ONA Interview: Integrating nursing care with the nutrition support team
Noreen Luszcz, RD, MBA, CNSC
Maintaining nutritional status in patients undergoing cancer treatment is one of the more challenging aspects of oncology nursing. The side effects of cancer and treatment such as fatigue, nausea and vomiting, and altered taste, to name a few, can make meeting daily nutritional requirements difficult for patients. Some patients may require parenteral or enteral nutrition support to ensure they receive adequate nutrients in the course of their cancer journey.
Oncology Nurse Advisor (ONA) talked to Noreen Luszcz, RD, MBA, CNSC, nutrition program director for Walgreens Infusion Services, about how oncology nurses can work with the infusion services clinicians to ensure patients undergoing cancer treatment are receiving adequate nutrition. Every nutrition patient cared for by Walgreens Infusion Services receives their care from a home nutrition support team, which includes registered dietitians and specially trained infusion nurses and pharmacists. These teams work with a patient's physicians and nurses to provide nutrition therapy in the patient's home.
ONA: Weight and eating habits are sensitive topics for many people. What would be an optimal approach for nurses to use when talking to patients about their weight or eating habits?
LUSZCZ: This topic can be difficult for oncology patients as they may struggle with weight loss, food aversions, loss of appetite, and the inability to meet daily nutritional needs. Some questions nurses can ask to tailor the discussion are: What is your day-to-day routine like? Do you eat regular meals? What have you had to eat and drink today? How about snacks? Are you able to eat throughout the day?
Nurses should consider weight and eating habits as part of their overall health assessment of the patient. Best practices for discussing nutritional needs include
- Emphasize the importance of nutrition
- Provide suggestions for improving nutrition intake
- Connect the patient with a registered dietitian for further advice
ONA: How are deficits that indicate a need for nutrition therapy identified?
LUSZCZ: Caloric deficits are identified by overall weight loss. Weight loss includes the breakdown of both fat and muscle tissue. The percent of weight loss over time can be categorized on a range from significant to severe and is a key indicator for the need for calories, protein, and vitamins/minerals via oral, enteral, and parenteral routes. Other physical signs that may be attributed to nutrient deficiencies can be observed during the nurse examination such as dry, scaly skin (vitamin A or essential fatty acid deficiency); spoon-shaped nails (iron deficiency); distorted taste (zinc deficiency), and vertical cracks in the lips (B-vitamin deficiency). Nurses can perform a nutrition screen to determine risk for nutritional deficiencies and follow-up with a referral to a dietitian for a comprehensive nutrition assessment, if indicated. Oncology patients who cannot eat, will not eat, or cannot eat enough over an extended period of time, in conjunction with significant weight loss, may be candidates for nutritional support.
ONA: Much is said about weight loss, but what about weight gain? What impact does weight gain have on overall nutrition status?
LUSZCZ: Gynecologic cancers, for example, may cause fluid retention and weight gain. Fluid retention can be treatment-related as well. The potential source of the weight gain should be determined. Again, a positive approach to choosing healthy foods, appropriate portion size, and not skipping meals is important. Nurses should encourage patients to work with a dietitian who can help them focus on healthy eating and behavior modification to lose weight safely if indicated.
ONA: How does obesity impact nutritional assessment?
LUSZCZ: People with cancer, at any size, are at risk of malnourishment. A comprehensive assessment by a dietitican is best to determine nutritional needs. For example, the patient may not be consuming enough protein; therefore, even obese patients should undergo a comprehensive assessment by a dietitian.
ONA: What steps can patients take to avoid or minimize their need for home nutrition therapy?
LUSZCZ: The following steps may help to minimize nutrition risk
- Upon diagnosis, understand the important role nutrition plays in the overall treatment process
- Undergo a nutrition assessment by a registered dietitian
- Pursue nutrition education from nurses and dietitians on what constitutes a balanced intake, how to maintain adequate intake, the foods to avoid if experiencing treatment side effects, ways to increase calories and protein, and suggestions for maintaining hydration
- Keep a list of resources for support such as web sites, patient advocacy groups, support groups, agencies, and clinicians, including nurses and dietitians.
ONA: How should a nurse prepare the patient with cancer for managing home nutrition therapy?
LUSZCZ: An oncology nurse can typically advise patients on what to expect during their home nutrition support therapy and answer questions the patient may have; but after that, the nurse can call in the home infusion experts to handle most of the details. Home infusion nurses who are part of the patient's home nutrition support team can conduct many activities that prepare and train the patient for home nutrition support.
