Nutritional status is a key factor in patient’s overall immune function and a patient’s ability to mount a stress response. Underfeeding a patient may lead to increased nosocomial infections, poor wound healing, respiratory muscle dysfunction, and respiratory failure. Overfeeding patients, in contrast, may increase physiological stress and lead to problems such as hyperglycemia, fluid overload, azotemia, and hepatic dysfunction. Therefore, measuring energy
expenditure and determining the patient’s caloric requirements and feeding status should be included in a thorough nutritional assessment. Specifically designed nutritional therapy can be administered by the parenteral or enteral route when the use of standard diets via the oral route is inadequate or not possible or enteral route when the use of standard diets via the oral route is inadequate or not possible to prevent/correct protein-calorie malnutrition.
Enteral nutrition is preferred for the patient who has a functional GI tract but is unable to consume an adequate nutritional intake or for whom oral intake is contraindicated/impossible. Feeding may be done via NG or orogastric tube, esophagostomy, gastrostomy, duodenostomy, or jejunostomy. Parenteral nutrition may be chosen because of altered metabolic states or when mechanical or functional abnormalities of the GI tract prevent enteral feeding. Amino acids, fat, carbohydrates, trace elements, vitamins, and electrolytes may be infused via a central or peripheral vein.
CARE SETTING
May be any setting, including community/home care
RELATED CONCERNS
Burns: thermal/chemical/electrical (acute and convalescent phases)
Cancer
COPD
Fluid and electrolyte imbalances
Inflammatory bowel disease
Pancreatitis
Psychosocial aspects of care
Renal failure: chronic
Surgical intervention
Patient Assessment Database
Clinical signs listed here depend on the degree and duration of malnutrition and include observations indicative of vitamin, mineral, and protein/calorie deficiencies.
ACTIVITY/REST
May exhibit: Muscle wasting (temporal, intercostal, gastrocnemius, dorsum of hand); thin extremities, flaccid muscles, decreased activity tolerance
CIRCULATION
May exhibit: Tachycardia, bradycardia
Diaphoresis, cyanosis
ELIMINATION
May report: Diarrhea or constipation; flatulence associated with food intake
May exhibit: Abdominal distension/increased girth, ascites; tenderness on palpation
Stools may be loose, hard-formed, fatty, or clay-colored
FOOD/FLUID
May report: Recent weight loss/weight loss of 10% or more of body weight within previous 6 mo
Problems with chewing, swallowing, choking, or saliva production
Changes in the taste of food; anorexia, nausea/vomiting; inadequate oral intake (NPO)
status for 7–10 days, long-term use of 5% dextrose intravenously
May exhibit: Actual weight (measured) as compared with usual or pre-illness weight is less than 90% of ideal body weight for height, sex, and age or equal to or greater than 120% of
ideal or usual body weight (patient risk in obesity is a tendency to overlook protein and calorie requirements). A distorted actual weight may occur because of the presence of edema, ascites, organomegaly, tumor bulk, anasarca, amputation
Edentulous or ill-fitting dentures
Bowel sounds diminished, hyperactive, or absent
Thyroid, parotid enlargement
Lips dry, cracked, red, swollen; angular stomatitis
Tongue may be smooth, pale, slick, coated; color often magenta, beefy red; lingual papillae atrophy/swelling
Gums swollen/bleeding, multiple caries
Mucous membranes dry, pale, red, swollen
NEUROSENSORY
May exhibit: Lethargy, apathy, listlessness, irritability, disorientation, coma
Gag/swallow reflex may be decreased/absent, e.g., cerebrovascular accident (CVA), head trauma, nerve injury
Loss of balance and coordination
RESPIRATION
May exhibit: Increased respiratory rate; respiratory distress
Dyspnea, increased sputum production
Breath sounds; crackles (protein deficiency/related fluid shifts)
SAFETY
May report: Recent course of radiation therapy (radiation enteritis)
May exhibit: Hair may be fragile, coarse, lackluster, falling out (alopecia), decreased pigmentation may be present
Skin dry, scaly, tented; “flaky paint” dermatosis; edema; draining or unhealed wounds, pressure sores; ecchymoses, perifollicular petechiae, subcutaneous fat loss
