10.2 Nutritional and Metabolic Symptoms

Anorexia-cachexia is not starvation

Families say she is starving. The CHPN nurse has to decide whether the body would use calories if they were forced in. Anorexia-cachexia of advanced disease is a cytokine-driven syndrome: muscle wasting, early satiety, altered taste, and a resting metabolism that does not behave like famine. Offering more food does not rebuild lean mass the way it does in a recovering surgical patient who is otherwise well. Starvation is a lack of access to calories in a body that can still anabolize. That distinction drives every feeding-tube stem on this exam.

Do not make a feeding tube the default. In advanced dementia and in active dying, artificial nutrition does not reliably prevent aspiration, restore strength, or prolong meaningful life. It can add restraints, diarrhea, edema, and a new infection risk. The honest plan is small, frequent, favorite foods, no shame when a plate comes back full, and meticulous mouth care. If the patient still enjoys ice cream at 2 a.m., that is treatment. If the patient turns away from all intake, that is dying physiology, not a nursing failure to spoon harder.

A time-limited trial of assisted feeding is reasonable when goals are uncertain and the patient is not in the last hours. A time-limited trial of a tube is sometimes requested; name the burdens, set a review date, and stop when the tube is not meeting the stated goal. CHPN stems punish the nurse who orders a tube to reverse cachexia and the nurse who withholds all oral pleasure in the name of aspiration risk when the patient is still asking for tastes.

Pharmacologic appetite support, used as a tool

Dexamethasone can improve appetite, energy, and a sense of well-being within days. It is a short-horizon drug: hyperglycemia, insomnia, proximal myopathy, and infection risk accumulate. Use it when prognosis is measured in weeks, not as a forever vitamin.

Megestrol can increase appetite and some weight, much of it fat or fluid. Counsel thrombosis. Patients with prior venous thromboembolism, limited mobility, or pancreatic and other high-clot cancers are poor candidates. Edema and adrenal suppression with prolonged use are additional costs. Megestrol is not a cachexia cure and is not first-line in someone already anticoagulated for a fresh clot.

Other agents appear in practice (mirtazapine for sleep and appetite, cannabinoids for selected patients). Know dexamethasone and megestrol well; they are the exam's usual pair. Never present a stimulant appetite plan as a substitute for explaining the disease.

Hydration as comfort versus edema and secretions

Thirst and dry mouth are not the same as dehydration on a lab printout. A dry mouth is treated with sips, swabs, sprays, and ice chips. Liters of intravenous or subcutaneous fluid will not fix xerostomia if the patient cannot swallow well, and those liters can worsen edema, ascites, pulmonary congestion, and oropharyngeal secretions.

A time-limited hydration trial is fair when delirium might be volume-related, the family wants a trial, and the patient is not drowning in secretions. Write the goal (clearer thinking in 24 to 48 hours). Stop if edema or rattling secretions increase. Do not hydrate solely because a sodium or urea number looks dry if the patient is comfortable and dying.

Hypercalcemia and hyponatremia

Hypercalcemia of malignancy is a CHPN classic: confusion or delirium, constipation, polyuria and polydipsia, fatigue, and sometimes nausea. Bones, groans, stones, and psychiatric overtones still apply. If goals include reversing a treatable delirium, give fluids and consider a bisphosphonate (or denosumab when renal function or prior bisphosphonate failure makes that the better osteoclast block). If the patient is imminently dying and the family has chosen comfort only, treat constipation and delirium as symptoms; do not send the patient to an infusion chair for a calcium number that will not change the dying day.

Hyponatremia is a different map. Syndrome of inappropriate antidiuretic hormone from lung cancer is euvolemic and hypo-osmolar. Mild cases may use fluid restriction if that matches goals. Severe neurologic symptoms may need hypertonic saline only if the goals still include hospital-level correction. In the last days, treat seizures and delirium for comfort rather than chasing a sodium of 118 with intensive care. Do not restrict fluids in a hypovolemic patient who is actually dry, and do not treat hypercalcemia with fluid restriction — that pairing is a common distractor because both cause confusion.

Food as comfort versus medical nutrition

Walk into a stem with a daughter demanding a percutaneous tube because Dad stopped eating after his third hospitalization for heart failure. Name anorexia-cachexia or organ-failure wasting, offer favorite foods in small amounts, keep the mouth moist, and do not make the tube the required next order. If the same stem adds confusion, constipation, and large urine output in metastatic breast cancer, think hypercalcemia and match fluids plus a bisphosphonate to the goals — not megestrol, and not automatic fluid restriction for SIADH.