Effects of Malnutrition

1. Outline the metabolic changes that occur during starvation/inadequate nutritional intake (not related to disease) that could result in weight loss.

During starvation, carbohydrates are depleted after 24 hours, major substrates for gluconeogenesis are amino acids that come from skeletal muscle protein that breakdown, ketone body concentrations rise during prolonged starvation and result in significant excretion of ketones, and the metabolism allows consistent fuel supply to the brain and other tissues during prolonged starvation.

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2. Read the consensus statement of the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition.

Explain the differences between malnutrition associated with chronic disease and malnutrition associated with acute illness and inflammation.

Malnutrition related to chronic disease is when inflammation is mild to moderate but constant (chronic). An example is rheumatoid arthritis. Malnutrition related to acute illness and inflammation is when the inflammation is acute and at a severe degree. An example is major trauma.

3. Find the current definitions of malnutrition in the United States using the current ICD 10 codes. List all of them and describe the criteria for one of the diagnoses.

Malnutrition includes codes E40-E46 going into a category of type 1 or type 2.

E40 Kwashiorkor

E41 Nutritional marasmus

E42 Marasmic kwashiorkor

E43 Unspecified severe protein-calorie malnutrition

E44 Protein-calorie malnutrition of moderate and mild degree

E45 Retarded development following protein-calorie malnutrition

E46 Unspecified protein-calorie malnutrition

Type 1 excludes: intestinal malabsorption ICD-10-CM Diagnosis Code K90

sequelae of protein-calorie malnutrition ICD-10-CM Diagnosis Code E64.0

Type 2 excludes: nutritional anemia ICD-10-CM Range D50-D53

Starvation ICD-10-CM Diagnosis Code T73.0

4. Current ICD definitions of malnutrition use biochemical markers as a component of the diagnostic criteria. Consider the effect inflammation has on visceral proteins and how that may impact the clinician’s ability to diagnose malnutrition. Discuss the following clinical findings and relate to inflammation and ability to diagnose malnutrition.

a) Why is there down-regulation of albumin synthesis? Relate to positive acute-phase protein for the immune system (antibodies, complement, cytokines, C-reactive protein), clotting (fibrinogen) and wound healing.

Malnutrition or long term starvation can reduce a full positive acute phase protein reaction while reducing the negative part as well by the starvation process itself. This starts the depression of hepatic protein synthesis. Which this moves on to affecting pro-inflammatory cytokines in the brain and the rest of the inflammation process. Albumin is characterized as a negative acute phase protein and is affected by inflammatory conditions and drugs which affects liver function. But there are so many disease processes that alter the level of albumin that it becomes an unreliable serum marker for malnutrition.

b) Why is the production of cytokines such as IL-I, IL-6, and tumor necrosis factor (TNF) increased and what is the impact on metabolism and protein synthesis (albumin, prealbumin, transferrin, retinol-binding protein) and muscle repair?

Because pro inflammatory cytokines are released, the vascular system and inflammatory cells are activated. These responses are associated with an increase of production of cytokines. Cytokines IL-I, Il-6 and TNF modulate intermediary metabolism of carbohydrates, fats, and protein, regulate hypothalamic and pituitary outflow and act in the brain to reduce intake of food.

c) What is impact of edema and the ability to interpret some biochemical tests?

Edema is when fluids build up incorrectly in your tissues which will cause abnormal swelling of your body parts. Protein is a common cause of malnutrition edema because if you have the right amount of albumin in your blood, your body can maintain a balance keeping water out. But without enough protein your cells retain water which then leads to edema. So it can be hard to interpret different tests because of the different things that can happen in your body that leads to that fluid retention which can cause more problems.

d) What happens to resting energy expenditure?

I believe that a person’s resting energy expenditure would decrease because if they are not eating enough because malnourished then their body naturally would not have enough to keep burning so it would slow down because it doesn’t have enough nutrients to stay functional like before if getting proper nourishment.

e) If metabolic stress is prolonged, do you feel albumin/prealbumin measurements are an accurate diagnosis of malnutrition when inflammation is present? Why or why not?