Eyes sunken, dull, dry, with pale conjunctiva; Bitot’s spots (triangular, shiny, gray spots on the conjunctiva seen in vitamin A deficiency) or scleral icterus
Nails may be brittle, thin, flattened, ridged, spoon-shaped
SEXUALITY
May report: Loss of libido
Amenorrhea
TEACHING/LEARNING
May report: History/presence of conditions causing protracted protein/caloric losses, e.g.,
malabsorption or short-gut syndrome, diarrhea, acute pancreatitis, renal dialysis, fistulas, draining wounds, thermal injuries; problems with chewing/swallowing (e.g., CVA or Parkinson’s disease)
Presence of factors known to alter nutritional requirements/increase energy demands, e.g.,
single or multiorgan failure; sepsis; fever; AIDS, cancer; trauma; extensive burns; use of steroids, antitumor agents, immunosuppressants
Use of treatments that greatly alter intake and medications that cause untoward drug/nutrient interactions, e.g., laxatives, anticonvulsants, diuretics, antacids, narcotics, immunosuppresants, radiation, high-dose chemotherapy
Illness of psychiatric origin, e.g., anorexia nervosa/bulimia
Educational/social factors, e.g., lack of nutrition knowledge, kitchen facilities,
reduced/limited financial resources
Discharge plan
DRG projected mean length of inpatient stay: 6.1 days, depending on underlying
disease process necessitating therapy
May require assistance with solution preparation, therapy supplies, and maintenance of
feeding device for home nutritional care
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Weight: Ideal body weight (IBW): Men—106 lb for first 5’ plus 6 lb for each additional inch of height. Women—100 lb for first 5’ plus 5 lb for each additional inch of height. 120% of IBW is obese, 70%–79% of IBW is moderately underweight. Weight may be inaccurate as a result of factors such as edema, ascites.
Anthropometrics: Includes measurement of weight-to-height ratio, osteometry, and ratios of lean-to-fat weight:
Triceps skin-fold measurement: Estimates subcutaneous fat stores; fat reserves less than 10th percentile suggest advanced depletion; levels less than the 30th percentile suggest mild-to-moderate depletion.
Midarm muscle circumference: Measures somatic muscle mass and is used in combination with triceps skin-fold measurement; a decrease of 15–20 percentiles from the expected value suggests a significant reduction.
Visceral proteins: (Note: Recent research questions the reliability of serum albumin and transferrin as markers for malnutrition.)
Serum albumin (the classic marker measured): Values of 2.7–3.4 g/dL indicate mild depletion; 2.1–2.7 g/dL, moderate depletion; and less than 2.1 g/dL, severe depletion. Decreased levels are due to poor protein intake, nephrotic syndrome, sepsis, burns, HF, cirrhosis, eclampsia, protein-losing enteropathy; above-normal values (more than 4.5 g/dL) are seen in dehydration. (Serum prealbumin has a shorter half-life than albumin, so body stores turn over quickly, theoretically making it a more sensitive indicator of improvement/change in protein status.)
Serum transferrin: More sensitive to changes in visceral protein stores than albumin; levels of 150–200 mg/dL reflect mild depletion; 100–150 mg/dL, moderate depletion; and 100 mg/dL, severe depletion. Elevated values are seen with iron deficiency, pregnancy, hypoxia, and chronic blood loss. Decreased values are seen with pernicious anemia, chronic infection, liver disease, iron overload, and protein-losing enteropathy.
Thyroxine-binding prealbumin: Reflects repaid changes in hepatic protein synthesis and thus is a more sensitive indicator of visceral protein depletion. Decreased levels less than 200 mEq/mL are noted with cirrhosis, inflammation, and surgical trauma.
Amino acid profile: Alterations reflect an imbalance of plasma proteins with depressed levels of branched-chain amino acids (common with hepatic encephalopathy or sepsis).
Tests of immune system:
Total lymphocyte count: Less than 1500 cells/mm3 indicates leukopenia and results from decreased generation of T cells, which are very sensitive to malnutrition. Less than 800 cells/mm3 indicates severe depletion. Levels are also altered by severe stress, renal failure, cancer, infection, and administration of corticosteroids.
