Frenn, Marilyn

Willadsen, Sharon

English

epublications@Marquette

Marquette Universitye-Publications@MarquetteNursing Faculty Research and Publications Nursing, College of1-1-1992Nutrition, Less Than Body Requirement: RiskMarilyn FrennMarquette University, marilyn.frenn@marquette.eduSharon WilladsenPublished version. "Nutrition, Less Than Body Requirement: Risk," in Nursing Diagnosis in ClinicalPractice: Guides for Care Planning. Eds. Kathy V. Gettrust and Paula D. Brabec. Albany: NY: DelmarPublishers, 1992: 366-368. Permalink. © 1992 Delmar Learning, a part of Cengage Learning, Inc.Used with permission.A state in which conditions exist th)at predispose an individual to less intake of nutrients than is required for health. RISK FACTORS Pathophysiological Acute illness Marilyn Frenn, R.N., Ph.D. Sharon Willadsen, R.N., B.S.N. . . . . . . . . . . . . . . 1. Moderate risk (e.g., infection, bleeding, renal impairment) 2. Severe risk (e.g., head injury, major burns, multiple trauma, severe sepsis) Chronic health problems (e.g., absorptive disorders, anorexia, chemical dependency, confusion, dental caries or periodontal disease, depression) Dysphagia Hypermetabolic/catabolic states Inability to eat for several days prior to admission for acute illness or surgery Medications that interfere with appetite or eating Nausea and vomiting Nothing by mouth (NPO) status supplemented only with low caloric intravenous solutions (e.g., 5% Dextrose in water) for more than three to four days Responses to illness or disability (e.g., diarrhea, drowsiness, incontinence, pain, reduced ability to smell or taste, requires assistance to eat) Serum albumin 1. 3.0%-3.4%/g indicates mild visceral protein depletion 2. 2.1 %-2.9%/g indicates moderate depletion 3. 2.0% g or less indicates severe depletion Total lymphocyte count 1. Less than 1500 cells/cu mm indicates risk 2. Less than 900 cells/cu mm indicates severe depletion 366 NUTRITION, LESS THAN BODY REQUIREMENT: RISK 367 Weight loss 1. 10%, no major problems if at ideal weight (Problematic if greater than 5% lost in last month or 10% lost in last six months) 2. 10%-20%, moderate risk 3. Greater than 20%, severe risk 4. Greater than 30%, death due to cardiac malnutrition Psychosociobehavioral Foodfadism Inability to procure appropriate foods (e.g., emotional distress, home bound, inadequate income) Lack of knowledge regarding nutritional needs Lack of time to prepare nutritious foods Social isolation Starvation Stress (Additional risks for less vitamins or minerals than Recommended Dietary Allowance [RDAJ) Does not eat raw fruits and vegetables (folacin, vitamins A and C) Low carbohydrate diet (B vitamins, carbohydrates) Poverty (vitamins) Over age 65 (protein, calcium, iron, Vitamins A, C, BJ' B6' and BI2 ) Overuse of alcohol (B vitamins, protein) EXPECTED OUTCOMES Client's nutritional intake will be appropriate to body requirements. Risks for nutritional depletion are identified. Preventive measures are taken before actual nutritional depletion or other sequelae develop (e.g., impaired healing, impaired weaning from ventilator). INTERVENTIONS Universal Complete nutritional assessment including: 1. Anthropometric measure-ments (skinfold thickness, arm circumference, weight) 2. Consumption of: calories sufficient to maintain weight RATIONALE Early identification of risk can result in more effective treatment, prevention of other health problems, enhanced performance, and enhanced recovery from illness. r " II 368 SECTION TWO necessary n\Jtrients relatively more complex carbohydrates, such as whole grain, fruits and vegetables, rather than simple sugars relatively more fish, poultry, and legumes and less red meats relatively more nutrient-rich foods as compared with empty calories. 3. Finances available/used for food 4. Food likes/dislikes 5. General knowledge of nutrition and what constitutes a balanced diet 6. One- to two-day diet history including foods from all four food groups 7. Patterns of eating including three meals per day 8. Persons eating with client 9. Presence of other risk factors for nutritional depletion (e.g., illness) 10. Present and usual weight, patterns of weight loss Provide, in collaboration with other disciplines, individual and group health education, prepare and distribute informa-tion regarding nutrients neces-sary for health, risk factors for nutritional depletion, and com-munity resources for subsidized or delivered meal programs. Dietary consult for those at high risk. Maintenance of nutrition can prevent other health problems. Collaboration is essential for quality health care. .... .