Interventions for Clients with Malnutrition and Obesity
Nutrition plays a major role in promoting and maintaining health. Nutritional health not only contributes to positive care outcomes but also saves health care dollars. As part of a comprehensive health assessment, the nurse should include nutritional screening to identify clients who have nutritional deficits or are at risk for developing nutritional deficits. Nurses may also conduct a complete nutritional assessment (Grindel & Costello, 1996).
NUTRITION STANDARDS
Dietary Planning
Several national standards are available for planning and evaluating nutrition. The standard most widely accepted in the
The RDA can be used to estimate the adequacy of nutrient intake over time. If a client does not meet 100% of the RDA, it is incorrect to assume that he or she is nutritionally deficient. The risk of inadequate intake for any nutrient is not presumed to be increased until less than 70% of the RDA is consumed. It is also incorrect to assume that all clients in a specific population who meet 100% of the RDA are not at risk for malnutrition.
The FNB, with the involvement of Health
Disease Prevention and Health Promotion
The role of diet and nutrition in disease has been a subject of interest for many years. The current focus is on health promotion and the prevention of disease. In 1995, the Dietary Guidelines for Americans were revised by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS). These seven guidelines emphasize the importance of selecting foods to maintain a healthful diet with balance, moderation, and variety (Figure 61-1). One of the most noticeable changes from previous editions occurs in the weight guideline. For the first time, diet and physical activity are emphasized in the second guideline with the goal of maintaining or improving body weight (Kennedy, Meyers, & Layden, 1996). The Nutrition Recommendations for Canadians (Table 61-1) are similar to the Dietary Guidelines for Americans. In addition, they recommend limiting the caffeine content of the diet to no more than the equivalent of four cups of coffee per day, as well as adding fluoride to community water supplies to a level of 1 mg/L.
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The USDA developed the Food Guide Pyramid in 1992 to translate food recommendations into a practical graphic format (Figure 61-2). A pyramid format was chosen to communicate three key dietary principles: variety, moderation, and proportionality. The pyramid design emphasizes building the diet on a base of grains, fruits, and vegetables. Moderate quantities of lean meats, protein sources, and dairy products are added, and the intake of fats and sweets is limited. This guide to daily food choices has replaced the basic four foodgroups as the standard for evaluating the nutritional adequacy of dietary intake. Table 61-2 suggests the daily servings of each food group and clarifies the size of a serving. Adhering to this pattern results in a nutritionally adequate intake if a variety of foods is chosen.
A variety of vegetarian diet patterns are being adopted by increasing numbers of people for health, environmental, and moral reasons. Thelacto-vegetarian eats milk, cheese, and dairy foods but avoids meat, fish, poultry, and eggs. The lacto-ovo-vegetarian also includes eggs. The vegan eats only foods of plant origin. Vegans can develop megaloblastic anemia as a result of vitamin B12 deficiency. Vegans should include a daily source of vitamin B12 in their diets, such as a fortified breakfast cereal, fortified soy beverage, or meat analog (Messina & Burke, 1997). All vegetarians should ensure that they get adequate amounts of calcium, iron, zinc, and vitamins D and B12. Well-planned vegetarian diets can provide adequate nutrition. The Vegetarian Food Pyramid, endorsed by the Vegetarian Resource Group, can assist vegetarians withdaily food choices (Figure 61-3).
NUTRITIONAL ASSESSMENT
Malnutrition and obesity are commoutrition problems that occur as progressive changes within the client. When nutritional deficiencies or excesses develop, the body adapts through the use of homeostatic mechanisms. As the intake moves farther away from the accepted range, however, the body accommodates by reducing functional levels or changing the status or size of the affected body compartments. Thenutritional status of a client can be determined by the presence or absence of these adaptations.
Nutritional status reflects the balance between nutrient requirements and nutrient intake. Factors affecting nutrient requirements include disease, infection, and psychologic stress. Nutrient intake is influenced by disease, eating behavior, economic factors, emotional stability, medication, and cultural factors.
CULTURAL CONSIDERATIONS
Lactose intolerance (inability to tolerate milk and milk products) is a relatively common condition that occurs in a number of ethnic groups. It is found in more than 66% of Mexican Americans and 79% of African Americans, as well as in some Native American tribes, Asian Americans, and Ashkenazic Jews (Giger & Davidhizar, 1999). A small percentage of Caucasians are also lactose intolerant. The cause oflactose intolerance is an insufficient amount of the lactase enzyme, which converts lactose into absorbable glucose.
Optimal nutritional care is a major interdisciplinary outcome for clients with malnutrition and obesity. Evaluation of nutritional status is an important part of total client assessment. A thorough assessment of nutritional status includes the following:
· Review of the diet history
· Food and fluid intake record
· Laboratory data
· Food-medication interactions
· Physical examination and health history
· Anthropometric measurements
· Psychosocial assessment
Monitoring the nutritional care of a client is as important as the initial assessment. The health care provider, nurse, and dietitian collaborate to identify clients at risk for nutritional problems.
Initial Nutritional Screening
Not every client needs a complete nutritional assessment, but it is important to identify clients at risk for nutritional problems through screening. An initial nutritional screening provides the nurse with an inexpensive, quick way of determining which clients need more extensive nutritional assessment by the health care provider and dietitian.
The initial nutritional screening includes visual inspection, measured height and weight, weight history, usual eating habits, ability to chew and swallow, and any recent changes in appetite or food intake. Questions that may alert the nurse to clients at risk for nutritional problems can be incorporated into the history and physical assessment (Chart 61-1).
CONSIDERATIONS FOR OLDER ADULTS
BIO Nutritional screening can take place in the home, ambulatory care setting, hospital, or nursing home. The Nutrition Screening Manual for Professionals Caring for Older Americans (1991) is a multidisciplinary project of the American Dietetic Association, the
1. The DETERMINE Your Nutritional Health Checklist to alert older adults about the warning signs for poor nutritional health (Figure 61-4)
2. The Level I screen developed for use by professionals in health or social service settings, such as adult day-care centers, congregate meal programs, and assisted-living facilities
3. The Level II screen developed for use in medical settings such as acute care hospitals, physicians’ offices, and long-term care facilities.
Another nutritional assessment tool, the Mini Nutritional Assessment (MNA), has recently been designed and tested worldwide to provide a single, rapid assessment of older adults in ambulatory care, hospitals, and nursing homes (Vellas et al, 1999). The MNA can be completed in about 10 minutes; a low score indicates malnutrition or a risk for malnutrition.
Anthropometric Measurements
Anthropometric measurements are noninvasive methods of evaluating nutritional status. These measurements include height and weight and assessment of body fat.
BEST PRACTICE/or
Initial Nutrition Screening Assessment
The presence of one or more of the following conditions should alert the nurse that the client is at risk for malnutrition or has had a condition in the past requiring special nutritional care.
General
• Does the client have any conditions that cause nutrient loss, such as malabsorption syndromes, draining abscesses, wounds, fistulas, or protracted diarrhea?
• Does the client have any conditions that increase the need for nutrients, such as fever, burn, injury, sepsis, or antineoplastic therapies?
• Has the client been on NPO status for 3 days or more?
• Is the client receiving a modified diet or a diet restricted in one or more nutrients?
• Is the client being enterally or parenterally fed?
• Does the client describe food allergies, lactose intolerance, or limited food preferences?
• Has the client experienced a recent, unexplained weight loss?
• Is the client taking medications, either prescription, over-the-counter, or herbal/natural products?
Gastrointestinal
• Does the client complain of nausea, indigestion, vomiting, diarrhea, or constipation?
• Does the client exhibit glossitis, stomatitis, or esophagitis?
• Does the client have difficulty chewing or swallowing?
• Does the client have a partial or total gastrointestinal obstruction?
• What is the client’s state of dentition?
Cardiovascular
• Does the client have ascites or edema?
• Is the client able to perform activities of daily living?
• Does the client have congestive heart failure?
Genitourinary
• Does fluid input approximately equal fluid output?
• Does the client have an ostomy?
• Is the client hemodialyzed or peritoneally dialyzed?
Bespiratory
• Is the client receiving mechanical ventilatory support?
• Is the client receiving oxygen via nasal prongs?
• Does the client have chronic obstructive pulmonary disease (COPD) or asthma?
Integumentary
• Does the client have nail or hair changes?
• Does the client have rashes or dermatitis?
• Does the client have dry or pale mucous membranes or de
creased skin turgor?
• Does the client have pressure areas on the sacrum, hips, or
ankles?
Extremities
• Does the client have pedal edema?
• Does the client exhibit cachexia?
MEASUREMENT OF HEIGHT AND WEIGHT
Height and weight provide a baseline determination of nutritional status. The nurse or assistive nursing personnel obtains accurate measurements, because clients who report their own measurements tend to overestimate height and underestimate weight. Subsequent measurements may indicate an early change iutritional status.
