Nutrition

Nutrition

September 1, 2019 0 By Ewald Bahringer


>>This lecture is protein
calorie malnutrition and obesity. Some basic objectives we’ll
cover are to be able to identify which patients may be affected
by protein calorie malnutrition, be able to develop a nursing
care plan for patients affected by PCM, discuss the management
and complications of enteral and parental nutrition
and discuss obesity and nursing care plans for patient having
bariatric surgery. I am going to shorten
protein calorie malnutrition to the acronym PCM
for this lecture. When looking at protein
calorie malnutrition, the path of physiology
is usually a form of undernutrition resulting from
a lack of protein and calories. If you remember,
carbohydrates, protein and fat supply the
body with energy. Carbohydrates are the
preferred source of energy. So, usually the patient
is suffering from inadequate nutritional
intake related to some factor such as poverty, substance
abuse, decreased appetite, age, infectious diseases,
anorexia, hospitalization, or surgery and trauma. These are only a few of
the multitude of ways that a patient can wind up
experiencing malnutrition. You have different
types of malnutrition. The first we will look
at is Kwashiorkor. This is primarily a protein
deficiency which may develop in as little as two weeks. So this is an acute situation. These individuals may
appear well-nourished or over nourished
because of edema. Their weight for their
height is also normal, but the serum albumin is less
than 3 grams per deciliter, also when you look
at other lab values, their transferrin is low, their
total lymphocyte count is low, their BUN and creatinine
levels are also low. So, the primary goal
in this PCM type is to correct the protein
deficiency for these individuals. In Kwashiorkor what happens
is that there is a depletion of proteins which leads to a
fatty infiltration of the liver. This is the results in
a decrease in the number and function of intestinal
cells which results in diarrhea and then malabsorption develops. You have another type of PCM
which is called Marasmus. So, it lacks both protein and
calories in this condition. So this is a condition
of chronic starvation. It has been occurring
over a longtime. So these individuals
are emaciated, they demonstrate
generalized wasting and an absence of
subcutaneous fat. When you take their measurements
their weight, their triceps, skin folds are low when you
take these measurements. However, when you look at
their lab values you find that they are within
normal limits. Their albumin is normal. Their transferrin is normal and
their muscle mass may be normal. So, because this is
a chronic condition, protein tissues are preserved
because the body has adapted. So, the goals for
these individuals is to reintroduce calories slowly to avoid the overfeeding
syndrome. We discuss this later. These slides just show a
couple additional pictures of an individual with Marasmus. Now an individual can
also have a situation of mixed Marasmic
Kwashiorkor PCM. So, what happens here
is that this develops in a chronically starved
or malnourished patient who experiences stress. So, usually these
individuals the stress that they are experiencing is
they have a trauma or a surgery, something that’s going to require additional
proteins for healing. These individuals
appear cachectic. If you remember cachexia
is a state of ill-health, malnutrition and wasting. So, when you look at their
anthropometric measurements, these are depleted as are their
somatic and visceral proteins. So, their weight, their skin
folds, their waist, hip, and chest measurements
are all depleted. So, if you remember, we can get
proteins from the somatic area and usually these are
from the musculoskeletal and makeup approximately 75%. Also, there are visceral
proteins that the body can rob and these are from internal
organs, blood cells, serum and it makes up about 15%. So, a mixed Marasmic
Kwashiorkor can develop within a matter of weeks. So, it’s important to remember that these individuals have both
types, but it’s really important to determine which
is malnutrition that is primarily dominating. So before they had the mix
happen, you need to find out was it Kwashiorkor
or Marasmus because with Kwashiorkor, the risk is underfeeding
the patient. With Marasmus, the risk is
overfeeding the patient, and which ever on it is that
it falls into, that is going to be the main way you’re going to resupply calories
for this patient. In reviewing of the
phases of starvation, in phase one initially the body
is going to use carbohydrates, glycogen to maintain
metabolic function. So, these are stored in
the liver and the muscle and these stores are depleted
in about eighteen hours. The next proteins to be
converted to glucose, excuse me, next proteins are converted
to glucose; gluconeogenesis. So, if this continues
then the body will move on to the next one. One of the problems
with gluconeogenesis if this continues is
that the body is going to have a negative nitrogen
balance and we’re going to be excreting more nitrogen. The body, if it continues,
will then move into phase two and in five to nine days,
body fats are mobilized to help supply energy. So, at this point, fats become
the primary source of energy. Again, if this still continues
and the body is not able to resolve the malnutrition, the individual will
move into phase three. Once fat stores are used up,
the body will revert back to using body proteins including
those of body organs and plasma which are usually
used as last resort. Once at this phase, the
individual is at risk for having a liver function
impairment and the synthesis of protein decreases overall. So, when we’re looking
at individuals with PCM, we need to do a nutritional
assessment and some of the things that we’re
going to be looking at are anthropometric
data, fiscal data, and what are the causes of PCM. So, let’s look at the
anthropometric data. In [inaudible] on page 1329,
it has a good coverage of it. It starts out with we want to
know where is this patient? Are they at ideal body weight? If you remember, ideal body
weight is 90 to 100% of normal and to calculate this, you take
your current weight divided by what the ideal body weight
should and multiply it by a 100. Is the patient at low weight? A low weight individual is
somebody who has 85% or less of what the ideal
body weight should be. Has there been a weight loss? We’re looking for whether or not
this patient has less than 90% of what their usual weight
should be and that loss has been in the last six months. So, body mass index
is a measurement of nutritional status that does
not depend upon frame size. So, frequently it is
used for individuals. Normal body mass index
ranges from 18.5 to 24.9. To determine body mass index
you take the weight divided by the height in inches
squared and multiply it by 703. Other measurements that can
be used to monitor progress of weight gain or a loss
are skin fold measurements, mid arm circumference,
calf circumference and waist and hip measurements. When you’re looking at
the physical data, you’re, this is part of your
actual physical assessment. In neurosensory, are they
listless, apathetic or confused? Is their skin dry, flakey? Have they been losing hair? Do they have bruises? Musculoskeletal, do we have
prominent bony structures on the vertebral processes
and on the shoulders? Do they have poor posture
indicating muscle wasting because the muscles are
no longer able to hold up the skeletal frame? Usually with thermoregulation
we find that these individuals have a
low body temperature, excuse me. Cardiovascular, the patient
can be either bradycardic or tachycardic or you could have
hypotension or hypertension. With the GI tract, a lot of these patients have
what’s called hypogeusia which is a loss of taste or a
dysgeusia which is a bad taste in the mouth, usually they
complain of a metallic taste and frequently they’ll
have glossitis or irritation of the tongue. Fluids are going to show
that they’re going to move out into the extremities,
so you’ll have edema in the extremities