-NUTRITION, LESS THAN BODY REQUIREMENT: RISK 369 INTERVENTIONS RATIONALE Inpatient Include thorough nutritional The combination of prior risk factors and stress assessment with each admission of illness increases likelihood of nutritional (also see "Nutrition, Less Than depletion. Body Requirement"). Institute calorie count in Calorie counts are helpful in identifying problems collaboration with dietitian for in consumption. those at high risk. Review serum albumin, Serum albumin levels decline slowly (half-life transferrion, and thyroxine- of 20 days), so levels need to be reviewed binding proalbumin levels at frequently. 1Iansferrion and proalbumin are regular intervals for those at more sensitive indicators of malnutrition. high risk. Community/ Home Health Initiate screening and referral Screening enables services to be targeted to for those at high risk. those in greatest need. Bistran, B. (1988). Nutritional support of the long-term care patient, part il: Nutritional assess-ment of the elderly. Nutritional support services, 8(10), 17-2l. Champagne, M.T., & Ashley, M.L. (1989). Nutritional support in the critically ill elderly patient. Critical Care Nursing Quarterly, 12(1),15-25. Gettrust K.Y., Ryan, S.c., & Engelman, D.S. (Eds.). (1985). Applied nursing diagnosis. Albany, NY: Delmar. Green, M.L., & Harry, J. (1987). Nutrition in contemporary nursing practice. New York: Wiley. * Murphy, L.c. (1989). Establishing and clarifying the etiologies and characteristics of the nursing diagnosis alteration in nutrition: Less than body requirements. In M. Carroll-Johnson (Ed.). Classification of nursing diagnoses: Proceedings of the eighth conference (pp. 341-344). Philadelphia: Lippincott. * Stotts, N.A, & Whitney, J.D. (1990). Nutritional intake and status of clients in the home with open surgical wounds. Journal of Community Health Nursing, 7(2), 77-86. 1Iamposch, T.S., & Blue, L.S. (1987). A nutrition screening and assessment system for use with the elderly in extended care. Journal of the American Dietetic Association, 87, 1207-1210. The authors wish to thank Barbara Troy, M.s., R.D., Adjunct Assistant Professor, Marquette University College of Nursing, for her consultation regarding this care planning guide. 

Nutrition, Less Than Body Requirement: Risk

Marquette Universitye-Publications@MarquetteNursing Faculty Research and Publications Nursing, College of1-1-1992Nutrition, Less Than Body RequirementSharon WilladsenMarilyn FrennMarquette University, marilyn.frenn@marquette.eduPublished version. "Nutrition, Less Than Body Requirement," in Nursing Diagnosis in ClinicalPractice: Guides for Care Planning. Eds. Kathy V. Gettrust and Paula D. Brabec. Albany: NY: DelmarPublishers, 1992: 357-365. Permalink. © 1992 Delmar Learning, a part of Cengage Learning, Inc.Used with permission.A state in which an individual experiences an inability to ingest, digest, and/or absorb nutrients in quantities sufficient to fulfill nutritional requirements. Sharon Willadsen, R.N., B.S.N. Marilyn Fret/n, R.N., Ph.D. . . . . . . . . . . DEFINING CHARACTERISTICS Body weight 20% or more under ideal for height and frame Caloric intake (observed or reported) less than minimum daily requirement for current metabolic need Decreased serum albumin Decreased serum transferrin or iron-binding capacity Decreased total protein Decreased triceps skinfold or midarm circumference, less than 90% of the reference standard Electrolyte imbalance Lack of interest in food Loss of weight with adequate food intake Poor skin turgor Recent, unintentional weight loss of 20% or more of usual adult weight Satiety immediately after ingesting food . Weakness with loss of mobility CONTRIBUTING FACTORS Pathophysiological Alteration in smell Alteration in taste Chronic production of sputum Decreased appetite Decreased mental status Decreased salivation Diarrhea Dysphagia 357 -j I 358 SECTION TWO Dyspnea Fatigue Inability to use the muscles needed for mastication Increased metabolic rate Malabsorption