Malnutrition Edapt Notes.pdf

What factors increase a client's risk of developing malnutrition? Select all that apply. Depression Dialysis Dysphagia Excessive dieting to lose weight Current infection Enteral Nutrition What are the essential characteristics of enteral nutrition? Select all that apply. Administration requires a...

What factors increase a client's risk of developing malnutrition? Select all that apply. Depression Dialysis Dysphagia Excessive dieting to lose weight Current infection Enteral Nutrition What are the essential characteristics of enteral nutrition? Select all that apply. Administration requires a nonfunctioning gastrointestinal (GI) tract Administration requires an intact and functioning gastrointestinal (GI) tract Administered through an intravenous route Administered through a tube or stoma Administered by bolus, intermittent, or continuous infusion Nursing Care: Enteral Nutrition What is the purpose of elevating a client's head of the bed prior to administering enteral nutrition? To assist movement of food through the client's gastrointestinal tract To help the client taste the nutrition for a better experience To put the client in a more natural eating position To reduce the risk of the client aspirating Forms of Malnutrition Malnutrition, in all its forms, is a concern that can impact client populations. Healthcare providers provide support, resources, and education to assist clients from all walks of life to improve their nutritional standing and, ultimately, impact their lives in a positive way. Therefore, it is important to understand the ways that malnutrition presents. • Starvation-related malnutrition occurs in clients when nutritional needs are not being met and there is no inflammation present, like in clients with anorexia nervosa. • Chronic disease-related malnutrition is associated with conditions that have consistent mild to moderate inflammation. Under normal circumstances, the client's intake would meet the body's requirements. However, in chronic disease-related malnutrition, the inflammation present increases the body's metabolic demands, rendering the nutritional intake insufficient. This is seen in clients with obesity, cancer, and inflammatory conditions like rheumatoid arthritis. • Acute disease- or injury-related malnutrition is related to an acute disease process or an injury, like burns, infections, or trauma. Nursing Management of Malnutrition Manifestations of malnutrition can include mild symptoms to emaciation and, ultimately, death. It is vital that healthcare professionals identify clients who are malnourished or at risk of developing malnutrition. The Joint Commission requires nutritional screenings for all clients within 24 hours of admission, with a detailed follow-up assessment if the client is deemed to be at risk. Health promotion is a large component of client education. Reinforcing healthy eating habits by utilizing resources such as MyPlate and assisting clients in understanding food labels is helpful for their success. How can these resources help? Let's take a look at some tips for a healthy lifestyle that can be incorporated into client education. Nutritional Assessment It is imperative to identify clients who not only have nutritional imbalances, but also those who are at risk for malnutrition. Review the components of a client’s nutritional assessment by selecting each tab. Anthropometric Measurements • • • • height and weight body mass index (BMI) amount of weight loss rate of weight changes Diet History • • • • chewing and swallowing ability changes in appetite and taste food and nutrient intake availability of food Physical Exam • physical appearance • muscle mass and strength • dental and oral hygiene Laboratory Data • • • • • glucose electrolytes lipid profile blood urea nitrogen (BUN) albumin, C reactive protein (CRP) Health History • • • • personal and family history acute or chronic illness current medications, supplements, etc . cognitive status, depression Functional Status • ability to perform activities of daily living (ADLs) • handgrip strength • performance tests (like timed walk test) Assessment The nurse is conducting a nutritional assessment on an older adult client who was admitted for diabetes mellitus type 1. Which questions are most important for the nurse to ask the client? Select all that apply. Do you take any medications? Do you wear dentures and do they fit comfortably? Do you participate in programs such as Meals on Wheels? How much do you sleep at night? Have you recently gained or lost weight? Specialized Nutrition: Enteral If clients are unable to maintain or achieve adequate nutritional intake to meet their metabolic demands, then enteral nutrition may be prescribed. While oral intake (PO) is preferred, other specialized nutrition therapies, such as through an enteral route, may be necessary. More commonly known as “tube feeding,” enteral nutrition is provided to the client in the gastrointestinal (GI) tract via a tube, stoma, or catheter. Enteral feeding requires that the client have a working GI tract. It may be indicated for clients who are neurologically injured and are unsafe or unable to swallow, for those with anorexia, or for critically ill clients who require intubation and mechanical ventilation. Some of the options to achieve enteral nutrition are through a nasogastric (NG) or orogastric (OG) tube, a percutaneous gastrostomy tube (PEG tube), or a jejunostomy. A nasogastric or orogastric tube can be placed at the bedside and is considered a common nursing procedural skill. A PEG tube is placed surgically and is indicated for clients who need enteral nutrition for