especially around the joints such as the elbow and the knees. You will see decreased
weight loss, excuse me, decreased urine output
with these individuals. They may have ascites as fluid
moves into the belly area because of the drop in proteins or these individuals
may have diarrhea since the GI tract is
not working very well. And with labs, you’re going to
see an overall decrease in all of their labs with the
exception of potassium and the reason why
potassium is elevated is because with the cell breakdown,
the potassium is released into the blood system and this
increases the potassium level. So, let’s look at
some causes of PCM. You can have inadequate nutrient
intake which can be a result of poverty, poor eating
habits, loneliness, alcoholism or anorexia. You can have excessive
nutrient losses from something like a burn or a fistula. Your individual could just
have failure to absorb. That can be nausea,
vomiting and diarrhea where they just don’t have
the opportunity to absorb. They can have maldigestion
because of pancreatitis. They could have had an
extensive bowel resection which doesn’t allow
for absorption. They could have severe
nausea and vomiting. There are some medications
and treatments that can cause catabolism. These would be steroids,
chemotherapeutic agents, radiation treatment
and major surgery. All of those are going
to need energy to heal. And then finally,
you can have diarrhea which just doesn’t allow
anything to be absorbed. So disease states that
contribute to PCM, you can have severe burns
because of the loss of exudates and that’s very high with
the protein, chronic liver or renal disease, bone fractures
with prolonged immobilizations, hemorrhage, inflammatory
bowel disease with the malabsorption syndrome, also with irritable bowel
disease because it will pass through quickly, tuberculosis,
AIDS, trauma, cancer, hyperthyroidism because that
increases the metabolism, infection you have increased
protein requirements needed to produce immunoglobulins
and to make leukocytes to fight the infection
and finally, fever. Fever causes an increase
metabolic rate. Don’t forget, your caloric
needs are going to increase 7% with every 1 degree of increased
temperature Fahrenheit. So complications with the
acutely ill patient with PCM; malnutrition of a hospitalized
patient delays recovery and prolongs hospitalization and these are all studies
that they have shown. So if the patient is severely
malnourished the length of hospitalization can
be extended up to 90%. Undernourished surgical patients
are three times more likely to develop major
postsurgical complications, such as wound dehiscence,
decubitus ulcers, sepsis, and pulmonary infections. Undernourished medical patients
have a two time higher mortality rate than well-nourished
medical patients. So, what happens here is
these individuals wind up with immunosuppression
with secondary infections and they are just
basically in a state of what’s called
emaciation which is a state of exhaustion resulting
from nutritional depletion. A malnourished patient with a stressor lacks the
nutrient reserves as needed for adaptation to occur. They’re just not able to do it
and for malnourished patients, a stressor can be something
as basic as surgery, trauma, infections or a burn. So let’s look and review very
quickly the three responses to stress. You first have your
alarm reaction where you have your
fight or flight reaction and an individual who undergoes
stress undergoes this all the time. So you have your increased
level of catecholamines, gluconeogenesis is going
to occur which can lead to hyperglycemia as the
body is trying to get ready for the fight of flight,
and so the patient is going to display an increased
heart rate, increased blood glucose levels and the metabolic
rate will be elevated. If it’s not resolved from
here they’ll usually go into an adaptive phase
if the stress continues and the stress hormones
are going to remain elevated continuing
to cause a hypermetabolic state. So these hormones that are going to remain elevated
are glucocorticoids, catecholamines, and glucagons. Hopefully the patient will
go into the recovery phase where they return to
homeostasis and then that way their stress
hormones will subside, their glucose levels
will go back down and they nitrogen
balance is restored. However, they have the
possibility of progressing into failure to adapt,
and in this case, the patient then undergoes
exhaustion, infection and death if the stressors
are not relieved. So with clinical manifestations
of PCM, we’re going to look at the GI tract mostly
and systemic effects because the GI tract is
most affected by PCM. So what you see with the GI
tract is your patient is going to have decreased
esophageal motility. There’s going to be decreased
sphincter tone usually of the esophagus
and the stomach. We’re going to also see
decreased contractility of the small intestine, so bowel
function will be hypoactive, decreased liver function,
decreased secretion of hydrochloric acid which
makes it difficult for patients to be able to digest an absorb
what nutrients they do take in, and therefore, decrease
absorption of nutrients especially
of calcium and iron. The systemic effects that we
see on the patients as a result of this, is they have
poor wound healing. They’re also at increased
susceptibility to infection, because they’re not
making those lymphocytes. They have a decreased
response to infection; phagocytosis is depressed
due to the lack of energy. They have decreased
wound tensile strength, increased tendency to
develop pressure ulcers. Edema will develop in the
face, the legs and the abdomen. In abdomen it develops
as ascites, and what’s happening
here your osmotic and oncotic pressure
normally keeps the fluid within the vascular space
minimizing these extravasations or minimizing the
fluid moving out. So, osmotic pressure is the
pull that draws the fluid to the more concentrated side and is usually exerted
by electrolytes. So, if you have a decrease
in osmotic pressure, it’s going to allow fluid
to move and result in edema. You also have oncotic pressure, also known as colloid osmotic
pressure and it’s created by high molecular weight, substances like the
protein and the albumin. So when the total
protein falls below 5.3, then the patient
experiences movement of fluid, because there’s nothing
to hold it in. The patient is also going to
experience muscle weakness, fatigue and decreased endurance. So, remember proteins are
constituents or components of muscle and enzymes,
hormones, transport vehicles and hemoglobins and
we need proteins to be able to make all of these. So as the body is using them, they may deplete the
cardiovascular system, and therefore, there’s not a
very good pool to keep the fluid in the cardiovascular system. So, when you have
a patient with PCM, then we have some
diagnostic studies that we’re going to look at. Normally, total protein is 6.0
to 8.0, so if we fall below 5.3 in a total protein, that
is usually a critical value for the patient. So the total protein is
a measurement of albumin, globulin, fibrinogen,
prothrombin, lipoproteins, glycoproteins and
metal-binding proteins. The albumin out of all of those
is going to make-up about 60% of this total protein. So if we have decreased levels
of protein that is going to prolong malnutrition
and starvation. Increase levels can be seen in
a patient that has dehydration such a from vomiting
and diarrhea, because we have lost fluid
and it looks like there’s more when there’s really not. So, if you’re going to draw
and albumin, a total albumin, you don’t need to
worry about food or fluid restrictions
for your patient. However, the patient
should avoid a fat; diet high in fat
before the do that test. Now, component of total
protein is serum albumin and that’s what they look
at a lot when they’re trying to figure out the protein and malnutrition content
of this individual. So, serum albumin usually
is between over 3.5 to 5; we just want it over 3.5
and it’s major purpose is to maintain colloidal
osmotic pressure. This, albumin is
smaller than globulin and can be lost during increased
capillary permeability, so anything that happens
