Malnutrition

Malnutrition

1. Undernutrition

   • A state of poor nourishment because of inadequate diet or disease that interfere with normal appetite and assimilation of ingested food.
   • Path
     • Undernutrition can include primary or secondary protein-calorie malnutrition.   Marasmus and Kwashiorkor are forms of malnutrition seen in with children in developing countries and are not to be used when describing adults.  When carbohydrate stores are depleted the body begins to convert skeletal muscle proteins into glucose for energy. This may cause a person to progress into a negative nitrogen balance. 
     • After 5-9 days the body mobilizes fat to supply the needed energy.  The depletion of fat stores depends on the amount available. They are typically used up in 4-6 weeks.  When fat stores are completed the body begins to use its protein stores.  As protein depletion continues the liver becomes impaired causing a decrease in plasma oncotic pressure causing fluids space shifts and edema becomes apparent and masks the muscle wasting. Na+ increases within the cell, K+ and Mg increases in the ECF.  The Na/K+ pump fails.  Death is imminent if nutrients are not given. 
     • Diagnostic Studies
       • H&P, LABS
         • Serum Albumen Prealbumen CBC CMP CRP Lipids
         • CBC, CMP, Serum Albumen, Prealbumen, CRP, Lipids
       • Anthropometric measurements
         • Measurements of fat and muscle tissue by taking skin fold measurements at certain sites. 
       • Functional Measurements
         • Measurements of ADLs by using the Katz Index and Lawson Scale. 
   • clinical manifestations
     • Skin will be dry and scaly, nails will be brittle, rashes and hair loss.  Dry mouth, crusting of lips, oral ulcerations, and changes in the tongue.  Decreased muscle mass and weakness.  Mental changes such as confusion and irritability. 
     • Skin dry, rash, brittle nails, hair loss
       • Muscle wasting
         • Mental changes such as confusion/irritability
   • contributing factors
     • -Socioeconomic factors -Physical illness -incomplete diets -drug-nutrient interactions
     • Socioeconomic
       • physical illness
         • incomplete diets
           • Drug/Nutrient interaction

2. Overnutrition

   • The ingestion of more food than is required for bodily needs. 
   • Path
     • Obesity is an increase in body weight beyond the body's physical requirements. There is an increase in the number of adipocytes and an increase in their size.  This process can increase their volume several thousand fold to accommodate large increases in lipid storage. Preadipocutes are triggered to become adipocytes once storage of exisiting fat cells is exceeded.  This primarily occurs in the visceral and subQ tissues. 
     • There is Primary obesity and secondary obesity.  Primary is the excess of caloric intake over energy expenditure for the bodies metabolic demands.  Secondary obesity results from metabolic problems, CNS lesions and disorders, or drugs.  There are genetic and biological factors 
     • Diagnostic Studies
       • H&P, Labs
         • CBC, CMP, Lipids, TSH, Hgb A1c, Microalbumen Urine,
       • Anthropometric Measurements
   • clinical manifestations
     • Associated Health Risks:  Cardiovascular problems Diabetes Mellitus GI and Liver Problems Respiratory and Sleep Problems Musculoskeletal problems Cancer  Metabolic Syndrome Psychosocial Problems
     • Excessive weight gain
     • Cardiovascular, DM2, GI & Liver, Respiratory & Sleep, Musculoskeletal, Psychosocial problems, Metabolic Syndrome, Cancer
   • Contributing factors
     • Genetic Link-estimates that obesity is an inherited problem are more than 50%.  Physiologic Regulatory Mechanisms-hypothalamus, gut and adipose tissues that synthesize hormones and peptides that stimulate or inhibit appetite.   Environmental Factors-prepackaged food, the 'now' culture, fast food.  Psychosocial Factors-using food fro comfort/reward. 
     • Genetic
     • Physiologic regulatory mechanisms
     • Environmental & Psychosocial factors

3. Nursing Dx

   • Disturbed Body Image. 
   • Nursing Intervention
     • Determine the patients view of their current body shape. Provide privacy during care activities as patient is self-conscious of body image. Promote conversation of body image while avoiding criticism and judgement of patient behavior of health. Continue to foster and encourage patient self responsibility for taking an active role in bettering their health and ensure patients understand their personal responsibilities. 
     • Patients view of current body shape
     • Promote conversation while preventing judgement/criticism
     • Foster & Encourage self-responsibility for Health Promotion
     • Set attainable goals
   • Disturbed Body Image

4. Nursing dx

   • Imbalanced nutrition; less than body requirements related to decreased access. 
   • Nursing Intervention
     • Discuss with patient meal prepping, utilizing food services such as meals on wheels, grocery delivery.  Hiring an UAP to come in and assist with meal prep for the week. 
     • Weekly meal prepping
     • utilizing local services: Grocery delivery, Meals on Wheels
     • If low income meet with Social Services to see if pt qualifies for aid.
   • Imbalanced Nutrition: Less than body requirements related to decreased access

5. Nursing Dx

   • imbalanced nutrition: More than body requirements 
   • Nursing Intervention
     • Assist patient with meal planning, discuss what the patient assumes a portion is as to what the standard portion size is.  Teach patient how to utilize a food scale and read nutrition labels.   Referring patient to group programs such as Weight Watchers, Jenny Craig, TOPS may help patient become more accountable and they may find encouragement to continue with weight loss programs. 
     • Assist with meal prepping
       • Correct portion size & Learning how to read nutrition labels.
     • Encourage patient accountability
     • Suggest group programs i.e. Weight Watcher, TOPS, Jenny Craig
   • Imbalanced Nutrition: More than body requirements

6. Nursing Dx

   • Risk for impaired skin integrity related to poor nutritional state.
   • Nursing intervention
     • Monitoring of I&Os to ensure patient is getting nutritional requirements.  Patient may need supplemental nutrition via EN or TPN. Provide patient with pressure reduction mattress and ensure that pressure points are continually assessed for breakdown.  Reposition patient q2h. keep skin warm and dry. 
     • Monitor I&O, EN/TPN feedings
     • Frequent skin assessment
       • Utilize pressure reduction mattress
         • frequent repositioning q2h
     • ensure skin remains warm and dry
   • Risk for impaired skin integrity r/t poor nutritional state

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