1. Introduction
Nutrition
is a process whereby food is taken into the body and broken down, allowing for
a production in energy, necessary for all living cells to maintain their
structure and function (Field & Smith, 2008). A balanced nutritional status
consists of a diet comprised of carbohydrates, proteins, fats, vitamins and
mineral. An excess, or deficiency, in these essential components can lead to
poor nutritional status and in some cases malnutrition.
Nutritional process means processes involved
in nutrient intake and use which together influence the nutritional status of a
person (Fuller & Shcaller, 2000). Beside ingestion,
digestion, absorption and transport, metabolism is also one and the final
process in the nutritional processes.
Metabolism consists of processes that produce
and use the energy within body cells.
Thus this complex process starts as the cell is fueled by
nutrients. Hence, to achieve an optimal
health, energy used must be matched with energy production. Generally, energy is used in two major ways;
firstly to maintain essential life processes such as breathing, nervous system
function and blood circulation.
Secondly, to support nonessential life activities such as running,
working, thinking and dealing with stress.
In addition to those, some of the energy is also being used for
nutritional processes like digestion and absorption
2. Importance of Nutrition and metabolism
Good
nutrition, an adequate and well balanced diet is a cornerstone of good health
(World Health Organization, 2012). Poor nutrition can lead to reduced immunity,
increased susceptibility to disease, impaired physical and mental development,
and reduced productivity. Nutrients preserve
health and ensure proper growth and development, with longlasting effects on immunity, cognition, and
behavior (2011).
Therefore, adequate nutrition is necessary to build up
immunity against diseases, and prevent the diseases caused by certain
nutritional deficiencies.
Nutritional
care of patients is a primary responsibility of nurses, and is essential to
maintaining optimum health, preventing complications, and improving wound
healing. A poor nutritional status can
lead to malnutrition, which can have serious impacts on individual’s quality of
life (Field and Smith, 2008). Therefore, nurses need to perform nutritional
assessment to identify nutritional risks, and to provide interventions
fulfilling the nutritional needs of the individual patient.
Metabolism composed of anabolism and catabolism hence,
refers to the highly integrated network of chemical reactions, such as growth,
generation of energy, elimination of wastes, and other bodily functions as they
relate to the distribution of nutrients in the blood after digestion and living
cells growth and sustaining (Dillon, 2007).
Based on (Krapp, 2002),
anabolic and catabolic networks have three major functions including to extract energy from nutrients, to
synthesize the building blocks that make up the large molecules of life such as
proteins, fats, carbohydrates, nucleic acids, and combinations of these
substances, then finally synthesize and degrade molecules require for special
functions in the cell; These reactions are controlled by enzymes, protein
catalysts that increase the speed of chemical reactions in the cell without
themselves being changed.
The importance
role of metabolic pathways in human health is to supply the body with the
energy and nutrients it needs for maintenance of body functions, growth, tissue
repair, and other processes (Fuller & Schaller-Ayers, 2000).
3. Assessment of Nutrition and Metabolism
Assessment of nutrition involves
collecting and interpreting data to identify healthy nutritional practices,
nutrition risks, altered nutrition status, and the effects of altered nutrition
(Fuller & Schaller-Ayers, 2000). Data collection is performed by interview, diagnostics studies, anthropometric measurement and physical
examination.
3.1.History taking and interview:
Interview enquiring about body
weight such as recent weight changes is important. Unintentional weight loss
may indicate serious nutrition and health problem, and sudden weight gain may indicate
fluid retention, electrolyte imbalance and medication side effect. Interview
about eating habits, food preference and dislike, food allergies is required to
probe nutritional problems and risks which contribute to negative health
outcome.
The nutritional
history of clients experiencing alterations in nutrition and metabolism is of
critical importance in the development of the plan of care. Several methods can
be used in collecting these subjective data namely: 24-hour recall, food
frequency questionnaire, food record, and diet history; The 24-hour recall
requires client identification of everything consumed in the previous 24 hours.
Family members can often assist with these data, if necessary. The
food-frequency method gathers data relative to the number of times per day,
week, or month the client eats particular foods and helps to validate the
accuracy of the 24- hour recall and provides a more complete picture of foods
consumed. The food record provides quantitative information regarding all foods
consumed, with portions weighed and measured for three consecutive days which
requires full client or family member cooperation. The diet history elicits
detailed information regarding the client’s nutritional status, general health
pattern, socioeconomic status, and cultural factors.