Height
Clients should be measured and weighed while wearing minimal clothing and no shoes. The nurse or assistive nursing personnel determines the client’s height in inches or centimeters with the measuring stick of a weight scale. The client should stand erect and look straight ahead, with the heels together and the arms at the sides.
CONSIDERATIONS FOR OLDER ADULTS
BBS Some older adults may have difficulty standing erect, and their actual height may be less than their height on recall. If height cannot be measured directly, it should be estimated by arm span or with use of a knee-height caliper, which provides a more precise height estimate.
Weight
The nurse or assistive nursing personnel weighs ambulatory clients with an upright balance beam scale. Nonambulatory clients can be weighed with a movable wheelchair balance beam scale or a bed scale. The manufacturer should calibrate weight scales twice yearly to ensure accurate readings. For daily or sequential weights, the nurse or assistive nursing personnel notes the time and obtains the weight at the same time each day, if possible. Conditions such as heart failure and renal disease affect fluid balance and, therefore, weight.
Normal weights for adult men and women are shown in the Metropolitan Life tables (Table 61-3). The latest U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (DHHS) Dietary Guidelines contain weight guidelines that emphasize both weight maintenance and weight loss. The same healthy weight guideline applies to all adults. Older adults are no longer permitted a higher weight standard.The weight range appears in the guidelines as a chart with three categories: healthy weight, moderate overweight, and severe overweight (Figure 61-5). Either the Metropolitan Life tables or the New Weight Guidelines from the USDA and the DHHS may be used for comparison with a client’s height and weight. Some health care professionals prefer the Metropolitan Life tables because they consider body build differences by gender.
Changes in body weight can be expressed by three different formulas:
An involuntary weight loss of 10% at any time significantly affects nutritional status. Weights may need to be taken daily, several times a week, or weekly for monitoring status and the effectiveness of nutritional support.
ASSESSMENT OF BODY FAT I Body Mass Index
The body mass index (BMI), or Quetelet index, is a measure of nutritional status that does not depend on frame size. The BMI indirectly estimates total fat stores within the body by the relationship of weight to height:
BMI can also be determined using a nomogram. The least risk of death from malnutrition is associated with scores between 20 and 25 (Mahan & Escot-Stump, 1996). BMIs above and below these values are associated with increased health risks. Older, healthy adults should have a BMI between 24 and 27.
Skin Fold Measurements
Skin fold measurements estimate body fat. The nurse or dietitian may measure the client. The triceps and subscapular skin folds are most commonly measured. Both are compared with standard measurements and are recorded as per-centiles.
The nurse or dietitian can measure the triceps skin fold thickness by using a tape measure to locate and mark the midpoint on the client’s upper arm. To obtain the midpoint, the left arm is bent 90 degrees at the elbow, and the forearm is placed palm down across the middle of the body. The midpoint is half the distance between the tip of the shoulder (acromion process) and the tip of the elbow (olecranon process). The skin should be marked at this point before any measurements are made. The triceps skin fold is measured on the back of the left arm over the triceps muscle at the marked midpoint. The nurse holds a double fold of skin and subcutaneous adipose tissue between the fingers and thumb. The skin fold is held until the jaws of the skin fold caliper are placed perpendicular to the length of the skin fold at the marked midpoint. The nurse records this measurement.
Subscapular skin fold thickness indirectly estimates body fat. The body position is the same as for triceps skin fold thickness, and the same caliper is used. The nurse holds a double fold of skin and subcutaneous adipose tissue in a line from the inferior angle of the left scapula to the left elbow, applies the calipers, and records the measurement.
Arm Circumference
The midarm circumference (MAC) can be obtained to measure muscle mass and subcutaneous fat. To measure MAC, the nurse or dietitian places a flexible tape around the arm at the same marked midpoint used to measure skin fold thickness, taking care to hold the tape firmly but gently to avoid compressing the tissue. This measurement is recorded in centime-
ters. The midarm muscle mass (MAMM) measures the amount of muscle in the body and is a more sensitive indicator of protein reserves. It can be computed from the MAC and the triceps skin fold measure.
MALNUTRITION
OVERVIEW
Carbohydrates, protein, and fat supply the body with energy. Under healthy conditions, the majority of this energy undergoes digestion and is absorbed from the gastrointestinal tract. Food energy is used to maintain body temperature, respiration, cardiac output, muscle function, protein synthesis, and the storage and metabolism of food sources.
Energy balance refers to the relationship between energy expended and energy stored. When energy expended exceeds energy intake, energy stores are used to supply the deficit; this results in weight loss. Body proteins are used for energy when calorie intake is insufficient. The body attempts to meet its calorie requirements even if it is at the expense of proteieeds.
Many severely ill or traumatized hospitalized clients are at risk for protein-calorie malnutrition (PCM), also known as protein-energy malnutrition (РЕМ). PCM may present in three forms: marasmus, kwashiorkor, and maras-mic-kwashiorkor. Marasmus is generally a calorie malnutrition in which body fat and protein are wasted. Serum proteins are often preserved. Kwashiorkor is a lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low. Marasmic-kwashiorkor is a combined protein and energy malnutrition. This problem often presents clinically when metabolic stress is imposed on a chronically starved client. The outcome of unrecognized or untreated PCM is often dysfunction or disability and increased morbidity and mortality.
Pathophysiology
Malnutrition is a multinutrient problem because foods that are good sources of calories and protein are also good sources of other nutrients. In the malnourished client, protein catabolism exceeds protein intake and synthesis, resulting iegative nitrogen balance, weight loss, decreased muscle mass, and weakness.
CONSIDERATIONS FOR OLDER ADULTS
BfiaOlder adults are at a high risk for poor nutrition due to cognitive impairments, complicated physical conditions, or chronic disease. Malnutrition in older adults has been associated with increased complications from infections and slower recovery from physiologic stresses such as surgical wounds, bone fractures, pressure ulcers, and loss of functional capacity (
The functional ability of the liver, heart, lungs, gastrointestinal tract, and immune system diminishes in the client with malnutrition. A decrease in serum proteins (hypopro-teinemia) occurs as protein synthesis in the liver decreases. Vital capacity is also reduced as a result of respiratory muscle atrophy; cardiac output diminishes. Malabsorption occurs because of atrophy of gastrointestinal mucosa and the loss of intestinal villi.
Other complications of severe malnutrition in adults include the following:
· Leanness and cachexia (muscle wasting)
· Decreased effort tolerance
· Lethargy
· Intolerance to cold
· Edema
· Dry, flaking skin and various types of dermatitis Poor wound healing and a higher than usual number of infections, particularly postoperative infection
Etiology
Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently. Infectious diseases, such as tuberculosis and human immunodeficiency virus (HIV) infection, are also precipitating factors in PCM. Diseases that produce diarrhea and respiratory and other infections leading to anorexia result iegative calorie and protein balance; anorexia then leads to poor food intake. Vomiting leads to decreased absorption with increased nutrient losses. Medical treatments such as chemotherapy can also cause malnutrition. In addition, catabolic processes increase nutrient requirements and metabolic losses.
Inadequate nutrient intake can also result when a person is admitted to the hospital or nursing home (Dudek, 2000). Decreased staffing may not allow time for clients who need to be fed, especially older adults who may eat slowly (
Unrecognized dysphagia is a common problem iursing homes and can cause malnutrition, dehydration, and aspiration pneumonia. A study by Kayser-Jones and Pengilly (1999) found that 45 of 82 residents in one nursing home had some degree of dysphagia (difficulty swallowing) ranging from mild to profound. Only 10 of the 45 residents had been referred for dysphagia evaluation by a speech-language pathologist.
Eating disorders, such as anorexia nervosa and bulimia ner-vosa, also lead to malnutrition. Anorexia nervosa is a self-induced starvation resulting from a fear of fatness, even though the client is underweight. Bulimia nervosa is characterized by episodes of binge eating in which the client ingests a large amount of food in a short time. The binge eating is followed by some form of purging behavior, such as self-induced vomiting and/or an excessive use of laxatives and diuretics. If not treated, death can result from starvation, infection, or suicide. Information about eating disorders can be found in textbooks on mental health nursing.
Incidence/Prevalence
Malnutrition is present in many hospitalized clients (Dudek, 2000). In a review of eight studies with more than 1347 hospitalized adults, 40% to 55% were determined to be malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Malnourished clients heal more slowly, suffer more complications, and have a higher mortality rate. Surgical clients with a likelihood of malnutrition were two to three times more likely to experience minor and major complications and excess mortality. Length of hospitalization in mal-
nourished medical-surgical clients can be extended by as much as 90%, which clearly increases health care costs (Gallagher-Allred et al., 1996).
The prevalence of PCM in long-term care facilities has been reported to range from 10% to 85% (
Acute PCM may develop in clients who were adequately nourished before hospitalization if they experience starvation while in a catabolic state from infection, stress, or injury. Chronic PCM can occur in clients who have cancer, end-stage renal or hepatic disease, or chronic neurologicdisease.