of nutrients Mechanical obstruction Psychosociobehavioral Aversion to food Cultural food preferences Depressed state Inability to prepare foods Inability to procure foods (related to physical or financial reasons) EXPECTED OUTCOMES Muscle weakness and/or paralysis Nausea and/or vomiting Pain Self-care deficit Stomatitis, glossitis Surgical interventions Lack of knowledge regarding nutritional needs Loneliness Perceived inability to ingest food Self-induced malnutrition Stress Client will gain 0.5-1.0 lb/wk until ideal weight is achieved. Total caloric intake is increased, preferably by the oral route; second choice, enteral; and third choice, parenteral. Serum albumin levels are maintained within normal limits. Decreased or eradicated nausea, vomiting, diarrhea, and/or stomatitis are experienced. Client and/or significant other(s) will verbalize a knowledge of nutritional needs. An achievable and realistic personal nutritional improvement plan is designed and implemented. INTERVENTIONS Universal Perform a comprehensive nutritional assessment. This assessment needs to include such things as eating habits and personal preferences. Monitor skin turgor and mucous membranes. RATIONALE Formulating a plan that meets the nutritional requirements and is acceptable to the client is based on an accurate collection of information. Inadequate food/fluid intake causes dehydration. Adequate food/fluid intake increases moistness of oral mucosa, enhances taste, and facilitates swallOwing. Fluids also increase excretion of chemotherapeutic agents, thereby decreasing the cause of nausea and vomiting. NUTRITION, LESS THAN BODY REQUIREMENT 359 INTERVENTIONS RATIONALE Help to maintain a food record Objective data can be obtained regarding the (food diary). types and amounts of food consumed. Monitor weight daily. A careful assessment of weight is provided and the effectiveness of interventions used to meet nutritional requirements can be determined. Monitor bowel function . Constipation can cause feeling of abdominal fullness, thus decreasing appetite. Monitor for stomatitis. Mouth sores decrease the ability and desire to eat. Specify foods to be eliminated Refraining from ingesting these foods minimiz~s from diet (e.g., very hot or icy irritation to the oral mucosa. Medications and cold foods; spicy, acidic, or irradiation can also alter taste sensations. coarsely textured foods). Use Xylocaine 2% Viscous Oral anesthetizing agents decrease pain of Solution to anesthetize oral mouth sores and improve tolerance of foods. mucosa. Provide sufficient fluids with Decreased salivation makes ingestion of certain meals. foods difficult. Provide comfort measures such Pain and/or shortness of breath decrease appetite as positioning, analgesics, and ability to eat. and/or oxygen. Change consistency of diet to Soft or pureed foods can aid in swallowing and meet needs. ingesting of food. Provide alcoholic beverage with Alcohol can stimulate gastric juices and increase meals. appetite. Provide small, frequent meals Large meals three times a day increase a sense and limit fluids at mealtime. of fullness. Smaller meals and less fluid volume at meals facilitate gastric emptying and improve appetite. The small meals are also less over-whelming psychologically. --360 SECTION TWO Iii I I NTERVENTIONS RATIONALE Offer high-calorie, low-volume Additional caloric intake allows for ingestion supplements between meals. of foods in small volumes with high nutrient density. Encourage periods of exercise, Exercise acts as an appetite stimulant and aids as tolerated. in digestion. r Compliment for eating well. . Positive feedback reinforces good eating habits. " Elevate head of bed or have Proper positioning prevents epigastric discom-client sitting during meals and fort and minimizes potential for aspiration of for one hour after completion food. of meals. Offer antiemetics one hour Antiemetics suppress the vomiting center in the before meals. medulla. Suggest alternate measures to Chewing gum, hard candy, and dry, salty foods reduce nausea. such as popcorn or crackers, may aid in control-ling nausea and prevent development of an aversion to food. Provide for rest periods before Energy is conserved to minimize fatigue at meals and during meals meals. maintain a quiet, unhurried