with that is going to take the albumin
with it and take fluid. So, remember the pressure
that’s exerted by the protein in the blood plasma that
usually tends to pool the water into the circulatory system
is created by the albumins, those are the proteins. So, additional purposes of
serum albumin is that it’s going to transport drugs,
hormones, calcium, magnesium, bilirubin fatty acids
and enzymes. The primary nutritional
source for protein for the body tissues
is the albumin. Now, it has a half-life
of 20 to 22 days, so it is a poor indicator
of acute changes in nutritional status
because you have to, you’ll see decreases after
protein deficiency is prolonged and severe, so you need to take about three weeks before
you’re actually going to see this change. So, there is no fluid or
food restrictions, again, if you’re going to draw this. However, you need to be aware
that there are certain drugs that can cause false
changes; aspirin and penicillin can
give a false increase, while heparin can
give a decrease. So when we look at PCM and
we look at serum albumin and we’re looking
at our patients, where the patient is falling
with serum albumin is going to determine what is the
level of their malnutrition. We want our patients
to be over 3.5, that is no protein depletion
then; 2.5 to 3.8 is mild, 2.1 to 2.7 is moderate,
and anything less than 2.1 is severe
depletion of the proteins. Another thing that we’re going to take a look at
is pre-albumin. If you have it, now this
is a great little test. Normal is 17 to 40 because the
half-life is only two days. The body pool of this is
very small, so it adjusts and shows a change in
nutritional status much quicker; however, you will rarely
see a pre-albumin drawn because it’s an expensive test. It’s a very sensitive test and
is expensive, and they go more by the graph that was in the
previous slide as the indicator where protein status is. But if ever went across one,
then you know that if changes, it’s a reflection of
the last couple of days. We’re going to take a
look at serum iron levels for individuals; males
run between 50 to 175, females run between 50 to 170, and iron if you remember is
absorbed from the duodenum and the upper jejunum. Now part of iron levels is
a total iron-binding count, excuse me, total iron-binding
capacity which runs between 250 and 425 and what this represents
is the maximum amount of iron that can bind to the
protein transferrin. That transferrin we mentioned it
before is that little globulin that binds and transport the
iron from the bloodstream to the bone marrow to
make red blood cells. So, this represents
the largest quantity of iron-binding proteins
and these decrease as an individual gets older. Part of what may also be looked at if they don’t have a TIBC
would be maybe a transferrin saturation which runs 20 to
50%, and it’s the percentage of transferrin and other
mobile iron-binding proteins that are saturated
with iron and whether or not you have a good amount,
so if a saturation is high and reaching the levels that
it should, then the iron and the red blood cell is not
able to take on anymore iron. If it’s low, then you know
patient’s deficient in iron. So, the iron levels decrease
with protein deficiency because you need to
have the protein to make that globulin transferrin
to be able to transport the iron
into the bone marrow. The half-life of iron
levels is about 8 to 9 days, so it responds very
quickly to protein depletion when you’re looking at it. The red blood cell count, RBCs
are ranging normally from 3.8 to 5.8; hemoglobin
is 11.7 to 17.4, remember this is a component
of the red blood cell and hematocrit is 34 to 50%
and this is the percentage of RBCs in the whole blood. So all three of these components
are going to vary with gender, but you can use these
numbers for the exam. Anemia is also present
when we’re looking at PCM, and it can be present as a
result of decreased H and H or it can present
just as a result that the individual’s not
making red blood cells. Also in red blood cell
count, we have a lack iron and folic acid building blocks that are needed to
be make an RBC. Iron deficiency is going to
result in decreased production of hemoglobin which then results
as small pale hemoglobins, they’re also called macrocytic
that’s small and hyperchromic, they’re pale, so your RBCs
aren’t going to look very good. So when drawing, you don’t
have to worry about fluid or food restrictions, however
you do want to remember that you do not want to
draw your RBCs from an IV or from an arm where
an IV line is running, because the IV could
artificially lower the results of the reading. So let’s look at some
nutritional interventions. The first choice for nutritional
intervention is always enteral. Remember, enteral means within
or by way of the intestine. This route is the
best one for helping to maintain gut structure
and function, it’s easy to administer
providing you don’t have a huge aspiration risk in your patient and it is also the
most cost-effective for the individual. Here’s a choice between enteral
versus parental nutrition, and when we want to
choose parental nutrition as a first choice and
that is going to be when our GI tract is impaired
temporarily during acute pancreatitis, because remember
the patient needs to be NPO, because any food or
fluids that are put into the patient’s mouth
starts triggering the digestive processes, therefore the
pancreas starts secreting enzymes and we give the
patient a wonderful dose of extreme pain. So they need to be NPO, but depending upon how long
the pancreatitis lasts, they may need to have
some parental nutrition. And also if you have
an individual who has extreme hemodynamic
instability and they are not able to eat, so
that may be instituted for them to continue to provide them with
the nutrition that they need. So you have options, so there is
total enteral nutrition or TEN. These are for patients
who can eat but cannot maintain adequate
nutrition by oral intake of fluid alone, so we’re
supplementing what they’re eating by giving them some
additional calories via the peripheral site. Now if you remember,
parental nutrition, excuse me, this is total enteral
nutrition I am so sorry; so, we’re going to give this
through tube feedings for these individuals. So, they can eat but not enough,
so we’re going to supplement with some tube feedings. It’s also for patients who
have permanent neuromuscular impairment and they can’t
swallow, or for patients who do not have permanent
neuromuscular impairment but they’re critically
ill and they cannot eat because their condition. So we may supplement their
food with tube feedings, so there’s different ways that we can deliver
this enteral nutrition. We can deliver it through
the nasogastric tube, the nasoenteric tube,
or a nasoduodenal tube, so the tube will go down
to those different areas. Also you can do it through
enterostomal feedings if the patient has a
stoma of some kind, so individuals can be fed
through the gastrostomy tube, through the percutaneous
endoscopic gastrostomy or PEG tube, through a
low-profile gastrostomy device or LPGD, or through a
jejunostomy if they have a stoma and usually it’s done
either by a syringe or through tube feedings. There are different ways to
administer the tube feedings. The first way is bolus feeding, also called intermittent
infusion and that can be administered by
a gravity dip or syringe bolus for those patients with
gastric tube feedings. The patient can be fed by
continuous feeding and a lot of hospitalized patients
may initially benefit from the continuous infusion
to help establish a tolerance to that enteral nutrition
therapy and then later they
will be transitioned to an intermittent
infusion schedule, or the patient can be
on a cyclic feeding. This is where the
patient may need to be off of the tube feeding for a set
number of hours such as 8 to 12 so they can go do something,
and these can also be used in patients with intestinal
feeding tube sites in and duodenum or jejunum. So, if the patient needs
to have some free time, the cyclic feeding may be a
better option for that patient. Complications of enteral