WOMEN’S HEALTH CONSIDERATIONS As many as 25% of the general older adult population may be malnourished, most of them women (Wellman, 1997). Older women are particularly at risk for PCM (Chart 61 -2) because of the following:
• Acute and chronic disease
• Processes that lead to a reduction of food intake
• Malabsorption and maldigestion
• Decreased efficiency of nutrient use
• Multiple medication therapy
• Poverty
• Social isolation
• Dependency/disability
Women, especially adolescents and young adults, are more likely than men to have eating disorders. Caucasian women are at the highest risk for these health problems.
CULTURAL CONSIDERATIONS
In Western countries, cultural factors do not seem to have a major influence on the development of malnutrition. However, newly arriving immigrants from developing countries may be at risk for malnutrition because of limited food supplies, poverty, and eating habits.
In the Native American population of the
COLLABORATIVE MANAGEMENT
Assessment
HISTORY
The nurse reviews the medical history to determine the diagnosis, possibility of increased metabolic needs or nutritional losses, chronic disease, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent, significant weight loss. Each of these conditions can contribute to malnutrition. For older adults, the nurse also explores mental status deterioration, poor eyesight or hearing, diseases affecting major organs, constipation or incontinence, slowed reactions, a review of prescription and over-the-counter medications (including herbal and natural supplements), and physical disabilities.
For clients who live independently, the nurse or occupational therapist assesses the performance of instrumental activities of daily living (IADLs). Functional status can best be evaluated for institutionalized clients by assessing their performance of activities of daily living (ADLs). An inability to perform any of the eight IADLs or any of the six ADLs indicates a high level of dependence and the potential for disease and poor nutritional status (Nutrition Screening Manual, 1991). When functional status is evaluated with nutritional status, there appears to be a strong predictability of infections and complications among institutionalized adults. Chapter 10 describes functional assessment in detail.
The nurse interviews the client to obtain information about his or her usual daily food intake, eating behaviors, change in appetite, and recent weight changes. The client is asked to describe the usual foods eaten daily and the times of meals and snacks. This information is then compared with the Food Guide Pyramid for gross deficiencies. The dietitian can more thoroughly analyze the diet, if necessary.
The nurse explores with the client any changes in eating habits as a result of illness. Any change in appetite, taste, and weight loss is recorded. A weight loss of 5% or more in 30 days, a weight loss of 10% in 6 months, or a weight that is below ideal body weight is significant for malnutrition.
Difficulty or pain in chewing or swallowing is also assessed. The nurse asks the client whether any foods are avoided and why. The occurrence of nausea, vomiting, heartburn, or any other symptoms of discomfort with eating is also recorded. Finally, the client is asked about dental health problems, including the presence of dentures. Dentures or partial plates that do not fit well interfere with food intake.
iPHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The nurse assesses for signs and symptoms of various nutrient deficiencies (Table 61-4). The nurse inspects the client’s hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems. The condition of the skin, including any red dened or open areas, is observed. The anthropometric measurements previously described may also be obtained. The nurse or assistive nursing personnel monitors all food andfluid intake, observes the client at mealtime, and notes any mouth pain or difficulty in chewing or swallowing.
PSYCHOSOCIAL ASSESSMENT
The psychosocial history provides information about the client’s economic status, occupation, educational level, living and cooking arrangements, and mental status. The nurse determines whether financial resources are adequate for providing the necessary food. If resources are inadequate, the social worker may refer the client to available community services.
LABORATORY ASSESSMENT
Routine laboratory tests provide additional information about nutritional status. These tests supply objective data that can support subjective data and identify preclinical deficiencies. Laboratory tests must be carefully interpreted with regard to the total client; an isolated value may yield an inaccurate conclusion.
HEMATOLOGY. Hemoglobin is measured to detect iron deficiency anemia. A low hemoglobin level may indicate anemia, recent hemorrhage, or hemodilution caused by fluid retention. Hemoglobin may be low secondary to conditions such as low serum albumin, infection, catabolism, or cancer. High hemoglobin levels may indicate hemoconcentration or dehydration, or they may be secondary to liver disease.
Hematocrit, a measure of cell volume, indicates iron status. Low hematocrit levels may reflect anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis. High hematocrit levels may indicate dehydration or hemoconcentration.
PROTEIN STUDIES. Serum albumin, transferrin, and thyroxine-binding prealbumin can be measured in the laboratory. Serum albumin indicates the body’s protein status but is not sensitive enough to detect early changes iutritional status. The normal serum albumin level for men and women is greater than 3.5 g/dL. Table 61-5 indicates the level of protein depletion based on the serum albumin level.
Serum transferrin, an iron-transport protein, can be measured directly or calculated as an indirect measurement of total iron-binding capacity (TIBC) as follows:
Calculated transferrin = (0.68 x TIBC) + 21
Serum transferrin has a shorter half-life of 8 to 10 days and therefore is a more sensitive indicator of protein status than is albumin. Table 61-6 indicates the level of protein depletion based on serum transferrin level.
Thyroxine-binding prealbumin (PAB) provides a more sensitive indicator of protein deficiency because of its short half-life of 2 days. Depending on the laboratory test used, the normal PAB range is 17 to 40 mg/dL. PAB can also assess improvement iutritional status withrefeeding; levels can increase by 1 mg/dL/day with adequate nutritional support. However, this test is expensive, and its cost may be prohibitive except at large facilities.
SERUM CHOLESTEROL. Cholesterol levels normally range between 160 and 200 mg/dL in adult men and women. Values are typically low with malabsorption, liver disease, pernicious anemia, terminal stages of cancer, sepsis, or stress. A cholesterol level below 160 mg/dL has been identified as a possible indicator of malnutrition.
OTHER LABORATORY TESTS. Total lymphocyte count (TLC) can be used to assess immune function. Malnutrition suppresses the immune system and leaves the client more vulnerable to infection. When a client is malnourished, the TLC is usually decreased below 1500 mm3(Bender et al., 2000).
Analysis
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The most common diagnosis for the client with malnutrition is unbalanced Nutrition: Less Than Body Requirements related to inadequate food intake or increased nutrient requirements.
К ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnosis, clients with malnutrition may have one or more of the following:
• Risk for Impaired Skin Integrity related to depleted protein stores
Risk for Infection related to suppressed immune system
• Risk for Disturbed Body Image related to physical changes from weight loss
Some clients with malnutrition are at risk for collaborative problems such as the following:
• Anemia
• Immunocompromised state
•
Planning and Implementation
■ UNBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
PLANNING: EXPECTED OUTCOMES. The client with malnutrition is expected to (1) demonstrate an adequate nutrient intake, (2) maintain body mass and weight within normal limits (WNL), and (3) maintain laboratory values WNL (e.g., albumin).
INTERVENTIONS. The preferred route for feeding is through the gastrointestinal tract because it enhances the immune system and is safer, easier, less expensive, and more physiologically sound (Chart 61-3).
NUTRITION MANAGEMENT. In collaboration with the health care provider and dietitian, the nurse provides high-calorie, high-protein foods (e.g., milkshakes, cheese and crackers). A feeding schedule of six small meals benefits many clients. If the client has difficulty chewing or is edentulous (toothless), a pureed or dental soft diet may facilitate food intake.
Malnourished ill clients ofteeed to be encouraged to eat. The nurse provides a quiet environment, which is conducive to eating. Some clients, especially older adults, may take a long time to eat even small quantities of food.
Restorative feeding programs help nursing home residents who need special assistance. These residents eat in a separate dining area so that time and attention can be given to them. Chart 61-4 offers additional interventions to increase nutritional intake for older adults in any setting.
DRUG THERAPY. Medications may be given to some clients to stimulate appetite. For example, cyproheptadine (Periactin), an antihistamine, may be ordered for clients who are underweight, especially those with eating disorders. Megestrol acetate (Megace), an antineoplastic drug, may be used to increase appetite in clients who have cachexia, acquired immunodeficiency syndrome (AIDS), or unexplained weight loss. The mechanism for how these drugs work to increase appetite is unknown.
PARTIAL ENTERAL NUTRITION. The dietitian calculates the nutrients required daily and translates these requirements into meals for the client. If the client cannot ingest sufficient nutrients as food, partial enteral nutrition with fortified medical nutritional supplements (MNSs) (e.g., Ensure or Carnation Instant Breakfast) may be given, especially for older adults. Many commercial enteral products are available. For clients with medical diagnoses such as liver and renal disease, special products that meet their needs are also available. The client must enjoy the taste of the product for acceptability and optimal intake.
