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Malnutrition Associated With Chronic Disease

Malnutrition Associated With Chronic Disease. KNH 411 Brittany Wrasman December 3, 2013. What is Malnutrition?. Defined by the International Dietetics and Nutrition Terminology as:

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Malnutrition Associated With Chronic Disease

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  1. Malnutrition Associated With Chronic Disease KNH 411 Brittany Wrasman December 3, 2013

  2. What is Malnutrition? • Defined by the International Dietetics and Nutrition Terminology as: • “Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting including starvation-related malnutrition, chronic disease-related malnutrition, and acute disease or injury related malnutrition.”

  3. Diagnosis of Adult Malnutrition in Clinical Setting

  4. Laboratory Values Used to Confirm Inflammation • Positive Acute-Phase Proteins • Fibronectin • C-reactive protein • Ceruloplasmin • Serum amyloid • Visceral Proteins • Albumin • Prealbumin

  5. Changes in Metabolism in Response to Starvation • Decrease in overall energy need. • Metabolic rate decreases 20-25 kcal/kg/day • Energy from fat storage >90% of kcal • Energy from protein <10% for gluconeogenesis • Hormone adaptation preserves protein stores.

  6. Patient Description • Harry Campbell, 68 y.o., Male • Height: 6’3” • Current Weight: 156 lbs.; BMI: 19.6 kg/m2 • UBW: 220 lbs. • %UBW: 70.9% • % Weight Change: 29.1% • Admitted to acute care for possible dehydration, weight loss, generalized weakness, and malnutrition. • Ordered a mechanical soft diet and started on I.V. fluids.

  7. Patient’s Diagnosis • Chronic-Disease Related Malnutrition • Supported by: • Patient’s energy intake of <75% of estimated energy requirements for >1 month. • Patient’s 29.1% weight change in the past 2 years. • Patient’s decrease muscle tone and loss of lean mass in his quadriceps and gastrocnemius. • Lab results indicating inflammation: • Elevated C-reactive protein level of 2.4 mg/dL • Low albumin (1.8 g/dL) and pre-albumin (9 mg/dL) levels

  8. Support of Dehydration • Patient feels lethargic • Skin turgor: TENT • Receiving only 360 mL of fluid orally • High Sodium and Chloride levels • Low Potassium Levels • Elevated BUN and Creatinine Serum levels • Slightly elevated specific gravity in urinalysis

  9. Braden Score • A Braden scale is used score a patient’s level of risk for developing pressure ulcers. • The Braden Scale measures six risk factors: • Sensory pressure • Moisture • Activity • Mobility • Nutrition • Friction/shear, • Scored on a scale of 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). • Total scores range from 6-23 (friction/shear is scored with values of 1-3, only).

  10. Nutrition • EER: 1,850-2,050 kcal/day • EPR: 106-142 grams • Fluid Requirements: 1,850- 2,050 mL/day • Usual Dietary Intake: • ~582 calories/day • 30 grams PRO • Ordered a mechanical soft diet upon admission • Intake % of meals: <5%; sips of liquid • Intake/Output • Intake: P.O.= 360 mL; I.V.= 2,160 mL • Output: 1,444 mL • Net I/O= +1,076 mL

  11. Usual Dietary Intake

  12. Nutrition Diagnoses • Malnutrition (NI-5.2) • Unintended Weight Loss (NC-3.2) • Inadequate Energy Intake (NI-1.2)

  13. Malnutrition (NI-5.2) • Malnutrition related to chronic disease (squamous cell carcinoma of tongue) as evidenced by patient’s unintentional weight loss of 29.1% of his usual body weight in the past 1-2 years, patient’s insufficient energy intake over the past several months, patient’s lack of appetite, patient’s decreased muscle tone and loss of lean mass in his quadriceps and gastrocnemius, and patient’s prealbumin level of 9 mg/dL.

  14. Unintended Weight Loss (NC-3.2) • Unintended weight loss related to client’s inability to consume sufficient energy as evidenced by a 29.1% weight change within the last two years, client’s decreased appetite over the last several months, patient’s decreased muscle tone and loss of lean mass in his quadriceps and gastrocnemius, and patient’s partial glossectomy 5 years ago.

  15. Inadequate Energy Intake (NI-1.2) • Inadequate energy intake related to patient’s decreased ability to consume sufficient energy as evidenced by patient’s 29.1% weight change within the last two years, client’s decreased appetite over the last several months, patient’s failure to consume estimated needs from diet, and patient’s partial glossectomy 5 years ago.

  16. Intervention • Enteral Nutrition • 1500 mLIsosource HN • 1,800 kcal • 80 gprotein • 240 g carbohydrate • 58.5 g fat • Goal rate= 63 cc/hr • Start: 32 cc/hr, increasing by 10 cc every 3 hours until goal is reached. • After tolerance is established, bolus feeds (250 cc), 6x’s/day will be initiated. • Once this is tolerated, bolus feeds (375 cc), 4 x’s/day will be implemented.

  17. Monitoring/Evaluation • Sufficiency of nutrient intake: intake/output • Hydration Status • Electroyltes, BUN, creatinine • Electrolyte Balance • Magnesium, phosphorus, calcium • Weight • Bowel Function • Blood Glucose • Nitrogen Balance

  18. Questions?

  19. References 2014 ICD-10-CM diagnosis codes E40-E46: Malnutrition. (n.d.). Retrieved from http://www.icd10data.com/ICD10CM/Codes/E00-E89/E40-E46 Academy of Nutrition and Dietetics (2013). Pocket guide for international dietetics & nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, Ill: Academy of Nutrition and Dietetics. Dixon, M. (2012). Caring~Web: Education and support for caregivers of stroke survivors. Retrieved from http://caringweb.utoledo.edu/softdiet.html Hamilton, C., & Boyce, V. (2013). Addressing malnutrition in hospitalized adults. Journal of Parenteral and Enteral Nutrition, 1-8. Retrieved fromhttp://malnutrition.andjrnl.org/Content/articles/Hamilton-Addressing.pdf Jensen, G., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, A., Grijalba, R., & Waitzberg, D. (2010). Adult starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Clinical Nutrition, 29(2), 151-153. doi:10.1016/j.clnu.2009.11.010 Mahan, L. K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy. Philadelphia: Saunders. Marcason, W. (2012). Malnutrition: Where do we stand in acute care? Journal of the Academy of Nutrition and Dietetics, 200. Retrieved from http://malnutrition.andjrnl.org/Content/articles/4-Malnutrition_where.pdf

  20. References Cont. Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study approach. Stamford, Connecticut: Cengage Learning. Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy andpathophysiology(2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning. Nestle Nutrition. (n.d.) Your source chart: Product reference guide. U.S. National Library of Medicine (2013). 2012AB Braden Scale source information. Retrieved from http://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/ U.S. National Library of Medicine (2011). Dehydration: MedlinePlus Medical Encyclopedia. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000982.htm USDA (2013). SuperTracker. Retrieved from https://www.supertracker.usda.gov/foodtracker.aspx?CatgoryID=-1&FoodDescription=Ensure+Plus Sonora Quest Laboratories (2013). Understanding the Complete Blood Count. Retrieved from http://www.sonoraquest.com/test-information/understanding-the-complete-blood-count-cbc/?AspxAutoDetectCookieSupport=1 White, J., Guenter, P., Jensen, G., Malone, A., Schofield, M., The Academy Malnutrition Work Group, The A.S.P.E.N. Malnutrition Task Force, & The A.S.P.E.N. Board of Directors (2012). Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738. Retrieved from http://malnutrition.andjrnl.org/Content/articles/1-Consensus_Statement.pdf

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