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OPIC (Y4) > 5- Nutrition and swallow > Flashcards

5- Nutrition and swallow Flashcards

1
Q

what is food?

A
  • Energy
  • Macronutrients
    • Protein
    • Carbohydrate (CHO)
    • Fat
  • Micronutrients
    • Vitamins
    • Trace elements
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2
Q

energy is measured in

A

kilocalories

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3
Q

1kcal is the

A

is the amount of energy required to heat 1kg of water by 1oC at sea level

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4
Q

1kcal =

A

4.2kj

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5
Q

Not all macronutrients provide the same energy

A
  • Fat is most energy dense- 9kcal/gram of substrate
  • CHO and protein= 4kcal/gram
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6
Q

basal metabolic rate

A

the number of calories you burn as your body performs basic (basal) life-sustaining function at rest

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7
Q

to sustain BMR how many kcal required

A

BMR 25 kcal/kg/day

  • Women 1440 kcal (1800)
  • Man 1750 kcal (2200)
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8
Q

Additional energy is required for:

A
  • Dietary induced thermogenesis (DIT)
    • Eating
    • Absorption
    • Metabolism
    • Distribution of food
  • Exercise and stress factors
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9
Q

Protein

A
  • Most important
  • Source of nitrogen required for
    • Muscle
    • DNA
      albumin
  • Expensive in both price and energy (DIT)
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10
Q

Carbohydrates

A
  • Important for storage of energy
  • Stored as glycogen in liver and muscle
  • Broke down to glucose and used by all organs esp the brain (glycogenolysis)
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11
Q

Fat

A
  • Highest density energy storage
  • Broken down to fatty acids and glycerol
  • Converted to glucose and ketones in starvation state
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12
Q

Vitamins

A
  • Cannot be synthesised in the body and need to be included in the diet
  • Can be fat or water soluble
    • Fat: Always do eat KitKat
    • Non fat: vit B1, B2, B3, B5, B6 etc
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13
Q

trace elements

A
  • Selenium
  • Zinc
  • Phosphate
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14
Q

electrolyte and water requirements

A
  • Na/K/Cl-= 1mmol/kg/day
  • Water = 25ml/kig/day
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15
Q

malnutrition causes

A

Reduced Dietary Intake

Malabsorption

Increased losses or altered requirements

Energy expenditure

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16
Q

the older person at risk of

A

Sarcopenia

  • Age related loss of skeletal muscle
  • Major cause for the increased prevalence of frailty and disability
  • Muscle mass decreases, reducing mobility

i.e. if youre old and sick you have less physiological reserve

  • you lose what little muscle you have left → more likely to become bed bound
  • respiratory function decreases → increased risk of chest infections
  • reduced skin healing →pressure sores
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17
Q

when you starve you lose……. whereas when you are sick you lose……

A

when you starve you lose fat whereas when you are sick you lose muscle

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18
Q

When you starve… you lose fat

A
  • Glycogenolysis
  • Decreased insulin levels
  • Decreased catecholamine levels
  • Reduced metabolic rate
  • Increased hormone sensitive lipase
  • Gluconeogenesis from fat (glycerol)
  • Ketogenesis from fat (fatty acids)
  • Gluconeogenesis from AA (muscle)
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19
Q

When you’re sick… you lose muscle

A
  • No adaption
    • High catecholamine levels
    • No adaptive drop in insulin or BMR
    • No rise in hormone sensitive lipase
    • Fat not mobilised
    • Massive muscle breakdown
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20
Q

how should we feed in hospital

A
  • Enough to maintain weight of patient
  • Weight loss in illness equals muscle loss and therefore inhibits recovery
  • E.g. if someone is obese this shouldn’t be taken as a time for them to lose weight
    *
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21
Q

the feeding hierarchy

A

Best →worse

  • Normal oral feeding
  • Oral nutritional supplements → fortisips
  • NG feed
  • PEG (percutaneous endoscopic gastrostomy →a feeding tube fitted during endoscopy)/ RIG (radiologically inserted gastrotomy (no endoscopy required)
  • PEG-J (percutaneous endoscopic gastrostomy with jejunal extension) / NJT (naso-jejunal tube)
  • PN- parenteral nutrition
  • TPN- total parenteral nutrition
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22
Q

Nasogastric feeding

A
  • Short to medium term feeding
  • Nutritional bridge to:
    • Recovery
    • Gastrostomy
  • Not entirely benign
    • Gastric erosions
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23
Q

PEG feeding

A
  • Medium to long term feeding
  • Nutritional support for:
    • Chronic disease
    • Radiotherapy
    • Chemotherapy
    • Palliative care
  • Considerations
    • Mouth opening
    • Neck flexion
    • Abdominal scars
    • Respiratory reserve
  • Does not protect against aspiration
    • reflux
    • saliva
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24
Q

what to remember with PEG feeding

A

that an endoscopy is required for the insertion of a PEG feeding tube and therefore the patient has to be anatomically and physically able to have an endoscopy.