CONSIDERATIONS FOR OLDER ADULTS
Supplements used in acute care, long-term care, and home care are costly. In addition, older adults may refuse them, and the supplements are then wasted. Bender at al. (2000) found that a more successful alternative to having the MNS distributed by food service or nursing assistant staff in the nursing home was to have the supplements delivered by nurses during their usual medication passes. In this study, the nurses gave 60 mL or more of the MNS at least four times a day with the clients’ medications. The subjects increased weight and had fewer pressure ulcers, thus making the program very cost-effective.
Nutritional supplements are supplied as liquid formulas, powders, bars, and puddings in a variety of flavors. They come in different degrees of sweetness and are also available as modular supplements that provide single nutrients. Examples of modular supplements are Polycose for carbohydrates and ProPac for protein. Carbohydrate modulars are useful only if additional calories are needed. Protein modulars are indicatedwhen metabolic stress causes a need for higher protein intake.
The nurse bases adequate daily fluid intake on 30 mL of fluid per kilogram of body weight. This recommendation is not for clients with severe cardiac problems or fluid restrictions. The health care provider may also prescribe vitamin and mineral supplements.
The nurse or assistive nursing personnel maintains a daily calorie count and fluid intake to assess whether the client can meet the goals of nutritional therapy. The dietitian usually asks the nursing staff to keep the food intake record for at least 3 consecutive days. Accurate daily or weekly weights are also essential depending on the amount of depletion.
TOTAL ENTERAL NUTRITION. Clients often cannot meet the goals of nutritional therapy through their usual oral intake because of increased metabolic demands or a decreased ability to eat. In such cases, enteral tube feeding may be necessary to supplement oral intake or to provide total nutritional support.
CANDIDATES FOR TOTAL ENTERAL NUTRITION.
Clients likely to receive total enteral nutrition (TEN) can be divided into three groups:
Clients who can eat but cannot maintain adequate nutrition by oral intake of food alone Clients who have permanent neuromuscular impairment and cannot swallow
Clients who do not have permanent neuromuscular impairment but are critically ill and cannot eat because of their condition
Clients in the first group are often older adults or clients receiving cancer treatment who cannot meet their calorie and proteieeds (see the Legal/Ethical Issues in Health Care box below). Clients in the second group usually have permanent swallowing problems and require some type of feeding tube for delivery of the enteral product on a long-term basis. Examples of conditions that can cause permanent swallowing problems are strokes, severe head trauma, and advanced multiple sclerosis. Clients in the third group receive enteral nutrition for as long as their illness lasts. The feeding is discontinued when the client improves and can eat again. Total enteral nutrition is contraindicated for clients with diffuse peritonitis, severe pancreatitis, intestinal obstruction, intractable vomiting or diarrhea, and paralytic ileus (Bowers, 1996).
TYPES OF ENTERAL PRODUCTS. Many commercially prepared enteral products are available. An appropriate combination of carbohydrates, fat, vitamins, minerals, and trace elements is available in liquid form. Differences among products allow the dietitian to select the right formula for each client. An order from the health care provider is required for enteral nutrition, but the dietitian usually makes the recommendation and computes the amount and type of product needed for each client.
METHODS OF ADMINISTRATION OF TOTAL ENTERAL NUTRITION. TEN is administered as “tube feedings” through one of the available gastrointestinal tubes, either via a nasoenteric tube (NET) or an enterostomal tube.
Types of Tubes. A nasoenteric tube is any feeding tube inserted nasally and then advanced into the gastrointestinal tract. Commonly usedNETs include the nasogastric (NG) tube and the nasoduodenal tube (NDT). A nasojejunal tube (NJT) is also available but is used less often than the other NETs. NDTs and NJTs are usually indicated for critically ill clients at risk for aspiration or delayed stomach emptying.
NETs are used for delivering short-term enteral feedings because they are easy to use and are safer for the client at risk for aspiration if the tip of the tube is placed below the pyloric sphincter of the stomach. Small-bore polyurethane or silicone tubes from 8 to 12 French external diameter are preferred over large-bore plastic or latex tubes. The smaller tubes are more comfortable and are less likely to cause complications such as nasal irritation, sinusitis, tissue erosion, and pulmonary compromise.
Enterostomal feeding tubes are used for clients who need long-term enteral feeding. The most common types are gas-trostomies andjejunostomies. The physician directly accesses the gastrointestinal tract using various surgical, endoscopic, and laparoscopic techniques.
A gastrostomy is a stoma created from the abdominal wall into the stomach through which a short feeding tube is inserted by the physician. Thegastrostomy may require a small abdominal incision or may be placed endoscopically; these tubes are called percutaneous endoscopicgastrostomy (PEG) or dual access gastrostomy-jejunostomy (PEG/J) tubes. The PEG does not require general anesthesia and is more secure and more durable than traditional gastrostomies. An alternative to either device is the low-profile gastrostomy device (LPGD). The LPGD is available with a firm or balloon-style internal bumper or retention disk. An antireflux valve keeps gastrointestinal contents from leaking onto the skin. This device is less irritating to the skin, longer lasting, and more cosmetically pleasing, and it allows greater client independence. However, skin-level devices do not allow easy access for checking residuals.
Jejunostomies are used less often than gastrostomies. A je-junostomy is used for long-term feedings when it is desirable to bypass the stomach, such as with gastric disease, upper gastrointestinal obstruction, and abnormal gastric or duodenal emptying.
Types of Feedings. Tube feedings are administered by bolus feeding, continuous feeding, and cyclic feeding. Bolus feeding is an intermittent feeding of a specified amount of en-teral product at specified times during a 24-hour period— typically every 4 hours. This method can be accomplished manually or by infusion through a mechanical pump or controller device. A more popular method of tube feeding is continuous enteral feeding. Continuous feeding is similar to IV herapy in that small amounts are continuously infused (by gravity drip or by a pump or controller device) over a specified time. Cyclic feeding is the same as continuous feeding except that the infusion is stopped for a specified time in each 24-hour period, usually 6 to 10 or more hours (“down time”). Down time typically occurs in the morning to allow bathing, bed making, and other treatments.
Infusion rates for continuous and cyclic feedings (and to some extent for intermittent bolus feeding) vary with the total amount of solution to be infused, the specific composition of the product, and the response of the client to the procedure.
The health care provider and dietitian usually decide the type, rate, and method of tube feeding, as well as the amount of additional water needed. If the client can swallow small amounts of food, he or she may also eat orally while the tube is in place.
The nurse is responsible for the care and maintenance of the feeding tube and the enteral feeding. Chart 61-5 lists the major nursing interventions for the client receiving an enteral feeding.
COMPLICATIONS OF TOTAL ENTERAL NUTRITION.
The nurse is responsible for the prevention, assessment, and management of complications associated with tube feeding. Some complications of therapy result from the type of tube used to administer the feeding, and other complications result from the enteral product itself. The most common problem associated with feeding tubes is the development of a clogged tube. Chart 61-6 lists nursing interventions for maintaining a patent tube.
A less common but more serious complication is dislodge-ment of the tube. Several techniques should be used to confirm proper placement. An x-ray study is the most accurate confirmation method and should always be done on initial tube insertion. After the initial placement is confirmed, the nurse checks the placement before each intermittent feeding or at least every 8 hours during continuous or cyclic feeding.
The traditional auscultatory method is not reliable, especially for clients with small-bore tubes (see the Evidence-Based Practice for Nursingbox on p. 1371). In this method, the nurse instills 20 to 30 mL of air into the tube while listening over the stomach with a stethoscope. The whooshing sound that results does not guarantee correct tube placement. The nurse should instead aspirate a sample of the gastrointestinal content, observe its color, and test its pH. When aspirating fluid, the nurse waits at least 1 hour following medication administration, then flushes the tube with 20 mL of air to clear it. The aspirate is collected and tested with pH paper. The pH of gastric fluid ranges from 0 to 4.0. If the tube has migrated down into the intestines, the pH will be between 7.0 and 8.0. If the tube is in the lungs, the pH will be greater than 6.0 (Metheney at al., 1998). The pH may also be as high as 6 if the client takes certain medications, such as H2 blockers (e.g., ranitidine [Zantac] and famotidine[Pepcid]).
Fluid Imbalances
Clients receiving enteral nutrition therapy are at an increased risk for fluid imbalances. Clients who receive this therapy are often older or debilitated and may also have cardiac or renal problems. Fluid imbalances associated with enteral nutrition are usually related to the body’s response to increased serum osmolarity.
Increased Osmolarity. Osmolarity is the amount or concentration of particles dissolved in solution. This concentration exerts a specific osmotic pressure within the solution. Normal osmolarity of extracellular fluid (ECF) ranges between 270 and 300 mOsm. Enteral feeding products range in osmolarity from isotonic (about 300 mOsm) to extremely hy-pertonic (600 mOsm). Electrolytes (including sodium) contribute to this hypertonicity, but more of the osmolarity is determined by the concentration of proteins and sugar molecules in the enteral product. Even when the product is isotonic, the ECF can become hyperosmolar unless some hy-potonic fluids are also administered to the client. This situation is most likely to develop in clients who are unconscious, unable to respond to the thirst reflex, on fluid restrictions, or receivinghyperosmotic enteral preparations.
