Malnutrition, Weight Loss and Eating Disorders — Initiation of Nutritional Rehabilitation and Ongoing Care — Clinical Pathway: ICU and Inpatient

Malnutrition, Weight Loss and Eating Disorders Clinical Pathway — ICU and Inpatient

Initiation of Nutritional Rehabilitation and Ongoing Care

Prepare families and patients for the hospital stay and discuss goals to be achieved during the admission. Give families the Welcome Packet.

Key Points

  • Length of stay is anticipated to be 10-14 days.
  • On the first few days the patient will be seen by a team of different disciplines to assess stability and needs and discuss the treatment plan and goals of admission.
  • The treatment is standardized and the goal is to initiate the pathway as quickly as possible.
  • Patient will be on a heart monitor 24 hours a day and cannot leave the unit.
  • Patient will have daily labs in the morning to ensure normal electrolytes.
    • The daily blood drawing will stop when calories do not need to be increased (reached goal) given that electrolytes have remained normal and the patient did not require electrolyte supplementation.
  • Nutrition is key to achieving medical stability: “food is medicine”.
  • During the admission, the patient will not receive counseling.
  • Patients receive a psychologic assessment and therapeutic support to help cope with the hospitalization and potential diagnoses.
  • Discharge is based on medical criteria, including cardiovascular and electrolyte stability, and not on a certain amount of weight gain. Severely underweight patients typically need to reach a certain amount of weight (e.g., 75% of goal weight) to achieve medical stability.
  • Aggressive treatment of young patients with eating disorders, weight restoration and family involvement has been proven to improve prognosis and lead to full recovery.

Rehabilitation and Care

Diet Order (Nutritional Rehabilitation)
  • If the dietitian has not assessed the patient, can safely start at 1600 calories for the first day, or 400-500 calories above what they are typically eating at home
  • Standardized menu in place and modifications to menus only if lifelong/family religious preferences and/or diagnosed allergies
  • Calories increase by 400 calories/day until goal calories range reached, may progress by 200 a day if signs of severe refeeding syndrome, or patient symptomology
  • Goal calories:
    • REE x 2.5-3.5 for age ≥ 12 years of age
    • REE x 2-3 for age < 12 years of age
  • Meal plan will likely start at 3 meals/day and advance to 3 meals and 2 snacks by discharge
  • Given 30 minutes per meal and 15 minutes per snack to complete
  • If food is not completed, nutritional supplement offered and given 15 minutes to complete
  • If supplement not completed, nasogastric feeds are considered and used as needed
Order Level of Supervision
  • At least Meals/Rest/Snack
  • If actively suicidal, needs to be on Suicide Bundle
Continuous Heart Monitoring
  • Telemetry if HR < 30 overnight or < 35 with additional arrhythmias or severe electrolyte abnormalities (Telemetry Guidelines)
Blind Daily Weights in a.m.
  • Daily a.m. weights (blind to the patient) — post-void, before breakfast, in gown and underwear
  • Height for every patient upon admission to calculate BMI
Daily Orthostatic Vital Signs
  • Supine: 5 minutes, standing: 2 minutes
  • Abnormal: Increase in heart rate of > 20 beats per minute, or decrease in systolic blood pressure of > 20 mm Hg; or decrease in diastolic blood pressure of > 10 mm Hg
  • Detail in flowsheet, note any sign/reports of dizziness
Daily Refeeding Labs
  • Basic metabolic profile, magnesium, phosphorus
Manage Other Comorbid Medical Conditions  
Start Prophylactic Vitamins  
Advance Activity
  • Maximum of three 10 minute walks
Continue Daily Weights and Vital Signs  
Continue labs as clinically indicated (still at risk for refeeding syndrome, transition from a catabolic state to an anabolic state)
  • Basic metabolic profile, magnesium, phosphorus
Electrolyte Repletion as Needed
Behavioral Health
  • Confirm suspicion of eating disorder diagnosis
  • Evaluate supervision status
Discuss Disposition
  • Team updates during multidisciplinary rounds, family meetings, family education