IMBALANCED NUTRITION (CARE PLAN) AND MUST (Malnutrition Universal Screening Tool)

IMBALANCED NUTRITION (LESS THAN BODY REQUIREMENTS)

Intake of nutrients insufficient to meet metabolic needs.

Common related factors: inability to ingest or/and digest foods, inability to absorb, metabolize foods or to procure adequate amounts of food, knowledge deficit, unwillingness to eat and increased metabolic needs caused by disease process or therapy.

Common expected outcome: patient or caregiver verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss. Patient weights within 10% of ideal body weight.

IMBALANCED NUTRITION (MORE THAN BODY REQUIREMENTS)

Intake of nutrients that exceeds metabolic needs.

Common related factors: excessive intake in relation to metabolic need, lack of knowledge of nutritional needs, food intake and/or appropriate food preparation, poor dietary habits, use of food as coping mechanism, metabolic disorders, sedentary activity level.

Common expected outcomes: patient verbalizes accurate information about benefits of weight loss and necessary measures to achieve beginning weight reduction. Patient demonstrates appropriate selection of meals or menu planning toward the goal of weight reduction.

MUST (Malnutrition Universal Screening Tool)

‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition 

(undernutrition), or obese. It also includes management guidelines which can be used to develop 

a care plan.

Step 1 

Measure height and weight to get a BMI score using chart provided.

Step 2 

Note percentage unplanned weight loss and score using tables provided.

Step 3 

Establish acute disease effect and score.

Step 4 

Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition.

Step 5 

Use management guidelines and/or local policy to develop care plan.

Sources:

http://www.bapen.org.uk/pdfs/must/must_full.pdf

Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation). This provides enteral nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition (which is only used when the GI tract must be avoided).

Complications
-Cellulitis (infection of the skin) around the gastrostomy site.
-Hemorrhage.
-Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
-Perforation of bowel (most commonly transverse colon) leading to peritonitis.
-Puncture of the left lobe of the liver leading to liver capsule pain.
-Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon).
-Gastric separation.
-"Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall).

PEG nutrition formulas

1. Ready-made formula: All ready-made formulas contain carbohydrates, fats, proteins, and water. Certain formulas may be lactose-free, gluten-free, or low in fat or sugar. Some formulas are made for a specific disease, condition, or treatment. 

2. Blenderized formula:  Formula made from pureed foods. A larger feeding tube is needed to use blenderized formula. This is because the thickness of these formulas increases the risk that the tube will get clogged. Blenderized formulas are can be bought ready-made. The ready-made blenderized formulas have added vitamins and minerals. Compared to ready-made formulas, home blenderized formulas are not sterile (germ-free) and may not have all of the nutrition that your body needs.

PEG tube may also be used to give medecines (usually taken by mouth), extra water (to prevent dehydration) and flush water to clear formula or medicine from the PEG tube).

PEG replacement and care.

When replacing a gastric tube remember to apply an anesthesic jelly to facilitate insertion and minimise discomfort (not shown in the video).

Also, an X-ray should be done if the PEG tube has been replaced within the four first weeks after initial insertion to check that it is in the correct place. If the PEG tube has been in position for four weeks since the initial insertion or it has been replaced other times after initial insertion, it is not needed to do an X-ray.

We can always check, when is not needed to do an X-ray, that the PEG is in position by aspirating through the PEG tube, gastric content should flash back. To confirm that is gastric content, you can always use a pH strip.

PEG site should be cleaned with saline and dried at least once a day. If there is an infection on the PEG site, antibiotics and creams might be prescribed and it should be cleaned more often.

ENTERAL TUBE FEEDING (CARE PLAN)

Enteral tube feedings provide nutrition using a nasogastric tube, a gastrostomy tube, or a tube placed in the duodenum or jejunum.

NANDA-1: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

Common related factor: mechanical problems during feedings, such as clogged tube, inaccurate flow rate, stiffening of tube, delivery pump malfunction.

Common expected outcome: patient´s nutritional status improves, as evidenced by gradual weight gain or stable weight and increased physical strength.

Related risks when using a nasogastric tube, a gastrostomy tube, or a tube placed in the duodenum or jejunum.

RISK FOR ASPIRATION

Common related factor: depressed or lack of gag reflex, poor positioning of tube placement, migration of the tube, supine positioning of patient as feeding is administered, increased gastric residual volume and delayed gastric emptying.

Common expected outcome: patient maintains a patent airway, as evidenced by normal breath sounds, absence of coughing, no shortness of breath and no aspiration.

RISK FOR DIARRHEA

Common related factor: intolerance to tube feeding formula.

Common expected outcome: patient does not experience diarrhea during tube feedings.

Sources:

http://www.drugs.com/cg/how-to-use-and-care-for-your-peg-tube.html

Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

SHINGLES (HERPES ZOSTER)

After chickenpox infection, the varicella zoster virus (VZV) lies dormant in the ganglia of the spinal nerve tracts. Shingles is an infectious viral condition caused by a reactivation of this latent VZV. Reactivation usually occurs in individuals with impaired inmunity; it is common among older adults. 

VZV produces painful vesicular eruptions along the peripheral distribution of nerves from posterior ganglia and is usually unilateral and characteristically occurs in a linear distribution, abruptly stopping at the midline both posteriorly and anteriorly. Although VZV typically affects the trunk of the body, the virus may also be noted on the buttocks or face. With facial involvement there is concern about involvement of the eye and cornea, potentially resulting in permanent loss of vision. Secondary infection resulting from scratching the lesions is common.

Shingles is characterized by burning, pain and neuralgia.

An individual with an outbreak of VZV is infectious for the 2 to 3 days after the eruption. The incubation period ranges from 7 to 21 days. The total course of the disease is 10 days to 5 weeks from onset to full recovery.