An increase in the osmolarity of the plasma increases the osmotic pressure of the plasma. Because this increased osmolarity is largely a result of extra glucose and proteins (which tend to remain in the plasma rather than move to interstitial spaces), the plasma osmotic pressure (water-pulling pressure) is increased. In this situation, intracellular and interstitial water move into and expand the plasma volume. This volume expansion results in an increased renal excretion of water (among clients with normal renal function) and leads to osmotic dehydration. If clients do not have normal renal and cardiac function, the expansion of the plasma volume can lead to circulatory overload and the formation of pulmonary edema, especially in older adults. The nurse assesses for signsand symptoms of circulatory overload and collaborates with the dietitian and physician in planning the correct amount of fluid to be provided to the client.
Dehydration. Excessive diarrhea may develop when hyperosmolar enteral preparations are delivered quickly. This situation can also lead to dehydration through excessive water loss. The nurse consults with the health care provider and dietitian for recommendations to prevent diarrhea.
First, the dietitian usually changes the feeding to a more iso-osmolar formula. Most of these formulas can be started full-strength but slowly at 15 to 20 mL/hr. The rate is gradually increased as the client tolerates and as the expected nutritional outcome is achieved. If diarrhea continues, the client should be evaluated for Clostridium difficile and its toxins.
In some cases, diarrhea may be the result of liquid medications, such as elixirs and suspensions that have a very high osmolality. Examples include acetaminophen, digoxin, furos-emide, phenytoin, and potassium chloride. Clients receiving multiple liquid medications need to be evaluated to determine if their drug regimen can be changed to prevent diarrhea. Diluting these liquids may also be an option.
Another cause of diarrhea-related fluid imbalance among clients receiving enteral feeding preparations is lactose intolerance. Clients receiving milk-based enteral feeding preparations may become lactose intolerant. Most commercial enteral products, such as Ensure, are lactose free.
Vines et al. (1992) conducted a comprehensive review of research on diarrhea related to tube feeding. They concluded that diarrhea often results from bacterial contamination, and they implemented interventions for decreasing this risk.
Electrolyte Imbalances. Depending on the client’s state of health, certain electrolyte imbalances can be avoided. This is achieved by the use of enteral preparations containing lower concentrations of the electrolytes that the client cannot handle well.
In addition to the client’s specific electrolyte imbalances, the two most common electrolyte imbalances associated with enteral nutrition therapy are hyperkalemia and hypernatremia. Both of these conditions may be related to hyperglycemia-in-duced hyperosmolarity of the plasma and the resultant osmotic diuresis. Electrolyte imbalances are discussed in detail in Chapter 13.
CRiTICAL THINKING CHALLENGE
W An older adult in your nursing home has been eating less than 50% of her meals since admission the previous week. She has lost 3 pounds in 5 days. The nursing assistant reports to you today that the resident has a reddened area on her sacrum that does not blanch. When you speak to this client, she tells you that she is upset about being “put in a home.”
• What other assessments should you perform at this time?
• What are her priority nursing diagnoses?
• What interventions are appropriate for her now?
PARENTERAL NUTRITION. When a client cannot effectively use the gastrointestinal tract for nutrition, parenteral nutrition therapy may maintain or improve his or her nutritional status. This form of IV therapy differs from standard IV therapy in that all nutrients (carbohydrates, proteins, fats, vitamins, minerals, and trace elements) are delivered to the client.
One liter of fluid containing 5% dextrose, which is often used as standard IV therapy, provides only 170 kcal. A hospitalized client typically receives 3 or
Parenteral nutrition (hyperalimentation, or “hyperal”) is subdivided into two categories:
• Partial parenteral nutrition, or peripheral parenteral nutrition
• Total parenteral nutrition, or central parenteral nutrition
As suggested by the names, these categories differ by the site of administration and the content of the solutions.
PARTIAL PARENTERAL NUTRITION. Partial parenteral nutrition (PPN) provides nutritional support to clients who are unable or unwilling to take a feeding via the gastrointestinal tract. PPN is typically used when a client has a prolonged postoperative ileus or when placement of a central IV line is not advised. It is used wheutritional support is needed less than 14 days. The client should be able to tolerate large fluid volumes and have readily accessible peripheral veins.
PPN is usually delivered through a cannula or catheter in a large distal vein of the arm. Two types of solutions are commonly used in various combinations for PPN: lipid (fat) emulsions and amino acid dextrose solutions.
Most lipid emulsions (20%) are isotonic, but the tonicity of commercially prepared amino acid dextrose solutions ranges from 300 mOsm to nearly 1200 mOsm. Amino acid dextrose solutions are considered more stable than the lipid emulsions, and therefore additives (e.g., vitamins, minerals, electrolytes, and trace elements) tend to be mixed with the amino acid dextrose solutions. The amino acid dextrose solution must be delivered through an in-line filter. Lipids and amino acid dextrose solutions are administered by a pump or controller device for accuracy and constancy in delivery rate.
A newer product for PPN is a mixture of lipids (10% or 20% fat emulsion) and an amino acid dextrose (usually 10%) solution. This mixture of three types of nutrients is referred to as a 3:1, total nutrient admixture (TNA), or triple-mix solution; it is available in 3-L bags.
TOTAL PARENTERAL NUTRITION. When the client requires intensive nutritional support for an extended time, the health care provider prescribes centrally administered total parenteral nutrition (TPN). TPN is delivered through access to central veins, usually the subclavian or internal jugular veins. Central venous catheters and associated nursing care are described in detail in Chapter 14.
TPN solutions contain higher concentrations of dextrose and proteins, usually in the form of synthetic amino acids or protein hydrolysates(3% to 5%). These solutions are hyper-osmotic (three to six times the osmolarity of normal blood). The base solutions are available as commercially prepared solutions. The hospital or community pharmacist adds components (specific electrolytes, minerals, trace elements, and insulin) according to the client’s nutritional needs. This therapy provides needed calories and spares body proteins from ca-tabolism for energy requirements.
TPN solutions are administered with a pump or an infusion controller device. The osmolarity of the fluid and the concentrations of the specific components make controlled delivery essential.
COMPLICATIONS OF PARENTERAL NUTRITION.
Clients receiving PPN or TPN are at risk for a wide variety of serious and potentially life-threatening complications. Complications may result from the PPN and TPN solutions or from the central venous catheter. The following discussion is limited to the complications of PPN and TPN that involve fluid or electrolyte balance. Complications of IV cannulas and central venous catheters are discussed in Chapter 14.
Fluid Imbalances. Clients receiving PPN or TPN are at increased risk for fluid imbalance. Not only is fluid delivered directly into the venous system, but the extreme hyperosmo-larity of the solutions stimulates fluid shifts between body fluid compartments.
The hyperosmolarity of parenteral nutrition solutions is caused by their amino acid and dextrose concentrations. Increased dextrose causes hyperglycemia. As a result, some of the dextrose moves into the interstitial and intracellular spaces, where it is metabolized. However, dextrose remains in the plasma volume when the solutions are administered too rapidly, without enough insulin coverage, or in the presence ofhyponatremia and hypokalemia. The result is a shift of water from the interstitial and intracellular spaces into the plasma. Expansion of the plasma volume together with hyperglycemia can cause osmotic diuresis and lead to serious dehydration and hypovolemic shock. If the client has an accompanying cardiac or renal dysfunction, the situation can lead to overhydration, congestive heart failure, and pulmonary edema.
The nurse monitors for these complications by taking daily weights and by recording accurate intake and output while the client is receivingparenteral nutrition. Serum glucose and electrolyte values are also monitored (Chart 61-7). Any major changes or abnormalities are reported to the health care provider.
Electrolyte Imbalances. Clients receiving either PPN or TPN are at an increased risk for many different electrolyte imbalances, depending on the electrolyte composition of the solution and whether a fluid imbalance occurs. The health care provider usually orders daily determinations of serum electrolyte levels to detect these imbalances. The risk of metabolic and electrolyte complications is reduced when the rate of administration is carefully controlled and clients are closely monitored for response to treatment. Potassium and sodium imbalances are common among clients receiving PPN and TPN, especially when insulin is also administered as part of the therapy. Calcium imbalances, especiallyhypercalcemia, are associated with PPN and TPN, although immobility may play more of a role than the actual parenteral therapy in the development of this imbalance.
EFFECTS OF MEDICATION. There is no specific drug therapy for malnutrition, although multivitamins and an iron preparation may be prescribed to treat or prevent anemia. The nurse carefully reviews the client’s medications because of food-medication interactions. Medications can affect nutritional status, and the foods ingested can affect the efficacy of medications.