environment. Assist with eating as needed. Assistance with eating when physically unable to feed seU assures adequate nutritional intake. Utilize relaxation techniques. Stress that is reduced or relieved can result in an improved appetite. Provide adaptive or assistive Necessary equipment such as plate guards, devices. special utensils, or splints provide independence with meals. Instruct client and/or significant Education is essential for understanding of other(s) in specific nutritional specific needs and for follow-through with the needs, including restrictions. nutritional program. INTERVENTIONS Initiate enteral tube feedings as ordered. Include the following: 1. Check for hypoalbuminemia 2. Insert enteral feeding tube as ordered 3. Administer feedings at room temperature 4. Elevate head of bed at least 35 0 _ 40 0 during tube feeding and for one hour after completion of intermittent tube feedings 5. Check osmolality of medica-tions with dietitian before administration via feeding tube 6. Change enteral feeding bag and tubing every 24 hours and rinse with tap water every six hours or following each intermittent feeding 7. Monitor intake and output, skin turgor, and stool consistency NUTRITION, LESS THAN BODY REQUIREMENT 361 RATIONALE Hypoalbuminemia is associated with a decrease in colloid osmotic pressure and results in significant intestinal mucosal edema, which impairs intestinal absorption of the enteral feeding and diminishes its effectiveness. Replace-r'nent of albumin is rec-ommended before enteral feeding is initiated. The insertion of a patent tube into the stomach provides an alternate route for nutritional support. Abdominal cramping that is associated with tube feeding administration is reduced by careful . attention to the temperature of the feeding. Aspiration of the tube feeding is minimized by correct positioning. Medications with osmolalities greater than 700 mOsm/kg can cause diarrhea when given concomitantly with the tube feeding solution. Some examples are: Cimetidine, 4035 mOsm/kg; Sulfamethoxazole-'llimethoprim (Bactrim) Suspension, 4560 mOsm/kg; and Potassium Chloride (KCI) Elixir, 3000 mOsm/kg. These procedures prevent bacterial contamina-tion of the tube feeding solutions. Sufficient fluid intake is insured for hydration and fluid overload is prevented. \ i 362 SECTION mo INTERVENTIONS 8. Check for tube placement and monitor for gastric residuals every four hours with contin-uous feeding and before initi-ation of intermittent feedings. If gastric return is greater than 100 cc, hold feeding for one hour and repeat aspiration before continuing feeding 9. Monitor complete blood counts, electrolytes, albumin levels, blood glucose levels, and urea nitrogen 10. Monitor tube insertion site Initiate total parenteral nutrition as ordered. Include the following: 1. Administer all parenteral solutions via IV pump 2. Change dreSSings every 48 hours using aseptic technique 3. Change administration tubing and filter daily 4. Monitor vital signs every four hours 5. Monitor intake and output RATIONALE These precautions prevent aspiration of the tube feeding. These laboratory studies help determine the effectiveness of the tube feeding regime and also monitor for complications that can occur as a result of this regime. Frequent inspection of the site and daily care can assist in the prevention of redness and skin breakdown to the pressure areas. IV pumps offer the advantage of closely monitor-ing parenteral solution rate. If parenteral nutri-tion is given too rapidly, hypermolar diuresis occurs and excess sugar is excreted leading to intractable seizures. If the solution is run too slowly, inadequate nutritional intake is the result. This allows for close inspection of the insertion site and assists in the prevention of bacterial growth at the site. This procedure prevents th/? risk of bacterial contamination to the parenteral solution. Vital sign changes can signify complications of parenteral administration. Especially note temperature rise, which could signify possible septicemia. Sufficient fluid intake is insured and fluid over-load is prevented. NUTRITION, LESS THAN BODY REQUIREMENT 363 INTERVENTIONS RATIONALE Inpatient Institute a calorie count. Objective data are obtained on actual caloric intake. Monitor intake and output. Adequate