Tests of micronutrients:
Potassium: Deficiency occurs with inadequate intake and with loss of potassium-containing fluids (e.g., urine, diarrhea, vomiting, fistula drainage, continuous NG suctioning). Potassium is also lost from cells during muscle wasting and is excreted by the kidneys.
Sodium: Levels depend on state of hydration/presence of active loss as may exist in excessive diuresis, GI suctioning, burns.
Phosphorus: May be decreased, reflecting inadequate intake or increased cellular uptake; may be elevated in renal failure.
Magnesium: Deficiency is common in alcoholics, chronic vomiting, diarrhea; may be elevated in renal failure.
Calcium: Levels are decreased with conditions associated with hypoalbuminemia, e.g., renal failure (majority of calcium is bound to albumin). Absorption is decreased by fat malabsorption and low-protein diet.
Zinc: Deficiency is seen in alcoholic cirrhosis; or may be secondary to hypoalbuminemia and GI losses (diarrhea).
Tests reflecting protein (nitrogen) loss:
Nitrogen balance studies: Nitrogen (protein) excretion via urine, stool, and insensible losses often exceeds nitrogen intake in the acutely ill, reflecting catabolic response to stress and use of endogenous protein stores for energy production (gluconeogenesis). BUN may be severely decreased as a result of chronic malnutrition and depletion of skeletal protein stores.
24-hr creatinine excretion: Because Cr is concentrated in muscle mass, there is a correlation between lean body mass and 24-hr Cr excretion. Actual values are compared with ideal values (based on height and weight) times 100, known as the Cr height index: 60%–80% indicates moderate depletion; less than 60%, severe depletion.
Tests of GI function (include Schilling test, D-xylose test, 72-hr stool fat, GI series): Determine malabsorption.
Chest x-ray: May be normal or show evidence of pleural effusion; small heart silhouette.
ECG: May be normal or demonstrate low voltage, dysrhythmias/patterns reflective of electrolyte imbalances.
NURSING PRIORITIES
1. Promote consistent intake of adequate calorie and protein requirements.
2. Prevent complications.
3. Minimize energy losses/needs.
4. Provide information about condition, prognosis, and treatment needs.
DISCHARGE GOALS
1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Fatigue alleviated.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
expenditure and determining the patient’s caloric requirements and feeding status should be included in a thorough nutritional assessment. Specifically designed nutritional therapy can be administered by the parenteral or enteral route when the use of standard diets via the oral route is inadequate or not possible or enteral route when the use of standard diets via the oral route is inadequate or not possible to prevent/correct protein-calorie malnutrition.
Enteral nutrition is preferred for the patient who has a functional GI tract but is unable to consume an adequate nutritional intake or for whom oral intake is contraindicated/impossible. Feeding may be done via NG or orogastric tube, esophagostomy, gastrostomy, duodenostomy, or jejunostomy. Parenteral nutrition may be chosen because of altered metabolic states or when mechanical or functional abnormalities of the GI tract prevent enteral feeding. Amino acids, fat, carbohydrates, trace elements, vitamins, and electrolytes may be infused via a central or peripheral vein.
CARE SETTING
May be any setting, including community/home care
RELATED CONCERNS
Burns: thermal/chemical/electrical (acute and convalescent phases)
Cancer
COPD
Fluid and electrolyte imbalances
Inflammatory bowel disease
Pancreatitis
Psychosocial aspects of care
Renal failure: chronic
Surgical intervention
Patient Assessment Database
Clinical signs listed here depend on the degree and duration of malnutrition and include observations indicative of vitamin, mineral, and protein/calorie deficiencies.