an extended period of time. Nursing Considerations: Enteral Nutrition There are several different options for enteral feeding formulas. Many of them are lactose-free. While the concentrations of fat, proteins, and sodium vary, there are special formulas for clients who are diabetic or who have renal, liver, or lung diseases which have specific nutritional needs or restrictions. Aspiration and dislodgement of tubes are two very important safety concerns. Prior to using any enteral feeding method other than those surgically inserted under direct visualization (i.e., PEG tube), correct placement needs to be ensured. An x-ray will be ordered to confirm the placement of the tube prior to usage. Nursing Considerations What else is important regarding nursing management with tube feeding? Let’s take a closer look. • Check tube placement before feeding a client or medication administration. • Use liquid medications instead of pills if available. • Verify that medications can be safely crushed and/or used with a feeding tube. • If using pills/tablets, crush the medications into a fine powder and dissolve in water to avoid clogging the feeding tube. • Check for gastric residuals before every enteral feeding and medication administration. Remember that residuals are assessing the amount of gastric contents left in the stomach. High residuals can indicate delayed gastric emptying. Residuals should be less than approximately 200 mL or the feeding should be held. • Assess for bowel sounds prior to initiating feeding. • Do not add medications to enteral feeding formulas. • Keep the head of the bed at 30 to 45 degrees. • Assess regularly for complications. Specialized Nutrition: Parenteral Nasogastric or orogastric tubes are a temporary intervention due to the risk of tissue breakdown. Clients who require long-term nutritional support or high protein or caloric intake are candidates for parenteral nutrition (PN). Different from enteral nutrition, parenteral nutrition is administering nutrition directly into the bloodstream. It is administered when the client's gastrointestinal (GI) tract is not intact. When is Parenteral Nutrition Indicated? Chronic vomiting and diarrhea Complicated surgery or trauma GI obstruction Severe anorexia Severe malabsorption Short bowel syndrome Gastrointestinal Obstruction A client is admitted to the hospital and diagnosed with a small bowel obstruction (SBO). Which intervention for nutritional support does the nurse anticipate will be prescribed for the client? Oral intake Parenteral nutrition (PN) Enteral nutrition (EN) Dextrose 5% in 0.9% saline infusion Benefits of Parenteral Nutrition The benefits of parenteral nutrition include mixtures that are specifically formulated to meet the client’s caloric intake and metabolic needs to help prevent malnutrition. Protein, glucose, fats, and electrolytes are all included in the prescribed mixture. While this type of nutrition is more expensive than enteral nutrition, it is individualized per client and is administered as either central parenteral nutrition (CPN) or peripheral parenteral nutrition (PPN). • Central Parenteral Nutrition (CPN) CPN is administered through a peripherally inserted central catheter (PICC) or a central venous catheter (CVC) where the tip of the catheter sits in the superior vena cava. The client needs this nutrition to be rapidly diluted into the bloodstream, so a large central vein must be used. The glucose content for central PN is anywhere from 20% to 50%, which would irritate a peripheral vein and potentially cause thrombophlebitis. The CVC or PICC is inserted under sterile procedure guidelines and needs to be maintained appropriately with sterile dressing changes and the IV caps scrubbed prior to infusing. Peripheral Parenteral Nutrition (PPN) PPN is indicated for short-term nutritional support if the protein or caloric needs are not too high or there is a risk to the client of inserting a central venous access device. PPN is also used to supplement a client's oral intake, which may be inadequate. PPN does not contain as many calories as central PN. It also carries an increased risk of fluid volume overload to the client as it requires large volumes of fluid that all clients may not be able to handle. Nursing Considerations: Parenteral Nutrition While parenteral nutrition (PN) is a safe way to supplement a client's nutritional needs, special management is still required. • PN is prescribed and mixed daily to meet the changing requirements of the client. • It is not the nurse's responsibility to prepare this; a pharmacist or trained technician will do so. However, it is the responsibility of the nurse to check that the label and ingredients in the solution match what the physician has prescribed. PN is administered through an infusion pump and uses a dedicated line or catheter. Filters and IV tubing should always be labeled and changed every 24 hours. With such a high concentration of glucose, hyperglycemia and hypoglycemia are associated risks. The client's blood sugar should be checked at the bedside every 4 to 6 hours while maintaining an appropriate glucose range of 110–150 mg/dL. Sliding scale insulin may be indicated for clients. Hypoglycemia occurs when the client's PN infusion bag runs empty before the next one is initiated. This lack of nutritional supplement with included glucose can drop the client's glucose levels. If the next PN infusion bag is not readily available, a dextrose solution (like 5%, 10%, or 20% dextrose) may be hung to prevent hypoglycemia. Refeeding syndrome is a serious complication related to parenteral nutrition and can happen at any time when a malnourished