Chapter 40: Nutrition Problems

Question 1

Mifflin–St. Jeor equation

Answer 1

recommended to
estimate daily adult energy (calorie) requirements based on
resting metabolic rate for individuals

A more convenient way to estimate daily calories is based on
kilocalories per kilogram (kcal/kg).

Question 2

average adult

requires an estimated 20 to 35 cal/kg of body weight per day

Answer 2

Rule-of-thumb estimations are that an
individual should consume 20 to 25 cal/kg body weight to lose
weight, 25 to 30 cal/kg to maintain body weight, and 30 to
35 cal/kg to gain weight.

Question 3

Major Minerals

Answer 3

• Calcium
• Chloride
• Magnesium
• Phosphorus
• Potassium
• Sodium
• Sulfur

Question 4

Trace Elements

Answer 4

• Chromium
• Copper
• Fluoride
• Iodine
• Iron
• Manganese
• Molybdenum
• Selenium
• Zinc

Question 5

watersoluble

vitamins

Answer 5

(vitamin C and the B-complex vitamins)

Question 6

fat-soluble vitamins

Answer 6

(vitamins A, D, E, and K)

Because the body
stores excess fat-soluble vitamins, there is the potential for toxicity
when too much is consumed.

Question 7

Minerals are necessary for the body

Answer 7

to build and repair
tissues, regulate body fluids, and assist in various functions.
Some minerals are stored and can be toxic if taken in excess
amounts.

Question 8

The primary deficiency for a strict vegan is lack of

Answer 8

cobalamin.
This vitamin can be obtained only from animal protein,
special supplements, or foods that have been fortified with the
vitamin
Vegans not using cobalamin supplements are susceptible
to the development of megaloblastic anemia and the neurologic
signs of cobalamin deficiency.

Question 9

A Jewish patient who

eats only Kosher food may be comforted

Answer 9

knowing that
most enteral formulas are manufactured Kosher and are labeled
as such.

Question 10

Socioeconomic Factors

Answer 10

Food security refers to access by all
people, at all times, to sufficient food for an active and healthy
lifestyle.2 Individuals or families with limited financial resources
may have food insecurity (inadequate access). Food insecurity is
problematic because it affects the overall quality of food that is
available in both quantity and nutritional value

Question 11

CONDITIONS THAT INCREASE

THE RISK FOR MALNUTRITION

Answer 11

• Dementia
• Depression
• Chronic alcoholism
• Excessive dieting to lose weight
• Swallowing disorders (e.g., head and neck cancer)
• Decreased mobility that limits access to food or its preparation
• Nutrient losses from malabsorption, dialysis, fistulas, or wounds
• Drugs with antinutrient or catabolic properties such as
corticosteroids and oral antibiotics
• Extreme need for nutrients because of hypermetabolism or
stresses such as infection, burns, trauma, or fever
• No oral intake and/or receiving standard IV solutions (5% dextrose)
for 10 days (adults) or for 5 days (older adults)

Question 12

As the total blood volume is reduced, the skin appears dry
and wrinkled. As fluids shift to the interstitial space, ions also
move.

Answer 12

Sodium (a predominant extracellular ion) is found in
increased amounts within the cell, and potassium (a predominant
intracellular ion) and magnesium are shifted to the extracellular
space.

Question 13

Many malnourished individuals are

Answer 13

anemic, generally as a
result of nutritional deficiencies in iron and folic acid, the necessary
building blocks for red blood cells (RBCs).

Question 14

Prealbumin

Answer 14

a protein synthesized by the liver, has a half-life
of 2 days and is a better indicator of recent or current nutritional
status. Serum transferrin level is another indicator of protein
status. Transferrin, a protein synthesized by the liver and used
to transport iron, decreases when protein is deficient.

Question 15

Hospital-specific screening tools based on common

admission assessment criteria include

Answer 15

history of weight loss,
prior intake before admission, use of nutritional support,
chewing or swallowing issues, and skin breakdown.