Some individuals may experience painful postherpetic neuralgia long after the lesions heal. 

Common risk factors:
-Skin lesions (papules, vesicles, pustules).
-Crusted-over lesions.
-Itching and scratching.
Common expected outcomes:
-Patient remains free of secondary infection, as evidenced by intact skin without redness or lesions.
-Risk for disease transmission is minimized through use of universal precautions.

Source: Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

CONSTIPATION (CARE PLAN) AND RISK SCALE

CONSTIPATION (NANDA - 1 diagnosis)

Definition: decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

Common Related Factors
-Inadequate fluid intake
-Low-fiber diet
-Inactivity, immobility
-Medication use
-Lack of privacy
-Fear of pain with defecation
-Habitual denial and ignoring of urge to defecate
-Laxative abuse
-Stress/depression
-Tumor or other obstruction mass
-Neurogenic disorders

Defining characteristics
-Infrequent passage of stool
-Passage of hard , dry stool
-Straining at stools
-Passage of liquid fecal seepage
-Frequent but nonproductive desire to defecate
-Anorexia
-Abdominal distention
-Nausea and vomiting
-Dull headache
-Verbalized pain or fear of pain with defecation


Common Expected Outcome
Patient passes soft, formed stool at a frequency perceived as normal by the patient.
Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

Source: Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

ETON/NORGINE CONSTIPATION RISK SCALE

LAXATIVES

1. Bulk-forming laxatives:

-Ispaghula husk (Fibrelief, Fybogel, Isogel, Ispagel orange, Regulan).

-Methylcellulose (Celevac).

-Sterculia (Normacol).

2. Stimulant laxatives:

-Bisacodyl

-Dantron (Co-danthramer, Co-danthrusate).

-Docusate sodium (Dioctyl, Docusol, Norgalax Micro-enema).

-Glycerol (Glycerol suppositories).

-Senna (Manevac, Senokot).

-Sodium picosulfate (Dulcolax).

3. Faecal softeners:

-Arachis oil

-Liquid paraffin

4. Osmotic laxatives:

-Lactulose.

-Macrogols (Laxido, Movicol).

-Magnesium salts (Magnesium hydroxide Mixture, Magnesium hydroxide with liquid paraffin, Magnesium sulphate).

-Phosphates (rectal): Carbalax, Fleet Ready-to-use enema, Phosphates Enema. 

-Sodium citrate (rectal): Micolette Micro-enema, Micralax Micro-enema, Relaxit Micro-enema.

5. Bowel cleansing solutions: Citrafleet, Citramag, Fleet Phospho-soda, Klean-Prep, Moviprep, Picolax).

6. Peripheral opioid-receptor antagonists (licensed for the treatment of opioid-induced constipation in patients receiving palliative care):

-Methylnaltrexone Bromide (Relistor sc injection).

Source: BNF 57 March 2009.

PROFESSIONAL HEALTH CARE BODIES

Here it is a brief summary of some of the Professional Health Care Organizations in UK/Northern Ireland and their basic role.

NURSING AND MIDWIFERY COUNCIL (NMC)

They are the nursing and midwifery regulator for England, Wales, Scotland, Northern Ireland and the Islands.

As regulator for the largest group of healthcare professionals at work in these islands – there are some 670,000 registered nurses and midwives – their responsibilities and activities are considerable. 

-They exist to safeguard the health and wellbeing of the public.

-They set standards of education, training, conduct and performance so that nurses and midwives can deliver high quality healthcare consistently throughout their careers.

-They ensure that nurses and midwives keep their skills and knowledge up to date and uphold the professional standards.

-They have clear and transparent processes to investigate nurses and midwives who fall short of the standards.

Their mission

Their primary purpose is to protect patients and the public in the UK through effective and proportionate regulation of nurses and midwives. They set and promote standards of education and practice, maintain a register of those who meet these standards and take action when a nurse or midwife’s fitness to practise is called into question. By doing this well they promote public confidence in nurses and midwives, and regulation.

More information: http://www.nmc-uk.org/

REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

RQIA is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services.

RQIA's main functions are:

1. to inspect the quality of services provided by Health and Social Care Services (HSC) bodies in Northern Ireland through reviews of clinical and social care governance arrangements within these bodies;
2. to regulate (register and inspect) a wide range of services delivered by HSC bodies and by the independent sector. The regulation of services is based on new minimum care standards to ensure that service users know what quality of services they can expect to receive, and service providers have a benchmark against which to measure their quality; and
3. with the transfer of duties of the Mental Health Commission to RQIA under the Health and Social Care (Reform) Act (NI) 2009, they undertake a range of responsibilities for people with a mental illness and those with a learning disability. These include: preventing ill treatment; remedying any deficiency in care or treatment; terminating improper detention in a hospital or guardianship; and preventing or redressing loss or damage to a patient's property.

More information: www.rqia.org.uk/‎

ROYAL COLLEGE OF NURSING (RCN)

The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.

To deliver their mission they aim to:

-Represent the interests of nurses and nursing and be their voice locally, nationally and internationally.

-Influence and lobby governments and others to develop and implement policy that improves the quality of patient care, and builds on the importance of nurses, health care assistants and nursing students to health outcomes.

-Support and protect the value of nurses and nursing staff in all their diversity, their terms and conditions of employment in all employment sectors and the interests of nurses professionally.

-Develop and educate nurses professionally and academically, building their resource of professional expertise and leadership the science and art of nursing and its professional practice.

-Build a sustainable, member led, organisation with the capacity to deliver their mission effectively, efficiently and in accordance with their values the systems, attitudes and resources to offer the best possible support and development to their staff.

More information: https://www.rcn.org.uk