client starts aggressive nutritional support. This is a massive shift of intracellular electrolytes and causes fluid retention and electrolyte imbalances. Hypophosphatemia is a hallmark sign of refeeding syndrome. Nursing Actions Robin (pronouns: she/her) has a peripherally inserted central catheter (PICC) placed for parenteral nutrition. Which nursing actions are most appropriate to consider in the client’s plan of care? Select all that apply. Thorough respiratory assessments Assess blood glucose levels Catheter site assessments Rotate intravenous site every 72 hours Maintain accurate intake and output Daily weights Robin’s prescribed parenteral nutrition is delayed by the pharmacy. Which prescription would the nurse anticipate being used until the medication is received? Administer acetaminophen 325 mg PO. Check blood glucose at bedside every 2 hours. Initiate 10% dextrose solution IV. Initiate 0.9% sodium chloride bolus of 500 mL. Recognizing Cues Identify the findings that require follow-up by the nurse. Eric (pronouns: he/him/his), a 67-year-old client, was admitted five days ago to the intensive care unit for an ischemic stroke. He is dysphagic and lethargic, so a percutaneous gastrostomy (PEG) tube was prescribed for the administration of enteral feedings. His partner, Lydia, is concerned regarding the upcoming surgical procedure and insertion of a PEG tube. Vital signs are stable, lungs clear bilaterally, the heart sounds strong and regular, bowel sounds present in all four quadrants. The client has lost 4 pounds since admission. Case Study: Eric Eric (pronouns: he/him/his), a 67-year-old client, was admitted five days ago to the intensive care unit for an ischemic stroke. He is dysphagic and lethargic, so a percutaneous gastrostomy (PEG) tube was prescribed for administration of enteral feedings. His partner, Lydia, is concerned regarding the upcoming surgical procedure and insertion of a PEG tube. Vital signs are stable, lungs clear bilaterally, heart sounds strong and regular, bowel sounds present in all four quadrants. The client has lost 4 pounds since admission. Analyzing Cues Eric’s partner, Lydia, asks the nurse, “Why does he need surgery and a tube in his stomach?” What is the most appropriate response by the nurse? “It is not safe for Eric to eat by mouth because of his inability to swallow, so this is the safest route to meet his nutritional needs." “Let me contact the healthcare provider to see if we can have a nasogastric tube placed instead.” "Eric will not be able to go to the nursing home or rehab after discharge without a PEG tube.” "Eric's gastrointestinal system is no longer working on its own, so the PEG tube will allow him to still get nutrition.” Case Study: Eric Eric (pronouns: he/him/his), a 67-year-old client, was admitted five days ago to the intensive care unit for an ischemic stroke. He is dysphagic and lethargic, so a percutaneous gastrostomy (PEG) tube was prescribed for administration of enteral feedings. His partner, Lydia, is concerned regarding the upcoming surgical procedure and insertion of a PEG tube. Vital signs are stable, lungs clear bilaterally, heart sounds strong and regular, bowel sounds present in all four quadrants. The client has lost 4 pounds since admission. Generating Solutions Eric has returned from the operating room with a percutaneous gastrostomy (PEG) tube. He currently has 50 mL/hour of IV lactated Ringer's solution running. Nothing is infusing in the PEG tube. Which actions should the nurse implement? Select all that apply. Auscultate for bowel sounds. Continue to monitor without infusing anything into the PEG tube at this time . Call dietary to have them deliver enteral nutritional formula as soon as possible. Assess the incisional dressing. Connect the lactated Ringer's solution to the PEG tube for administration. Case Study: Eric Eric (pronouns: he/him/his), a 67-year-old client, was admitted five days ago to the intensive care unit for an ischemic stroke. He is dysphagic and lethargic, so a percutaneous gastrostomy (PEG) tube was prescribed for administration of enteral feedings. His partner, Lydia, is concerned regarding the upcoming surgical procedure and insertion of a PEG tube. Vital signs are stable, lungs clear bilaterally, heart sounds strong and regular, bowel sounds present in all four quadrants. The client has lost 4 pounds since admission. Client Safety The nursing student is preparing to administer Eric’s medications and is accompanied by the clinical instructor. Which action by the student will require the nurse to immediately intervene? The student assessed for bowel sounds prior to feeding. The student lowered the client's head of the bed below 30 degrees prior to medication administration. The student crushed the tablet medications and mixed them with water for administration. The student checked for residual. Complications The nurse observes that the client’s parenteral nutrition bag has run dry and a new one has not been sent from the pharmacy. Which complication is the nurse anticipating? Hypertension Hypoglycemia Hypotension Hyperglycemia Delegation The primary nurse is to delegate activities to other members assigned to their unit team. Which activities can the nurse safely delegate to the designated personnel? Select all that apply. John, RN, will develop a plan of care for a client who is malnourished. Maria, LVN, will remove a client's nasogastric tube. Joy, LVN, will administer medications to a stable client through the percutaneous endoscopic gastrostomy (PEG) tube. Eve, unlicensed assistive personnel (UAP), will educate the client about the percutaneous endoscopic gastrotomy (PEG) tube.