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Transcript of Nutrition Assessment and Nutrition Care-What Nurses Need to Know Chapter 1 Obesity and Eating...
![Page 1: Nutrition Assessment and Nutrition Care-What Nurses Need to Know Chapter 1 Obesity and Eating Disorders as Examples of Malnutrition Chapter 14.](https://reader035.fdocuments.us/reader035/viewer/2022062409/5697bf9e1a28abf838c945a5/html5/thumbnails/1.jpg)
Nutrition Assessment and Nutrition Care-What Nurses
Need to KnowChapter 1
Obesity and Eating Disorders as Examples of Malnutrition
Chapter 14
Nutrition Assessment and Nutrition Care-What Nurses
Need to KnowChapter 1
Obesity and Eating Disorders as Examples of Malnutrition
Chapter 14
![Page 2: Nutrition Assessment and Nutrition Care-What Nurses Need to Know Chapter 1 Obesity and Eating Disorders as Examples of Malnutrition Chapter 14.](https://reader035.fdocuments.us/reader035/viewer/2022062409/5697bf9e1a28abf838c945a5/html5/thumbnails/2.jpg)
Nutritional ScreeningNutritional 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.
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Nutritional Screening—(cont.)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
o Assessment
o Nutritional diagnosis
o Implementation
o Monitoring and evaluation
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Nutritional Screening—(cont.)Nutritional Screening—(cont.)
• Comprehensive nutritional assessment—(cont.)
– Different from nursing care plan
o Dietitians (if available) or otherwise nurses/physicians can get most of information from nursing admission assessment.
o Dietitians (if available) or otherwise nurses/physicians interview patients and/or families to obtain a nutrition history.
– Helps to differentiate
o Nutrition problems caused by inadequate intake from those caused by disease
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Nutritional Screening—(cont.)Nutritional Screening—(cont.)
•Comprehensive nutritional assessment—(cont.)
– Dietitians (if available) or otherwise nurses/physicians
o Calculate estimated calorie and protein requirements based on the assessment data
o Determine nutrition diagnoses that define the nutritional problem, etiology, and signs and symptoms
o May also determine the appropriate malnutrition diagnosis
o Formulate nutrition interventions
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Integrating Nutrition Integrating Nutrition
• Assessment
– Data classified as ABCD
o Anthropometric
o Biochemical
o Clinical
o Dietary data
– Client’s medical–psychosocial history is also evaluated for its impact on nutritional status.
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Integrating Nutrition—(cont.)Integrating Nutrition—(cont.)• Anthropometric data
– Physical measurements of the body
– Body mass index
o “Healthy” or “normal” BMI is defined as 18.5 to 24.9.
o Above or below related to health risks
– Edema or dehydration skews accurate weight measurements.
– Recent weight change
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Integrating Nutrition—(cont.)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.
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Integrating Nutrition—(cont.)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
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Integrating Nutrition—(cont.)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.
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Integrating Nutrition—(cont.)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
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Integrating Nutrition—(cont.)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:o Habitually consume fewer calories and nutrients
than they needo Have increased nutrient requirements including
infants, adolescents, and pregnant and lactating women
o Are elderlyo Have chronic illnesses
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Integrating Nutrition—(cont.)Integrating Nutrition—(cont.)
• Medication—(cont.)
– At greatest risk for development of drug-induced nutrient deficiencies include those who—(cont.)
o Take large numbers of drugs (five or more), whether prescription drugs, over-the-counter medications, or dietary supplements
o Are receiving long-term drug therapy
o Self-medicate
o Are substance abusers
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Integrating Nutrition—(cont.)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.
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Integrating Nutrition—(cont.)Integrating Nutrition—(cont.)• Nursing interventions
– Nutrition therapy
o Diet is a four-letter word with negative connotations.
o 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.
o Nutrition theory does not always apply to practice.