Community-Based Care
Malnourished clients can be cared for in a variety of settings, including the acute care hospital, subacute unit, nursing home, or their own home. Malnutrition is often diagnosed when the client is admitted to the acute care hospital or as a consequence of events that occur after hospitalization, such as poor wound healing or sepsis. If the client is severely compromised, he or she may require admission to a subacute unitor traditional nursing home for either transitional or long-term care and be followed by a case manager. If adequate home support is available, the client may be discharged to home in the care of a family member, significant other, or other care-giver. Home care nurses may be needed to monitor and direct the care.
HEALTH TEACHING
The dietitian instructs the malnourished client and the family about high-calorie, high-protein diet and nutritional supplements. The pharmacist reviews any parenteral solutions with the client and family or significant others.
The nurse reinforces the importance of adhering to the diet and reviews any medications the client may be taking. If the client takes an iron preparation, the nurse teaches the importance of taking the medication immediately before or during meals. The nurse also cautions the client that iron tends to cause constipation. For the older adult already susceptible to constipation, the nurse stresses measures for prevention, including adequate fiber intake, adequate fluids, and exercise.
HEALTH CARE RESOURCES
The malnourished client may need help from community resources. Once nutrition therapy has progressed, the client may be discharged to the home setting or to a long-term care facility. The nurse collaborates with the case manager or discharge planner to find the best placement for each client. If the client is discharged to home, a home care nurse may visit until the client is stable.
Whether the client is discharged to home or to another facility, the dietitian provides written instructions about the diet and nutritional supplements. Communication with the new care provider is essential for continuity of care.
Evaluation: Outcomes
NOO The nurse evaluates the care of the malnourished client on the basis of the identified nursing diagnoses and collaborative problems. Expected outcomes include that the client:
• Has an adequate intake of all required nutrients on a daily basis
• Experiences no further weight loss or has a weight in crease
• Has laboratory values withiormal limits (WNL)
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OBESITY
OVERVIEW
The terms obesity and overweight are often used interchangeably, but they refer to different conditions. Overweight is an increase in body weight for height compared with a reference standard, such as the Metropolitan Life height and weight tables (see Table 61-3) or 10% greater than ideal body weight. However, this weight may not reflect excess body fat. It is possible for well-developed athletes to appear overweightbecause of increased muscle mass; in such cases the proportion of muscle to fat is greater than average.
An obese person weighs at least 20% above the upper limit of the normal range for ideal body weight. Morbid obesity refers to a weight that has a negative effect on health—usually more than 100% above ideal body weight.
■ HOME CARE MANAGEMENT
The malnourished client needs a variety of resources at home to continue aggressive nutrition support. If the client can consume food by the oral route, the case manager or other discbarge planner determines whether his or her financial resources are adequate for providing the necessary food and nutrition supplements. If the hospital provides ambulatory nutrition counseling services, the client is scheduled for follow-up after discharge for assessment of weight gain. The nurse assesses the ability of the client and family to understand and comply with instructions.
The malnourished client discharged to home on enteral or parenteral nutrition support needs the specialized services of a home nutrition therapy team. This team generally consists of the physician, nurse, dietitian, pharmacist, and social worker. Several commercial companies supply these services to clients in addition to the feeding supplies and formulas.
Pathophysiology
Obesity refers to an excess amount of body fat. It is possible to be obese at a weight that is withiormal range according to a reference standard. The normal amount of body fat in men is between 15% and 20% of body weight. Obese young men have body fat greater than 22%, and older obese men have body fat greater than 25%. For women, the normal amount of body fat is 18% to 32%. Obese young women havebody fat greater than 35% (Bray, 1994). Body fat can be measured in several ways. Height and weight are the easiest and most practical measurements for determining the degree of overweight.
OBESITY INDICES
To establish the percentage of ideal body weight (IBW), the height and weight of the client are compared with the midpoint of the desirable weight for a medium frame of the client’s height and sex in the Metropolitan Life height and weight tables (see Table 61-3). The body mass index (BMI), as described previously on p. 1363, is a measure of heaviness and is only an indirect indicator of body fat. It reflects the combined effects of body build, proportions, lean body mass, and body fat. However, BMI has exhibited substantial correlations with fat mass for adult men and women and has been validated as a risk factor for cardiovascular disease. As a general rule, a BMI of 27 indicates obesity and an increased risk for health problems. Arm circumference and skin fold measurements more completely define body composition and adiposity.
The distribution of excess body fat rather than the degree of obesity has been used to predict increased health risks. The waist-to-hip ratio (WHR) or abdominal/gluteal ratio (AGR) differentiates a predominantly peripheral (gynecoid) lower body obesity from a central (android) upper body obesity. A WHR of 0.95 or greater in men (0.8 or greater in women) indicates android obesity with excess fat at the waist and abdomen; this pattern carries the greatest health risk. Two risk groups have been identified by location of abdominal fat: one with subcutaneous fat and one with intra-abdominal fat. The group with subcutaneous fat had fewer complications than did the group with excess intra-abdomi-nal fat. Cross-sectional studies have shown that increased abdominal fat has been related to stroke, insulin resistance,hyperinsulinemia, and frank diabetes mellitus. Excessive abdominal fat may also enhance the risk for gallbladder disease (Pi-Sunyer, 1993).
COMPLICATIONS OF OBESITY
Obesity is a major public health problem and is associated with many complications, including death. As a result of this increasing problem, the Healthy People 2010 agenda addresses the need to reduce the proportion of children, adolescents, and adults who are obese. Nurses can help meet this goal through education and role modeling (see the Meeting Healthy People 2010 Objectives box above).
Complications of obesity that improve with weight loss include the following:
· Diabetes mellitus
· Hypertension
· Hyperlipidemia (increased serum lipids)
· Cardiac disease
· Sleep apnea
· Cholelithiasis
· Chronic back pain
· Early degenerative arthritis
· Certain types of cancer
Obese people are also more susceptible to infectious diseases than are thinner people.
CLASSIFICATION
Bray (1994) has developed a classification of obesity based on BMI and the corresponding risk for disease (Table 61-7). This classification system eliminates describing obesity in unflattering and prejudicial terms such as morbid or gross.
Etiology
The cause of obesity involves complex interrelationships of many factors, including the following: 1 Genetic
Environmental
· Psychologic
· Social
· Cultural
· Pathologic
· Physiologic
Five major causes of both human and animal obesity have been identified (Bray, 1994). The first, neuroendocrine causes, include injury to the hypothalamus, Cushing’s disease, polycystic ovary failure, hypogonadism, and growth hormone deficiency and insulinoma.
A second cause is dietary obesity associated with high-fat diets. Data suggest that obesity associated with a high-fat diet is more pronounced when the diet contains a significant amount of saturated fat.
Genetic factors are being studied as a third cause. They are found in clinically uncommon states, such as Prader-Willi syndrome. Genetic composition may predispose some people but not others to obesity. Researchers have recently identified the ob gene in mice, which helps to regulate energy balance. Leptin, the hormone encoded by the ob gene, appears to send a message to the brain that the body has stored enough fat; this serves as a signal to stop eating. For obese humans, a variant in this gene may mean that the body does not receive the signal to stop eating. More recent evidence suggests that energy balance and adiposity are regulated not only by the hormonal action of leptin and its receptors but also by the interaction of leptin and insulin with the hypothalamic neuropeptide Y system (Schwartz & Seeley, 1997).
The fourth cause of obesity is drug treatment. Drugs that promote obesity include the following:
· Corticosteroids
· Estrogens
· Nonsteroidal anti-inflammatory drugs
· Antihypertensives
· Antidepressants
· Antiepileptics
· Phenothiazines
Physical inactivity has been identified as the fifth cause. The major identified barriers to increasing physical activity include a lack of time and a lack of safe environments in which to be active. Regular exercise is associated with lower death rates for adults of any age. It also increases lean muscle, decreases body fat, aids in weight control, and enhances psychologic well-being. Regular exercise can also decrease the risk of falling in older adults.
Incidence/Prevalence
The number of overweight children, adolescents, and adults has continued to rise over the past four decades. In the
Familial and genetic factors play an important role in obesity. When both parents are overweight, approximately 80% of their children will be overweight. If neither parent is overweight, fewer than 10% of the children will be overweight. In studies of identical twins, nonidentical twins, and parent-sibling relationships, about 50% of the difference in body fatness is transmitted to children, and approximately 50% of this amount is genetically controlled. A combination of improper diet and lack of physical activity produces obesity in genetically predisposed people.
CULTURAL CONSIDERATIONS
Culture seems to be a factor in the prevalence of obesity. The prevalence of obesity among ethnic minorities, including African Americans, Hispanic Americans, Asian Americans and Pacific Islanders, Native Americans, Native Alaskans, and Native Hawaiians, is substantially higher than in Caucasians, especially among women (Kumanyika, 1993). A study by Harrell and Gore (1998) found that African-American women of low and middle socioeconomic status (SES) were much more likely to be obese and inactive than were African-American women of high SES. Among Caucasian women, those with low SES had the greatest prevalence of obesity and inactivity. After controlling for income and education, African-American women were twice as likely as Caucasian women to be obese and inactive.
