Care of the Malnourished Elderly Patient

Introduction

Origin of the Problem

In our society, malnutrition and under-nutrition is a rising problem for the older adult population. Approximately 35%-85% of residents living in a long-term care facility, 60% of hospitalized older adults, and an estimate of 5%-10% of older adults living in community settings are malnourished (Maher and Eliadi, n. d. ).

These statistics sadly show that hospitalized and long-term care patients are more likely to become under nourished compared to the elderly population in the community. According to the Joanna Briggs Institute (JBI, 2007), malnutrition can lead to serious or adverse health outcomes. Malnutrition has been linked to lengthy hospital stays with higher complications, morbidity, mortality, and frequent visits to their general practitioner (JBI, 2007). There are several risk factors (i. e. physical, psychosocial, social, and medical factors) that lead to malnutrition (Maher & Eliadi, n. . ). It is predicted that by 2030, the elderly population in the United States will double in size and exceed 70 million people. In light of these predictions, addressing the nutritional needs of the elderly will reach epic proportions and become a complex issue. Based on clinical observation, the signs and symptoms of malnutrition and under nutrition are often overlooked. Observing residents in a clinical setting at a local long- term health care facility precipitated our interest in this problem with malnutrition.

The majority of elderly people living in care homes either have dementia, suffer from some form of physical disability, or have difficulty swallowing, which restricts them from adequately hydrating and nurturing themselves. With dementia, they usually do not remember how to eat or how to chew. With various physical disabilities, such as upper extremity contractures, their ability to feed themselves is often limited. In the event of swallowing difficulties, their food preference is often altered to prevent choking or aspiration.

This often discourages them from eating due to the texture of the diet ordered. With the issues fore-stated, the residents often have to rely on the staff to assist them with meals. Caregivers often contribute to the problem of malnutrition because not enough time is devoted to assisting and supervising the residents to ensure they are eating properly. It is our job as caregivers to know the signs of malnutrition and risk factors that lead to malnutrition so that it can be detected and reported to the physician or dietitian early, before major problems occur.

Various nutritional screening tools, assessment tools, studies, and research programs are available to help isolate and provide aggressive preventive treatment strategies for those at risk. The Nutritional Form for the Elderly (NUFFE), Malnutrition Screening Tool (MST), and the Malnutrition Universal Screening Tool (MUST) are instrumental in detecting and providing interventions to decrease morbidity and mortality. These various studies help support the fact that malnutrition is overlooked, unrecognized, and left untreated by nurses and healthcare professionals.

Other studies find that even though malnutrition was identified, no interventions were put into place to treat this growing concern.

Significance of the Problem for Nursing

In a hospital based setting, there are several different groups and departments that deal with patient care. These departments and groups consist of nutritionists, doctors, social workers and other disciplines. However, the nurses are ultimately responsible for the entire care of the patient throughout their stay.

Nurses realize that many elderly patients come into the hospital undernourished or malnourished related to their being on a fixed income, having reduced access to food, having poor knowledge of nutrition, or being dependent on others for food preparation. These elderly patients sometimes have chronic illness such as depression, cancer, diabetes, renal failure, and cardiovascular disease that leads to malnutrition or under- nutrition (Briggs 2007). Under-nutrition is a wide spread problem that usually results in the elderly staying in the hospital longer related to a delay in recovery, more complications, and higher mortality rate.

That is why it is important for nurses to do a detailed assessment upon admission to prevent these issues or problems. It is the nurse’s responsibility to gather all the background information about a patient during the assessment period. This will help to diagnose the nutritional status from the beginning of the patient’s care. Some of the information that is collected during this time, such as the patient’s mental status, allows the nursing team to identify if the patient is oriented or has problems with dementia.

According to Briggs’ 2007 article, dementia is a common cause of under nutrition, as are the adverse effects of medications, such as digoxin and some anti-depressants. Antihistamines, angiotensin-converting enzyme inhibitors, and lithium zinc deficiency can alter a patient’s taste and smell. For this reason, the nurse needs to collect a medication list that is current (Briggs 2007). During this process, nurses should ask questions that will reveal information about the patient’s medical history. This is done to identify possible diseases that have an effect on the patient’s nutritional status.

Nurses should use all resources available to them after collecting data to assist with care of the patient. It is important for the nurse to know the policies and procedures at the current hospital to consult specialists in order to improve patient care. This allows each department access to review the patient’s medical information and provide patient care as needed. Nurses are the primary caregivers for elderly patients in the hospital. When a malnourished patient is admitted nurses often develop plans of care to assist patients with improving their nutrition.

Some of the ways that have been recommended are serving food at the appropriate temperature, providing food that is packed with nutrients, offering food that the patient enjoys eating, and giving oral supplements throughout the day to increase caloric intake. A good tip that nurses could use would be to always offer food or drinks when entering the patient’s room. From this research we know that poverty is one reason for malnutrition. When developing a plan of care for this patient the nurses can solicit the help of a social worker to help find resources to save money and provide food (Mayo Clinic, 2011).

