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53 Cards in this Set
- Front
- Back
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Marasmus
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- from concomitant deficiency in caloric and protein intake
- generalized loss of muscle and body fat - appear emaciated but have NORMAL SERUM PROTEIN LEVELS |
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Kwashiorkor
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- Deficiency of protein intake superimposed by CATABOLIC STRESS event (GI obstruction, surgery, cancer, malabsorption syndrome, infectious disease, trauma)
- MAY appear well nourishd but will have LOW PROTEIN LEVELS - IE: soldier |
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First stage of Starvation process
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1. body uses carb storage from liver and muscle to meet metabolic needs
- they are minimal and may be depleted in 18 HOURS |
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Second stage of starvation
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2. Protein is converted to glucose for energy
- hepatic gluconeogenesis - Catabolism- NEGATIVE NITROGEN BALANCE |
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3rd stage of starvation process
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metabolic processes continue and in 5-9 days FAT is mobilized to supply energy (KETOSIS)
- fat stores used in 4-6 weeks |
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Prolonged Starvation (4th stage)
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- 97% of calories from fat and protein are conserved
* Once fat stores are used, body proteins (FROM INTERNAL ORGANS AND PLASMA) are no longer spared |
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Starvation --> diminished protein synthesis -->
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- albumin --> decreased plasma osmotic pressure --> edema
- IgG--> immunosuppressed - Hgb--> anemia - Clotting factors |
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Starvation and liver
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- liver loses mass, becomes infiltrated with fat (cirrhosis)
- liver function impaired |
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Skin and Starvation
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dry and wrinkled
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Na an K pumps and starvation
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deficiency in calories and proteins make pumps fail
***Diet of protein and other constituents must be initiated or death will occur |
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Causes of starvation
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- socioeconomic status
- cultural (fasting) - Psychological (bulemia, anorexia, stress) - medical conditions - medical treatments (chemo, radiation to gut) |
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Fever
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increases basal metabolic rate, leading to protein depletion (inflammatory process)
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Malabsorption syndrome
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impaired absorption of nutrients from the GI tract
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Causes of malabsorption syndrome
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Decreased enzymes:
-by damage to pancreas (don't make pancreatic enzymes preoperly and don't digest fats, etc. correctly, need replacement) - Cystic fibrosis (stools are fatty, passing fat through system and not digesting it) Drug side effects - bowel surface area Celiac disease (antigen, antibody) |
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Incomplete diets usually found in
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- Alcoholics (folate, numbness of extremities)
- Drug abusers - Fad diet followers - Poorly planned vegetarian diets (iron deficiency, etc) |
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Malnutrition vitals
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- decreased RR
- decreased vital capacity - crackles, weak cough - increased or decreased HR - low BP, dysrhythmias |
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Malnutrition lab levels
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- anything signifying anemia
- altered electrolytes - hyperkalemia - decreased BUN and creatinine - decreased serum albumin, transferrin, prealbumin - decreased lymphocytes - increased liver enzymes - decreased serum vitamin levels |
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Anthropometric measurments
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- Triceps skinfold thickness
- midarm circumfrance - compared with standard for healthy persons - provide long term assessment of nutrition status |
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Albumin
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- doesn't change for 20-22 days (half life)
- Indicator of LONGER TERM nutrition status - not for acute situations (trauma, etc.) - changes dependant on the dehydration/hydration of pt - may be affected by chronic illness, like cirrhosis and hydration |
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Prealbumin
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- half life of 2 days
- BEST LAB for indicator of ACUTE changes in nutrition status |
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Serum transferrin
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Protein that carries iron
- if protein goes down, so will this |
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C reactive protein
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elevated during inflammation and help to determine if protein changes reflect inflammation or undernutrition
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Metabolic crt studies