I believe it is not because of what has been said about albumin. I read that it is affected by inflammatory conditions and drugs that affects the liver. Also by many disease processes that tend to alter the level of albumin regularly that it becomes an unreliable serum marker for testing for malnutrition.

5. Mr. Campbell was ordered a mechanical soft diet when he was admitted to the hospital. Describe how his meals will be modified with this diet order.

This type of diet is for people who have trouble chewing and swallowing. This will include foods being chopped, ground, and pureed with no need for a knife because they will easily break apart. This diet will allow Mr. Campbell to eat more and obtain the nutrients he needs to help heal his body. The mechanical soft diet includes dairy, vegetables, fruits, starches, meat or meat substitutes, fats, soups, desserts, and beverages. But with all these categories that he can eat they will have to be soft, pureed, whipped and cooked so that he can eat it more easily.

6. What is the Ensure Complete supplement that was ordered? Determine additional options for Mr. Campbell that would be appropriate for a high-calorie, high-protein beverage supplement.

Ensure Complete is a balanced nutrition supplement to help gain or maintain a healthy weight. It is an all in one blend that offers 6 grams fat, 33 grams of carbohydrates and 9 grams of protein. It also included 26 essential vitamins and minerals including antioxidants.

An additional option is carnation breakfast essentials. In 9fl ounces it has 1 gram of fat, 39 grams of carbohydrates and 13 grams of protein.

7. Assess Mr. Campbell’s height and weight. Calculate his BMI and % usual body weight.

Mr. Campbell is 6’3” and 156 pounds.

156lbs/2.2kg=70.9 kg

75inches x .0254m=1.9m

70.9/1.9^2 =19.6 which indicates normal weight with that BMI

Percent usual body weight

156lbs/220lbs x 100= 70.9%

8. After reading the physician’s history and physical, identify any signs or symptoms that support the diagnosis of malnutrition using the proposed definitions of malnutrition by AND/ASPEN malnutrition guidelines.

What characterizes adult malnutrition is inadequate energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, fluid accumulation and evidence of inadequate intake. Looking at Mr. Campbell’s history it says that he has lost weight, is dehydrated, and feels weak. In his physical he says he feels like he cannot do anything and weak all over. He appears to look cachectic which makes him look older than his actual age. His neurological strength is reduced, he has declined muscle tone and his blood work is low which is relates to malnutrition.

9. Evaluate Mr. Campbell’s initial nursing assessment. What important factors noted in his nutrition assessment may support the diagnosis of malnutrition? Mr. Campbell lost over 60 pounds 1-2 years ago. He is at 70.9% of his usual body weight. He is at less than 5% for intake percent of meals with sips of liquids. His recommended fluid requirement is 2000-2500 mL, but he is consuming 360 mL without an IV. Mr. Campbell’s intake has been unsatisfactory to meet the required nutritional needs.

10. What is a Braden score? Assess Mr. Campbell’s score. How does this relate to his nutritional status?

The Braden score is a tool used to help predict a patients level of risk for developing a pressure ulcer. It assess a patient by measuring six different criteria’s:

Sensory perception: this measures a patient’s capability to distinguish discomfort that is related to pressure on different parts of the body. This shows a patients ability to be able to react to pressure related discomfort.

Moisture: constant skin moisture can pose risk to the integrity of a person’s skin by causing damage and being at risk for epidermal erosion.

Activity: this looks at level of physical activity because little activity causes breakdown of muscles and tissue.

Mobility: this assess the physical competency to move and the willingness to move.

Nutrition: this looks at pattern of daily nutrition and if having an imbalance of nutrition which would indicate a high risk in this category.

Friction and Shear: this measures the amount of assistance a person needs to move and the degree of sliding on beds or chairs that they might experience. This looks at the sliding motion that can cause shear which is the skin and bone moving in opposite directions causing breakdown of cell membranes.

Most of the categories have a rate of 1-4 except friction and shear which is a rate of 1-3.

Mr. Campbell’s Braden score is a 17 which means he is at a low risk for developing a pressure ulcer. Getting a Braden score can tell us if that a patients food intake is very poor to excellent.

