1b// Malnutrition and Nutritional Assessment Flashcards by rachael a

What is the definition of malnutrition?

A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome

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Who is most at risk of malnutrition?

chronic illness e.g., diabetes
over 65 y/o
any gastrointestinal dysfunction
progressive disease e.g., cancer
misuse of alcohol or drugs

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What happens to 1 in 3 patients who are malnourished at acute admission?

hospitalisation exacerbates nutrition risk

70% have lost weight at discharge- mainly muscle

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What are the causes of malnutrition in hospital? (3)

Reduced intake
Maldigestion/ malabsorption
Altered metabolism

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What are reasons for reduced intake in hospital?

*Contraindicated
* Disease related anorexia
* Taste changes
* Nil by mouth
* Food options
* Depression
* Inactivity
* Oral health
* Fatigue

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What are reasons for maldigestion, malabsorption in hospital? (4)

Function
Length
Losses
Drug-nutrient interactions

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Describe the altered metabolism in hospital?

Figure 1. Metabolic response to injury proposed by Cuthbertson et al. A short ebb phase characterized by hypometabolism occurs immediately after the injury and is characterized by a decrease in metabolic rate, oxygen consumption, body temperature, and enzymatic activity. The ebb phase is followed by a longer hypermetabolic flow phase marked by an increased catabolism, with a high oxygen consumption and an elevated REE rate.

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What is the impact of malnutrition on mortality?

postoperative mortality 10x greater in those who had lost >/20% bodyweight preoperatively, compared to those who had lost less

direct cause of hospital deaths
and a contributory factor in hospital deaths

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What is the impact on the patient of malnutrition?

increase= 6
decrease= 4

Physical and functional decline and poorer clinical outcomes

↑ Mortality, septic and post surgical complications, length of hospital-stay, pressure sores, re-admissions, dependency

↓ Wound healing, response to treatment, rehabilitation
potential, quality of life

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What is an economic negative of malnutrition?

£ 19.6 billion 15% of the total public expenditure on health and social care.

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What will a dietician need information on to assess a patient to see if they are malnourished?

Ø Anthropometry
Ø Body composition Ø Function
Ø Biochemistry
Ø Clinical
Ø Dietary
Ø Social
Ø Physical
Ø Requirements

screen-> assess-> diagnose

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What types of people will need nutrition support?

malnourished

at risk of malnutrition

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What are the indications for nutrition support for malnourished people according to NICE 2006?

BMI < 18.5 kg/m2 or

Unintentional weight loss >10 % past 3 - 6 / 12 or

BMI<20kg/m2 +unintentional weight loss >5% past 3–6/12

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What are the indications for nutrition support for people at risk of malnutrition according to NICE 2006?

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or
longer or

Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

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What is the algorithm for the treatment of malnutrition?

*always aim for oral nutrition

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What is artificial nutrition?

The provision of enteral or parenteral nutrients to treat or prevent malnutrition.

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What are the nutritional options available via the oral route? (5)

Fortification of meals and snacks

Altered meal patterns

Practical support

Oral nutritional supplements (ONS)

Tailored dietary counselling

What are the types of artificial nutrition support?

enteral and parenteral

What is better, enteral or parental nutrition?

Enteral nutrition (EN) is superior to parenteral nutrition (PN).

Where parenteral nutrition is used, the aim is to return to enteral → oral feeding as soon as (where) clinically possible.

What is the access for enteral nutrition?

Is gastric feeding possible?

Yes = Naso-gastric tube (NGT)
No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Long term (> 3 months) = Gastrostomy / jejunostomy

What is the nutritional feeds in enteral nutrition?

renal, low sodium, respiratory, immune, elemental, peptide, high energy, high protein.

What are the complications associated with enteral feeding?

Mechanical: misplacement, blockage, buried bumper

Metabolic: hyperglycemia, deranged electrolytes

GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Misplaced NGTs
- aspirate </5.5pH
- if pH is more than 5.5–> chest x-ray, interpreted by trained professional following NPSA guidelines

What is parenteral nutrition?

The delivery of nutrients, electrolytes and fluid directly into venous blood.

What are the indications to need parenteral nutrition? (2)

An inadequate or unsafe oral and/or enteral nutritional intake
OR
A non-functioning, inaccessible or perforated
gastrointestinal tract

What is the composition of parenteral nutrition?

* Ready made / bespoke “scratch” bags * MDT → fluid and electrolyte targets

What is the access of parenteral nutrition?

* Central venous catheter (CVC): tip at superior vena cava and right atrium. * Different CVCs for short / long term use.

What are the complications associated with parenteral nutrition?

Does Nutrition Support Benefit the Malnourished Patient?

Research confirms the benefits of managing malnutrition with nutritional support, such as the use of oral nutritional supplements alongside the diet, resulting in improvements in patients' function (e.g. strength), quality of life and clinical outcomes, and reductions in health care use (e.g. hospital stays, admissions (text is google, image is from lecture)

In what state is albumin decreased?

inflamed state (so nutrition won't affect) A negative acute phase protein = ↓ plasma albumin when ↑ inflammation

Where is albumin synthesised?

liver

Describe the acute phase response. (specific to protein synthesis)

Inflammatory stimulus → activation of monocytes & macrophages → release cytokines. Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst down regulating production of others e.g. albumin.

Is albumin a valid marker of malnutrition in the acute hospital setting?

No. Albumin synthesis ↓es in response to inflammation ∴ poor predictor of malnutrition during acute phase. However, do consider the aetiology / impact of the inflammatory response on nutrition status.

What is refeeding syndrome (RFS)?

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.

What are the consequences of refeeding syndrome? (5)

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death Respiratory depression Encephalopathy, coma, seizures, rhabdomyolysis Wernicke’s encephalopathy Ultimately death

What is the pathogenesis of refeeding syndrome?

According to the National Institute for Health and Care Excellence (NICE), what are the criteria for defining the risk of RFS?

At risk: - Very little or no food intake for > 5 days High risk: >/ 1 of the following... - BMI < 16 kg/m2 - Unintentional weight loss > 15 % 3 – 6 /12 - Very little / no nutrition > 10 days this - Low K+, Mg2+, PO4 prior to feeding Or 3 2 of the following for high risk... - BMI < 18.5 kg/m2 - Unintentional weight loss > 10 % 3 – 6 / 12 - Very little / no nutrition > 5 days - PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics) Extremely high risk: - BMI < 14 kg/m2 - Negligible intake > 15 days

In who else can refeeding syndrome occur?

Refeeding syndrome can occur in overweight individuals particularly those who have eaten nothing for protracted periods.

Can you still develop refeeding syndrome even if you have normal K, PO4, Mg2?

Yep

What is the management of refeeding syndrome?

Describe the role of each of these meds: hydroxocobalamin Adcal D3 Atorvastatin bisprolol metformin

hydroxocobalamin for pernicious anaemia Adcal D3 for osteoporosis/ falls Atorvastatin for hypercholesteraemia bisprolol for heart problems/ hypertension metformin for T2DM

Should you feed someone with dementia via a feeding tube?

It is difficult to decide whether or not to tube-feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection feeding via tube/ other feeding options do not prolong life in those with advanced dementia if give IV, very hard to stop (people withg dementia can pull on lines, can also lead to ascites, oedema)

What is the difference between clear and free fluid?

clear fluid; water, broth, gelatin, contains no fat and v little protein to reduce stimulation given pre surgery free fluids means that you can take any item that is a smooth liquid, with no lumps or pieces or anything that quickly melts in the mouth into liquid form. Liquid at room temperature and contains carbohydrates