ACTIVITY/REST
May exhibit: Muscle wasting (temporal, intercostal, gastrocnemius, dorsum of hand); thin extremities, flaccid muscles, decreased activity tolerance
CIRCULATION
May exhibit: Tachycardia, bradycardia
Diaphoresis, cyanosis
ELIMINATION
May report: Diarrhea or constipation; flatulence associated with food intake
May exhibit: Abdominal distension/increased girth, ascites; tenderness on palpation
Stools may be loose, hard-formed, fatty, or clay-colored
FOOD/FLUID
May report: Recent weight loss/weight loss of 10% or more of body weight within previous 6 mo
Problems with chewing, swallowing, choking, or saliva production
Changes in the taste of food; anorexia, nausea/vomiting; inadequate oral intake (NPO)
status for 7–10 days, long-term use of 5% dextrose intravenously
May exhibit: Actual weight (measured) as compared with usual or pre-illness weight is less than 90% of ideal body weight for height, sex, and age or equal to or greater than 120% of
ideal or usual body weight (patient risk in obesity is a tendency to overlook protein and calorie requirements). A distorted actual weight may occur because of the presence of edema, ascites, organomegaly, tumor bulk, anasarca, amputation
Edentulous or ill-fitting dentures
Bowel sounds diminished, hyperactive, or absent
Thyroid, parotid enlargement
Lips dry, cracked, red, swollen; angular stomatitis
Tongue may be smooth, pale, slick, coated; color often magenta, beefy red; lingual papillae atrophy/swelling
Gums swollen/bleeding, multiple caries
Mucous membranes dry, pale, red, swollen
NEUROSENSORY
May exhibit: Lethargy, apathy, listlessness, irritability, disorientation, coma
Gag/swallow reflex may be decreased/absent, e.g., cerebrovascular accident (CVA), head trauma, nerve injury
Loss of balance and coordination
RESPIRATION
May exhibit: Increased respiratory rate; respiratory distress
Dyspnea, increased sputum production
Breath sounds; crackles (protein deficiency/related fluid shifts)
SAFETY
May report: Recent course of radiation therapy (radiation enteritis)
May exhibit: Hair may be fragile, coarse, lackluster, falling out (alopecia), decreased pigmentation may be present
Skin dry, scaly, tented; “flaky paint” dermatosis; edema; draining or unhealed wounds, pressure sores; ecchymoses, perifollicular petechiae, subcutaneous fat loss
Eyes sunken, dull, dry, with pale conjunctiva; Bitot’s spots (triangular, shiny, gray spots on the conjunctiva seen in vitamin A deficiency) or scleral icterus
Nails may be brittle, thin, flattened, ridged, spoon-shaped
SEXUALITY
May report: Loss of libido
Amenorrhea
TEACHING/LEARNING
May report: History/presence of conditions causing protracted protein/caloric losses, e.g.,
malabsorption or short-gut syndrome, diarrhea, acute pancreatitis, renal dialysis, fistulas, draining wounds, thermal injuries; problems with chewing/swallowing (e.g., CVA or Parkinson’s disease)
Presence of factors known to alter nutritional requirements/increase energy demands, e.g.,
single or multiorgan failure; sepsis; fever; AIDS, cancer; trauma; extensive burns; use of steroids, antitumor agents, immunosuppressants
Use of treatments that greatly alter intake and medications that cause untoward drug/nutrient interactions, e.g., laxatives, anticonvulsants, diuretics, antacids, narcotics, immunosuppresants, radiation, high-dose chemotherapy
Illness of psychiatric origin, e.g., anorexia nervosa/bulimia
Educational/social factors, e.g., lack of nutrition knowledge, kitchen facilities,
reduced/limited financial resources
Discharge plan
DRG projected mean length of inpatient stay: 6.1 days, depending on underlying
disease process necessitating therapy
May require assistance with solution preparation, therapy supplies, and maintenance of
feeding device for home nutritional care
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Weight: Ideal body weight (IBW): Men—106 lb for first 5’ plus 6 lb for each additional inch of height. Women—100 lb for first 5’ plus 5 lb for each additional inch of height. 120% of IBW is obese, 70%–79% of IBW is moderately underweight. Weight may be inaccurate as a result of factors such as edema, ascites.
Anthropometrics: Includes measurement of weight-to-height ratio, osteometry, and ratios of lean-to-fat weight:
Triceps skin-fold measurement: Estimates subcutaneous fat stores; fat reserves less than 10th percentile suggest advanced depletion; levels less than the 30th percentile suggest mild-to-moderate depletion.
Midarm muscle circumference: Measures somatic muscle mass and is used in combination with triceps skin-fold measurement; a decrease of 15–20 percentiles from the expected value suggests a significant reduction.