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Integrating Nutrition—(cont.)Integrating Nutrition—(cont.)• Nursing interventions—(cont.)
– Client teaching
o Clients in clinical settings may be more receptive to nutritional advice.
o Hospitalized patients are also prone to confusion about nutrition messages.
• Monitoring and evaluation
– Monitoring precedes evaluation.
– Evaluation assesses whether client outcomes were achieved.
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Physical Signs and Symptoms of Malnutrition
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
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Nursing Diagnoses with Nutritional SignificanceNursing 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
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Nursing Diagnoses with Nutritional Significance—(cont.)
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
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Obesity and Eating Disorders as Examples of Malnutrition
Malnutrition
Chapter 14
Obesity and Eating Disorders as Examples of Malnutrition
Malnutrition
Chapter 14
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Obesity and Eating DisordersObesity 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
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ObesityObesity
• Overweight is defined as having a BMI ≥25.
• Obesity is defined as having a BMI ≥30.
• Waist circumference is a better measure than BMI
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Obesity—(cont.)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.
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Obesity—(cont.)Obesity—(cont.)
• Genetics
– Estimates on the heritability of body mass index range from 40% to 70% (Herrera and Lindgren, 2010).
– Genetics are involved in:
o How likely a person is to gain or lose weight
o Where body fat is distributed
o Response to overeating
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Obesity—(cont.)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
o Abundance of palatable, low-cost, high–calorie density foods that are readily available in prepackaged forms and in fast-food restaurants
o Increasing consumption of soft drinks and snacks
o Great proportion of food expenditures spent on food away from home
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Obesity—(cont.)Obesity—(cont.)• Environment—(cont.)
– Environmental influences include—(cont.)
o Growing portion size of restaurant meals
o Low levels of physical activity
o Increases in television watching
o Widespread use of electronic devices in the home, such as computers and video games
– All lead to sedentary lifestyle.
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Obesity—(cont.)Obesity—(cont.)
• Environment—(cont.)
– Gene–environment interaction
o 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
o 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)
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Obesity—(cont.)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
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Obesity—(cont.)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.
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Obesity—(cont.)Obesity—(cont.)
• Goals of treatment—(cont.)
– Modest weight loss
1. Is more attainable
2. Is easier to maintain over the long term
3. Sets the stage for subsequent weight loss
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Obesity—(cont.)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.
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Obesity—(cont.)Obesity—(cont.)• Evaluating motivation to lose weight—(cont.)
– Treatment approaches
o A lifestyle approach is the basis of treatment for all people whose BMI is ≥30.
Includes diet modification
Exercise
Behavior modification
o Pharmacotherapy and surgery may be used in conjunction with lifestyle interventions, based on the individual’s BMI and the presence of comorbidities.
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Obesity—(cont.)Obesity—(cont.)• Treatment approaches—(cont.)
– Diet modification
o Cornerstone of most weight loss programs
o Fewer calories
o Macronutrient composition
o Micronutrient composition
o Nutrition education
o Promoting dietary adherence
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Obesity—(cont.)Obesity—(cont.)
• Treatment approaches—(cont.)
– Physical activity
o Benefits of exercise are numerous.
o Favorably impacts metabolic rate
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Obesity—(cont.)Obesity—(cont.)• Physical activity—(cont.)
– Sixty to 90 minutes of daily moderate-intensity physical activity are recommended to sustain weight loss.
– Promoting exercise adherence
o Seems to increase with less structure
o Strategies that may promote exercise adherence
Exercise at home
Exercise in multiple short bouts (10 minutes each)
Adopt a more active lifestyle
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Obesity—(cont.)Obesity—(cont.)• Behavior modification
– Focuses on changing the client’s eating and exercise behaviors
– Key behavior modification strategies
o Self-monitoring
o Goal setting
o Stimulus control
o Problem solving
o Cognitive restructuring
o Relapse prevention
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Obesity—(cont.)Obesity—(cont.)• Pharmacotherapy
– Recommended for
o People with a BMI ≥30
o People with a BMI ≥27 with comorbid conditions
o People with waist circumferences at or above IDF cut offs are also candidates for pharmacotherapy if comorbidities are present.
