Chapter 44: Nutrition Problems Nursing Care

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Welcome to the Deep Dive.

We're here to help you cut through the noise and get right to the essentials.

Today, we're tackling a topic from Lewis's Med Serg that's, well, fundamental.

Absolutely fundamental.

We talk a lot about diseases, meds, fancy procedures, you know, but what about the basic fuel, the stuff that keeps every single patient going?

What happens when that system breaks down?

It's easy to overlook sometimes, isn't it?

But it impacts everything, recovery, overall health.

It really does, and it's not just about like feeling hungry or full.

Nutrition is this incredibly complex physiological process.

It determines quality of life.

So our mission today really is to equip you, our future nurses, with the solid knowledge you need.

We want you to be able to spot nutrition problems, understand what's going on, and manage them effectively.

Right.

We're diving deep into that critical chapter in Lewis's.

Yeah.

Pulling out those key pieces you'll use on the floor.

And let's be honest, for the NCLEX too.

Definitely.

So let's map this out.

We'll start with the basics.

What is normal nutrition?

Then we'll look at the whole spectrum, right?

Optimal, problematic.

Exactly.

We'll really get into malnutrition, what causes it, what it does to the body.

And then crucially, what you do about it.

Your role in assessment, management, specialized support like tube feeds or IV nutrition,

the whole nine yards.

The nuts and bolts.

Okay.

Foundations first.

Normal nutrition.

What are we talking about here?

Well, basically it's the sum of all the ways the body takes in nutrients and actually uses them.

But the really key idea here is the continuum.

The continuum.

Yeah.

Think of it like a scale.

On one end, you've got under nutrition.

In the middle, optimal nutrition.

And on the other end, over nutrition.

Any imbalance too little, too much, or just the wrong mix can cause problems.

And it's not just about what someone eats, right?

There are other factors.

Oh, absolutely.

You have to consider things like their attitude towards food, their lifelong habits, maybe cultural or religious practices that affect diet.

Finances too, I imagine.

Huge factor.

Financial status, access to grocery stores.

We even hear about the heat or eat dilemma people having to choose between paying bills and buying food.

It's critical info for your assessment.

Gotcha.

So sticking with biology for a sec,

what are the core components of a balanced diet?

Assuming no specific disease state, you're looking at your macronutrients, carbs, fats, proteins, and your micronutrients, vitamins, minerals, electrolytes, plus water, of course.

These are the essential building blocks.

And everyone needs different amounts, right?

Like calories.

Totally variable.

Depends on body type, age, gender, activity level, any meds they're taking, and especially any disease or injury.

How much does illness change things?

Significantly.

A rough guide might be 25 -30 calories per kilogram of body weight just for maintenance in a healthy adult.

But if someone's injured, septic, recovering from major surgery, that can easily jump to 30 -35 calories per kilogram, sometimes even more.

Wow.

The big takeaway.

Stress and illness crank up the body's energy demands big time.

Okay, let's break down those macros.

Carbohydrates first.

I think energy, right.

Mostly energy, yeah.

About four calories per gram.

But their protein sparing role is just as important, maybe even more so.

Protein sparing, meaning?

Meaning if you don't get enough carbs, your body has to find energy somewhere else.

And where does it turn?

Your protein stores, your muscles, even organ tissue.

Oof.

So carbs basically protect your muscles?

Exactly.

They let protein do its main job, which is building and repairing tissue.

Plus carbs provide fiber, which is crucial for gut health.

Okay, next up, fats.

Also energy, right?

But more concentrated.

Yep, nine calories per gram, so very energy dense.

They're also vital for storing energy, insulating the body, carrying those fat soluble vitamins ADEK, and helping us feel full, you know, satiety.

But there are good fats and bad fats.

Definitely.

We need to guide patients away from too much saturated and trans fat, which can harm heart health, and towards healthier options like monounsaturated fats, think olive oil and polyunsaturated fats, especially omega -3s found in fish, which are great for the heart.

Makes sense.

And finally, proteins, building blocks.

The ultimate building blocks, also four calories per gram.

Essential for growing new tissue, repairing damage, making enzymes, hormones, antibodies, really critical functions.

And we need to get certain types from our diet.

Right.

Proteins are made of amino acids.

Some are essential, meaning our body can't make them, so we must get them from food.

Complete proteins like eggs, meat, fish, dairy, soy, contain all of them.

And incomplete proteins.