If PEG is not possible a RIG can often be inserted as this is placed with direct puncture of the abdominal wall, but as this is held in place with a balloon only it does need to be regularly changed and is more prone to becoming dislodged.

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25
Q

RIG feeding

A
  • Gastrostomy insertion without intubation
  • Nutritional support where:
    • Upper GI tract inaccessible
    • Respiratory disease present
  • Disadvantages
    • More complications than PEGs
    • Have to be changed
    • Relatively easily dislodged
      *
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26
Q

NG/PEG/RIG feed

A
  • Generally 1 kcal/ml (Nutrison)
  • Some 1.5-2.0 kcal/ml (Nutrison energy)
  • Can also give supplementary water via NG/PEG/RIG
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27
Q

When do I use PN/TPN?

A
  • Intestinal failure
  • Inaccessible gut
  • Obstructed gut

Acceptable to use PN and EN together

28
Q

tool used to assess for malnutrition

A

MUST

  • BMI
  • unplanned weight loss
  • no nutritional intake for >5 days

MUST Score (each step scores out of 2)

  • Step 1: BMI
  • Step 2: Unplanned weight loss
  • Step 3: Acute illness and decreased intake for 5 days

Score 0 = low risk: repeat weekly in hospital, monthly in care homes, yearly in community for at risk groups (including the over 75s)

Score 1 = medium risk: food chart for 3 days – if intake adequate then monitor w/screening as above (except in community do 2-3 monthly), if intake inadequate – formulate plan for increased intake

Score 2 or more = refer to dietician, set goals to improve nutritional intake, monitor regularly weekly, monthly, monthly.

29
Q

How to measure / detect malnutrition

A
  • Commonest is MUST score (in UK)
  • Simple measurements like weight, height and BMI often not that simple (estimations, fluid etc).
  • Mid upper arm circumference (MUAC) to estimate BMI
  • Ulnar length as estimation of height
30
Q

intravenous fluids

A
31
Q

parenteral nutrition summary

A

Nutrition delivered to a patient without accessing or utilising the GI tract

  • Delivered IV
  • when gut inaccessible
32
Q

what is in. TPN

A
33
Q

how is TPN given

A

prolonged infusion over 12-24 hours via central venous catheter

  • PICC or Hickman
  • long flexible cannula that sits with its tip in a large vein
    • stops thrombosis or thrombophlebitis
34
Q

Why is PN sometimes clear and sometimes cloudy and always covered?

A
  • PN is clear when no lipid had been added to the bag.
  • The admixture of constituents is unstable and quickly degraded by exposure to light. This means that PN should be kept covered.
35
Q

Complications of PN

A

1) Mechanical

  • Thrombosis
  • Line fracture
  • Line occlusion
  • Pneumothorax (usually on CVC insertion)
  • Air embolus (if line left open)

2) Biochemical

  • Any electrolyte disturbance
  • Abnormal liver function (carbohydrate overload)
  • Hyperglycaemia
  • Fluid overload

3) Infectious

  • CVS related bacteraemia
  • CVC related septicaemia
36
Q

refeeding syndrome

A

the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding

37
Q

presentation of refeeding syndrome

A
  • Congestive cardiac failure precipitated by fluid shifts associated with reintroduction of CHO after prolonged starvation
38
Q

Refeeding is biochemical triad of

A
  • Hypophosphatemia (biochemical marker)
  • Hypokalaemia
  • Hypomagnesaemia
39
Q

who is at risk of refeeding syndrme

A

Anyone who has prolonged starvation state or severely malnourished e.g. anorexic patients, cachectic cancer patients and severely malnourished.