Question 16

……a critical

indicator for further assessment, especially in the older adult

Answer 16

A loss of more than 5% of usual body weight over

6 months, whether intentional or unintentional

Question 17

The arm demi-span is the

Answer 17

distance
from a point on the midline at the suprasternal notch to the web
between the middle and ring fingers with the arm horizontally
outstretched

Question 18

Body mass index (BMI) is a measure of weight for height

Answer 18

A BMI of less than 18.5 kg/m2 is considered
underweight, normal weight is a BMI between 18.5 and 24.9 kg/
m2, and overweight is a BMI between 25 and 29.9 kg/m2. A
BMI of 30 kg/m2 or greater is obese. BMIs outside the normal
weight range are associated with increased morbidity and
mortality

Question 19

Nursing diagnoses for the patient with malnutrition include,

but are not limited to, the following: pg894

Answer 19

• Imbalanced nutrition: less than body requirements related
to decreased access, ingestion, digestion, or absorption
of food or related to anorexia, dysphagia, or increased
metabolic needs
• Feeding self-care deficit related to decreased strength and
endurance, fatigue, and apathy
• Deficient fluid volume related to factors affecting access
to or absorption of fluids
• Risk for impaired skin integrity related to poor nutritional
state
• Noncompliance related to alteration in perception, lack of
motivation, or incompatibility of regimen with lifestyle or
resources

Question 20

Anthropometric

Measurements

Answer 20

• Height and weight
• Body mass index (BMI)
• Rate of weight change
• Amount of weight loss

Question 21

Diet History

Answer 21

• Chewing and swallowing ability
• Changes in appetite or taste
• Food and nutrient intake
• Availability of food

Question 22

Physical Examination

Answer 22

• Physical appearance
• Muscle mass and strength
• Dental and oral health

Question 23

Laboratory Data

Answer 23

• Glucose
• Electrolytes
• Lipid profile
• Blood urea nitrogen (BUN)

Question 24

Health History

Answer 24

• Personal and family history
• Acute or chronic illnesses
• Current medications,
herbs, supplements
• Cognitive status,
depression

Question 25

Functional Status

Answer 25

``` • Ability to perform basic and instrumental activities of daily living • Handgrip strength • Performance tests (e.g., timed walk tests) ```

Question 26

Health Impact of a Well-Balanced Diet

Answer 26

• Reduces incidence of anemia • Maintains normal body weight and prevents obesity • Maintains good bone health and reduces risk of osteoporosis • Lowers the risk of developing elevated cholesterol and type 2 diabetes mellitus • Decreases the risk of heart disease, hypertension, and certain types of cancers

Question 27

For patients undergoing | major surgery or those with or at risk for malnutrition

Answer 27

several weeks of increased protein and calorie intake are needed preoperatively to promote healing postoperatively. fever is present, the metabolic rate is increased

Question 28

Some patients may benefit from appetite stimulants such as

Answer 28

``` megestrol acetate (Megace) or dronabinol (Marinol) to improve nutritional intake ```

Question 29

Keeping a diet diary for 3 days at a time is one way to analyze and reinforce healthful eating patterns.

Answer 29

helpful to the health care team in the follow-up care. Encourage self-assessment of progress by having the patient weigh himself or herself once or twice a week and keep a weight record

Question 30

Daily requirements for healthy older adults for weight maintenance include

Answer 30

30 cal/kg of body weight, and 0.8 to 1 g/kg of | protein per day, with no more than 30% of calories from fat

Question 31

Contraindications to enteral nutrition

Answer 31

``` • Intestinal obstruction • Ileus • Peritonitis • Bowel ischemia • Intractable vomiting and diarrhea ```

Question 32

Enteral Nutrition long term

Answer 32

Gastrostomy | Jejunostomy

Question 33

enteral nutrition short term

Answer 33

Nasogastric Nasoduodenal Nasojejunal

Question 34

``` Enteral nutrition (EN), also known as tube feeding, is defined as nutrition ```

Answer 34

provided through the GI tract via a tube, catheter, or | stoma that delivers nutrients distal to the oral cavity.