nutrition are refeeding syndrome which we will discuss
more later, tube misplacement especially
if you have an ostomy that could be dislodged or the patient pullout
their feeding tube, abdominal distention if the
fluid is not passing through and is simply accumulating, or
fluid and electrolyte imbalances if their labs are not being
addressed or over addressed. So let’s also look at
parental nutrition. Parental nutrition,
there are three types; you can have peripheral
parental nutrition, and remember parental
nutrition is anything that is going to go not orally. So, this is going to go into
the circulatory system directly whether it’s through an IV,
through a central venous access, some of it can also be
delivered IM subcube. Usually through parental
nutrition it’s either peripherally or central
venous access. So we have PPN, the
peripheral parental nutrition, TPN which is total
parental nutrition, and TPA which is a total
nutrient admixture also called lipids for short among a lot
of nurses, and that is used to supply some of other
things for the patient. So, let’s look at
PPN a little bit. With PPN, the solution
is isotonic usually with 5 to 10% dextrose. It has to go into a
large peripheral vein, because dextrose at 5
to 10% is irritating, so you want a large vein. So this is not going to go in
the hand, it may go into further up on the arm or antecubital
or something like that, there’s a bigger vein. It’s very effective when
the patient only needs it for short-term. We’re looking at 7 to 14 days of nutritional support
being needed, and the patient is really
only needing to have less than 2500 calories a
day supplementation. So, all we’re doing really here
is supplementing inadequate oral intake and so they don’t need
a lot, but they need some. Total parental nutrition
on the other hand, is we’re giving them
everything in this solution. It is the hypertonic solution. It has 20 to 50% dextrose,
very high sugar concentration and so it has to go through a
central venous access device so that it can rapidly diluted because it’s very
hard on the veins. Now please remember, a central
venous access device is going into the upper chamber of
the heart, the right atrium, and so we want to make sure that we are always following
strict aseptic technique so that we don’t
introduce any infection. This form is used when we
need it for a long-term, over two weeks and so
what happens here is because this is more
concentrated we can deliver a smaller volume of fluid
and so the patient is able to get the nutrients they need
in a little bit less fluid than we would do if we
had to do it by a PPN. Total nutrient admixture
is isotonic, it’s composed of dextrose, amino
acids and fats or lipids and they’re all mixed together. So, lipids make the solution
isotonic and it helps also to protect the blood vessels. You have a variety
of components that go into creating the solution
for parental nutrition. Parental nutrition is a
sterilely produced admixture for the patient. Pharmacy does it under
the hood in pharmacy so that it is sterile and
usually you will have most if not all of these
items located in there. You have carbohydrates, lipids,
proteins, sodium chloride, sodium acetate or sodium,
or potassium acetate, sodium phosphate or potassium
phosphate, potassium chloride, magnesium sulfate, calcium
gluconate, trace elements, vitamins and other
medicines and, of course, the fluid that needs
to transport them. Now, I’m not going to look at
all of the components in here because some of them are
basically self-explanatory, we need proteins because
we need to be able to provide energy
and building blocks. The sodium, potassium maybe some
calcium are all electrolytes. They’re based upon what the
patient’s lab values are. We’re going to adjust
how much they get, same thing with the trace
elements and vitamins, but we will take a look
at a couple other ones. So, in carbohydrates,
the carbohydrate is going to be either a moderate, mild, or severe formula depending upon
how bad their protein calorie malnutrition is. So, based upon that, it
will be either 25, 30, 35 is what the needs
are going to be. Also, when you take a look at
lipids, lipids are not actually in the same bottle as the TPN,
it comes as a separate model that then gets piggybacked
into the line of the TPN. So, lipids are used to prevent
essential fatty acid deficiency and it also provides a
large amount of calories in a small amount of fluid. Now, when you get your lipids,
you want to examine the bottle or the container because
sometimes they come in glass bottles for separation. The lipids should not be
separating into layers, you should not be able
to see fat globules and there should be no
accumulation of froth. If there is, you
need to return it to pharmacy and let them know. We don’t want to infuse these. If you separate into layers
and you do infuse this, you infuse fat globules, you are
then infusing basically a fat embolism into your patient
and that will go to the lungs and create a pulmonary embolism. You want to begin
the infusion slowly for the first 15 to 30 minutes. We’re looking for a reaction. We want to make sure
that everything is okay, and we’re going to continue to
give a slow, continuous volume as it’s delivered over
the next 12 hours. It usually runs as
something where between 30 and 50 mils an hour, and
then it’s going to run for 12 hours and it’s complete. Sodium acetate or potassium
acetate are a lot of times added into the TPN because the acetate
is then converted to bicarb and this is really a nice
component to have in there if you are battling metabolic
acidosis in your patient, because then it will help to
reduce some of that acidity. Vitamins and other medications
are added and in this one, what I really want
to talk about is not so much the vitamins
but the medications. You can see regular insulin
added into the TPN especially if the patient is diabetic
or they’re having issues with hyperglycemia because
of a hypermetabolic state, and so if insulin is added
in you should be finding out whether or not there is
a protocol at your facility for glucose sticks and
how often you’re going to do those finger sticks
to monitor, because we need to make sure that the patient
does not become hyperglycemic or go into a hypoglycemia state
because we’ve added insulin. Also, they have the ability to
add something like famotidine into the TPN to help
reduce gastric acid reflux in these individuals
because they are stressed. Fluids, we have to have a
fluid to transport it in. So, usually what they do is
they’re going to required and plan for 25 to 35
mils per kilogram per day. So, that’s about how much
they’re going to give over a 24-hour period. If the patient is running
a fever, then they’re going to increase the amount of
fluid by a 150 mils per day for each degree of
body temperature over 37 degrees centigrade
and that will help count for that increase
in insensible loss. So, we have multiple
complications that can result from parental nutrition. You have hyperglycemia, because
this remember is a concentration of 20 to 50% Dextarim. So, you may not have orders
to do [inaudible] sticks, but you need to find out what
your policy is and you need to be familiar with
signs and symptoms of hyperglycemia
in your patient. Also, if you have something like
insulin in, you need to be aware of hypoglycemia in case your
patient goes the other way. You can have hypokalemia, have
hypocalcemia if not enough, electrolytes are added into the
container in order to be able to balance what the labs are. You can have respiratory
acidosis as the individual
becomes acidotic, and then fluid overload
is a huge potential because of the amount of fluid that we’re giving these
individuals every single day. So, the next ones I want to talk about further in
some other slides. So, the rest of the
complications are sepsis, the refeeding syndrome, pneumothorax, and
an air embolism. Again, with hyperglycemia,
one thing I do want to touch on here is remember that
with hyperglycemia it’s going to cause osmotic diuresis. Because of the extra glucose
it’s going to pull fluid out and you patient is going to be