40
Q

process of refeeding syndrome: during starvation

A
  • During prolonged starvation insulin levels drop activating hormone-sensitive lipase which results in the breakdown of fat.
  • This results in the production of fatty acids and glycerol.
  • The fatty acids are converted to ketone bodies which are used as an alternative fuel to glucose, and the glycerol is used for gluconeogenesis.
  • In addition muscle is also broken down to amino acids which are used for gluconeogenesis.
  • During starvation state phosphate stores become depleted
41
Q

process of refeeding syndrome: during refeeding

A
  • When carbohydrate is reintroduced in starvation, the insulin levels quickly rise to accommodate the glucose load to facilitate the production of glycogen, muscle and fat.
  • This process requires phosphate and drives phosphate, potassium, magnesium and water into cells and sodium out.
  • As a result the phosphate stores become further depleted and the corresponding fluid shift causes oedema.
  • The hypophosphataemia reduces the production of ATP and impairs function of cardiac muscle.
  • In addition 2,3-DGP is reduced in red cells and this decreases the ability of red cells to deliver oxygen to tissues.
  • The combined effect of fluid shifts, reduced tissue oxygenation and impaired cardiac function is potentially catastrophic.
42
Q

MDT approach to nutrition

A
  • Doctors: look for non-intake cause of malnutrition e.g. catabolic state of illness or cancer, malabsorption, medication review e.g. gastritis, dry mouth, nausea, constipation, low mood, SOB
  • Nurses / HCAs: mood, co-ordinating person centred care plan of preferences, recommendations etc., liaising with family e.g. food likes, dislikes, identification of assistance to mealtimes (e.g red trays), encouraging / prompting vs assistance. Mouth care / dentition.
  • Dietician: skilled calculation of requirements and deficits and prescription of supplements if needed
  • SALT: if dysphagia present in particular to assess cause and recommend appropriate thicknesses/ consistencies. Good at working out cause, so in particular pattern of dementia indicating longer term issue versus acute decline.
43
Q

Malnutritional states can lead to increased risk of complications such as

A
  • Higher risk of skin breakdown
  • Impaired immunity
  • Reduced functional reserve.
44
Q

Wound healing: primary intention

A

Primary intention

Occurs when wound with dermal edges are close together e.g. a scalpel incision

  • Faster than secondary intention
  • End result of healing by primary intention is (in most cases) a complete return to function, with minimal scarring and loss of skin appendages.

Stages

  • Haemostasis
    • Haematoma formation (platelet and cytokines)
    • Vasoconstriction- limiting blood loss at the affected area
    • The close proximity of the wound edges allows for ease of clot formation and prevents infection by forming a scab
  • Inflammation – a cellular inflammatory response acts to remove any cell debris and pathogens present
  • Proliferation – cytokines drive proliferation of the fibroblasts and the formation of granulation tissue
    • Angiogenesis is promoted by the presence of growth mediators (e.g VEGF), allowing for further maturation of the granulation tissue; the production of collagen by fibroblasts allows for closure of the wound after around a week
  • Remodelling – collagen fibres are deposited within the wound to provide strength in the region, with the fibroblasts subsequently undergoing apoptosis

Example: surgical wound healing

Any wound made by a scalpel will heal by primary intention. Surgeons can aid healing by ensuring adequate opposition of the wound edges, through use of surgical glue, sutures, or staples.

When sutures are used to close a wound, ensuring the correct tension of the sutures is essential:

  • Too loose and the wound edges will not be properly opposed, limiting the primary intention healing and reducing wound strength
  • Too tight and the blood supply to the region may become compromised and lead to tissue necrosis and wound breakdown
45
Q

Wound healing: secondary intention

A

Secondary intention

Occurs when sides of the wound are not opposed, therefore healing must happen from the bottom up

  • Myofibroblasts are vital cells in secondary intention. They are modified smooth muscle cells that contain actin and myosin, and act to contract the wound; decreasing the space between the dermal edges. They also can deposit collagen for scar healing.

Stages

  • Haemostasis – a large fibrin mesh forms, which fills the wound
  • Inflammation – an inflammatory response acts to remove any cell debris and pathogens present
    • There is a larger amount of cell debris present, and the inflammatory reaction tends to be more intense than in primary intention
  • Proliferation – granulation tissue forms at the bottom of the wound
    • This is an important step, as the epithelia can only proliferate and regenerate once granulation tissue fills the wound to the level of the original epithelium; once the granulation tissue reaches this level, the epithelia can completely cover the wound
  • Remodelling – the inflammatory response begins to resolve, and wound contraction can occur- fibromyoblasts
46
Q

