Nursing care plan for malnutrition child ppt


  • 4 Obesity Nursing Care Plans
  • Enteral feeding: Indications, complications, and nursing care
  • Schizophrenia
  • Client will demonstrate a change in eating patterns and involvement in individual exercise program. Client will display weight loss with optimal maintenance of health. Nursing Interventions Review individual cause for obesity organic or nonorganic.

    Identifies and influences choice of some interventions. Carry out and review daily food diary caloric intake, types and amounts of food, eating habits. Provides the opportunity for the individual to focus on a realistic picture of the amount of food ingested and corresponding eating habits and feelings. Identifies patterns requiring change or a base on which to tailor the dietary program.

    Explore and discuss emotions and events associated with eating. Helps identify when patient is eating to satisfy an emotional need, rather than physiological hunger.

    Determine which diets and strategies have been used, results, individual frustrations and factors interfering with success. Although there is no basis for recommending one diet over another, a good reducing diet should contain foods from all basic food groups with a focus on low-fat intake and adequate protein intake to prevent loss of lean muscle mass.

    A plan developed with and agreed to by the patient is more likely to be successful. Emphasize the importance of avoiding fad diets. Elimination of needed components can lead to metabolic imbalances like excessive reduction of carbohydrates can lead to fatigue , headache, instability and weakness, and metabolic acidosis ketosis , interfering with effectiveness of weight loss program. Discuss need to give self permission to include desired or craved food items in dietary plan.

    Be alert to binge eating and develop strategies for dealing with these episodes substituting other actions for eating. The patient who binges experiences guilt about it, which is also counterproductive because negative feelings may sabotage further weight loss efforts. Identify realistic increment goals for weekly weight loss. Reasonable weight loss 1—2 lb per wk results in more lasting effects. Excessive and rapid loss may result in fatigue and irritability and ultimately lead to failure in meeting goals for weight loss.

    Weigh periodically as individually indicated, and obtain appropriate body measurements. During hospitalization for controlled fasting, daily weighing may be required. Weekly weighing is more appropriate after discharge. Exercise furthers weight loss by reducing appetite; increasing energy; toning muscles; and enhancing cardiac fitness, sense of well-being, and accomplishment.

    Commitment on the part of the patient enables the setting of more realistic goals and adherence to the plan. Develop an appetite reeducation plan with patient.

    Signals of hunger and fullness often are not recognized, have become distorted, or are ignored. Emphasize the importance of avoiding tension at mealtimes and not eating too quickly. Reducing tension provides a more relaxed eating atmosphere and encourages more leisurely eating patterns. This is important because a period of time is required for the appestat mechanism to know the stomach is full. Encourage patient to eat only at a table or designated eating place and to avoid standing while eating.

    Techniques that modify behavior may be helpful in avoiding diet failure. Discuss restriction of salt intake and diuretic drugs if used. Water retention may be a problem because of increased fluid intake and fat metabolism.

    Reassess calorie requirements every 2—4 wk; provide additional support when plateaus occur. Changes in weight and exercise necessitate changes in plan. As weight is lost, changes in metabolism occur, resulting in plateaus when weight remains stable for periods of time.

    Patient may need additional support at this time. Consult with dietitian to determine caloric and nutrient requirements for individuals weight loss. Note: Standard tables are subject to error when applied to individual situations, and circadian rhythms and lifestyle patterns need to be considered. Provide medications as indicated: Appetite-suppressant drugs like diethylpropion Tenuate , mazindol Sanorex , Sibutramine Meridia May be used with caution and supervision at the beginning of a weight loss program to support patient during stress of behavioral and lifestyle changes.

    They are only effective for a few weeks and may cause problems of addition in some people. Hormonal therapy like thyroid Euthyroid , levothyroxine Synthroid May be necessary when hypothyroidism is present.