having an increase urine output and they’re going to start
to show signs of dehydration. So, we’re going to see
a blood sugar over 200. They may complain of thirst. We’re going to have that
diuresis of the urine. They’re going to be
tired and restless. So our nursing interventions
that we’re going to do is monitor the blood
sugars every 4 to 6 hours. Now, if your patient happens to
have more fluid in their bottle than they’re supposed to
have, you never speed up or slowdown the rate
of administration without an M.D. order. So, if you have 300 cc’s that
are left and you you’re due to change the IV bag in 2 hours,
you do not increase the amount of fluid that’s going in, because that can make them
hyperglycemic, you keep them at the level that they’re at. When you’re watching
for hypoglycemia, and remember you have
to be aware and remember that hypoglycemia can
be caused by disruption of that parental nutrition
or too much insulin. So, one or the other
of this can happen. So, signs and symptoms that
you’re going to have here, your blood sugar is
going to be below 60. You’re going to have
tachycardia. The patient is going to be pale
and trembling, and so we want to gradually reduce infusion
rates if we’re trying to wean the patient off, because
their body has gotten used to that hyperglycemic
solution and if you remove it, the body has been putting
out insulin for that solution and they’re going to
go into a hypoglycemia. If the parental nutrition is
interrupted and you’re not able to hang another bag for over an
hour, they you’re going to want to hang a bag of D10 and
give them some glucose. Also, you want to monitor the
blood sugars again every 4 to 6 hours. Hypokalemia, potassium if
going to fall below 3.5 and you’re going to see
signs and symptoms of this. They’re going to have muscle
fatigue, muscle weakness, fatigue decreased
bowel motility, because the bowel will start
to quiet down, arrhythmias, and electrocardiogram changes,
so you are going to want to notify your physician
if you have any of these. With hypocalcemia, again,
your calcium is less than 8.5. They’re going to have signs
and symptoms that twitchy. They’re going to have the
positive Chvostek’s sign which is where you tap the cheek
and they get that twitch in it or the Trousseau’s sign where when you take their blood
pressure their hand twitches. They will also have arrhythmias
with the heart, again, you to notify the physician. Respiratory acidosis
can be caused from excess carbohydrates. Remember, carbohydrates are
broken down into CO2 and water. So, they within 24 to 48 hours
after infusion has begun, you already have this
metabolism that is occurring. So signs and symptoms
that you’re going to see on this is your carbon
dioxide is going to be over 45, your patient is going to
be in respiratory distress. It may not be acute, but you’re
going to start to see signs and symptoms that they’re not
having an easy time breathing or they’re air hunger or
they’re becoming very sedated and if you have a patient with
impaired pulmonary function, you could actually wind up with
respiratory failure because, remember, these individuals
their drive is CO2; a lack of CO2, so if
we increase their CO2, they don’t have a
drive to breathe. So, we’re going to monitor the
patient’s meals to make sure that they don’t have excessive
carbohydrates in their meal, and if we see any of these
signs and symptoms we’re going to notify the physician. Fluid overload can occur, so
because we’re giving them fluid, we’re giving them you know, 25 to 35 milliliters
per kilogram per hour. So what you’re going to see in
fluid overload is you’re going to see that neck
vein distention, the jugular venous distention,
they may develop a cough which is a natural reflex of the
body to try to clear the lungs of extra fluid, and you’re
going to see a weight gain on these individuals,
usually it’s over 5 pounds. Nursing interventions
that we’re going to have, definitely monitoring
those intakes and output. We’re going to follow a
strict I and O procedure, daily weights are
very important. So, as an RN you
want to be watching for are there daily
weights that are happening and being recorded
for your patient? And if you see signs and
symptoms of fluid overload, of course, we’re going
to notify the physician. Sepsis, with PCM,
you have to remember that these individuals need
to have aseptic technique, not clean technique when you
change, but aseptic technique. So, signs and symptoms that
you’re going to see are all of the infection ones;
fever and chills, flushing, an elevated white blood
count, and redness or drainage at the IV site or around the
central venous access device insertion site. So, don’t forget, this catheter
is going, the tip is going into the upper chamber
of the heart so we really don’t
want infection. So, if there is an infection,
or there’s a question about it, you’re going to remove and culture both the parental
solution and the catheter tip, so be careful that you
don’t throw it away and that you don’t
contaminate the catheter tip. You want to keep it sterile
and cut that off and put it into a sterile specimen
container so that it doesn’t
get contaminated. You can expect that they
are probably going to want to obtain cultures of the IV
site if they suspect the IV site to be the reason for the
infection and they are also more than likely going to draw blood
cultures on these patients. The refeeding syndrome
for these individuals, what happens here is the patient
has an excessive calories greater than their needs. Remember, these patients
are Marasmic, they have been a
longtime with starvation. They have adjusted and adapted
to living on the lower level of calories and so now
when we start to feed them if we feed them too fast, then
they have too many calories. So, what can happen here is your
peripheral nutrition can force electrolyte shifts from the
plasma into the intracellular. Usually this is going to incur in your moderately-to-severely
malnourished patient. So, one of the things that
you’re going want to do with these is going to want to start your peripheral
nutrition gradually. So, signs and symptoms
that you’re going to see of the refeeding syndrome
is you’re basically going to be based on the shifting
of those electrolytes; a low phosphorus, a low
potassium, low magnesium, low calcium and because those
are all going to be low, you may see arrhythmias
with the heart. You’re going to see
decreased reflexes. You may have, the patient
may complain of paresthesias such as numbness and tingling. They could have tetany. Their heart rate
could be sped up and they could have
respiratory insufficiency because they just
don’t have the strength and the electrolytes
needed to be able for, to have that musculoskeletal
tissue retract the ribs and the diaphragm. You can have too
rapid lipid infusion. So, this is that, the TPA
that white milky substance that we’re going to
be giving the patient. So, one of the things
that you’re going to want to be watching for are
allergic manifestations. You’re going to have the
urticaria, the angioedema with the swelling that’s going
to happen and anaphylaxis, also hopefully before
you get to that point, maybe there might be a little
increase in the heart rate so you’re going to want to
consider, if I have an increase in the heart rate,
what’s going on? What is new that I had
introduced to my patient? So, when the rapid infusion
happens too quickly, your patient is going to display
signs of nausea, vomiting. They may have a fever. They may have dyspnea, cyanosis
because they can’t breathe, phlebitis from irritation
because it’s going in too quickly, they could
have chest and back pain from the dyspnea or if they have
some kind of an embolus going on and they could have pain
at the insertion site also which is part of the phlebitis. So, we definitely want to
verify our allergies prior to giving this mixture, or
any mixture to the patient. We want to maintain an
accurate infusion rate, again, not speeding up or slowing down, and if your patient does display
any of these signs and symptoms when you start, the
admixture and the lipids, the total admixture,
