Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
- General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine if an older adult is at nutritional risk. These parameters include the following:
- Subjective assessment, including present history, assessment of symptoms, past medical and surgical history, and co-morbidities (University of Texas, School of Nursing, 2006).
- Social history (University of Texas, School of Nursing, 2006).
- Drug–nutrient interactions: Drugs can modify the nutrient needs and metabolism of older people. Restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with long-term drug treatment are some of the risk factors in elderly that place them at risk for drug–nutrient interactions (Boullata, 2004 [Level VI]). The U.S. Food and Drug Administration and National Institutes for Health have Internet resources for common drug–nutrient interactions.
- Functional limitations (Salva et al., 2004 [Level V]).
- Psychological status (Salva et al., 2004 [Level V]).
- Objective assessment: physical examination with emphasis on oral exam (see the Hartford Institute for Geriatric Nursing [HIGN] topic Oral Health Care on the HIGN Web site), loss of subcutaneous fat, muscle wasting, body mass index (BMI) (University of Texas, School of Nursing, 2006) and dysphagia.
- Dietary Intake: in-depth assessment of dietary intake during hospitalization may be documented with a 3-day calorie count (dietary intake analysis) (DiMaria-Ghalili & Amella, 2005 [Level VI]).
- Risk Assessment Tool: The Mini Nutritional Assessment (MNA) should be administered to determine if an older hospitalized patient is either at risk for malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease and dementia or other psychological conditions. If the score is 11 points or less, the in-depth MNA assessment should be administered (DiMaria-Ghalili & Amella, 2005 [Level VI]; Salva et al., 2004 [Level V]). See www.consultGeriRN.org resources section for the MNA tool.
- Anthropometry
- Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If patient cannot stand erect to measure height, then knee-height measurements should be taken to estimate height using special knee-height calipers. Height should never be estimated or recalled, due to shortening of the spine with advanced age; self-reported height may be off by as many as 2.4 cm (DiMaria-Ghalili & Amella, 2005 [Level VI]; Salva et al., 2004 [Level V]).
- Weight history: A detailed weight history should be obtained along with current weight. Detailed history should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds during a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment (DiMaria-Ghalili & Amella, 2005 [Level VI]; National Collaborating Centre for Acute Care, 2005).
- Calculate BMI to determine if weight for height is within the normal range of 22 to 27. A BMI below 22 is a sign of under-nutrition (National Collaborating Centre for Acute Care, 2005; Nutrition Screening Initiative, 2002 [Level V]).
- Visceral Proteins. Serum albumin, transferrin, and prealbumin are visceral proteins commonly used to assess and monitor nutritional status (DiMaria-Ghalili & Amella, 2005 [Level VI]). However, these proteins are negative acute-phase reactants; therefore, during a stress state, production is usually decreased. In an older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status (Sullivan, Roberson, & Bopp, 2005 [Level IV]).
Nursing Care Strategies (DiMaria-Ghalili & Amella, 2005 [Level VI])
- Collaboration
- Refer to dietitian if patient is at risk for or has under-nutrition.
- Consult with pharmacist to review patient's medications for possible drug–nutrient interactions.
- Consult with a multidisciplinary team specializing in nutrition.
- Consult with social worker, occupational therapist, and speech therapist as appropriate.
- Alleviate dry mouth
- Avoid caffeine; alcohol; tobacco; and dry, bulky, spicy, salty, or highly acidic foods.
- If patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva.
- Keep lips moist with petroleum jelly.
- Encourage frequent sips of water.
- Maintain adequate nutritional intake:
Daily requirements for healthy older adults include 30 kcal per kg of body weight and 0.8 to 1g/kg of protein per day, with no more than 30% of calories from fat. Caloric, carbohydrate, protein, and fat requirements may differ depending on degree of malnutrition and physiological stress.
- Improve oral intake
- Mealtime rounds to determine how much food is consumed and whether assistance is needed.
- Limit staff breaks to before or after patient mealtimes to ensure adequate staff are available to help with meals.
- Encourage family members to visit at mealtimes.
- Ask family to bring favorite foods from home when appropriate.
- Ask about and honor patient food preferences.
- Suggest small frequent meals with adequate nutrients to help patients regain or maintain weight.
- Provide nutritious snacks.
- Help patient with mouth care and placement of dentures before food is served.
- Provide conducive environment for meals
- Remove bedpans, urinals, and emesis basin from room before mealtime.
- Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
- Serve meals to patients in a chair if they can get out of bed and remain seated.
- Create a more relaxed atmosphere by sitting at the patient's eye level and making eye contact during feeding.
- Order a late food tray or keep food warm if patients are not in their room during mealtime.
- Do not interrupt patients for round and nonurgent procedures during mealtimes.
- Specialized nutritional support (American Society for Parenteral and Enteral Nutrition, 2002)
- Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks.
- Prior to initiation of specialized nutritional support, review the patient's advanced directives regarding the use of artificial nutrition and hydration.
- Provide oral supplements
Supplements should not replace meals but rather be provided between meals but not within the hour preceding a meal and at bedtime (Wilson, Purushothaman, & Morley, 2002 [Level IV]). See National Collaborating Centre for Acute Care Clinical Guideline (2006) for algorithm for use of oral supplements.
- Nothing by mouth (N.P.O.) orders
- Schedule older adults for test or procedures early in the day to decrease the length of time they are not allowed to eat and drink.
- If testing late in the day is inevitable, ask physician whether the patient can have an early breakfast.
- See American Society of Anesthesiologists practice guideline regarding recommended length of time patients should be kept N.P.O. for elective surgical procedures.
Follow-Up Monitoring (National Collaborating Centre for Acute Care, 2006)
- Monitor for gradual increase in weight over time.
- Weigh patient weekly to monitor trends in weight.
- Daily weights are useful for monitoring fluid status.
- Monitor and assess for refeeding syndrome.
- Carefully monitor and assess patients the first week of aggressive nutritional repletion.
- Assess and correct the following electrolyte abnormalities: Hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
- Assess fluid status with daily weights and strict intake and output.
- Assess for congestive heart failure in patients with respiratory or cardiac difficulties.
- Ensure caloric goals will be reached slowly during 3 to 4 days to avoid refeeding syndrome when repletion of nutritional status is warranted.
- Be aware that refeeding syndrome is not exclusive to patients started on aggressive artificial nutrition but may also be found in elderly individuals with chronic co-morbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