Those are mostly plant -based foods, grains, legumes, nuts.

They're missing one or more essential amino acids.

So someone following, say, a vegan diet needs to combine different plant foods cleverly throughout the day, like beans and rice, to get the full set.

Good point.

Okay, moving on to the micros.

Vitamins first.

Okay, vitamins.

These are organic compounds needed for metabolism.

Lots of different enzyme reactions.

We split them into water soluble.

That's vitamin C and the B vitamin.

The ones you pee out if you take too much.

Pretty much, yeah.

They aren't strained well, so you need them regularly.

Then there are the fat soluble ones, A, D, E, and K.

These can be stored in body fat.

Which means you can get too much.

Toxicity.

Exactly.

Especially with A and D, toxicity is a real concern if people take excessive supplements.

And even small deficiencies can cause big problems, like not enough vitamin A, you might get night blindness.

Severe vitamin C deficiency leads to scurvy, poor wound healing, bleeding gums.

Wow.

And minerals.

Minerals are inorganic elements.

Also crucial.

They help build tissues like bone, calcium, regulate body fluids, sodium, potassium, oxygen transport, iron.

We need some in larger amounts, major minerals, and others in tiny amounts to trace elements like zinc or iodine.

Same principle applies.

Balance is key.

Too much or too little can cause issues.

And we have to remember culture again.

Absolutely crucial.

You can't provide good nutritional care without understanding the patient's background.

Are they Jewish and follow kosher dietary laws?

Are they Muslim and observing Ramadan fasting?

So you need to ask.

Always ask, never assume or stereotype, and then you adapt.

Maybe you need to find a specific kosher formula for their tube feeding or work with the pharmacy to adjust medication schedules around fasting periods.

It's about respect and individualization.

Makes sense.

Okay, let's shift now.

Let's talk about when things go wrong.

Malnutrition.

Right.

And technically malnutrition includes over nutrition, like obesity, which is a whole chapter.

But usually when we talk about malnutrition in the hospital setting, we're focusing on under nutrition.

Meaning a deficit.

A deficit or an excess or just an imbalance of energy, protein, or other nutrients.

It's a major problem.

How common is it?

Alarmingly common.

Studies show anywhere from 30 to 50 % of patients in acute care hospitals have some degree of malnutrition.

And in older adults, especially in rehab or long -term care, it can be even higher, maybe up to 50 % or more.

That's huge.

Why?

What's driving this?

A really key factor is inflammation.

The body's response to illness or injury.

We actually classify malnutrition based on this.

There are three main types, kind of a framework for thinking about it.

Okay, what are they?

First, you have starvation -related malnutrition.

This is chronic starvation without significant inflammation.

Think of conditions like anorexia nervosa or maybe severe food insecurity over a long time.

It's sometimes called primary PCM protein calorie malnutrition.

Okay, starvation without inflammation.

What's next?

Second is chronic disease -related malnutrition.

Here there is inflammation, but it's usually mild to moderate, and it's ongoing.

This is common with organ failure, like heart failure, kidney disease, cancer, rheumatoid arthritis, conditions like that.

Secondary PCM.

Got it.

Chronic disease with some inflammation.

And the third?

That's acute disease or injury -related malnutrition.

This is where you have a major marked inflammatory response happening quickly.

Think severe infections, sepsis, major burns, trauma, critical illness.

The inflammation is intense.

So inflammation is a really big player here.

It changes everything metabolically, but beyond inflammation, there are loads of contributing factors.

Socioeconomic stuff, we mentioned food insecurity.

Physical illness itself is a huge risk being hospitalized, having surgery, infections.

GI problems too, like nausea or diarrhea.

Definitely.

Anything that affects intake, digestion, or absorption.

Nausea, vomiting, diarrhea, malabsorption syndromes like Crohn's disease.

Even fever increases your metabolic rate, burning through energy and protein faster.

What about things like alcohol or drug use?

Big impact.

They often lead to poor intake and nutrient deficiencies.

Certain surgeries, especially on the GI tract, can cause problems too, like removing part of the stomach might affect B12 absorption.

And don't forget drug -nutrient interactions.

Some meds affect taste, appetite, or nutrient absorption.

Quick.

So let's trace what happens inside the body during starvation.

It's pretty grim, isn't it?

It is.

The body tries to adapt, but it's a losing battle eventually.

First, it burns through its very small stores of carbohydrates, glycogen in the liver, and muscles.