you definitely want to notify your physician
of what is going on. Your patient can
have a pneumothorax. Usually, this occurs when the
patient is having the device put in if it’s a central
venous access port. So, what happens there is the
catheter that is being threaded down through the vein, punctures
the subclavian and goes into the pleural cavity. So signs and symptoms
that you’re going to see from your patient are
dyspnea, they’re going to have difficulty breathing
as that lung is collapsing and unable to expand
because of air trapped in the pleural cavity. They’re going to
have chest pain. The heart rate is going to
go up because we’ll need to get what oxygen around that
we can, also the patient is in pain and they’re anxious,
so that is going to go up. And when you auscultate on
that side, you are not going to hear any breath
sounds on that side. Again, that’s near emergency
and you’re going to need to make sure that
somebody is aware of that and let them know right away. Now, an air embolism is
definitely a medical emergency. These are all very serious, but
this one is a medical emergency. Usually, again, it’s going
to occur during the insertion of the central venous
access device or it could also occur
during tubing changes when air can get sucked into
the tubing just by breathing and the changes in
the thoracic pressure. So, signs and symptoms that
the patient may be experiencing in an embolism is they’re going
to have respiratory distress, they’re going to have a hard
time breathing, they’re going to have chest pain, the
heart rate is going to go up, their pressure is going to drop. These individuals can
go into cardiac arrest. The nursing interventions
that you’re going to do, the first thing is you’re
going to clamp off the catheter to prevent any more air
going into the IV tubing. You want to put the
patient on their left side in Trendelenburg
position, so that is head down on the left side. So what this is going to do,
is it’s going to trap the air in the ventricle in the
bottom of the ventricle so hopefully it will not go
out into the pulmonary artery. So it’s in the right ventricle and hopefully it will
be reabsorbed over time and that won’t be an issue
for the patient anymore. Again, you’re also going to
start oxygen for your patient and somebody needs to know that
this is occurring in the patient so that appropriate
measures can be taken. So, let’s look at hanging
parental nutrition. So there some steps. Again, like any IV
fluid you’re going to check the physician’s order. You’re going to make sure
that the delivery route is, correlates with the solution. You do not want to give a
central formula which is 20 to 50% dextrose into a
peripheral IV and you don’t want to put 10; 5 to 10% into
a central venous access. So you’re going to make
sure that those match. You’re going to assess
you patient; does it look like they still need it? How are they doing? Do we have any kind of
fluid overload going on? What are their lab
values looking like? Have we had any weight changes? Are any physical appearance,
the support that we still need to have it such as, you know,
are they still suffering from nausea and vomiting
or diarrhea? Are they still not eating? You want to assess the IV site. We want to make sure that
it’s not infected and we need to always explain the procedure to the patient and
what we’re doing. Procedurally, we want to keep
the solution refrigerated until at least 30 minutes before
use, and what you’re going to do here because
the components, are a lot of components in
this, it’s not as simple as saying yes I have
D5W 1000 mls. You have all those components;
carbohydrates, electrolytes, vitamins, etcetera-etcetera. So it’s a lot easier if
you check these components in the peripheral
nutrition with another RN; one looking at the order
and one looking at the bag. Again, correlate the patient
need with the ordered solution. Maybe their potassium is
at the high-end of normal and maybe we need to make sure
that the physician is aware if they haven’t seen it; that
they may not want to have quite so much potassium in the bag. We want to check the
bag for cracking. So, we don’t want the bag
to have any cracking in it. We need to check if for
turbidity which means that it’s not cloudy,
there’s no cloudiness. There’s no little crystals or
precipitates that are floating around in it, and
we definitely want to check the expiration date. These things are going
to expire every 24 hours. You will change the parental
nutrition bag every 24 hours, and when you do, you are
changing everything; the bag, the tubing and the
filter that goes with it. You want to prime the tubing
and filter, it’s a 1.2 micron that is used for total
nutritional admixture, the white stuff that the
lipids that you’ll be adding. So you’re going to
want to make sure that there’s a filter on there. If you have any difficulties,
you may want to prime this away from the patient, so that you
have a question then you’re still displaying confidence
and you’re not coming and going and decreasing patient
confidence in your ability. So, you may want to
do it in the med room. So, in hanging the
parental, again, you’re going to through the normal steps
of identifying the patient, matching the order to the sheet. You’re going to use
strict aseptic technique. You have to be really
careful of the ends of your IVs on this one. You want to connect the parental
nutrition to the patient and they need to be
on an infusion pump so that it is delivered
where it’s supposed to be. Now, if you’re lucky and they
have a central venous access port, you’re going
to want to put it in the middle port
of this access line. For a peripheral line, if
they have an access valve on, it can get in the way
especially with the lipids and so you may need
to remove that. When we start infusing with
patient’s parental nutrition, we’re going to start slowly. It’s usually 1.6 milliliters
per kilogram per hour. Again, like I said before,
you will never speed up or slowdown the rate
without an M.D. order, because the body is adjusting
with its production of insulin to the amount of sugar
that is in the solution and you can affect
their glycemic standing if you do that. Again, if you interrupt
it longer than an hour, make sure you have 10% dextrose, and with this medications
you are never, ever going to put anything else
into this that is not already into the bag itself, so if
you an antibiotic to hang, you need another IV line. You’re not going
to put it in this. You want to assess
the infusion for rate and the amount delivered
frequently. You need to look every
couple of hours when you go into to check your
patient to make sure that the rate is infusing as
it should to prevent hyper and hypoglycemia episodes. Monitor their responses,
check their labs, how is their renal
function doing, because we’re giving them
extra fluid and glucose? What is their glucose levels? How are their vital signs doing? Their I and O, are we having an
adequate output for the amount of fluid that we’re
putting in, so again, look at the daily weights
and we’re monitoring for complications such as
crackles and fluid overload and all those other lovely
things that we just discussed. Before discontinuing parental
nutrition, you want to make sure that the patient has an
adequate oral intake first. So, you want to make sure
that they’re eating enough because you don’t want to
have to start another IV. These are larger bore IVs, so
it’s not going to be your 22 or your 20, it might be
an 18 and rarely a 16, but an 18 is a pretty good
size IV to put into somebody and it’s not painless. And when you do stop
it, you’re going to gradually stop it
over 4 to 6 hours. Generally, the rule of thumb
unless you have a specific order on how much to decrease it,
and when, is to decrease it by half every 1 to 2 hours. And you’re going to monitor
for rebound hypoglycemia, remember the body
was making insulin to support this plus sometimes
they were getting insulin so you’re going to be
watching for low blood sugars as the body adjusts to
the decrease in sugars. You have nursing
diagnosis that are related to protein calorie malnutrition,