    When no deficiency is present, replacement therapy is not helpful and may actually be harmful. Note: Other hormonal treatments, such as human chorionic gonadotropin HCG , although widely publicized, have no documented evidence of value. Facilitates weight loss and maintenance when used in conjunction with a reduced-calorie diet. Also reduces risk of regain after weight loss.

    Vitamin, mineral supplements Obese individuals have large fuel reserves but are often deficient in vitamins and minerals. Note: Use of Xenical inhibits absorption of water-soluble vitamins and beta-carotene.

    Vitamin supplement should be given at least 2 hr before or after Xenical. Hospitalize for fasting regimen and stabilization of medical problems, when indicated. Aggressive therapy and support may be necessary to initiate weight loss, although fasting is not generally a treatment of choice. Patient can be monitored more effectively in a controlled setting, to minimize complications such as postural hypotension , anemia , cardiac irregularities, and decreased uric acid excretion with hyperuricemia.

    Prepare for surgical interventions gastric partitioning or bypass as indicated. These interventions may be necessary to help the patient lose weight when obesity is life-threatening.

    Malnourished patients with inadequate caloric and protein intake may suffer emaciation, poor healing, and pressure injuries. In severe cases, they may develop osteopenia, osteomalacia, osteoporosis, muscle weakness, increased fracture risk, polyneuropathy, paresthesias, confusion, dementia, and pancytopenia. Some also may have low albumin and prealbumin levels, which can cause fluid to pool in a localized or generalized distribution. But before blaming malnutrition for abnormal albumin or prealbumin levels, clinicians must consider such factors as persistent inflammation and hepatic or renal impairment.

    Types of enteral feeding tubes The practitioner selects the type of feeding tube based on the specific enteral formula the patient requires and the anticipated duration of enteral feeding. The two main types of feeding tubes are prepyloric and postpyloric. Postpyloric feedings must be administered on a continuous basis. See Comparing enteral feeding tubes. Enteral feeding formulas Entering feeding formulas fall into several general categories, such as polymeric formulas, feeding modules, elemental, and specialized or disease-specific formulas.

    Nutritional demands vary with age, weight, height, current nutritional status, laboratory values, and activity level. Also, enteral feeding requirements may vary even within similar groups of patients, such as those with renal dysfunction or liver failure.

    Certain medical conditions create a higher metabolic demand, necessitating increased feeding volume. Enteral formulas can be administered using either an open or a closed ready-to-use system and can be delivered through several methods. See Understanding enteral feeding systems and methods.

    Complications of enteral feeding Patients with feeding tubes are at risk for such complications as aspiration, tube malpositioning or dislodgment, refeeding syndrome, medication-related complications, fluid imbalance, insertion-site infection, and agitation.

    To identify these problems, thoroughly assess the patient before tube feeding begins and monitor closely during feedings. For information on insertion-site infection and agitation, see Other enteral-feeding complications. Aspiration Gastrostomy G tube feedings can cause pulmonary aspiration. Multiple factors contribute to aspiration, including recent hemorrhagic stroke, high gastric residual volume GRV , high bolus feeding volumes, supine positioning, and conditions that affect the esophageal sphincters such as an indwelling endotracheal or tracheostomy tube with dysfunction of the upper esophageal sphincter and a nasogastric or an enteral tube traversing both esophageal sphincters.

    To help reduce risk, monitor GRV every 4 hours or according to protocol in patients receiving continuous tube feedings. Sometimes, healthcare providers order withholding of tube feedings at lower GRVs because of specific risk factors. To help prevent this problem, keep the head of the bed elevated 30 degrees or higher when possible. During patient transport or when placing the head of the bed flat for patient repositioning, turn the tube feeding off, especially if the patient has a high aspiration risk.

    However, be aware that no conclusive evidence shows that pausing tube feeding during repositioning reduces aspiration risk for patients with high GRVs. Tube malpositioning or dislodgment During initial placement, the feeding tube may be positioned improperly.