Visceral proteins: (Note: Recent research questions the reliability of serum albumin and transferrin as markers for malnutrition.)
Serum albumin (the classic marker measured): Values of 2.7–3.4 g/dL indicate mild depletion; 2.1–2.7 g/dL, moderate depletion; and less than 2.1 g/dL, severe depletion. Decreased levels are due to poor protein intake, nephrotic syndrome, sepsis, burns, HF, cirrhosis, eclampsia, protein-losing enteropathy; above-normal values (more than 4.5 g/dL) are seen in dehydration. (Serum prealbumin has a shorter half-life than albumin, so body stores turn over quickly, theoretically making it a more sensitive indicator of improvement/change in protein status.)
Serum transferrin: More sensitive to changes in visceral protein stores than albumin; levels of 150–200 mg/dL reflect mild depletion; 100–150 mg/dL, moderate depletion; and 100 mg/dL, severe depletion. Elevated values are seen with iron deficiency, pregnancy, hypoxia, and chronic blood loss. Decreased values are seen with pernicious anemia, chronic infection, liver disease, iron overload, and protein-losing enteropathy.
Thyroxine-binding prealbumin: Reflects repaid changes in hepatic protein synthesis and thus is a more sensitive indicator of visceral protein depletion. Decreased levels less than 200 mEq/mL are noted with cirrhosis, inflammation, and surgical trauma.
Amino acid profile: Alterations reflect an imbalance of plasma proteins with depressed levels of branched-chain amino acids (common with hepatic encephalopathy or sepsis).
Tests of immune system:
Total lymphocyte count: Less than 1500 cells/mm3 indicates leukopenia and results from decreased generation of T cells, which are very sensitive to malnutrition. Less than 800 cells/mm3 indicates severe depletion. Levels are also altered by severe stress, renal failure, cancer, infection, and administration of corticosteroids.
Tests of micronutrients:
Potassium: Deficiency occurs with inadequate intake and with loss of potassium-containing fluids (e.g., urine, diarrhea, vomiting, fistula drainage, continuous NG suctioning). Potassium is also lost from cells during muscle wasting and is excreted by the kidneys.
Sodium: Levels depend on state of hydration/presence of active loss as may exist in excessive diuresis, GI suctioning, burns.
Phosphorus: May be decreased, reflecting inadequate intake or increased cellular uptake; may be elevated in renal failure.
Magnesium: Deficiency is common in alcoholics, chronic vomiting, diarrhea; may be elevated in renal failure.
Calcium: Levels are decreased with conditions associated with hypoalbuminemia, e.g., renal failure (majority of calcium is bound to albumin). Absorption is decreased by fat malabsorption and low-protein diet.
Zinc: Deficiency is seen in alcoholic cirrhosis; or may be secondary to hypoalbuminemia and GI losses (diarrhea).
Tests reflecting protein (nitrogen) loss:
Nitrogen balance studies: Nitrogen (protein) excretion via urine, stool, and insensible losses often exceeds nitrogen intake in the acutely ill, reflecting catabolic response to stress and use of endogenous protein stores for energy production (gluconeogenesis). BUN may be severely decreased as a result of chronic malnutrition and depletion of skeletal protein stores.
24-hr creatinine excretion: Because Cr is concentrated in muscle mass, there is a correlation between lean body mass and 24-hr Cr excretion. Actual values are compared with ideal values (based on height and weight) times 100, known as the Cr height index: 60%–80% indicates moderate depletion; less than 60%, severe depletion.
Tests of GI function (include Schilling test, D-xylose test, 72-hr stool fat, GI series): Determine malabsorption.
Chest x-ray: May be normal or show evidence of pleural effusion; small heart silhouette.
ECG: May be normal or demonstrate low voltage, dysrhythmias/patterns reflective of electrolyte imbalances.
NURSING PRIORITIES
1. Promote consistent intake of adequate calorie and protein requirements.
2. Prevent complications.
3. Minimize energy losses/needs.
4. Provide information about condition, prognosis, and treatment needs.
DISCHARGE GOALS
1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Fatigue alleviated.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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