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ventilator pt attached to device to check metabolic status
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Nursing assessment
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First a nutritional screening within first 24h of admission, then if positive a further assessment
- daily weights and changes - more than just % of food eaten, need calories, protein, etc., record everything pt has eaten! - meds - lab test results - physical exam - anthropometric measurments |
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Enteral tube feeding guidelines
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- monitr weight 3x/week then 1x/month
- monitor for presence of bowel sounds q4-8h - slow tube feeding/decrease concentration to decrease diarrhea - change feeding containers and tubing q24h - open containers of enteral feeding needs to be refridgerated - Check for residual q4-6h - hold feeding if more than 500mL residual and reassess pts tolerance to feedings - elevate head during feeding to 30-45 degrees and keep raised for 30-60 min after last feeding before lying flat - Monitor for sensation of fullness, nausea, and vomiting (signs of gastric retention) - Check gravity drip or pump rate every h - provide free water with tube feedings to compensate for high-concentration feedings - Irrigate the tube q4-6h during continuous feeding and after intermittent feeding |
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Parenteral feeding guidelines
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- asepsis with access to central catheter, changing PN tubing and bags
- Chane peripheral IV and central line dressings according to guidelines (?) - Wash hands - Encourage rest so parenteral nutrition goes to healing - Monitor for manifestations of hyperkalemia, hypokalemia, hyper and hypoglycemia - monitor serum electrolytes daily - monitor capillary glucose q 4-6h - Maintain accurate infusion rate to control glucose admin to prevent fluctuations |
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Signs of hyperglycemia
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- thirst
- polyuria - confusion - elevated blood glucose - blurred vision - dizziness - N/V - dehydration |
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Signs of hypoglycemia
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- sweating
- hunger - weakness - tremors |
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Signs of hyperkalemia
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- muscle weakness
- flaccid paralysis - cardiac dysrhythmias - abdominal cramps - diarrhea |
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signs of hypokalemia
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- general weakness
- decreased muscle tone - weak or irregular pulse - low BP - shallow respirations - abdominal distentions - ileus |
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Complications of TPN
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- Air embolism
- Catheter Occlusion - Catheter sepsis (a big problem! a never event!), monitor for infection - Electrolyte imbalance - Increased CO2 excretion (cause of all the carbs, important if there is underlying disease) - Hyperglycemia- monitor glucose at least q6h, insulin coverage prn - Hypoglycemia- especially if turn TPN off rapidly, monitor q6h, can't give glucose orally so have to give D50 for glucagon - Pneumothorax - Thrombosis of central vein **Every pt (even if not diabetic) must be on insulin sliding scale and monitor glucose q6h!** |
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Adipocyte hypertrophy
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- Process by which adipocyts can increase colume several thousandfold to accommodate large increase in lipid storage
- weight gain in adulthood is characterized predominately by this |
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Primary obesity
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- majority of obese
- excess caloric intake for the body's metabolic demands |
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secondary obesity
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results from various congenital and chromosomal anomalies, metabolic problems, or CNS lesions and disorders
- rare |
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Optimal waist to hip ratio
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<0.80
- describes distribution of subcu and visceral adipose tissues - waist/hip > 0.80 indicates greater risk for health complications - preferred tool if pt is predominately muscular |
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Android obesity v. Gynoid
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- Apple, abdominal area, higher risk
- Pear-shaped body, fat located in upper legs |
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Severe obesity associated with
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- sleep apnea
- obesity hypoventilation syndrome - decreased chest wall compliance - increased work of breathing - decreased total lung capacity and functional residual capacity |
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Nonalcoholic steatohepatitis (NASH)
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- can eventually lead to cirrhosis
- weight loss can improve NASH |
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Obesity cancer risks in women
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Breast, endometrial, ovarian, cervical
- possible from increased estrogen postmenopausal |
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obesity cancer risk for men
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prostate
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Obesity cancer risks for both genders
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Colorectal, pancreas, esophogus, gallbladder
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Drug therapy for obesity
