Nutritional Screening

1. Nutrition Assessment and Nutrition Care-What Nurses Need to KnowChapter 1Obesity and Eating Disorders as Examples of MalnutritionChapter 14

2. Nutritional Screening • Nutritional screen • Quick look at a few variables to judge a client’s relative risk for nutritional problems • No accepted universal tool • Screen must be done within 24 hours of admission to the hospital.

3. Nutritional Screening—(cont.) • Comprehensive nutritional assessment • Moderate to high risk at screening referred to dietitian for assessment-dietitian may not always be available so nurses/physicians may very well have to do all four steps below • Nutritional care process: four steps • Assessment • Nutritional diagnosis • Implementation • Monitoring and evaluation

4. Nutritional Screening—(cont.) • Comprehensive nutritional assessment—(cont.) • Different from nursing care plan • Dietitians (if available) or otherwise nurses/physicians can get most of information from nursing admission assessment. • Dietitians (if available) or otherwise nurses/physiciansinterview patients and/or families to obtain a nutrition history. • Helps to differentiate • Nutrition problems caused by inadequate intake from those caused by disease

5. Nutritional Screening—(cont.) • Comprehensive nutritional assessment—(cont.) • Dietitians (if available) or otherwise nurses/physicians • Calculate estimated calorie and protein requirements based on the assessment data • Determine nutrition diagnoses that define the nutritional problem, etiology, and signs and symptoms • May also determine the appropriate malnutrition diagnosis • Formulate nutrition interventions

6. Integrating Nutrition • Assessment • Data classified as ABCD • Anthropometric • Biochemical • Clinical • Dietary data • Client’s medical–psychosocial history is also evaluated for its impact on nutritional status.

7. Integrating Nutrition—(cont.) • Anthropometric data • Physical measurements of the body • Body mass index • “Healthy” or “normal” BMI is defined as 18.5 to 24.9. • Above or below related to health risks • Edema or dehydration skews accurate weight measurements. • Recent weight change

9. Integrating Nutrition—(cont.) • Biochemical data • No single test is both sensitive and specific for protein–calorie malnutrition. • Biochemical data may help support the diagnosis of a nutritional problem.

10. Integrating Nutrition—(cont.) • Albumin • Often used to assess protein status • Serum levels may be maintained until malnutrition is in a chronic stage. • Low albumin may indirectly identify patients who may benefit from nutrition assessment and intervention. • Prealbumin • Thyroxin-binding protein • More sensitive indicator of protein status • More expensive to measure

11. Integrating Nutrition—(cont.) • Clinical data • Physical signs and symptoms of malnutrition observed in the client • Most signs cannot be considered diagnostic. • Physical signs and symptoms of malnutrition can vary in intensity among population groups because of genetic and environmental differences. • Physical findings occur only with overt malnutrition.

12. Integrating Nutrition—(cont.) • Dietary data • Nurse should ask, “Do you avoid any particular foods?” • Nurse should not ask, “Are you on a diet?” • Medical–psychosocial history • May shed light on factors that influence intake, nutritional requirements, or nutrition counseling

13. Integrating Nutrition—(cont.) • Medication • Both prescription and over-the-counter drugs have the potential to affect and be affected by nutritional status. • At greatest risk for development of drug-induced nutrient deficiencies include those who: • Habitually consume fewer calories and nutrients than they need • Have increased nutrient requirements including infants, adolescents, and pregnant and lactating women • Are elderly • Have chronic illnesses

14. Integrating Nutrition—(cont.) • Medication—(cont.) • At greatest risk for development of drug-induced nutrient deficiencies include those who—(cont.) • Take large numbers of drugs (five or more), whether prescription drugs, over-the-counter medications, or dietary supplements • Are receiving long-term drug therapy • Self-medicate • Are substance abusers

15. Integrating Nutrition—(cont.) • Nursing diagnosis • Provide written documentation of the client’s status • Serve as a framework for the plan of care that follows • Planning: client outcomes • Outcomes, or goals, should be measurable, attainable, specific, and client centered. • Focus on the client, not the health-care provider. • Keep in mind that the goal for all clients is to consume adequate calories, protein, and nutrients using foods they like and tolerate as appropriate.

16. Integrating Nutrition—(cont.) • Nursing interventions • Nutrition therapy • Diet is a four-letter word with negative connotations. • Usually general suggestions to increase/ decrease, limit/avoid, reduce/encourage, or modify/maintain aspects of the diet because exact nutrient requirements are determined on an individual basis. • Nutrition theory does not always apply to practice.