Malnutrition is a significant problem in nursing because it alters the type of care a nurse can provide. For instance, if a wound already exists, malnourished patients are at a higher risk for decreased wound healing. The nurse will then have to improve the nutritional status before proper wound healing can occur. The malnourished individual can become very weak and is thereby prone to falls. The impoverished elderly patient may not only be malnourished but have insufficient funds to purchase needed supplies, such as diabetic test strips and glucose monitoring systems.

This could also lead to weakness and the development of further complications. Nurses need to ensure that daily weights and labs are obtained to track the progress of each patient. Malnutrition may seem secondary in nature, but it can grow into a monumental problem.

Problem Statement

Do registered nurses use evidence-based standards in the care of elderly hospitalized patients who are undernourished? Purpose of Study The purpose of this study is to examine registered nurses usage of evidence-based standards in the care of undernourished elderly hospitalized patients.

Hypothesis Research Hypothesis: Registered nurses use evidence-based standards in the care of undernourished elderly hospitalized patients. Null Hypothesis: Registered nurses do not use evidence-based standards in the care of undernourished elderly hospitalized patients. Definition of Terms For the purpose of this study, the following terms have been defined:

1. Undernourished- defined as an imbalance of nutrients caused by either an excess intake of nutrients or a nutritional deficit. (Maher & Eliadi, n. d. )
2. Older Adults- Age 64 or older. Maher & Eliadi, n. d. )
3. Associate Degree Registered Nurse- Registered nurses (RN’s) provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members. Registered nurses must also become licensed by passing a national licensing examination. An associate degree is an academic degree awarded on satisfactory completion of a 2-year course of study, usually at a junior college. (Bureau of Labor Statistics, 2012) (Elsevier, 2009)

4. Evidence-Based Practice- the use of scientific evidence, integrated with clinical experience and incorporating patient values and preferences in the practice of professional nursing care. (Houser, 2012, p. 12)

5. Hospital Setting- a health care facility that provides inpatient beds, continuous nursing services, and an organized medical staff. (Elsevier, 2009)

Assumptions

1. If caregivers feed elderly patients, then the proper amount of the meal will be consumed.

2. Registered nurses help to prevent malnutrition in elderly patients.

3. The adequate amount of protein consumed in an elderly patient’s diet prevents malnourishment.

4. Registered nurses provide help with dietary interventions of the undernourished.

5. If the proper screening tools are performed on admission, the elderly patient’s weight will improve. Summary People in this nation are living longer. As recognized throughout this research, malnutrition in the elderly patient is at an extremely high level. It is not only the nursing home patients experiencing undernourishment but the hospitalized elderly patients also. Malnutrition is prevalent throughout the elderly community. Through using evidence based practice tandards, malnutrition tools, and education strategies this dilemma can be improved.

Review of the Literature

Undernourishment has long been a prevalent problem among the elderly, especially in an acute-care setting. It has been a long-standing challenge for health-care providers to determine the most effective process for identifying those that are undernourished, at-risk for undernourishment, as well as intervening promptly and appropriately. A review of literature was done to examine registered nurses usage of evidence-based standards in the care of undernourished elderly hospitalized patients.

Much of the literature supports the use of nutritional screenings to identify undernourished patients and reduce the number of those patients in the hospital setting. Undernourishment is often referred to as malnutrition. The effects of malnutrition, which is the inadequate consumption of essential nutrients, are very devastating to the health of an individual. As well-known among healthcare providers, inadequate nutrition can prolong wound healing, suppress the immune system, lead to increased length-of-stay, and increase the risk of mortality from comorbidities.

The article entitled, “How well do nurses recognize malnutrition in elderly patients,” describes how well nurses are able to recognize the problem of undernourished patients and if care is being provided to these patients. There are numerous methods that can be used in determining if a patient is malnourished. In this study Mini Nutritional Assessment (MNA), Body Mass Index (BMI), and a detailed questionnaire was used. The MNA is a simple, reliable, and well-validated tool used to determine a patient’s nutritional status.

MNA gives a maximum of 30 points. A score of less than 17 indicates the patient is undernourished, while a MNA of 17-23. 5 shows a patient is at risk for malnutrition. BMI is another tool used in determining the status of a patient’s nutritional state. In this study a BMI of less than 20 is considered to be high risk for malnutrition. A questionnaire was given to nurses to determine daily routines related to nutritional care such as amount of food consumed at each meal, snacks between meals, and any oral nutritional supplements given.

The study examined elderly patients in a long-term care unit in Helsinki City hospitals in Finland to determine if nurses are able to recognize undernourished patients and if adequate care was provided (Suominen, Sandelin, Soini, & Pitkala, 2009). The above study included 1,043 elderly hospitalized patients for a two-week period. The nurses measured the BMI of patients as well as their MNA, but the nurses were not aware of the values to determine an undernourished state. In addition, the nurses were asked if they believed the patients were malnourished by simply marking yes or no.

The nurses that performed the study participated in a 3-hour course to learn how to organize the study, assess the patients, and to complete the questionnaire (Suominen et al,. 2009). The results of the study, “How well do nurses recognize malnutrition in elderly patients,” revealed that malnutrition is not recognized by nurses and therefore results in the inability to provide evidence-based care to the patients.