systemic factors which effect wound healing

A
  • Age
  • Gender
  • Stress
  • Immunocompromised
  • Nutrition
  • Medication
    • Steroids
    • NSAIDS
    • Chemotherapy
  • Ischemia
  • Diseases:
    • Diabetes
    • Fibrosis
    • Jaundice
    • Uraemia
    • Obesity
47
Q

local factors which effect healing

A
  • Oxygenation
  • Infection
  • Foreign Body
  • Venous Insufficiency
48
Q

List five signs of wound infection

A
  1. Pain
  2. Swelling
  3. Warm to touch
  4. Itchy
  5. discharge
49
Q

other factors which effect nutrition

A

oral health

50
Q

oral health

A

dry mouth, mouth ulcers, poor dentition (missing or painful teeth) or ill fitting dentures can effect a patients diet

51
Q

dysphagia

A

difficulty in swallowing.

  • oral stage of swallowing (in the mouth)
  • pharyngeal stage of swallowing (in the throat)
  • oesophageal stage of swallowing (in the tube leading to the stomach)
  • or in any combination of these
52
Q

causes of dysphagia in the elderly

A
  • neurological
    • stroke
    • parkinsons
    • MS
    • dementia
    • brain tumours
  • obstructive
    • mouth or throat or oesophageal cancer
  • muscular
    • achlasia
  • other causes
    • COPD
    • head or neck surgery
53
Q

presentation of dysphagia

A
  • food sticking in gullet
  • regurgitation
  • vomiting
  • coughing
  • choking
  • aspiration pneumonia
54
Q

investigations for dysphagia

A
  • barium swallow
  • laryngoscopic examintion
  • MRI before any surgery
  • endoscopic US for staging oesophageal carcinoma
  • videofluorscopy for ‘difficulty swallowing’
55
Q

general management of dysphagia

A
  • patient must chew food well or it be liquidised
  • liquids thickened
  • SALT assessment
56
Q

complications of dysphagia

A
57
Q

examination: assessing swallow

A
58
Q

Top tips for safer swallowing if you are having difficulty:

A

* Choose foods and drinks that are comfortable to swallow

  • Softer foods are often easier
  • Sit upright to eat and drink
  • Stay upright for 40-60 minutes after eating and drinking
  • Take small mouthfuls, one at a time
  • Make sure you have swallowed all the food and drink before the next mouthful
  • Liquid medications may be easier to swallow if they are available (consult pharmacy)
  • Try to eat and drink when you are not tired
  • Alternate food with sips of water/drinks to help clear the food
  • Avoid drinking with a straw as this means fluids are directed straight to the back of the mouth before the airway is properly protected.
59
Q

treatment for dysphagia

A

Dysphagia is usually assessed and treated by Speech & Language Therapists. Treatment may include:

  • Exercises to help improve the efficiency of the swallow
  • Strategies to follow when eating and drinking to improve safety and/or comfort
  • Advice about:
    • posture and positioning
    • the rate of presentation of food or liquid
    • the time between bites and swallows
    • how the environment might help at meal and drink times (e.g. less distractions)
    • how others might be able to help at meal and drink times
    • texture modification.

Other people who also provide help for people with dysphagia may include:

  • Physiotherapists for advice about posture, positioning and chest care
  • Occupational therapists for advice about aids, adaptations and utensils at mealtimes
  • Dietitians for advice about nutritional intake, and
  • Psychologists for advice about distress at mealtimes.
60
Q

thickners and dysphagia

A

Thickened liquids are often used in the management of dysphagia to improve bolus control and to help prevent aspiration → increase the time between the liquid entering the mouth and hitting the throat to give the patient time to swallow

  • A range of starches and gums has historically been used to thicken liquids.
61
Q

thickening agents side effects

A

constipation, gassiness, or loose stools (soft poop or diarrhea).

62
Q

how much thickner in drinks

A

LEVEL 1 FLUIDS – 1 level scoop of Nutilis Clear per 200ml
LEVEL 2 FLUIDS – 2 level scoops of Nutilis Clear per 200ml
LEVEL 3 FLUIDS – 3 level scoops of Nutilis Clear per 200ml
LEVEL 4 FLUIDS – 7 level scoops of Nutilis Clear per 200ml

63
Q

risk feeding

A
64
Q

IDDSI (International Dysphagia Diet Standardisation Initiative)

A
65
Q

IDDSI (International Dysphagia Diet Standardisation Initiative)

A

OPIC (Y4) (20 decks)

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