17. Integrating Nutrition—(cont.) • Nursing interventions—(cont.) • Client teaching • Clients in clinical settings may be more receptive to nutritional advice. • Hospitalized patients are also prone to confusion about nutrition messages. • Monitoring and evaluation • Monitoring precedes evaluation. • Evaluation assesses whether client outcomes were achieved.

18. Physical Signs and Symptoms of Malnutrition • Hair is dull, brittle, dry, or falls out easily • Swollen glands of neck and cheeks • Dry, rough, or spotty skin • Poor or delayed wound healing or sores • Thin appearance with lack of subcutaneous fat • Muscle wasting • Edema of lower extremities • Weakened hand grasp • Depressed mood • Abnormal heart rate/rhythm and BP • Enlarged liver or spleen • Loss of balance and coordination

19. Nursing Diagnoses with Nutritional Significance • Altered nutrition: more than body requirements • Altered nutrition: less than body requirements • Altered nutrition: risk for more than body requirements • Constipation • Diarrhea • Fluid volume excess • Fluid volume deficit

20. Nursing Diagnoses with Nutritional Significance—(cont.) • Risk for aspiration • Altered oral mucous membrane • Altered dentition • Impaired skin integrity • Noncompliance • Impaired swallowing • Knowledge deficit • Pain • Nausea

21. Obesity and Eating Disorders as Examples of MalnutritionMalnutrition Chapter 14

22. Obesity and Eating Disorders • Prevalence of obesity (BMI ≥30) increasing • One of the most common causes of preventable death • A far less common weight issue is disordered eating manifested as anorexia nervosa or bulimia. • Historically, the study of obesity and eating disorders has been separate. • Commonalities between them

23. Obesity • Overweight is defined as having a BMI ≥25. • Obesity is defined as having a BMI ≥30. • Waist circumference is a better measure than BMI

24. Obesity—(cont.) • Causes of obesity • Occurs when people eat more calories than they expend over time • Why it occurs is not fully understood. • Some people are able to burn hundreds of extra calories in the activities of daily living to help control weight. • Likely that a combination of genetic and environmental factors is involved.

25. Obesity—(cont.) • Genetics • Estimates on the heritability of body mass index range from 40% to 70% (Herrera and Lindgren, 2010). • Genetics are involved in: • How likely a person is to gain or lose weight • Where body fat is distributed • Response to overeating

26. Obesity—(cont.) • Environment • Rise in obesity without change in gene pool-epigenetics can play a role • Root cause in most cases is lifestyle and environment, not biology. • Environmental influences include • Abundance of palatable, low-cost, high–calorie density foods that are readily available in prepackaged forms and in fast-food restaurants • Increasing consumption of soft drinks and snacks • Great proportion of food expenditures spent on food away from home

27. Obesity—(cont.) • Environment—(cont.) • Environmental influences include—(cont.) • Growing portion size of restaurant meals • Low levels of physical activity • Increases in television watching • Widespread use of electronic devices in the home, such as computers and video games • All lead to sedentary lifestyle.

28. Obesity—(cont.) • Environment—(cont.) • Gene–environment interaction • In people with a genetic predisposition to obesity, the severity of the disease is largely determined by lifestyle and environmental conditions. • Complications of obesity • Most common complications of obesity include • Insulin resistance, type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, gallstones and cholecystitis, sleep apnea, respiratory dysfunction, and increased incidence of certain cancers (e.g. colon, breast, prostate,endometrial)

29. Obesity—(cont.) • Complications of obesity—(cont.) • Increases the risk of complications during and after surgery • Obesity is considered to be a major contributor to preventable deaths in Canada. • Obesity presents psychological and social disadvantages. • Negative social consequences

30. Obesity—(cont.) • Goals of treatment • Ideally, treatment would “cure” overweight and obesity. • In reality, this ideal is seldom achieved. • A modest weight loss of 5% to 10% of initial body weight is associated with significant improvements in blood pressure, cholesterol and plasma lipid levels, and blood glucose levels.

31. Obesity—(cont.) • Goals of treatment—(cont.) • Modest weight loss • Is more attainable • Is easier to maintain over the long term • Sets the stage for subsequent weight loss

32. Obesity—(cont.) • Evaluating motivation to lose weight • Objectively identifying who may benefit from weight loss • Assessing the client’s level of motivation is crucial. • Imposing treatment on an unmotivated or unwilling client may preclude subsequent attempts at weight loss.

33. Obesity—(cont.) • Evaluating motivation to lose weight—(cont.) • Treatment approaches • A lifestyle approach is the basis of treatment for all people whose BMI is ≥30. • Includes diet modification • Exercise • Behavior modification • Pharmacotherapy and surgery may be used in conjunction with lifestyle interventions, based on the individual’s BMI and the presence of comorbidities.