Question 35

EN indications

Answer 35

persons with anorexia, orofacial fractures, head and neck cancer, neurologic or psychiatric conditions that prevent oral intake, extensive burns, or critical illness (especially if mechanical ventilation is required), and those who are receiving chemotherapy or radiation therapy

Question 36

Nasally and orally placed tubes

Answer 36

(orogastric, nasogastric [NG], nasoduodenal, or nasojejunal) are most commonly used for short-term feeding (less than 4 weeks).

Question 37

Nasoduodenal and | nasojejunal tubes are transpyloric tubes

Answer 37

These tubes are used when pathophysiologic conditions such as risk of aspiration warrant feeding the patient below the pyloric sphincter

Question 38

Failure to flush the tubing before and | after both drug administration and residual volume determinations

Answer 38

can result in tube clogging. When the tube becomes clogged, it may necessitate removal and insertion of a new tube, adding to cost and patient discomfort. The tubes can become dislodged by vomiting or coughing and can also become knotted or kinked.

Question 39

Capnography,

Answer 39

a direct monitor of breath-to-breath carbon dioxide level, may be used to detect inadvertent entry of tube into the trachea during insertion. X-ray confirmation is still needed to verify location before feeding. When in doubt, request an x-ray to determine tube location.

Question 40

Assess the skin around the feeding tube daily

Answer 40

for signs of | redness and maceration. To keep the skin clean and dry

Question 41

DELEGATION DECISIONS Nasogastric and Gastric Tubes and Enteral Feedings Role of Registered Nurse (RN)

Answer 41

• Insert nasogastric (NG) tube for unstable patient. • Irrigate NG or gastrostomy tube for unstable patient. • Insert nasointestinal tube. • After tube placement is verified, administer bolus or continuous enteral feeding for unstable patient. • Administer medications through the NG or gastrostomy tube to unstable patient. • Evaluate nutritional status of patient receiving enteral feedings. • Monitor for complications related to tubes and enteral feedings. • Develop plan for gastrostomy or jejunostomy tube care. • Teach patient and caregiver about home enteral feeding and gastrostomy or jejunostomy tube care. • Evaluate for therapeutic effect of NG tube connected to suction (e.g., decreased nausea or distention

Question 42

Role of Licensed Practical/Vocational Nurse (LPN/LVN)

Answer 42

• Insert NG tube for stable patient. • Irrigate NG and gastrostomy tubes. • Administer bolus or continuous enteral feeding for stable patient. • Remove NG tube. • Administer medications through NG or gastrostomy tube to stable patient. • Provide skin care around gastrostomy or jejunostomy tubes.

Question 43

Role of Unlicensed Assistive Personnel (UAP)

Answer 43

• Provide oral care to patient with NG, gastrostomy, or jejunostomy tube. • Weigh patient who is receiving enteral feeding. • Position and maintain patient receiving enteral feeding with the head of bed elevated. • Notify RN or LPN about patient symptoms (e.g., nausea, diarrhea) that may indicate problems with enteral feedings. • Alert RN or LPN about enteral feeding infusion pump alarms. • Empty drainage devices and measure output.

Question 44

With aging, there is an increased risk of

Answer 44

glucose intolerance. As a result, the older patient may be more susceptible to hyperglycemia in response to the high carbohydrate load

Question 45

It is becoming more common to administer lipid-free PN | for the first 3 to 5 days of a critical illness

Answer 45

because of the potential for omega-6 fatty acids to produce proinflammatory mediators

Question 46

The following are ranges for average daily electrolyte requirements for adult patients without renal or hepatic impairment

Answer 46

* Potassium: 1 to 2 mEq/kg * Chloride: as needed to maintain acid-base balance * Magnesium: 8 to 20 mEq * Calcium: 10 to 15 mEq * Phosphate: 20 to 40 mmol