Further research by Gore (1999) found that African Americans’ frame of reference for “normal” body weight is much larger that the standard indicator for weight. Another factor contributing to larger body size in African-American women is that Caucasian women engage in weight loss methods for significantly longer periods of time than do African-American women (Tyler, Allan, & Alcozer, 1997).
A descriptive study of Hispanic women and their daughters demonstrated that daughters ate more fat than did their mothers (Garcia-Maas, 1999). The greater the fat intake, the more negatively women seemed to perceive their health status.
COLLABORATIVE MANAGEMENT
Assessment
HISTORY
The nurse or dietitian collects the following information
about the client:
· Economic status
· Usual food intake
· Eating behavior
· Cultural background
· Attitude toward food
· Appetite
· Chronic diseases
· Medications
· Physical activity
A diet history usually incorporates a 24-hour recall of food intake and the frequency with which foods are consumed. The nurse or dietitian is objective but understands the personal nature of these questions. The adequacy of the diet can be rapidly evaluated by comparing the amount and types of foods consumed daily with the Dietary Guidelines for Americans (see Figure 61-1). Gross inadequacies for specific nutrients can be identified with this approach. The dietitian can provide a more detailed analysis of dietary intake.
WOMEN’S HEALTH CONSIDERATIONS
Women have a unique risk for nutrition-related diseases and conditions and weight-related problems due to biologic, social, and political factors. The American Dietetic Association (ADA) and the Canadian Dietetic Association (CDA) issued a joint position paper on women’s health and nutrition (
Being overweight adds many risks for women, especially if the fat stores are located in the abdominal or truncal areas of the body. A waist/hip ratio of 0.85 puts women at higher risk for coronary heart disease, hypertension, dyslipidemia, diabetes, gallstone formation, and cancer of the reproductive organs. In addition to these medical risks, women are vulnerable to the social, economic, and emotional pressures associated with being overweight. Overweight women may find it difficult to feel good about themselves when challenged by society’s discrimination against the overweight. The constant struggle for many women to lose weight often ends in failure and leads to patterns of weight cycling or disordered eating. Prevention and early intervention programs for overweight women and their families remain a critical need. The
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
In collaboration with the dietitian, the nurse accurately obtains the client’s height and weight and calculates the percentage of ideal body weight (% IBW) and the body mass index (BMI). The dietitian may:
• Calculate the waist/hip ratio
• Make the necessary skin fold measurements and record them in the chart
The nurse also examines the skin of the obese client for reddened or open areas; these may not be easily visible because of excess fat.
PSYCHOSOCIAL ASSESSMENT
The nurse obtains a psychosocial history to determine the client’s circumstances and emotional factors that might prevent success of therapy or be worsened by it. The nurse or social worker interviews the client to determine his or her perception of current weight. The client may or may not view weight as a problem, which will affect treatment and outcome. The nurse explores the client’s past history to assess the following:
· Cause and duration of weight gain
· Family history of obesity
· Past attempts at weight reduction and outcomes
· The nurse asks about the following:
· Current reasons for wanting to lose weight
· Stressors (e.g., home, employment, personal, financial, or community) that might prevent success
· Exercise patterns
· Current medications
· Perceptions of self-worth
The diet history provides a detailed analysis of the client’s eating habits. As a member of the health care team, the nurse can evaluate the data to coordinate an interdisciplinary approach that incorporates diet, exercise, behavior modification, and psychologic support. The client may be referred to a community support group if one is available.
LABORATORY ASSESSMENT
There are no significant laboratory tests for obesity. However, the nurse should review all laboratory test results to assess the nutritional status of the client.
Analysis
В COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are the most commoursing diagnoses for clients with obesity or overweight:
1. Imbalanced Nutrition: More Than Body Requirements related to a dysfunctional eating pattern or neuroendocrine disorder
2. Activity Intolerance related to a sedentary lifestyle
ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses, clients may have one or more secondary problems associated with obesity and overweight, which include the following:
• Situational Low Self-Esteem or Chronic Low Self-Esteem related to guilt associated with eating style
• Disturbed Body Image related to physical appearance
• Disturbed Thought Processes related to depression
• Ineffective Sexuality Patterns related to body image perception, rejection by partner, or difficulty assuming sexual positions
• Impaired Social Interaction related to poor self-esteem and rejection by others
• Impaired Physical Mobility related to decreased strength and endurance
•
Some clients with obesity are at risk for collaborative problems, which include the following:
• Diabetes mellitus
• Cardiovascular disease
• Hypertension
Planning and Implementation
IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS
PLANNING: EXPECTED OUTCOMES. The client with obesity or overweight is expected to (1) participate in a structured weight loss program, (2) approach ideal body weight, and (3) establish a lasting, healthful dietary pattern that will result in permanent, sustained weight loss.
INTERVENTIONS. Weight is lost only when energy expended is greater than intake. Weight loss may be accomplished by dietary restriction with or without the aid of drugs. Clients who are candidates for surgical treatment:
• Repeatedly fail at nonsurgical techniques
• Have a body mass index (BMI) equal to or greater than 40 (class IV)
• Weigh more than 100% above ideal body weight (IBW)
• Have medically significant obesity
NONSURGICAL MANAGEMENT. The first clinical practice Guidelines for Treatment of Adult Obesity outlines treatment decisions based on risk assessment. Recommendations for appropriate weight reduction strategies or weight maintenance to prevent further weight gain are also included (Shape Up America and American Obesity Association, 1996). Various diet programs and medications have attempted to helpobese clients achieve permanent weight loss.
DIET PROGRAMS. Modalities for helping people lose weight include fasting, very-low-calorie diets, balanced and unbalanced low-energy diets, and novelty diets.
Fasting. Short-term fasting programs have not been successful in treating morbidly obese clients, and prolonged fasting does not produce permanent benefits. Most clients regain the weight that was lost by this method. In addition, the risks associated with fasting (e.g., severe ketosis) require close medical supervision.
Very-Low-Calorie Diets. Very-low-calorie diets generally provide 200 to 800 calories/day. Two types of very-low-calorie diets are theprotein-sparing modified fast and the liquid formula diet.
The protein-sparing modified fast provides protein of high biologic value (1.5 g/kg of desirable body weight/day) within a limited number of calories. The diet produces rapid weight loss while preserving lean body mass. The liquid formula diet provides between 33 and
Both diets require an initial cardiac evaluation, supervision by an interdisciplinary health team with monitoring by a physician, nutrition counseling by a registered dietitian, and supplementation with vitamins and minerals. These diets are only one part of a weight reduction program. Clients who are following these diets should receive nutrition education, psychologic counseling, exercise, and behavior therapy. Comparable weight losses have been achieved with both diets, but most clients do not sustain the weight loss and regain the weight.
Balanced and Unbalanced Low-Energy Diets. Nutritionally balanced diets generally provide 1200 calories/day with a conventional distribution of carbohydrate, protein, and fat. Vitamin and mineral supplements may be necessary if energy intakes fall below 1200 calories for women and 1800 calories for men. This diet provides conventional foods that are economical and easy to obtain; thus the goal of weight loss is facilitated, and that loss is maintained.
Unbalanced low-energy diets, such as the low-carbohydrate diet (e.g., Atkins diet), restrict one or more nutrients. No evidence supports the claim that the restricted nutrient increases or decreases weight loss beyond the calorie deficit it produces.
Novelty Diets. Novelty diets, such as the grapefruit diet, are ofteutritionally inadequate. This type of diet implies that a certain food increases metabolic rate or accelerates the oxidation of body fat. Weight loss is achieved because energy is restricted by food choice, but clients do not sustain weight loss after terminating the diet.
DIET THERAPY. Diet recommendations for each client should be developed through close interaction between the client, physician, and dietitian. The diet should meet the client’s needs and habits and should be realistic.
The dietitian develops a diet plan and instructs the client. At a minimum, the diet should:
· Have a scientific rationale
· Be nutritionally adequate for all nutrients except energy
· Have a low risk/benefit ratio
· Be practical and conducive to long-term success
Calorie estimates are easily calculated. Resting metabolicrate is determined using a gender-specific formula that incorporates the appropriate activity factor. This figure reflects the total calories needed daily for maintaining current weight. To encourage a weight loss of
DRUG THERAPY.
A BMI of 30, or a BMI of 27 with co-morbidities, is one indicator for the use of drug therapy (Shape Up America and American Obesity Association, 1996). Anorec–tic drugs suppress appetite, which reduces food intake and over time may result in weight loss. These drugs play a valuable role in a comprehensive weight reduction program but should be used only as part of such a program. Currently available drugs to treat obesity act on either the noradrenergic or serotonergic systems in the central nervous system. The most commonly used anorectic drug for the treatment of obesity is sibutramine (Meridia). Sibutramine is an anorectic drag that inhibits the re-uptake of serotonin (which enhances satiety [feeling full when eating]) and norepinephrine (which raises metabolic rate). Adverse effects include dry mouth, constipation, and insomnia.