34. Obesity—(cont.) • Treatment approaches—(cont.) • Diet modification • Cornerstone of most weight loss programs • Fewer calories • Macronutrient composition • Micronutrient composition • Nutrition education • Promoting dietary adherence

35. Obesity—(cont.) • Treatment approaches—(cont.) • Physical activity • Benefits of exercise are numerous. • Favorably impacts metabolic rate

36. Obesity—(cont.) • Physical activity—(cont.) • Sixty to 90 minutes of daily moderate-intensity physical activity are recommended to sustain weight loss. • Promoting exercise adherence • Seems to increase with less structure • Strategies that may promote exercise adherence • Exercise at home • Exercise in multiple short bouts (10 minutes each) • Adopt a more active lifestyle

37. Obesity—(cont.) • Behavior modification • Focuses on changing the client’s eating and exercise behaviors • Key behavior modification strategies • Self-monitoring • Goal setting • Stimulus control • Problem solving • Cognitive restructuring • Relapse prevention

38. Obesity—(cont.) • Pharmacotherapy • Recommended for • People with a BMI ≥30 • People with a BMI ≥27 with comorbid conditions • People with waist circumferences at or above IDF cut offs are also candidates for pharmacotherapy if comorbidities are present.

39. Obesity—(cont.) • Pharmacotherapy—(cont.) • Drugs are central nervous system stimulants. • Tolerance may develop after only a few weeks. • Risk of abuse • Common side effects • Increased heart rate and blood pressure, dry mouth, agitation, insomnia, nausea, diarrhea, and constipation

40. Obesity—(cont.) • Surgery • Most effective treatment for severe obesity • Appropriate for clients whose BMI is 35 to 39.9 who have major comorbidities • Works by • Restricting the stomach’s capacity • Creating malabsorption of nutrients and calories • A combination of both

41. Obesity—(cont.) • Surgery—(cont.) • Laparoscopic adjustable gastric banding (LAGB) • An inflatable band encircles the uppermost stomach and is buckled. • Small pouch of approximately 15- to 30-mL capacity is created with a limited outlet between the pouch and the main section of the stomach. • Outlet diameter can be adjusted by inflating or deflating a small bladder inside the “belt” through a small subcutaneous reservoir.

42. Obesity—(cont.) • Surgery—(cont.) • Laparoscopic adjustable gastric banding (LAGB)—(cont.) • Size of the outlet can be repeatedly changed as needed. • Mortality rate for gastric banding is the lowest of all bariatric procedures. • Successful weight loss after LAGB requires frequent follow-up and band adjustments.

43. Obesity—(cont.) • Surgery—(cont.) • Roux-en-Y gastric bypass (RYGB) • Combines gastric restriction to limit food intake with the construction of bypasses of the duodenum and the first portion of the jejunum • Creates malabsorption of nutrients • “Dumping syndrome” • Superior to gastric resection in both promoting and maintaining significant weight loss • Major complication with RYGB is anastomotic leak.

44. Obesity—(cont.) • Postsurgical diet • Progression begins with small quantities of sugar-free clear liquids. • Advances as tolerated to full liquids, followed by pureed foods, and then a regular diet within 5 to 6 weeks after surgery • Nutrition therapy guidelines

45. Obesity—(cont.) • Weight maintenance after loss • Keeping weight off is even harder than losing it. • Diets that lead to weight loss are not necessarily effective for maintaining weight loss. • Single best predictor of who will be successful at maintaining weight loss is how long someone has kept his or her weight off.

46. Obesity—(cont.) • Obesity prevention • Small changes in diet and exercise that total a mere 100 cal/day may be enough to prevent obesity in most of the population. • One ounce of cheddar cheese a day for 1 year = 10-pound weight gain

47. Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS) • Defined psychiatric illnesses that can have a profound impact on nutritional status and health • Generally characterized by abnormal eating patterns and distorted perceptions of food and body weight • Continuum of disordered eating

48. Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont’d) • Etiology • Considered to be multifactorial in origin • Risk factors • Dieting, early childhood eating and GI problems, increased concern about weight and size, negative self-evaluation, sexual abuse, and other traumas

49. Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.) • Etiology—(cont.) • Precipitating factors • Onset of puberty, parents’ divorce, death of a family member, and ridicule of being or becoming fat • People with eating disorders often suffer from • Depression, anxiety, substance abuse, or body dysmorphic disorder

50. Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.) • Etiology—(cont.) • Treatment plans are highly individualized. • Antidepressant drugs effectively reduce the frequency of problematic eating behaviors. • Most eating disorders are treated on an outpatient basis. • Nutritional intervention seeks to reestablish and maintain normal eating behaviors.