapies.


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Nursing ImplementationNursing Implementation

•Teach/reinforce good eating habits.

•Assess nutritional state and other health problems.

•Record daily weights and I & O.


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Nursing ImplementationNursing Implementation

• Daily calorie count• High-protein, high-calorie

foods• Multiple, small feedings• Supplements• Appetite stimulants• Diet diary• Dietitian consult• Discharge instructions


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EvaluationEvaluation

•Patient will•Achieve and maintain

optimal body weight•Consume well-balanced diet•Experience no adverse

outcomes related to malnutrition


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Gerontologic Gerontologic ConsiderationsConsiderations

•Older adults at risk•Physiologic changes•Oral cavity •Digestion/motility•Endocrine system•Musculoskeletal system•Vision and hearing


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•27-year-old woman comes into the clinic with fatigue.

•She has lost 10 pounds in the past 2 months.


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•She is a graduate student working on her dissertation.

•History of Crohn’s disease


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•Claims she is unable to watch her diet because she “doesn’t have time to think about that”

• In addition to fatigue, she reports having diarrhea and no appetite.


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Discussion QuestionsDiscussion Questions

1.What nutrients is she likely deficient in?

2.What dietary recommendations can be made?

3.How can you help her monitor her diet without added stress?


focus on malnutrition (relates to chapter 40, “nursing management: nutritional problems,” in the...

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liver copyright

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infectious diseases

low serum protein levels

body fat

conserved fat stores