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Obesity—(cont.)Obesity—(cont.)
• Pharmacotherapy—(cont.)
– Drugs are central nervous system stimulants.
– Tolerance may develop after only a few weeks.
– Risk of abuse
– Common side effects
o Increased heart rate and blood pressure, dry mouth, agitation, insomnia, nausea, diarrhea, and constipation
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Obesity—(cont.)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
1. Restricting the stomach’s capacity
2. Creating malabsorption of nutrients and calories
3. A combination of both
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Obesity—(cont.)Obesity—(cont.)• Surgery—(cont.)
– Laparoscopic adjustable gastric banding (LAGB)
o An inflatable band encircles the uppermost stomach and is buckled.
o 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.
o Outlet diameter can be adjusted by inflating or deflating a small bladder inside the “belt” through a small subcutaneous reservoir.
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Obesity—(cont.)Obesity—(cont.)• Surgery—(cont.)
– Laparoscopic adjustable gastric banding (LAGB)—(cont.)
o Size of the outlet can be repeatedly changed as needed.
o Mortality rate for gastric banding is the lowest of all bariatric procedures.
o Successful weight loss after LAGB requires frequent follow-up and band adjustments.
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Obesity—(cont.)Obesity—(cont.)• Surgery—(cont.)
– Roux-en-Y gastric bypass (RYGB)
o Combines gastric restriction to limit food intake with the construction of bypasses of the duodenum and the first portion of the jejunum
o Creates malabsorption of nutrients
o “Dumping syndrome”
o Superior to gastric resection in both promoting and maintaining significant weight loss
o Major complication with RYGB is anastomotic leak.
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Obesity—(cont.)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
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Obesity—(cont.)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.
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Obesity—(cont.)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
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Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders
Not Otherwise Specified (EDNOS)
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
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Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont’d)
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
o Dieting, early childhood eating and GI problems, increased concern about weight and size, negative self-evaluation, sexual abuse, and other traumas
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Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.)
Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.)• Etiology—(cont.)
– Precipitating factors
o Onset of puberty, parents’ divorce, death of a family member, and ridicule of being or becoming fat
– People with eating disorders often suffer from
o Depression, anxiety, substance abuse, or body dysmorphic disorder
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Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.)
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.
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Nutrition Therapy for AnorexiaNutrition Therapy for Anorexia
• Step-by-step goals of nutrition therapy
1. To prevent further weight loss
2. To gradually reestablish normal eating behaviors
3. To gradually increase weight
4. To maintain agreed-on weight goal
• Half of those who receive care are expected to recover.
• Overall mortality rate is 5% to 16%.
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Nutrition Therapy for Anorexia—(cont.)Nutrition Therapy for Anorexia—(cont.)
• Involving the client in formulating individualized goals and plans promotes compliance.
• Large amounts of food may not be well tolerated.
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Nutrition Therapy for Bulimia NervosaNutrition Therapy for Bulimia Nervosa
• People with BN tend to have fewer serious medical complications than people with AN because their undernutrition is less severe.
• Nutritional counseling focuses on identifying and correcting food misinformation and fears.
• Structured and relatively inflexible to promote the client’s sense of control
• Initial meal plan provides adequate calories for weight maintenance.
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Nutrition Therapy for Bulimia Nervosa—(cont.)
Nutrition Therapy for Bulimia Nervosa—(cont.)
• Adequate fat is provided to help delay gastric emptying and contribute to satiety.
• Calories are gradually increased as needed.
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Eating Disorders Not Otherwise Specified Eating Disorders Not Otherwise Specified
• At least as common as AN and BN
• This group represents
– Subacute cases of AN or BN
– Binge eating disorder