    To prevent this problem, the tube should be placed by experienced personnel and its position confirmed radiographically. After initial placement, the tube may become fully or partially dislodged, causing such problems as bleeding, tracheal or parenchymal perforation, and GI tract perforation. To help prevent malpositioning and dislodgment, verify feeding tube integrity at the beginning of each shift.

    Be aware that verbal patients with dislodged tubes may complain of new-onset pain at or near the insertion site of a percutaneous endoscopic gastrostomy PEG tube, G tube, gastric-jejunal GJ tube, or J tube. Nonverbal patients may respond with vital-sign changes such as increased blood pressure or heart rate , increased agitation, and restlessness. This syndrome may trigger life-threatening arrhythmias and multisystemic dysfunction. Serum electrolytes then move into the intracellular space to help satisfy the higher demands, resulting in acute electrolyte abnormalities.

    In patients with long-term malnutrition, monitor for intolerance at the onset of enteral feedings by checking heart rate and rhythm and electrolyte levels. Although refeeding syndrome incidence is low, failure to recognize the sudden drop in potassium and magnesium levels can have catastrophic consequences.

    To reduce the risk of refeeding syndrome in patients with vitamin and mineral deficiencies, supplements may be ordered for parenteral administration before enteral feedings begin. Refer to specific guidelines based on total energy needs and specific micronutrient deficiencies; thiamine and other B-vitamin deficiencies are the most pressing ones to address before initiating enteral feeding. As the tube-feeding goal rate is achieved, taper micronutrient supplement dosages as indicated.

    Before and after medication administration, flush the tube with about 30 mL of fluid or more, depending on drug characteristics. Note: Be aware that some patients are at high risk for fluid overload and depend on a concentrated feeding formula to meet dietary needs. Medication-related complications Until recently, clinicians assumed diarrhea in patients receiving enteral feedings stemmed from malabsorption and feeding intolerance.

    But more recent research points to medications, especially those high in sorbitol, as the main culprit. So be sure to rule out medications as the cause of diarrhea before looking for other causes, including malabsorption and rapid delivery rates. The sorbitol content of certain premade liquid drugs such as potassium chloride, acetaminophen, and theophylline can cause a rapid fluid shift into the intestines, leading to hyperosmolarity and diarrhea.

    This effect increases when sorbitolbased liquid medications are given through a J tube. Gastric acid in the stomach acts as a buffer to medications and reduces osmolarity of fluid entering the small intestine.

    Consider a pharmacy consult for patient who experience diarrhea while receiving multiple sorbitol-based drugs. Changing the administration time as appropriate or switching to a non-sorbitol-based alternative may relieve diarrhea without necessitating feeding-rate adjustment. Take additional precautions with medications linked to a higher clogging risk, including psyllium, ciprofloxacin suspension, sevelamer, and potassium chloride tablets that can be dissolved in water.

    Know that tube replacement due to clogging is costly and subjects the patient to anesthesia. To help prevent clogging, maintain proper tube maintenance and flushing. Be aware that some medications must be given on an empty stomach to ensure effective absorption, including phenytoin, carbama zepine, alendronate, carbidopa levodopa, and levothyroxine. You may need to withhold tube feedings for 1 to 2 hours before and after administering these medications.

    Keep in mind that patients receiving multiple drugs may have absorption problems due to extended withholding of feedings, causing dehydration and malnutrition. Nursing care When beginning enteral feedings, monitor the patient for feeding tolerance.

    Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV. On an ongoing basis, monitor patients for gastric distention, nausea, bloating, and vomiting.

    Stop the infusion and notify the provider if the patient experiences acute abdominal pain, abdominal rigidity, or vomiting. Caloric requirements calculated by a dietitian must be ordered by a healthcare provider and delivered and monitored by a nurse. However, some states permit dietitians to initiate nutritional interventions. Nursing assistants can help with patient positioning and comfort care as well as behavioral monitoring.

    Consult additional specialists, such as a wound ostomy nurse, about the risk of pressure injuries compounded by malnutrition or dehydration. Keep the goal of care in mind. For terminally ill patients, palliative care specialists can help evaluate the benefits and risks of continuing enteral feeding and help clinicians navigate ethical issues, such as whether to continue enteral feedings and other life-prolonging measures.