fluid intake is insured without the complications of fluid overload. Monitor results of laboratory Metabolic activity and immune function are care-studies (serum albumin, total fully assessed through these laboratory studies. protein, serum transferrin, total lymph, urinary protein, glucose, acetone, 24-hour urinary creati-nine, nitrogen, and electrolytes). Provide oral care 30 min before These activities eliminate foul taste, moisten meals and frequently between mucous membranes, and increase taste for food. meals. They also prevent or promote healing of mouth sores. Open all food containers from Noxious stimuli caused by the immediate release food tray and release odors of combination of odors at the bedside are outside the room. reduced. Encourage family to bring foods Familiar foods may be more appealing to the from home. client. Provide an optimal mealtime A pleasant atmosphere has a positive influence environment (such as a sun- on appetite. room, lounge, or communal dining area). Encourage family and/or friends The socialization of being with others while to visit during meals. eating is important to many people. Supervise or assist with menu Feedback is obtained on awareness of nutritional selection. requirements and specific likes and dislikes and provides opportunity for reinforcement of good eating habits. 364 SECTION TWO i j I NTERVENTIONS RATIONALE Initiate referrals as needed (e.g., Appropriate referrals can assist with specific dietary, occupational and speech needs and concerns. therapy, social services, home care). I Community Health/ I Home Care Evaluate the availability of space Assessment of living conditions is obtained for food preparation, availability and needs determined. of refrigerator and other kitchen equipment for food preparation, and the presence of a significant other to assist with food preparation. Assess diet of client and/or Some diet regimens, such as vegetarian diets, Significant other(s) to determine lack the proper nutrients to maintain normal if basic nutritional needs are met. body weight. If client fatigues easily, have Significant other(s) prepare foods. If client lives alone and is ill, foods should be prepared in advance on days when client is feeling better. Eat in a positive atmosphere- A pleasant atmosphere has a positive influence a favorite table or with family on appetite. and friends when possible. Minimize noxious odors by Noxious odors can give rise to feelings of nausea using foods that need minimal or aversion to foods. cooking time and have client away from cooking area during preparation. Make use of kitchen appliances Convenience appliances aid in food preparation such as blenders, microwaves, by decreasing the amount of energy and time and food processors. spent to prepare foods. Initiate appropriate referrals for Appropriate referrals for assistive resources assistive resources as needed can assist with specific home care needs and (e.g., Meals on Wheels, Food concerns. Stamp Program, nutritionist, dentist, occupational therapist, I and/or support groups). NUTRITION, LESS THAN BODY REQUIREMENT 365 Bloch, A.S. (1990). Nutrition management of the cancer patient. Rockville, MD: Aspen. * Brinson, R.R., & Kolts, B.E. (1987). Hypoalbuminemia of diarrheal incidence in critically ill patients. Critical Care Medicine, 15(5), 506-509. * Flynn, K.T., Norton, L.c., & Fisher, R.L. (1987). Enteral tube feeding: Indications, practices, and outcomes. Image: Journal of Nursing Scholarship, 19(1), 16-19. Gettrust, K.v., Ryan, S.c., & Schmidt-Engelman, D.S. (1985). Applied nursing diagnosis: Guides for comprehensive care planning. Albany, NY: Delmar. Hermann-Zaidins, M., & Touger-Decker, R. (1989). Nutrition support in home health. Rockville, MD: Aspen. * Niemiec, P., Vanderveen, T., Morrison, J., & Hohenwarter, M. (1983). Gastrointestinal disorders caused by medication and electrolyte solution osmolality during enteral nutrition. Journal of Parenteral and Enteral Nutrition, 7(4), 387-389. The authors wish to acknowledge the consultation of: Joan Harkulich, R.N., M.S.N. Director of Research and Professional Services Barbara Troy, M.S., R.D. Adjunct Assistant Professor, Marquette University Milwaukee, WI 

Nutrition, Less Than Body Requirement

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