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- decrease food intake by reducing appetitie or increasing satiety (monitor cardio status and have increased pulmonary fibrosis)
- Meridia withdrawn from market - decrease nutrient absorption (Xenical blocks fat) - Drugs that increases energy expenditure are not approved by the FDA ** Problem is that a lot of meds increase sympathetic nervous system causing HTN and some cause arrhythmias |
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Criteria for bariatric surgery (ideal candidate)
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- > or equal BMI 40
BMI > or equal to 35 with one or more obesity related complication (apnea, DM, etc.) - 18y or older - Understand the risks and benefits - Has been obese for > 5y - Has tried and failed to lose weight - no serious endocrine problems (DM must be controlled) - has psychiatric and social stability - availability of a team of health care providers - surgery would decrease or eradicate high risk conditions (direct link) |
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3 broad categories of bariatric surgery
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- Restrictive (vertical banded gastroplasty and AGB)
- Malabsorptive (gastric bypass) - Combination of restrictive and malabsorptive |
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Vertical banded gastroplasty
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- restrictive surgery
-partitions stomach into a small pouch in upper portion - small pouch drastically limits capacity - stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch |
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Adjustable gastric banding (AGB) (lap band)
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- restrictive
- inflated band placed around fundus of stomach to reduce stomach size - band is connected to a suncu port - can be inflated or deflated to change stoma size - can be done laproscopically and can be modified or reversed - good for surgery risk pts - weight loss is SLOWER than in other procedures |
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Biliopancreatic diversion (BPD) (gastric bypass)
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- malabsorptive
- removes ~ 3/4 of stomach to decrease food intake and decrease acid output - remaining 1/4 of stomach is connected to lower portion of small intestine - pancreatic enzymes and bile enter final segment of intestine - nutrients pass w/o being digested **High risk for nutrition deficits and dumping syndrom (most nutrients routed to colon where they aren't digested) - may have low ADEK, diarrhea, vomiting, dumping syndrome if wat too much of something - high risk for gallstones (may need gallbladder removed) |
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Preoperative
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- need many clearances : many comorbidties
- teach approad- cardio, pulmonary, gynecologist, gastro, and others - have room ready prior to arrival (larger cuff, gown, bariatric beds and surgery table, bariatric wheelchair or one w/ removable arms) - strongly reinforced trapeze bar over bed for movement and positioning - may have to put beds together or socially construct a chair - have proper amount of staff on hand for ambulating, bathing, and turning pt - skin preparation- pt may need to bathe or shower before admission to help prevent post opinfection (fabby skinfolds, esp abdominal area) - Instruct pt in proper: - coughing technique - deep diagphragmatic breathing, incentive spirometry - need to know that they are going to hurt more - methods of turning and positioning to prevent pulmonary complications - obtaining venous access may be complicated, assitance may be needed - mark spot for injection with sterile marker once vein is found - if pt has excess fat or pitting edema, hold a firm finger over the spot with pressure - have increased risk of failing to wean off mechanical ventilation with anesthesia |
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Post operative
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- trained staff should assist transfer of unconscious pt
- during transfer ensure pt has an established airways and pain is managed ** In severely obese is is essential to monitor for rapid oxygen desaturation, pulse ox monitoring - early ambulation is essential - frequent increased ambulation after initial move (~ 3-4x/day) - DVT prophylaxis (more likely to get DVT) - sequential compression hose - low dose heparin wound monitoring - high risk for infection, dehiscence and evisceration - high risk for fungal infection in skin folds - support wound for activities that involve straining (cough, deep breathe, moving) - often in considerable abdominal surgery - pain medications should be given as frequently as necessary during immediate postoperative period |
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Changes in eating after bariatric surgery
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- no fluids with meals
- risk for dumping syndrome - need to understand how little they can eat now - must learn to adjust intake sufficiently with regard to nutrition and maintaining a stable weight |
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Diet normal prescribed after bariatric surgery
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- high protein
- low carbs - low fats - low roughage - 6 small feedings ** Fluids not to be ingested with meals and less than 1000mL/day |
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Possible complications of bariatric surgery
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- anemia
- vitamin deficiencies - diarrhea - psychiatric problems - peptic ulcer formation - dumping syndrome - small bowel obstruction |
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Signs of dumping syndrome
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- diaphoretic
- low BP - passout hyperglycemia - diarrhea - cramping |