That's gone in like 18 hours, maybe a day.

So quickly.

Then what?

Then it starts breaking down skeletal muscle protein.

It converts those amino acids into glucose in the liver.

That process is called gluconeogenesis, basically making new sugar from protein.

Which is bad because?

Because you're sacrificing functional tissue.

Muscle wasting starts.

And you go into a negative nitrogen balance, losing more protein than you're taking in or making.

But the body tries to preserve protein somehow, right?

Using fat.

Yeah, it's smart in a way.

If there are adequate fat stores after the initial protein breakdown, the body shifts primarily to using fat for energy.

This can last for several weeks, maybe four to six weeks in prolonged starvation.

Fat can supply up to 97 % of calories then, which helps spare the remaining protein for a while.

But eventually the fat runs out.

Exactly.

And once the fat stores are depleted, the body has no choice but to go back to breaking down protein.

But this time it's not just skeletal muscle.

It starts using protein from vital organs, the liver, kidneys, heart, and plasma proteins like albumin.

That sounds critical.

It is.

Liver function gets impaired, protein synthesis drops.

And when plasma proteins, especially albumin, decrease, the oncotic pressure in the blood vessels falls.

Oncotic pressure.

That's the pulling power for fluid.

Right.

It helps keep fluid inside the blood vessels.

When it drops, fluid leaks out into the surrounding tissues, the interstitial space.

And what do you see clinically?

Edema.

Swelling.

Bingo.

You see edema often in the legs, feet, maybe even the face.

Here's the really insidious part.

That edema can mask the severe underlying muscle wasting.

The patient might not look as thin or cachectic as they actually are because they're puffy with fluid.

Wow.

That's a crucial assessment point.

Huge.

And on a cellular level, things are breaking down too.

Electrolytes shift abnormally, the sodium potassium pump starts to fail, the liver shrinks, gets fatty infiltration.

It's a systemic collapse.

And this is worse if there's inflammation involved.

Oh yeah.

Inflammation actually increases the metabolic rate,

increases protein breakdown, and causes other changes, like decreased albumin production, that worsen the malnutrition state much faster than pure starvation.

So how do we spot malnutrition when we see a patient?

What are the signs?

You look for the physical manifestations.

Dry, flaky skin, maybe rashes, brittle nails, hair loss.

Changes in the mouth sores, inflammation.

You'll definitely see decreased muscle mass, weakness.

Sometimes CNS changes too, like confusion or irritability, especially in severe cases.

And these link back to problems like?

Poor wound healing is a big one.

Increased susceptibility to infections because the immune system is compromised.

Anemia, often from iron or folate deficiency.

So how do we diagnose it?

Is there one test?

Unfortunately, no single lab test screams malnutrition.

It's more about putting the whole picture together.

You need a thorough history, especially asking about unintentional weight loss,

physical exam findings we just talked about, vital signs, and then you look at a panel of labs.

Like what?

You might see electrolyte imbalances.

Often potassium can be high initially, then drop.

Low red blood cell count or hemoglobin indicating anemia.

A low total lymphocyte count can reflect immune suppression.

Liver enzymes might be elevated, and serum vitamin levels might be low.

What about albumin and prealbumin?

We hear about those a lot.

Right.

They're important, but you need to interpret them carefully.

They are negative, acute phase proteins, meaning their levels go down during inflammation, regardless of nutritional status sometimes.

So a low albumin or prealbumin level is a strong indicator that there's inflammation happening, which is often driving the malnutrition, but it doesn't directly measure protein stores in that context.

Prealbumin changes more quickly than albumin, so it might reflect recent changes better.

Okay, that makes sense.

So given how serious and common this is, the nurse's role is obviously huge.

Where do we start?

Assessment is your absolute first step.

You are the eyes and ears.

The Joint Commission actually mandates that every patient gets a nutrition screening within 24 hours of hospital admission.

Using specific tools?

Yeah.

There are validated tools like the MS Malnutrition Universal Screening Tool, or for older adults,

the M &A Mini Nutritional Assessment.

These are quick ways to identify patients who are at risk.

And if they screen positive as being at risk?

Then they need a comprehensive nutrition assessment.

This involves digging deeper, getting detailed medical, nutrition, and medication histories, performing that thorough physical exam looking for signs of deficiency or wasting,

taking anthropometric measurements, and reviewing the lab data.

Anthropometrics, that's height, weight, BMI.

Exactly.