Assessment of nutritional knowledge
is necessarily important to identify misconceptions about nutrition and
learning needs for nutrition. Nutritional knowledge involves asking patient
about food groups on the pyramid, foods high in calories, foods with limited
nutritional value, foods high and low cholesterol, and ability to interpret
food labels.
Interview about socioeconomic background such as income, education level and
mealtime setting; eating at home with family or outside, are important because these factors are affecting
patients’ nutritional status. Patient’s medical history is important
information to determine nutritional risks. Medication history is also
important that some drugs alter nutritional and metabolic states.
3.2.Diagnostic study:
When assessing nutritional status,
laboratory results are reviewed to; screen the patient for nutritional
problems, quantify the extent of protein-calorie malnutrition, and indentify
specific deficiencies in essential nutrients (Fuller, 2000). Blood albumin
level is monitored to determine the risk of protein-calorie malnutrition.
Albumin, transferrin, and lymphocytes are serum protein; decreased serum levels
indicate protein deficiencies (Fuller, 2000). Nitrogen balance is evaluated;
positive nitrogen balance (+2 to +4) indicates optimal nutritional status.
Haemoglobin, haematocrit, and
transfferin level are monitored to screen out iron deficiency anemia. Serum
potassium and sodium level are monitored to determined deficiency or excess. Calcium
and phosphate levels are measured for the patients who have potential risk of
mineral bone disorders. Cholesterol and lipid values are checked up for the
people with risk of cardiovascular disease.
3.3.Anthropometric assessment:
Anthropometric measurement includes
height, weight, skinfold thickness, and various body circumferences. Body mass
index (BMI) is calculated to determine normal weight, overweigh or obesity.
Midarm circumference (MAC) is
measured to determine the muscle mass and fat; MAC decreases with
under-nutrition and increases with obesity and muscle hypertrophy. Tricep
skinfold (TSF) is measured to determine total body fat.
3.4.Physical assessment:
General survey includes appearance
of overweight of underweight, signs of muscle wasting and patterns of fat
distribution. Examination of integumentary system involves skin; dry or
flakiness, hair; dry, thin sparse, or easily plucked, and nails; brittle, pale, spoon-shaped
or transverse ridges across the nail plate, which are signs of malnutrition.
Examination of oral cavity is
important to determine presence of infection or inflammation of gum and oral
mucosa, which hinder food intake. Oral
cavity examination involves; lips for puffy, swollen, fissure at the corner of
the mouth and cheilosis, tongue for pale or lesion, oral mucosa for swollen,
dryness or redness, and teeth for mottled, cavities of poor dentition. Missing
or decayed teeth of ill-fitting dentures lead to reduced food intake (Posthauer,
2012).
4. Challenges and issues related to nutrition and metabolism
According to
Park et al. (2011)
nurses who have direct interactions with patients during hospitalization are in
a good position to inform those who are at risk of nutritional problems and metabolic
diseases, and counsel them on scientific and practical dietary therapies. There are some challenges to fulfil
nutrition and metabolic needs of the patients.
4.1. Knowledge and competency
The level of nutritional knowledge will
influence nurses’ attitude and practice to provision of nutritional care for
the patients (Fletcher & Carey, 2011).
Warber
et al. (2000) and Schaller & James (2005) reported that nurses have suboptimal level of nutritional knowledge in
Western countries. Fletcher & Carey (2011) also highlighted that
inadequate nutritiona knowledge a key factor for inconsistancies in nutritional
screening. They recommended, developing nutritional teams and the
provision of further education as solutions to reduce the nutritional problems.
4.2. Identification of nutritional
problem
There is only a minor group of patient at risk
of nutrition are identified (Mowe et al., 2006). Malnutrition remains
undetected in common clinical practice, which contributes to prolong hospital
stays and negative health outcomes.
It is recommended that nutritional risk screening should be undertaken on
admission, and specific nutritional counseling should be undertaken when the
significant risk is detected.
4.3. Nutritional intervention related to
psycho-social factors
Psychological factors; depression,
anxiety and stress, and socioeconomic factors; income, education, lifestyles,
and family supports, all contribute to either healthy eating of poor eating
habits. The study done by (Mead, Gittelsohn, De Roose, & Sharma (2010) showed that food knowledge, self-efficacy and
healthy food intensions are associated with dietary behavior. Therefore, they
recommended that nutritional intervention should be target to behavioral changes
strategies.