Orlistat (Xenical) is a different type of drag that inhibits li-pase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased. Most clients taking orlistat experience gastrointestinal symptoms that include loose stools, abdominal cramps, and nausea.
BEHAVIORAL TREATMENT. Behavioral treatment of obesity consists of various strategies to change daily eating habits to achieve weight loss. This ongoing process should produce a change in behavior. Self-monitoring techniques include keeping a record of foods eaten (food diary), exercise patterns, and emotional and situational factors. Stimulus control involves controlling the external cues that promote overeating. Reinforcement techniques are used to self-reward the behavior change. Cognitive restructuring involves modifying negative beliefs by learning positive coping self-statements.
Fairbum and Cooper (1996) have developed a cognitive behavioral approach to the acquisition of weight maintenance behavior skills. Clients are encouraged to accept modest weight loss goals and are further discouraged from losing more weight. The treatment focuses on the acquisition of weight maintenance skills and on cognitive factors and any tendency to evaluate self-worth in terms of body size. The client’s focus is shifted from physical appearance to a concern for health.
CRITICAL THINKING CHALLENGE
You are caring for a 42-year-old female hospitalized client who is preparing to have bilateral knee replacements. She tells you that she has been obese her entire life and now has severe arthritis in both knees. She has tried every novelty diet available but regains the weight shortly after completing the diet. Her husband left her last year because he was embarrassed to be with her.
• What are the priority nursing diagnoses related to her obesity?
• What other options does she have for managing her nutritional problem?
• What is the psychologic impact of being obese?
SURGICAL MANAGEMENT. Clients who do not respond to traditional dietary intervention may be considered for a surgical procedure aimed at producing permanent weight loss. All clients with a body mass index (BMI) >40, or a BMI >35 with additional risk factors, should be considered for surgery (Shape Up America and American Obesity Association, 1996). Most surgical procedures fall into three categories:
1. Mechanical or physical (adipose tissue removal or in take restriction)
2. Malabsorptive (bypass of the gastrointestinal tract)
3. Regulatory (directly affecting hunger or thirst)
PREOPERATIVE CARE. The nurse reinforces health teaching before the client has surgery. Preoperative care is similar to that for any client undergoing abdominal surgery (see Chapter 17).
OPERATIVE PROCEDURES. Surgical procedures that physically restrict the intake of food include the following:
· Maxillomandibular fixation (jaw wiring) Esophageal banding
· Gastroplasty (banding or stapling the stomach)
· Intestinal bypass, in which the stomach and jejunum are connected
One of the most common procedures is gastroplasty, which decreases the size of the stomach. Stapling horizontally across the top of the stomach leaves only a small opening (0.8 to
· Soft calorie syndrome” (consumption of excessive amounts of soft or liquid, calorically dense foods)
· Vomiting from inadequate chewing
· Inappropriate consumption of liquids after solids
An intestinal bypass reduces the size of the stomach with stainless steel staples but connects a small opening in the upper portion of the stomach to the small intestine by means of an intestinal loop (Figure 61-6). Complications of the intestinal bypass include bloating of the pouch. The incidence of nausea and vomiting is similar to that with gastroplasty. Intestinal bypass usually leads to greater weight loss that doesgastroplasty, in part because of dumping syndrome as the use of the lower part of the stomach is omitted. Intestinal bypass operations have been modified to avoid blind loop bacterial overgrowth yndromes and are now performed as a biliointestinal bypass, jejunoileal bypass withileogastrostomy, or duodenoileal bypass. Surgical treatment of clinically severe obesity by either vertical banded gastroplasty or Roux-en-Y gastric bypass is a viable option for selected clients (NIH Consensus Development Conference Panel, 1991). Maximum weight loss from these procedures generally occurs 18 to 24 months after surgery. Two years after surgery, Roux-en-Y clients lost 60% to 70% of their weight, whereas gastroplasty clients lost 40% to 60%.
POSTOPERATIVE CARE.
The client has a nasogastric (NG) tube put in place immediately after gastroplasty or intestinal bypass. In gastroplasty, the NG tube drains both the proximal pouch and the distal stomach. The nurse closely
monitors the tube for patency. The tube is never repositionedbecause its movement can disrupt the suture line. The NG tube is removed on the third day if the client has bowel sounds and is passing flatus. The nurse gives the client
ACTIVITY INTOLERANCE
PLANNING: EXPECTED OUTCOMES. The client with obesity or overweight is expected to (1) tolerate usual activity as evidenced by endurance, energy conservation, and selfcare; and (2) incorporate daily exercise into his or her lifestyle.
INTERVENTIONS. Management of the overweight or obese client is an interdisciplinary effort. The nurse collaborates with the physician, dietitian, and physical therapist or exercise physiologist to meet the goal of improving the client’s physical activity tolerance. The major intervention is to increase the type and amount of daily exercise to create a calorie deficit along with modification of eating habits. Adding exercise to a diet intervention produces more weight loss than just dieting alone. More of the weight lost is fat, which preserves lean body mass. An increase in exercise produces a reduction in the waist/hip ratio.
Increasing and maintaining physical activity levels is important in maintaining weight loss. Many overweight or obese clients are so unfit that it may take several months of conditioning before they can exercise sufficiently to achieve weight loss.
The nurse or physical therapist or exercise physiologist first obtains a clinical exercise history. It is important to determine the client’s current exercise pattern and exercise habits over a lifetime. The client should understand the importance of an exercise component in a weight loss program. The nurse also ascertains the client’s desire to participate in an exercise program and his or her preferred types of exercise.
The health care provider evaluates the client by an exercise stress test. Not all clients need a stress test, but those with chronic disease may need a stress test and more specific exercise recommendations. The nurse counsels clients about unusual signs and symptoms during exercise (e.g., chest pain) and
what to do if they occur. The physical therapist or exercise physiologist first emphasizes the importance of exercising consistently and then stresses duration, intensity, and frequency.
A minimal-level workout should be developed for the client so that consistency can be achieved. The goal for the client is to maintain a lifetime of increased physical activity. The client is apt to be less fatigued and discouraged with a low-intensity, short-duration program. Sedentary clients are encouraged to increase their activity by walking 30 to 40 minutes daily (15 to 20 minutes/mile) or the equivalent. The activity may be performed all at once or divided over the course of the day. The nurse teaches the client to exercise only under the supervision of the physician. All members of the interdisciplinary team should provide encouragement and support for any increase in physical activity.
Community-Based Care
Obese clients can be cared for in a variety of settings, including the acute care hospital and subacute unit (particularly following surgical treatment for obesity) or in their own home. Obesity is a chronic, lifelong problem. Diets, drug therapy, exercise, and behavior modification can produce short-term weight losses with reasonable safety. However, most clients who do lose weight often regain the weight. Treatment of obesity should focus on the long-term reduction of health risks and medical problems associated with obesity, improving quality of life, and promoting a health-oriented lifestyle. Interdisciplinary team members need to provide a nonjudgmen-tal, supportive atmosphere that encourages the client to increase physical activity, decrease fat intake and reliance on medication use, establish a normal eating pattern in response to physiologic hunger, and address psychologic problems. Frequent, long-term ambulatory care follow-up coordinated by a case manager is essential for successful treatment.
HEALTH TEACHING
The most important features of client education focus on health-related behavior patterns. The dietitian counsels the client on a healthful eating pattern. The nurse provides support and reinforces the importance of maintaining a healthful eating pattern. The physical therapist or exercise physiologist recommends an appropriate exercise program. A psychologist recommends cognitive restructuring approaches that help alter dysfunctional eating patterns.
HOME CARE MANAGEMENT
The overweight or obese client needs proper weighing devices and measuring utensils to follow the diet prescribed by the physician. No other home care preparation is needed.
HEALTH CARE RESOURCES
The chances for success in a weight control program are enhanced if additional support is available. The nurse provides the client with a list of available community resources, such as Weight Watchers, Overeaters Anonymous, Take Off Pounds Sensibly (TOPS), comprehensive interdisciplinary treatment programs, and a list of professionals that includes a registered dietitian, psychologist, and exercise physiologist who may provide frequent follow-up in an ambulatory care setting.
Evaluation: Outcomes
The nurse evaluates the care of the client with obesity or overweight on the basis of the identified nursing diagnoses and collaborative problems. Expected outcomes include that the client:
· Establishes a lasting, healthful dietary pattern that results in permanent, sustained weight loss
· Slowly increases the amount of physical exercise to aid in promoting weight loss
· Incorporates daily exercise into lifestyle
· Participates in usual daily activities
