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Synoptic Revision > Clinical Nutrition > Flashcards

Clinical Nutrition Flashcards

1
Q

Define malnutrition

A

Where a deficiency, excess or imbalance of nutrients causes measurable adverse effects on:

  • Tissue or body form
  • Function and clinical outcomes
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2
Q

What are the signs and symptoms of malnutrition? (6)

A
  • Loss of appetite
  • Weight loss
  • Tiredness, lack of energy
  • Lethargy and depression
  • Poor concentration
  • Poor growth in children
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3
Q

What are the causes of malnutrition?

A
  • Altered nutrient processing e.g. changes in metabolic demands, liver dysfunction
  • Excess losses e.g. vomiting, nasogastric tube drainage, diarrhoea, surgical drains, fistulae, stomas
  • Impaired intake e.g. poor diet, hospital catering, appetite, missed meals, pain/nausea with food, mucositis, dysphagia, depression/psychological
  • Impaired digestion and absorption e.g. problems with stomach, intestine, pancreas and liver
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4
Q

Define the MUST score and the steps involved

A

The Malnutrition Universal Screening Tool

1) calculate BMI
2) Note % of unplanned weight loss
3) Establish acute disease effect
4) Add scores from steps 1-3 for complete score
5) Use management guidelines or local policies to create action plan

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5
Q

What are the principles of a nutritional assessment (ABCDE)

A
  • Anthropometry (physical size)
  • Biochemical
  • Clinical
  • Dietary
  • Environment
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6
Q

What is the Basal Metabolic Rate?

A

The amount of energy expended by the body to maintain basic physiological functions over 24h

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7
Q

What factors are used to estimate Basal Metabolic Rate?

A
  • Age
  • Weight (kg)
  • Gender
  • Height
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8
Q

According to NICE, what characteristics make a person malnourished? (3)

A
  • BMI < 18.5 kg/m2
  • Unintentional weight loss of > 10% within last 3-6 months
  • BMI < 20 kg/m2 AND unintentional weight loss > 5% within last 3-6 months
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9
Q

According to NICE, what characteristics consider someone to be at risk of malnutrition? (2)

A
  • Eaten little or nothing for more than 5 days and/or are likely to not eat anything for another 5 days
  • Poor absorptive capacity and/or nutrient losses and/or increased nutritional needs from causes such as catabolism
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10
Q

How is re-feeding syndrome caused?

A
  • Caused when a person is in a state of prolonged starvation is given nutrition
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11
Q

What happens when someone has re-feeding syndrome?

A

Sudden shift in energy source results in:

  • Insulin secretion
  • Glycogen, fat and protein synthesis for which phosphate, magnesium and thiamine are required
  • Increased absorption into cells

Leads to potentially fatal shifts in fluids and electrolytes within the body

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12
Q

What are the steps to avoiding re-feeding syndrome?

A
  • Start nutrition at a MAX of 10 kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days
  • Restore circulatory volume and monitor fluid balance and overall clinical status closely
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13
Q

What drugs and when should they be given to patients at high risk of re-feeding syndrome? (3)

A

Immediately before and during the first 10 days of feeding, provide:

  • Oral Thiamine, 200-300mg daily
  • Vitamin B co strong, 1 or 2 tablets QDS
  • A balanced multivitamin/trace element supplement, OD
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14
Q

What else should be given to avoid re-feeding syndrome, unless pre-feeding plasma levels are high?

A

Provide oral, enteral or IV supplements of:

  • Potassium
  • Phosphate
  • Magnesium
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15
Q

Which drugs/supplements can cause changes to absorption of nutrients?

A
  • Magnesium or aluminium, antacids with phosphate
  • Tetracyclines chelate with calcium, magnesium and iron
  • Quinolones - Ciprofloxacin absorption reduces by 50% if given with enteral feed
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16
Q

What can cause changes in metabolism?

A

Grapefruit juice - Cytochrome P450 enzyme inhibitor therefore reduce metabolism of certain drugs hence plasma concentrations e.g. Ciclosporin, Simvastatin

17
Q

Which drugs can cause changes to excretion?