4.4. Nutritional
issues related to vulnerable groups
Promoting
proper nutrition in infant and young children is the most important nutritional
intervention. World Health Organization (2012) reported that malnutrition
counted two third of death in children under five. Nutrition and nurturing during the first
years of life are both crucial for life-long health and well-being. Infant and
young children may have inborn errors of metabolism are: galactosemia,
phenylketonuria, lactose intolerance, and maple syrup urine disease (Fuller & Schaller-Ayers, 2000)..
Nurses have an important role in diagnosing metabolic disorders which requires
a physical examination and blood tests and then the diet modifications needed for
each disease.
Adolescents
are exposed to undernutrition, micronutrient malnutrition as well as obesity.
Their lifestyle and eating behaviours, along with underlying psychosocial
factors, are particularly important threats to adequate nutrition. Inadequate nutrition in adolescence can
potentially retard growth and sexual maturation. Therefore, nutritional education should be given effectively for
this target group.
Women with pregnancy and breastfeeding are a target
population who need special nutritional support. The consequences of
poor nutritional status in women during pregnancy directly affect women’s
health status, and impacts on birth weight and early childhood development
(WHO, 2012). Maternal health and nutrition before and during pregnancy, and early
infant nutrition may be important in the prevention of non-communicable diseases throughout the life course.
Elderly
people are also vulnerable to nutritional risk. World Health Organization
stated that many of the diseases suffered by older persons are the
result of dietary factors. These factors are then compounded by changes that
naturally occur with the ageing process; changes nutritional process and
metabolism. Dietary changes seem to reduce risk-factor in older people (WHO,
2012). For instance, reductions in saturated fat and salt intake would reduce
blood pressure and cholesterol concentrations, reducing the burden of
cardiovascular disease.
4.5.Nutritional Challenges in chronic diseases
Patients
with chronic diseases such as heart failure, coronary artery disease, chronic
obstructive pulmonary disease (COPD), hepatic cirrhosis, rheumatoid arthritis,
end-stage kidney disease, human immunodeficiency virus (HIV) infection,
diabetes, etc. will require integrated health care programs to maintain
functional autonomy and quality of life. These adjuvant interventions are
mainly based on nutritional support and exercise programs (Biolo, Guadagni, & Ciocchi, 2011).
The
overall goal of nutrition intervention in diabetes is to achieve and maintain
optimal metabolic outcomes with respect to glucose and lipid levels. Dietary
recommendations for people with diabetes do not differ significantly from those
for the general population. However, carbohydrate intake is a dietary focus
because it has a greater impact on postprandial glucose levels than protein and
fat intake. The postprandial glycemic response to carbohydrate is affected by
both the amount and the type of carbohydrate consumed. Whole-grain
carbohydrates, for instance, produce a lower and slower glycemic response than
processed carbohydrates (Mann et al., 2004).
Among
people with chronic kidney diseases, reduced dietary intake or malnutrition related
to anorexia, nausea and vomiting, changes in taste and smell, and dietary restrictions.
Also implicated are heightened catabolism and metabolism, which increase as the
disease progresses. Inflammation is linked to the increased energy expenditure
seen in CKD. Because kidney function is inadequate, metabolic abnormalities
appear, including anemia, acidemia, high blood levels of potassium, and
disruption of the calcium-vitamin D metabolic pathway. Nutrition intervention
for patients with CKD must consider their disease stage, nutritional status,
metabolic abnormalities, and for patients with ESRD, type of dialysis (Mann, et al., 2004).
4.6.Nutritional Challenges in palliative care
Weight
loss in cancer patients is associated with several serious complications
including increased toxicity of chemotherapy, decreased response to therapy, increased
morbidity such as infection, increased hospital LOS, decreased quality of life
and increased mortality (Biolo, et al., 2011). In advanced cancer, anorexia and cachexia and
malnutrition are highly prevalent. Nutrition support with an energy and protein
dense nutritional supplement as a part of overall care, has been shown to
reduce complications such as infection and length of hospital stay, promote
weight gain, help build lean body mass, improves immune function, enhances
quality of life, and increase strength and physical activity level in those who
gained weight (Gaertner et al., 2012).
5. Conclusion
Health assessment is central to nursing practice, and
nutritional and metabolic assessment is very important which nurses are often
omitted to perform. Since nutrition and metabolism
is influenced by internal and external factors, identification of these factors
is critical to rectify the nutritional risk and problem. Therefore,
nurses are required to be knowledgeable and skilful in history-taking, physical examination, diagnostic
measures, to determine potential or
actual nutritional and metabolic problems. Upon identification of problems and
issues collaborative actions with other professional, scientific researches
with interventional study are required to address these issues.
6.
References:
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