I’m just going to read a few, a couple of these and a
couple of the outcomes and then I will let you look at
them for your own information on your slides, so you
have nutrition imbalance, less than body requirements
related to decrease access, ingestion, digestion
or absorption of food as evidence by whatever. Risk for fluid volume deficiency
related to fluid shift secondary to decrease osmotic or oncotic
pressure as evidenced by. Constipation related to
decrease intestinal motility and dehydration as evidenced by;
diarrhea related to infection or increased permeability of
bowel mucosa as evidenced by. And then for nursing
outcomes, we have stabilization or improvement of
nutritional status by, or patient will maintain
or increase by, or a patient will achieve a
prescribed dietary intake by, etcetera. So you will have that. So let’s look at obesity. So that’s malnutrition and
unfortunately with nutrition, obesity is the other
end of the spectrum. So, with obesity
we have a patient, we have different
categories, we have overweight which is an increase of body
weight for their height compared to the standard or
up to 10% greater than the ideal body weight. Obesity is an excess amount
of body fat when compared to lean body mass or at
least 20% above upper limit of normal range for
ideal body weight. And I took a look as I promised
that I would and I took a look at the category, there is
now a severe obesity which is for body weight that is 30%
or more over ideal body weight and then morbid obesity is a
severe negative effect usually with more than 100%
above ideal body weight. So they continue as, as we
continue to have a problem with obesity in society,
they continue to add these different
categories to quantify where a patient is following
in the obesity spectrum. So complications of obesity
that we have are hypertension, because it, if you remember, each pound of fat is
approximately 2 miles of capillaries that the heart
has to push blood through. So if you have an individual
that’s 325 pounds, that’s a lot of pressure the heart is
needing to exert blood to go through all of those
capillaries. Hyperlipidemia, because even
if they have a diet that is low in fat, they have quite a store
of fat within their own body for their body to pool from,
coronary artery disease, stroke, peripheral artery disease. They could have metabolic
syndrome and so what metabolic syndrome
is is some simultaneous presentation of metabolic
factors known to increase the risk of
coronary artery disease and type II diabetes. So factors that are going to
indicate metabolic syndrome are; abdominal obesity, which is
a waste of 50 or 40 or more for men and 35 or more
women; hyperglycemia, they’re fasting blood sugar is
over a 100 or they’re already on medication for hyperglycemia
that automatically puts them in metabolic; hypertension,
if their systolic is over 130 and they’re diastolic’s over 85,
or dyslipidemia which just means that we have some kind of
abnormalities with their lipids and their triglycerides are over
a 150 or they’re on medication for some kind of dyslipidemia. Because of their weight,
the individual is going to have obstructive sleep apnea. They have a lot of tissue, the
tissue not only expands outward, it pushes and expands inward, so when they are sleeping those
tissues are making the airway downward and when the
tongue falls back, it obstructs it even more. Obesity, hypoventilation
syndrome, that’s where the individual
when they’re laying down all of the abdominal
contents are going to push against the diaphragm making
it difficult for the individual to take a good deep breath and they’re not going
to ventilate well. They could also have
a stroke as one of their complications for this. We talked about peripheral
vascular disease, a lot of these individuals for
complications are also depressed or have other mental
health problems because of their weight. They can urinary
incontinence just from the GI contents
pushing on the bladder. They usually develop gout,
because of the excess calcium and uremic crystals that are
floating around in their body. If they have chronic back pain
as their center of gravity in the front is pulled off
and pulls on their back. They usually wind up
with early osteoarthritis from increased workload
on the joints and they have decreased
wound healing, because adipose tissue does not
have real good vascularization so it is very difficult
to get blood out there to heal the wound. The reasons why individuals
become obese are varied. They’ve looked at a lot
of different reasons why. A big portion of it for
individuals is their diet. Their diet is high in
carbohydrates, high in fat, high in sugars, as we’ve all
heard over the years, you know, corn syrup is very bad and has
a tendency to lead an individual into an obese situation. Our society is much more
physically inactive now than it was years ago, so even
though we have a higher number of calories consumed, we
are not burning them off. Some individuals can
be under drug treatment that will just make it difficult
for them to lose weight, and in fact, with some drugs
they actually gain weight. There are some antidepressants
that they will gain weight. If they’re on glucocorticoids
or corticosteroids for long-term they
will gain weight. So, those make it very difficult
for those individually, and some individuals simply
come from a family that has more of a propensity and a
tendency towards being obese with the genetic factors. So, one of the things that
we want to do is we need to have a patient
centered collaborative care with our patient. We need to do a thorough
patient history. What’s been going on with them? What have they been suffering? Trying to get a diet log out of
these individuals to get an idea of exactly what are
they consuming so that we can help them adjust. What kind of clinical
manifestations are they demonstrating? Currently, based upon where
they are with their weight, and what is the psychosocial
assessment? Are they ready to lose weight? Some individuals just
aren’t ready to do it. They feel like they’re
not going to be able to. They may not have any social
support to help them with that, and so you want to know
where they are psychosocially because that is going
to change and it’s going to be difficult for them. They’re going to go to
family events and it’s like have some cake, have
this, have another helping and if they’re trying to say no,
sometimes it’s very difficult to not offend an individual
if they continue to request that they eat something. So there’s a couple
of different ways to manage these individuals
nonsurgically, there’s diet programs out there
whether it’s Weight Watcher’s, Monarch Medical, you know,
Nutrisystem, there’s a bunch of different diet
programs out there. You can have nutrition therapy
which is something like Medifast and high protein
diets, definitely trying to get your patient into
an exercise program. The nutrition therapy, the
best thing for them going back to that is if you could get
them connected with a dietician to explore their diet and help
them determine how many calories they need to safely
lose for weight. Exercise program,
these individuals need to have provider permission
first to be able to do this so that they don’t put
themselves at stress. There are drugs out there that
will help in losing weight. Some individuals will still
ask about Merida; what you need to know about Merida
is it is not on the market anymore,
so that one is gone. You also have some new ones
such as Tenuate or Bontril. Those are appetite suppressants. They act as a stimulant
and what you can have from those are some
common side effects, so you patient can have
hypertension, dizziness, dry mouth, nausea, vomiting,
diarrhea or constipation. Also, if it is taken late in
the day it can cause insomnia. Another common side
effect for Tenuate and Bontril is these
individuals can sometimes have hallucinations. Xenical is out there also
known as orlistat and what it, the way it works is by
absorbing the fat and breaking, blocking the enzyme that breaks
down the fats for absorption. So, the fat does