Height, weight, calculate the BMI.

Remember, less than 18 .5 is underweight, but the really critical indicator is unintentional weight loss.

How much weight loss is significant?

A loss of more than 5 % of their usual body weight in the last six months, or more than 10 % loss ever if it was unintentional, is clinically significant.

That's a major red flag, even if the person started out overweight or obese.

Losing weight without trying usually means something serious is going on.

It could do.

What about other measurements, like skin folds?

Skin fold thickness and mid -arm circumference can give an idea of fat spores and muscle mass, but they require proper training and serial measurements by the same person to be reliable.

They're used more in some settings than others.

And functional status.

How does that tie in?

It's really important.

Can the patient perform their activities of daily living ADLs?

Tools like the CATS index help assess that.

Objective measures like hand grip strength, how fast they can walk a short distance, or how many times they can stand up from a chair in 30 seconds can also give you real data on their functional decline due to muscle loss.

So once you've assessed, what are the goals for these patients?

The overall goals are usually to achieve an appropriate weight,

consume a specific target number of calories and protein decided with the dietitian, and importantly, avoid any complications related to their malnutrition or the re -feeding process.

Let's talk interventions.

What about health promotion?

Preventing this in the first place.

Teaching is key.

Using tools like MyPlate, the visual guide showing half the plate fruits and veggies, quarter protein, quarter grains,

teaching people how to read nutrition facts labels on food packages, encouraging balanced meals, portion control, choosing nutrient -thense foods.

There are lots of great online resources and apps now too for tracking intake.

Okay, but for patients already in the hospital and malnourished,

what are the acute care strategies?

First, it's collaborative.

You're working closely with the doctor and especially the registered dietitian.

Remember those increased needs patients undergoing surgery, trauma, fighting infection need significantly more calories and protein to heal.

So monitoring is key.

Absolutely.

Daily weights are crucial though.

You have to be careful interpreting them early on due to fluid shifts.

Strict intake and output records.

Often the dietitian will order a daily calorie count to see exactly what the patient is managing to eat.

How can we help them eat more?

Encourage high calorie, high protein foods.

Add butter, sauces, whole milk to things.

Use fortified foods.

Offer frequent small meals instead of three large ones.

And create a good eating environment.

Make sure the room is pleasant.

Help them with setup, oral care before meals.

Manage pain or nausea.

Little things make a big difference.

What about supplements like Insure or Boost?

Oral liquid supplements can be really helpful to boost calorie and protein intake between meals or if their appetite is poor.

Sometimes appetite stimulants might be prescribed like Magestral Acetate.

Okay, you mentioned re -feeding earlier.

Let's circle back to that.

Re -feeding syndrome sounds scary.

It can be very dangerous if not managed carefully.

It happens when you start feeding someone who is severely malnourished.

Maybe they haven't eaten properly for days or weeks.

Who's most at risk?

Patients with chronic conditions like alcoholism, cancer patients after chemo, patients with long -standing eating disorders, or those who've had very little intake for more than a week.

And what happens physiologically?

When you suddenly give carbs and calories insulin spikes.

This drives electrolytes, especially phosphate, potassium, and magnesium from the bloodstream into the cells very rapidly.

Leading to low levels in the blood.

Exactly.

The hallmark is hypophosphatemia, low phosphate.

But you also get hyperkalemia and hypomagnesemia.

This electrolyte shift plus fluid shifts and glucose fluctuations can overwhelm the heart and respiratory system.

Cardiac dysrhythmias, respiratory failure, neurologic disturbances.

It can be fatal.

So how do we prevent it or manage it?

The cardinal rule is start low and go slow.

Begin nutrition support, whether it's oral, enteral, or parenteral.

At a very low rate, maybe only 25 -50 % of their estimated goal needs initially.

Monitor electrolytes, especially phosphate, potassium, magnesium, very closely daily or even more often at first.

Check blood glucose frequently.

Monitor cardiac rhythm.

Replete electrolytes proactively.

And give thiamine, vitamin B1 before starting feeding, as it's crucial for carb metabolism.

Okay, super important safety point.

What about when patients go home or for older adults specifically?

Discharge planning is critical.

Patients and families need teaching on the diet.

Any supplements, maybe managing tube feeds at home.

Connect them with resources, home health nursing, outpatient dietitians, programs like Meals on Wheels or SNAPI if they have food insecurity.

Keeping a food diary or tracking weight at home can help monitor progress.