11. Identify any signs (including laboratory values) or symptoms from the physician’s history and physical and from the nursing assessment that are consistent with dehydration.

Mr. Campbell is very weak. His skin turgor test showed that it is tenting. He is only meeting 360 ml of 2000-2500 mL of his fluid requirements. His skin condition is ecchymosis, dryness and tears. This all relates to being dehydrated. It shows his sodium levels are high which leads to an increase of fluid loss. He does have high blood urea nitrogen levels which forms when protein break down and higher levels can indicate dehydration.

12. Determine Mr. Campbell’s energy and protein requirements. For the critically ill, mechanically ventilated patient, you might consider the Penn State equation (Steps of calculation using Penn State Equation). However, Mr. Campbell is not mechanically ventilated. This is an important factor to consider.

Explain the rationale for the method you use to calculate these requirements.

The usual recommendation for protein is 1.0 to 1.5 g protein/kg/day but for a person who is very ill it should be estimated at 2 grams protein per kg a day with ideal body weight and energy needs. With Mr. Campbell being malnourished I would calculate protein requirement with 1.5 and 2.0.

1.5grams x 70.9 kg (his body weight)= 106.4 grams

2.0grams x 70.9kg= 141.8 grams

So his protein intake should range from 106.4 to 141.8 based on how his body responds to the intake level.

13. Determine Mr. Campbell’s fluid requirements. Compare this with the information on the intake/output report.

He should be receiving around 2000 mL at least of fluids. He is orally in taking 360mL with an IV that gives him 2,160mL and his output is 1,444 with his net I/O being a +1,076.

14. From the nutrition history, assess Mr. Campbell’s usual dietary intake.

a) Use the USDA Super Tracker to estimate intake.

I searched USDA Super Tracker and every link told me that it was discontinued.

b) How does his estimated intake compare to the requirements that you calculated for him?

Egg 70calories 6gprotein

Coffee 5 calories

Toast ½ slice 52 calories 2.5g protein

Ensure complete 220 calories 9g protein

Soup ½ cup 59 calories .9protein

Milk ½ cup 62 calories 4g protein

Ground turkey 3oz 94 calories 15g protein

Potatoes mashed 59 calories 1g protein

Total calories: 621 calories with total 38grams of protein

He is nowhere close to meeting requirements for either. He is very low on calories he should be having a day. And very low on protein as well.

c) Can your evaluation of his dietary intake contribute to the evidence for diagnosing malnutrition?

It can be seen that Mr. Campbell’s intake is very little and not receiving much nourishment from what he is eating. Evaluating his intake can help diagnose malnutrition along with all the other assessments that are done to determine malnourishment.

15. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses and write at least two PES statements with one focused on the clinical domain.

Malnutrition related to tongue squamous cell carcinoma as evidenced by unintended weight loss of 29.1% of usual body weight in the past 2 years, reduced energy intake with lack of appetite and decreased muscle tone of patient.

Insufficient energy intake related to patient’s inability to ingest adequate energy as evidenced by patient’s declined appetite and failure to consume required needs from diet.

16. Determine the appropriate intervention for each nutrition diagnosis.

Being seen that Mr. Campbell cannot meet his nutritional needs orally an enteral nutrition route needs to be started within 48 hours following his admission. The objective will be to accomplish and maintain a healthy body mass and body fat. Enteral nutrition will help promote a heathy weight gain and give him nourishment. His input and output will be monitored along with his GI tolerance to make sure it is all functioning well. His calories, protein, carbohydrates and fats will be upped to a level that will give him his energy needs. He will consume in small quantities and be on a mechanical soft diet so it is easier to intake orally. It will be recommended to intake lots of fluids and consume a nutritious beverage supplement.

17. Identify the steps you would take to monitor Mr. Campbell’s nutritional status while he is hospitalized.

I would monitor his weight, albumin levels, oral intake, enteral caloric intake and when oral intake is increased. Main focus would be looking for a healthy weight gain and that he is receiving nutritional needs to put on that weight and reestablish his muscle.

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