not get absorbed, it passes through the
bowel and is eliminated in the bowel movement. So, one side effect of this
drug is that it can interfere with fat soluble vitamins and
medications that are taken. And a medication example of
that would be cyclosporine or levothyroxine. Also, when taking this drug, many patients have
expressed the side effect that they have an
increase in the number of bowel movements they have and frequently they
have poor bowel control when they have this. So, that is a side effect
that they need to be aware of. You can do behavioral management
such as biofeedback, meditation, and then complimentary
alternatives also incorporate the biofeedback,
meditation, some try herbs, some try acupuncture,
behavioral management is a lot of times too you may have
an individual who’s a buddy to help you with
that, so there’s a lot of different techniques out
there for individuals to try. If nonsurgical management
does not work, there’s a lot of times individuals may
try surgical management. A lot of individuals may try
liposuction with is really great if you have a small
amount of fat in an area that’s
pretty well-defined. However, bariatrics that is
becoming much more of a branch of medicine in managing obesity
and so what they’re going to use there is they’re going to use gastric restrictive
surgeries, malabsorption surgeries,
or both. They may use both
on an individual. So, with the operative
procedures when you’re looking at gastric resection, an example
of this is lap band surgery. So, this lap band
surgery is going to allow for normal absorption of food
that’s preventing nutritional deficiency, so that
is good for that and the patient is
simply not allowed to eat very many calories. If you think about that
medicine cup that you use to put your pills in,
in the beginning that’s about what they’re allowed
to eat, so they have to have multiple meals,
small meals and snacks. The patient, in teaching these
patients, needs to be educated and encouraged that they need to have their frequent
provider visits because the provider is going
to assess the band to make sure that fluid has not leaked out,
that it still at the restriction that they want it, and if it
needs to have more saline put into the band, usually once they
had done the lap band surgery they have inserted a port
underneath the skin to be able to inject more fluid into there. In the malabsorption surgeries, these are more drastic
surgeries. The most common malabsorption
surgery that is out there is what’s
called the Roux-En-Y. So what happens here is fewer
calories are actually absorbed because the stomach,
the duodenum and part of the jejunum are
totally bypassed. It’s call malabsorption surgery because we are actually
doing surgery to create lower absorption
of nutrients. So, a lot of people call it
gastric bypass for short, and patients need to be
monitored on a frequent basis for adequate levels of
vitamins and nutrients. Also, these individuals because
their weight loss is so rapid in the beginning, they
may be on medications to lower triglycerides because
those will be eliminated through the gallbladder and they
could wind up with gallstones. So, they’ll have that. Preoperatively, excuse
me, postoperatively on these individuals, we
need to manage their airway. They still have a lot of
adipose tissue so we need to manage their airway. We need to manage
their pain, and patient and staff safety are important. These individuals are not
going to be able move well, so you’re going to need to make
sure that you have adequate help in moving and turning
these patients and assisting them out of bed. Some bigger facilities
actually have teams that that’s all they do is
go around and move patients, turn patients, bathe
these very obese patients. They may have an NG
tube in for a day or 2, so you need to take care of that
NG tube, and we’re assessing for anastomotic leaks
in these individuals. So we are watching
for pain in the belly, rigidity of the belly, enlargement of the abdominal
girth, but mostly they’re going to wind up having pain
the belly and rigidity because these individuals
are difficult to assess because of their size. Also what we’re going to want to do is these individuals
are most likely, should have an abdominal binder. So, what that is for is to
help prevent wound dehiscence if they had to do an
open surgery at all. We don’t want any when they move
and put pressure and do any kind of Valsalva movement, we
don’t want that pressure from behind the abdominal
wall to push out and push on that incision so that
abdominal binder will help with that. Position for these patients
is usually Semi-Fowler’s to help prevent breathing. If they are having some
shortness of breath, you know, when we monitor their
SO2, then we’re going to usually probably have
an order to start them at about 2 liters nasocannula
until they feel better. These individuals should have
sequential compression hose and/or heparin, because
they are not very mobile and we definitely want to not
have a DVT in these individuals. Sometimes as one of your
classmates was saying in lecture, that if they are so
big then they may have to put 2 or these compression hose
together, these stocking, compression devices
together to be able to get it around the individual’s calf. We want to continually
assess their skin. They have multiple folds
because of their obesity and they can wind up with skin
issues between those folds. So if you do find areas that
are having issues, you’re going to want to place some absorbent
padding between them to cut down on the creation of moisture
and warmth there which leads to the growth of candida. A lot of these patients have a
catheter that is usually removed within 24 hours to
help prevent infection. You’re going to assist
the patient out of bed. You don’t want them
doing this on their own. You’re going to assist them so they’re not causing
pressure against that abdomen. We want to get them up and
ambulating as soon as possible. We’re going to monitor
that abdominal girth. We’re looking for abdominal
distention which is going to tell us that we
have a problem. Remember, meals are
6 small feedings. Also in between,
these individuals need to be continually learning
to sip all day long on water to help prevent dehydration. We want to observe
for signs and symptoms of the dumping syndrome
in these individuals. So the dumping syndrome
is caused by the food entering the
small intestine instead of the stomach. So with dumping syndrome, they wind up with increased
heart rate, nausea, diarrhea, abdominal cramping as
the intestine is trying to just push this out. Finally, when we
discharge the patient, we need to have the
patient understand that they are not at the end. That there is still
a lot of that’s going to be going on for them. They’re still going to
get teaching on nutrition and diet progression as
far as what they can have as they continue to lose weight. They’re going to have drug
therapy with analgesics and medics to help
prevent wound dehiscence if they have any vomiting, how
to take care of their wounds when they’re home and what to
watch for in terms of signs and symptoms of infection. [Coughing sounds] Excuse me. What their activity
level is going to be. These individuals are
going to have restrictions on what they can do, what they
can lift, when they’re going to be able to drive again. Signs and symptoms to
report; infection, fever, any epigastric pain,
shoulder pain, red hot or draining wounds, swelling of
the legs, difficulty breathing, we want to make sure
they do that. We need to teach them
that it is very important that they keep their follow-up
appointments with their surgeon and their providers, and
sometimes they may be referred to support groups
because it is going to be psychologically a
transition as they lose weight to going back into being able to do things they
couldn’t do before and just how people are
going to look at them. And also, that there is going
to be continued education on nutrition and exercise and what other follow-up
classes are available. That’s the end of the lecture. If you have any questions,
please let me know. Thank you.