    Future of enteral feedings Enteral feedings have the potential to advance patient care. Also, trials currently are underway in critical care units to study the use of feeding tubes with magnetic components at the end, which could allow confirmation of correct tube placement with a magnet instead of radiography. As technology progresses, enteral feeding efficiency will progress as well. For the best outcomes, healthcare providers must work as a team to treat the patient holistically.

    Paul Fuldauer is a clinical nutritional coordinator. Tube feeding troubleshooting guide. The Oley Foundation. March American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. Permissive underfeeding or standard enteral feeding in critically ill adults.

    N Engl J Med. Board of Directors. Enteral nutrition practice recommendations. Clinical guideline: management of gastroparesis. Am J Gastroenterol. Risk of regurgitation and aspiration in patients infused with different volumes of enteral nutrition. Asia Pac J Clin Nutr.

    Case study: Nutritional management of a patient at high risk of developing refeeding syndrome. S Afr J Clin Nutr.

    Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. Nutrition in the elderly. Frequently asked questions. Permissive underfeeding or standard enteral feeding in critical illness. Dysphagia after stroke and its management. Ojo O. Enteral feeding tubes: not perfect but necessary.

    Br J Nurs. Elimination of radiographic confirmation for small-bowel feeding tubes in critical care. Am J Crit Care. Romano MM. Medicines and tube feeding formula. June 24, Jejunal feeding in patients with pancreatitis. Nutr Clin Pract.

    Hepatic encephalopathy is characterised by a decline in brain function ranging from vague memory loss and confusion to coma. Again, if not treated quickly, it can lead to death. Patients presenting with any of these complications of portal hypertension, with or without jaundice, are described as having decompensated liver cirrhosis.

    Formation of ascites Portal hypertension causes the formation of shunts, which bypass the liver and connect the portal venous system to the systemic circulation. These substances cause arteries to dilate, which in turn causes BP to fall.

    A vicious cycle ensues: the fall in BP causes the kidneys to retain salt and water, making it even more difficult for the body to rid itself of ascites.

    4 Obesity Nursing Care Plans

    Furthermore, the dilation of blood vessels increases the risk of lymph leakage, which leads to the formation of ascites. As cirrhosis progresses, the liver is unable to produce enough of the protein albumin, so albumin levels fall. One of the functions of albumin is to help hold fluid within cells, so when its levels fall, fluid is pulled out of cells, resulting in ascites and peripheral oedema Kumar and Clark, ; Bacon et al, Diagnosis Symptoms People with ascites tend to become symptomatic only if moderate-to-large amounts have accumulated in the abdominal cavity.

    This can manifest as an increase in abdominal girth with associated discomfort and bloating. As the volume of fluid increases, pressure increases on the diaphragm, causing shortness of breath and a reduction in oxygen saturation. In addition, ascitic fluid can migrate across the diaphragm and accumulate around the lungs hydrothoraxwhich can also lead to shortness of breath. Ascites increases abdominal pressure, which can cause hernias to form; while these can occur anywhere in the abdomen, the most common site is in the umbilicus umbilical hernia.

    Surgery is only usually considered if the bowel within the hernia has become twisted. When this happens, the blood supply to the bowel becomes blocked, causing the bowel to become ischaemic; this causes severe pain and can lead to death. Large amounts of abdominal ascites can impair mobility and make it difficult for patients to sit upright and lie down flat. The excess abdominal fluid can exert pressure on internal organs such as the bladder, causing urinary urgency, or the bowel, which causes constipation.

    Detection Ascites can be detected on physical examination through a technique known as percussion. The patient is asked to lie flat on their back — if this can be tolerated — and the health professional taps the abdomen with their fingers Fig 1.