And older adults?

They are particularly vulnerable.

Age -related changes like decreased muscle mass, sarcopenia,

changes in taste and smell,

potential social isolation, chronic illnesses,

polypharmacy, all increase their risk.

Their protein and vitamin D needs might actually be higher than younger adults.

So assessment needs to be really thorough.

Yes.

Ask about appetite, chewing or swallowing difficulties,

income, ability to shop and cook, mood, oral health.

Focus on strategies to improve intake, making meal time pleasant, using adaptive utensils if needed, ensuring access to nutrient -dense foods.

And sometimes you need to have conversations about goals of care and advanced directives regarding artificial nutrition.

Right.

Okay, that brings us to specialized support.

What if someone just can't eat enough or can't use their gut?

That's when we turn to enteral nutrition EN, or tube feeding, and parenteral nutrition PN or intravenous feeding.

Let's start with EN, feeding the gut, right?

Yeah, exactly.

EN means delivering liquid nutrition directly into the stomach or small intestine through a tube.

We use it when the GI tract is functional, but the patient can't safely swallow or take in enough calories orally.

Think head and neck cancer,

stroke with dysphagia, critical illness requiring ventilation, severe burns.

Why use the gut if you can?

Because it's more physiologic, it keeps the gut lining healthy.

It's generally safer, associated with fewer serious complications, especially infections.

And it's significantly less expensive than PN.

If the gut works, use it is the mantra.

But not if the gut isn't working.

Correct.

Contraindications include things like a bowel obstruction, an ileus where the bowel isn't moving,

intractable vomiting or diarrhea, or severe malabsorption.

What goes in the tube?

Is it like a milkshake?

Sort of, but much more scientifically formulated.

There are many different EN formulas.

They vary in calorie density, usually 1 to 2 calories per milliliter, protein content, fiber, electrolytes.

Some are standard, others are specialized for conditions like diabetes or kidney disease.

Most are lactose free.

How is it delivered?

It can be given continuously via a pump, which is common in critical care to improve tolerance.

Or it can be given intermittently as bolus feedings over a shorter period using a pump, gravity drip, or even a large syringe, mimicking meal times more closely.

And the tubes themselves, where do they go?

For short -term use, less than four, six weeks, we typically use nasogastric NG tubes going through the nose into the stomach, or sometimes nasointestinal tubes that go past the stomach into the duodenum or dejunum.

And for longer term?

For long -term feeding, tubes are usually placed directly through the abdominal wall into the stomach, a gastrostomy tube or G -tube, often placed endoscopically as a PEG tube, or into the dejunum, a J -tube.

Sometimes a G -J tube has ports to both the stomach and dejunum.

Okay, nursing management for EN.

Yeah.

This seems like a huge area of responsibility.

Safety first.

Absolutely paramount.

The biggest risk is misplacement of the tube, especially NG tubes ending up in the airway instead of the stomach.

This can lead to feeding being infused into the lungs, which is catastrophic.

So how do you confirm placement?

The gold standard for initial placement confirmation of any blindly inserted tube, like an NG, is an x -ray.

You must get radiographic confirmation before instilling anything, food, water, meds.

Oscultation listening for air over the stomach is not reliable and should not be used for primary confirmation.

What about checking before each feeding or med administration later on?

After initial x -ray confirmation, you should regularly assess tube placement.

This includes checking the external length marking on the tube, assessing the appearance and pH of aspirated fluid.

Stomach aspirate should be acidic, pH 5 .5 usually.

And some facilities use capnography to detect carbon dioxide if the tube is inadvertently in the airway.

Always follow your institution's specific policy.

What about aspiration risk, food coming back up?

Also a major concern.

Best practice is to keep the head of the bed elevated at least 30 -45 degrees during feeding and for 30 -60 minutes after intermittent feeds.

Checking gastric residual volumes, how much feeding is left in the stomach before the next feed is controversial, and policies vary widely.

High residuals might indicate poor tolerance, but the number alone isn't always predictive of aspiration.

What else?

Tube clogging, skin care.

Yes, to both.

Keep the tube patent by flushing routinely with water, typically 30 milliliters of warm tap water every four hours during continuous feeds and before and after intermittent feeds and medications.

Sterile water might be used for immunocompromised patients.

If it clogs, there are protocols for trying to unblock it.

And for G -tubes or J -tubes, daily site care is important, assessing for redness, irritation, leakage, cleaning around the site gently, and applying protective ointments if needed.