A
  • Diuretics

- Lithium

18
Q

What is enteral nutrition?

A

‘Enteral’ = related to the intestine

A liquid mixture of all the needed nutrients given through a tube into the stomach or small intestine

19
Q

What is Fortsip bottle?

A

Indicated for short term bowel syndrome, intractable malabsorption, pre-operative preparation of undernourished patients, IBD, total gastrectomy, dysphagia, bowel fistulae, disease related malnutrition

20
Q

What are the different enteral routes? And their rationales?

A
  • Nasogastric - good for short term i.e. < 4 weeks
  • Nasojejunal - reduced risk of aspiration and important the feed is sterile as no gastric protection
  • Gastrostomy - Good for longer term feeding e.g. PEG (stomach)
  • Jejunostomy - Good for longer term feeding e.g. PEJ (intestine)
21
Q

What decided whether enteral feed is given to stomach or intestine?

A

If the stomach empties, use it

22
Q

In which conditions and instances would intestine enteral route (PEJ) be preferred to stomach (PEG)? (7)

A
  • Gastroparesis
  • Recent abdominal surgery
  • Sepsis
  • Significant gastroesophageal reflux
  • Proximal enteric fistula or obstruction
  • Aspiration
  • Ileus (lack of normal muscle contractions in intestine)
23
Q

What are the steps when choosing the kind of enteral feed? (5)

A
  • Estimate energy, protein (nitrogen) and fluid needs
  • Select most appropriate enteral formula
  • Determine continuous or bolus feed
  • Determine goal rate to meet estimate needs
  • Write/recommend the enteral nutrition Rx
24
Q

What are the 3 types of enteral feed? and which patients receive each?

A
  • Polymeric - Whole protein for patients with normal GI function
  • Pre-digested - peptide/semi-elemental/elemental for patients with severe GI function
  • Disease specific - formulas available for respiratory disease, diabetes, renal failure, hepatic failure and immune compromised
25
Q

What devices are used to administer enteral nutrition? (2)

A
  • Enteral syringe with plunger

- Electronic feeding plunge to give set amount over period of time, cna be continuous or intermittent

26
Q

What are the common complications of enteral nutrition? (5)

A
  • Oral discomfort or infection
  • Reflux or vomit
  • Abdominal distention or pain
  • Diarrhoea
  • Constipation
27
Q

Why is monitoring so important in enteral feeding?

A
  • Reduce risk of complications, electrolyte and metabolic abnormalities
  • To ensure adequate nutrition
28
Q

When is home enteral nutrition considered?

Who supports patients with home enteral nutrition?

A

Once medically stable on enteral nutrition in hospital

Pharmacist, dietician, nutrition nurse, speech and language therapist, consultant

29
Q

What is parenteral nutrition (PN) or total parenteral nutrition (TPN)

A

A mixture of nutrients given directly into the blood via a catheter in a vein

30
Q

When is parenteral nutrition needed by patients? (3)

A
  • Inadequate or unsafe oral and/or enteral nutrition intake
  • Non-functional, inaccessible or perforated (leaking) GI tract
  • Intestinal failure (temporary or permanent)
31
Q

What is intestinal failure?

A

Reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health/growth

32
Q

What are the 3 types of intestinal failure?

A
  • Type I - acute, short-term and usually self-limiting e.g. post-operative ileus
  • Type II - a prolonged acute condition, often in metabolically unstable patients, requiring complex multidisciplinary care and PN over weeks or months
  • Type III - a chronic condition, in metabolically stable patients, who require PN over months or years. May or may not be reversible
33
Q

in which conditions is parenteral feeding considered? (9)

A
  • Pre operation
  • Mucositis from chemo and radiotherapy
  • Major abdominal surgery- bowel resections
  • Post-operative anastomosis breakdown/ abdominal sepsis/ small bowel fistulae
  • Persistent paralytic ileus post-operation
  • Bowel obstruction
  • Bowel perforation
  • Severe acute pancreatitis
  • Severe burns

Synoptic Revision (7 decks)

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