    A resonant sound should be heard on percussion over air, but percussion performed over solid organs or fluid will produce a dull sound Epstein et al, The tapping should start in the midline and move out towards the flanks. Once a dull sound is heard, the patient should roll onto the opposite side. Gravity will then make any fluid present flow down to the other side of the abdomen Bickley et al, The health professional must keep their hand on the abdomen during this process and, once the patient has changed position, tap the exact same site again.

    A resonant sound should then be heard, as air should have filled the area previously occupied by fluid. Evidence of ascites can also be provided by imaging. Abdominal ultrasound is the quickest, cheapest and most-convenient method, but computerised tomography CT and magnetic resonance imaging MRI can be also used, especially for staging disease or following up patients after a cancer diagnosis.

    Ascitic Sim pedales sprint investigations One method that can help determine the cause of ascites is to measure the amount of protein it contains. Malnourished patients with inadequate caloric and protein intake may suffer emaciation, poor healing, and pressure injuries. In severe cases, they may develop osteopenia, osteomalacia, osteoporosis, muscle weakness, increased fracture risk, polyneuropathy, paresthesias, confusion, dementia, and pancytopenia.

    Some also may have low albumin and prealbumin levels, which can cause fluid to pool in a localized or generalized distribution. But before blaming malnutrition for abnormal albumin or prealbumin levels, clinicians must consider such factors as persistent inflammation and hepatic or renal impairment.

    Types of enteral feeding tubes The practitioner selects the type of feeding tube based on the specific enteral formula the patient requires and the anticipated duration of enteral feeding.

    The two main types of feeding tubes are prepyloric and postpyloric. Postpyloric feedings must be administered on a continuous basis.

    Enteral feeding: Indications, complications, and nursing care

    See Comparing enteral feeding tubes. Enteral feeding formulas Entering feeding formulas fall into several general categories, such as polymeric formulas, feeding modules, elemental, and specialized or disease-specific formulas. Nutritional demands vary with age, weight, height, current nutritional status, laboratory values, and activity level.

    Also, enteral feeding requirements may vary even within similar groups of patients, such as those with renal dysfunction or liver failure.

    Certain medical conditions create a higher metabolic demand, necessitating increased feeding volume. Enteral formulas can be administered using either an open or a closed ready-to-use system and can be delivered through several methods.

    See Understanding enteral feeding systems and methods. Complications of enteral feeding Patients with feeding tubes are at risk for such complications as aspiration, tube malpositioning or dislodgment, refeeding syndrome, medication-related complications, fluid imbalance, insertion-site infection, and agitation. To identify these problems, thoroughly assess the patient before tube feeding begins and monitor closely during feedings. For information on insertion-site infection and agitation, see Other enteral-feeding complications.

    Aspiration Gastrostomy G tube feedings can cause pulmonary aspiration. Multiple factors contribute to aspiration, including recent hemorrhagic stroke, high gastric residual volume GRVhigh bolus feeding volumes, supine positioning, and conditions that affect the esophageal sphincters such as an indwelling endotracheal or tracheostomy tube with dysfunction of the upper esophageal sphincter and a nasogastric or an enteral tube traversing both esophageal sphincters.

    To help reduce risk, monitor GRV every 4 hours or according to protocol in patients receiving continuous tube feedings. Sometimes, healthcare providers order withholding of tube feedings at lower GRVs because of specific risk factors.

    To help prevent this problem, keep the head of the bed elevated 30 degrees or higher when possible. During patient transport or when placing the head of the bed flat for patient repositioning, turn the tube feeding off, especially if the patient has a high aspiration risk.

    However, be aware that no conclusive evidence shows that pausing tube feeding during repositioning reduces aspiration risk for patients with high GRVs. Tube malpositioning or dislodgment During initial placement, the feeding tube may be positioned improperly. To prevent this problem, the tube should be placed by experienced personnel and its position confirmed radiographically.

    After initial placement, the tube may become fully or partially dislodged, causing such problems as bleeding, tracheal or parenchymal perforation, and GI tract perforation. To help prevent malpositioning and dislodgment, verify feeding tube integrity at the beginning of each shift.