And you mentioned misconnections earlier.

A huge safety issue.

Accidentally connecting EN tubing to an IV line or a tracheostomy cuff inflation port.

It can be fatal.

Prevention involves using EN -specific connectors, like ENFIT, always tracing lines from the patient back to their origin before connecting anything, labeling tubes clearly, and never modifying or adapting connectors.

Okay, lots to manage with EN.

Now, what if the gut truly cannot be used at all?

That's PN.

That's parenteral nutrition, yes.

Nutrition delivered directly into the bloodstream, bypassing the GI tract completely.

When is this necessary?

Indications include situations where the GI tract is non -functional or needs complete rest.

Things like severe prolonged diarrhea or vomiting, complicated abdominal surgery or trauma, GI obstruction, short bowel syndrome where there isn't enough intestine left to absorb nutrients, severe malabsorption.

What's actually in the PN bag?

It's a complex, customized sterile solution prepared by the pharmacy.

The main components are dextrose, a simple sugar for carbohydrates, providing about 3 .4 calories per gram, amino acids for protein, and a separate lipid emulsion, usually soybean or safflower oil -based, providing fat calories around 1 to 2 calm LL and essential fatty acids.

Plus, electrolytes, vitamins, and trace elements tailored to the patient's specific needs based on labs and clinical condition.

Why the fat emulsion?

It's a concentrated calorie source, prevents essential fatty acid deficiency, and helps limit the amount of dextrose needed, which can help with blood sugar control.

However, it's contraindicated in patients with severe hyperlipidemia or egg -soy allergies.

How is PN given?

I hear about central lines versus peripheral lines.

Right.

There are two main ways.

Central PN, CPN or TPN total parenteral nutrition,

uses highly concentrated solutions, often with high dextrose content, 20 to 50 percent.

Because these solutions are very hypertonic, thick, and irritating to veins, they must be infused into a large central vein, like the superior vena cava via a central venous catheter or a PICC line.

The high blood flow quickly dilutes the solution.

This is for long -term support or high nutritional needs.

And peripheral PN?

Peripheral PN, PPN uses less concentrated solutions, lower dextrose, usually at 10 percent, making it less hypertonic.

It can be given through a regular peripheral IV line.

But because it's less concentrated, you need to give large volumes to meet nutritional needs, increasing the risk of fluid overload.

It's also still irritating to peripheral veins, increasing the risk of phlebitis.

So PPN is generally only used for short -term support, maybe up to two weeks, when central access isn't feasible or necessary, and nutritional needs aren't extremely high.

Nursing management for PN sounds like it needs to be meticulous.

Absolutely meticulous.

Infection control is paramount because you're infusing directly into the bloodstream.

PN solutions are prepared under strict sterile conditions in the pharmacy.

Nothing should ever be added to the bag on the nursing unit.

Solutions are refrigerated until use and typically hang for no more than 24 hours.

Lipid emulsions might have shorter hang times.

What about administration?

Always use an infusion pump with alarms for accurate rate control.

PN requires a dedicated IV line.

Nothing else should be infused through it.

Specific filters are used, a 0 .22 micron filter for solutions without lipids, and a larger 1 .2 micron filter if lipids are mixed in or infused separately.

Tubing and filters are changed every 24 hours or with each new bag bottle.

Safety checks.

Critical.

Before starting any PN infusion, two RNs must verify the order against the pharmacy label, check patient name, ingredients, amounts, expiration date, and verify the pump settings.

Always inspect the solution for any precipitates, separation, cracking lipids, or discoloration.

And again, trace the line to ensure it's connected to the correct central or peripheral access.

What are the main complications to watch for?

Metabolic problems are common.

Hyperglycemia is frequent due to the high dextrose load, so blood glucose monitoring every 4 -6 hours is standard, and insulin may be added directly to the PN bag or given separately.

Hypoglycemia can occur if PN is stopped abruptly, so rates are usually tapered down.

Refeeding syndrome is also a risk if started too aggressively in malnourished patients.

Others include electrolyte imbalances, liver dysfunction over time, and hyperlipidemia.

And catheter issues.

Catheter -related blestroom infections, CRBSI, are a major life -threatening risk.

Strict aseptic technique during dressing changes and accessing the line is vital.

Other catheter problems include air embolism, pneumothorax during insertion, catheter occlusion or dislodgement, thrombosis, and phlebitis, especially with PPN.