Question 47

Catheter-Related Problems

Answer 47

``` • Air embolus • Pneumothorax, hemothorax, and hydrothorax • Hemorrhage • Dislodgment • Thrombosis of vein • Phlebitis ```

Question 48

Anorexia nervosa is characterized

Answer 48

by a self-imposed weight loss, endocrine dysfunction, and a distorted psychopathologic attitude toward weight and eating

Question 49

lanugo

Answer 49

(soft, downy hair covering the body except the palms and soles)

Question 50

The percentage of daily calories for a healthy individual consists of

Answer 50

50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids.

Question 51

During starvation, the order in which the body obtains substrate for energy is

Answer 51

glycogen, skeletal protein, fat stores, visceral protein.

Question 52

A patient with anorexia nervosa shows signs of malnutrition. | During initial refeeding, the nurse carefully assesses the patient for

Answer 52

d. hypophosphatemia.

Question 53

prealbumin level more accurately reflects the patient's nutritional status

Answer 53

Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status. Serum albumin has a half-life of approximately 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not a good indicator of acute changes in nutritional status.

Question 54

The nurse should flush feeding tubes with

Answer 54

30 mL of water (not normal saline) every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient.

Question 55

The nurse recognizes that the majority of patients' caloric needs should come from which source?

Answer 55

Carbohydrates should constitute between 45% and 65% of caloric needs, compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Monosaccharides are simple sugars.

Question 56

parenteral nutrition (PN). Which principle should guide the nurse's administration of the patient's nutrition?

Answer 56

Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.

Question 57

Which care could the RN delegate to the LPN

Answer 57

For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to the tube and the enteral feeding, and teach the caregiver about feeding via the gastrostomy tube at home.

Question 58

she reports bleeding gums, loose teeth, and dry, itchy skin. The nurse should know that this patient is most likely lacking which vitamin?

Answer 58

This patient is lacking Vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Clinical manifestations of Vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Clinical manifestations of Vitamin K deficiency include defective blood coagulation.

Question 59

The patient has parenteral nutrition infusing with amino acids and dextrose. In report, the oncoming nurse is told that the tubing, the bag, and the dressing were changed 22 hours ago. What care should the nurse coming on be prepared to do

Answer 59

The nurse should check the amount of feeding left in the bag, and that the next bag has been ordered to be sure the solution will not run out before the next bag is available. Parenteral nutrition solutions are only good for 24 hours and usually take some time for the pharmacy to mix for each patient. The label on the bag should be checked to ensure that the ingredients and solution are what was ordered. The patient would only receive insulin if the patient is experiencing hyperglycemia and was receiving sliding scale insulin or had diabetes mellitus. The insertion site should be checked, but the tubing is only changed every 72 hours unless lipids are being used.

Question 60

• Three etiologies of adult malnutrition

Answer 60

are starvation-related malnutrition, chronic disease-related malnutrition, and acute disease or injury related-malnutrition

Question 61

• Evidence-based procedures for EN therapy include the following:

Answer 61

o Positioning patient with head elevated at least 30 degrees. o Flushing feeding tubes to maintain patency. o Checking tube position on insertion and prior to feeding. o Monitoring for aspiration. o Using sterile, liquid EN formula with closed-systems are preferred. o Monitoring nutrition status and tolerance of EN.

Question 62

• Central parenteral nutrition is the delivery of a

Answer 62

nutritionally adequate hypertonic solution consisting of glucose, crystalline amino acids, fat emulsion, minerals, and vitamins using a central venous route

Question 63

are monitored a minimum of three times per week until stable and then weekly as the patient’s condition warrants

Answer 63

• Blood levels of glucose, electrolytes, and urea nitrogen; a complete blood count; and hepatic enzyme

Question 64

• Refeeding syndrome is characterized by

Answer 64

fluid retention and electrolyte imbalances including hypophosphatemia, hypokalemia, and hypomagnesemia

Question 65

Hypophosphatemia (serum phosphate level less than 2.4 mg/dL)

Answer 65

is the hallmark of refeeding syndrome and could result in cardiac dysrhythmias, respiratory arrest, and neurologic problems.