    Schizophrenia

    Be aware that verbal patients with dislodged tubes may complain of new-onset pain at or near the insertion site of a percutaneous endoscopic gastrostomy PEG tube, G tube, gastric-jejunal GJ tube, or J tube.

    Nonverbal patients may respond with vital-sign changes such as increased blood pressure or heart rateincreased agitation, and restlessness. This syndrome may trigger life-threatening arrhythmias and multisystemic dysfunction. Serum electrolytes then move into the intracellular space to help satisfy the higher demands, resulting in acute electrolyte abnormalities.

    In patients with long-term malnutrition, monitor for intolerance at the onset of enteral feedings by checking heart rate and rhythm and electrolyte levels. Although refeeding syndrome incidence is low, failure to recognize the sudden drop in potassium and magnesium levels can have catastrophic consequences.

    To reduce the risk of refeeding syndrome in patients with vitamin and mineral deficiencies, supplements may be ordered for parenteral administration before enteral feedings begin. Other factors include structural brain abnormalities e. Signs and Symptoms Behaviors and functional deficiencies seen in schizophrenia vary widely among patients. Signs and symptoms are divided into three clusters: positive, negative, and cognitive symptoms.

    Positive symptoms are associated with temporal lobe abnormalities. Negative symptoms are associated with frontal cortex and ventricular abnormalities. Positive Symptoms Deviant symptoms. These are symptoms that are present but should be absent.

    They indicate that patient has lost touch with reality. Primarily include delusions and hallucinations. Hallucinations are the most common feature of schizophrenia. These involve hearingseeing, smelling, tasting, and feeling touched by things in the absence of stimuli.

    An example is hearing voices that command the patient to do certain things, usually abusive and self-destructive. Delusions are fixed false beliefs.

    They cannot be changed by logic or persuasion. An example is a patient believing that people can read his mind. Several categories of delusions include: Persecutory delusions. Patient thinks he is being tormented, followed, tricked, or spied on.

    Reference delusions. Patient thinks that passages in books, music, TV shows, and other sources are directed at him. Patient believes others can read his mind, his thoughts are being transmitted to others, or outside forces are imposing their thoughts or impulses on him. Negative Symptoms Deficit symptoms. These symptoms reflect the absence of normal characteristics. Apathy is lack of interest in people, things, and activities. Anhedonia is diminished capacity to feel pleasure.

    Poverty of speech is a speech that is brief and lacks content. Thought disorder is characterized by confused thinking and speech e. Bizarre behavior include childlike silliness, laughing or giggling, agitation, inappropriate appearance, hygiene, and conduct.

    Phases of Schizophrenia Schizophrenia usually progresses through three distinct phases: Prodromal Phase Occurs before hospitalization or within the year. Characterized by clear decline from his previous level of functioning. May withdraw from friends and families and hobbies and interests, exhibit peculiar behavior, and deterioration in work and school performance.

    Active Phase Commonly triggered by a stressful event Characterized by presence of acute psychotic symptoms e. Prognosis worsens with each acute episode.

    Residual Phase This is at this point in which illness pattern is established, disability level may be stabilized, and late improvements may occur. Stress may worsen patient symptoms. Experience frequent auditory hallucinations but lack symptoms of other subtypes like incoherence, loose associations, and affect problems.

    Tend to be less severely disabled than other schizophrenics and are more responsive to treatments. Disorganized Marked by incoherent, disorganized speech and behaviors, and blunted or inappropriate affect.

    Usually includes extreme social impairment. Starts early and insidiously, with no significant remissions. Increased potential for destructive, violent behaviors when agitated. They remain mute and have refusal to move about or tend to personal needs. Undifferentiated Presence of schizophrenic symptoms such as delusions and hallucinations in patients who does not fall to the category of the other subtypes.

    Residual Muted form of the disease p068a battery stops short of recovery. No prominent psychotic symptoms.


    Nursing care plan for malnutrition child ppt