First, the home environment is assessed for cleanliness and the availability of water, refrigeration, etc. Next, the patient's or caregiver's ability to administer nutrition safely is determined. The nurse should provide thorough instruction, including a review of educational materials and return demonstration of infusion administration principles as instructed. Nurses also provide both psychological and emotional support as needed in the home setting.
ONA: What patient concerns and frequently asked questions should nurses be prepared to answer when discussing home nutrition support for patients with cancer?
LUSZCZ: The following are examples of frequently asked nutrition support questions.
- What type of side effects may I encounter with enteral or parenteral nutrition?
- How long will I need to be on nutrition support?
- Who can I call if I have questions, especially at odd hours?
- When should I call my physician?
If the patient's oncology nurse does not have the answers to these questions, the patient can be referred to the home nutrition support team members for help, advice, and education about their home nutrition support therapy process.
ONA: What contraindications would prohibit a patient's use of home nutrition therapy?
LUSZCZ: Nutrition support contraindications include an inappropriate home environment, inadequate family/caregiver support, and an inability to adequately store the formula. The patient and their home should demonstrate that the patient's environment is well-maintained and clean with fresh running water, and proper hand washing technique is used by all persons involved in the patient's care. The home should have proper refrigeration so the formula can be adequately stored. At Walgreens, we want to ensure that the patient's home environment and care support needs are suitable for home infusion. If there are concerns, we will often work with patients to identify and resolve obstacles.
ONA: For how long would a patient continue home nutrition support therapy?
LUSZCZ: The duration of home nutrition support therapy can vary depending on the patient's overall condition, disease state, degree of malnutrition, comorbidities etc. A person may be on short-term nutrition support (up to 6 months) or long-term nutrition support (6 months to lifelong) if they are unable to maintain their nutritional needs by oral route alone.
ONA: How does home nutrition therapy impact the patient's gastrointestinal system (eg, diarrhea, constipation, cramping, flatulence, etc)?
LUSZCZ: Parenteral nutrition typically does not cause gastrointestinal issues because the nutrition is provided through a large central vein, not via the GI tract. Side effects may be present with enteral nutrition; however, they are often not related to the enteral nutrition itself, but rather induced by the disease, treatment, or medication. If GI concerns or other side effects do occur, all aspects of the treatment plan are assessed. The enteral formula may need to be changed, the rate of the formula adjusted, antidiarrheals provided, water or fiber intake increased, or certain medications may need to be discontinued. Nutrition support dietitians work with nurses to make recommendations to patients and their physicians.
ONA: What are the indicators that a patient no longer needs to continue home nutrition support therapy?
LUSZCZ: If a patient reaches a goal weight, has a healthy BMI, is able to tolerate oral intake, and laboratory test results are in order and energy restored, the patient is probably a good candidate to be weaned off nutrition support. During the weaning process, which can take 1 to 3 weeks, the patient will be monitored for weight changes, increases in oral intake, tolerance of oral intake, and the patient's overall condition is assessed.
ONA: How is the patient's return to eating solid food managed when home nutrition support therapy is no longer needed?
LUSZCZ: Patients may be eating limited amounts of oral food and drinking fluids while receiving nutrition support. During the transition off nutrition support, the patient gradually increases oral intake while decreasing the nutrition support formula. A registered dietitian should be involved to guide the process and assess the patient's progress.
The weaning process can take only a few days if treatment is not severe, if there are no side effects, and the patient is able to tolerate solid foods. However, a slower pace is better, so patients should be encouraged not to rush the weaning process. The patient should keep a daily food diary for the nurse and/or dietitian to review, and the nurse should pay careful attention to the patient's physical appearance.
ONA: The FDA announced a decision to import injectable TPN drugs to ease a crucial shortage. What tips can you offer for managing patient care during a shortage of TPN drugs?
LUSZCZ: We work closely with the patient's prescribing physician and care team to answer patient questions and advise on information resources.
Take-home points for oncology nurses:
- Incorporate an early nutrition screening tool into the patient care plan to determine risk for malnutrition
- Have a positive approach to nutrition and be pro-active about asking patients how well they are eating (eg, more, less, difficulties, taste problems)
- Ask the patient to quantify symptoms if possible, as this information is helpful in determining if action needs to be taken (eg, if the patient complains of nausea and vomiting, ask about frequency, appearance, and volume)
- Build a library of resources you can share with patients (eg, support, information)
- Consider becoming involved with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), a multidisciplinary health care professional organization dedicated to educating patients and health care providers about nutrition support