You need to constantly assess the insertion site and monitor for local and systemic signs of infection.

How do you know if PN is working?

Monitor vital signs, daily weights, intake and output carefully.

Track lab values regularly.

Glucose, electrolytes, BUN, creatinine, liver enzymes, triglycerides, CBC.

Nutritional parameters like pre -abumin might be followed.

Ultimately, you want to see wound healing improve, weight stabilize or increase appropriately, and overall clinical improvement.

And getting off PN.

The goal is always to transition back to enteral or oral feeding as soon as feasible.

Typically, PN is gradually tapered off as the patient increases their oral or enteral intake.

Usually, they need to be meeting at least 60 % of their needs via the GI tract before PN is discontinued completely.

Okay, one last area to cover eating disorders.

A very different kind of nutrition problem.

Very different, yes.

These are serious psychiatric conditions, but they have profound physiological consequences related to nutrition and carry a high risk of mortality.

Who's affected?

They can affect anyone, any age, gender, socioeconomic background, though often emerge during adolescence or young adulthood.

Risk factors are complex.

A mix of biologic predisposition, psychological factors like perfectionism or anxiety, and sociocultural pressures, especially related to body image.

We're even seeing things like bigorexia or muscle dysmorphia, particularly in males.

Let's touch on anorexia nervosa, AN.

What are the hallmarks?

Intense fear of gaining weight, severe restriction of energy intake leading to significantly low body weight, and a disturbed perception of body shape or weight.

They often see themselves as overweight, even when severely underweight, BMI 17 or even lower.

May involve compulsive exercise, purging behaviors, or food rituals.

What physical signs might you see?

Signs of severe malnutrition, extremely thin, muscle wasting, dry skin, brittle hair nails, maybe Lenugo, that fine body hair, feeling cold all the time, hypothermia, low blood pressure, slow heart rate.

Osteopelosis is a major long -term risk.

Lab findings might include anemia, electrolyte imbalances, especially low potassium if purging, low white blood cell count.

How is it treated?

It requires a multidisciplinary approach, medical stabilization,

intensive nutritional rehabilitation,

and psychiatric therapy, individual, family, group.

Hospitalization is often needed for severe cases or medical instability.

Refeeding must be done very carefully due to the high risk of refeeding syndrome.

Building trust and therapeutic rapport is essential but can be very challenging.

And bulimia nervosa, BIN, how is that different?

BIN involves recurrent episodes of binge eating, consuming a large amount of food in a short time with a sense of lack of control, followed by inappropriate compensatory behaviors to prevent weight gain.

Most commonly, this is self -induced vomiting, but can also be misuse of laxatives, diuretics, fasting, or excessive exercise.

Do people with BIN look underweight?

Not necessarily.

Unlike AN, individuals with BIN are often normal weight, or even slightly overweight, though their weight might fluctuate.

They still have intense concern about their body shape and weight.

What physical signs might point to BIN?

Signs related to purging are common.

Calluses or scars on the knuckles, Russell sign from inducing vomiting, swollen salivary glands, parotitis, broken blood vessels in the eyes, significant dental erosion from stomach acid.

Lab findings often show hypokalemia, low potassium, and metabolic alkalosis from vomiting.

Treatment for BIN.

Again, multidisciplinary.

Psychological counseling, especially cognitive behavioral therapy, CBT, is highly effective.

Nutritional counseling helps normalize eating patterns.

Sometimes antidepressant medications, like fluoxetine, are used as their FDA approved for BIN.

Wow, that's a lot to cover.

So bringing it all together, what's the big clinical takeaway for our nursing students listening?

I think the biggest takeaway is just how fundamental nutrition is to everything we do in nursing.

Understanding that spectrum from optimal health through the complexities of malnutrition driven by starvation or inflammation, to the specialized support with EN and PN, and even the psychological aspects of eating disorders,

it all impacts patient outcomes profoundly.

Your assessment skills, your interventions, your advocacy for proper nutrition, they are absolutely critical pieces of patient care.

This isn't just a side issue, it's core.

So thinking about your own practice,

what does this all mean for you?

How many patients might have these silent nutrition issues that you might overlook if you're not actively looking?

How will digging into this chapter change how you observe, how you assess, and ultimately how you intervene to really support your patient's nutritional health?

Something to think about.

Thank you so much for joining us on this deep dive today.

Keep learning, keep questioning, and we'll catch you next time.