Malnutrition Flashcards
Able to recognise the malnourished patient Able to describe the consequences of under nutrition Able to describe measures to improve nutrition
What are some consequences of malnutrition?
Impaired immune function Delayed healing Pressure sores Immobility Muscle weakness Cardio-respiratory weakness Pyschosocial effects Length of stay Hospital costs Prolonged recovery
What are causes of undernutrition?
Decreased intake
Increased requirements
Impaired absorption
Increased losses/utilisation
What should be determined and recorded when assessing a malnutritioned patient?
Determine current nutritional status
Determine nutritional goals
Record baseline to facilitate monitoring.
What should you be careful of when measuring weight and weight loss?
Be careful if oedema is present
What percentage of weight loss is significant?
5-10 %
What BMI signifies a) significant malnutrition, b) possible malnutrition and c) desirable BMI
a) <18.5
b) 18.5 - 20
c) 20-25
Does a normal or high BMI exclude malnutrition?
No
Why is BMI in the elderly inaccurate?
Because of height and muscle loss
Why is albumin a poor marker of malnourishment?
It has a long half life.
It has a reduced concentration secondary to many things e.g. inflammation, sepsis, IV fluids, nephrotic syndrome and impaired liver synthesis
What tool is used in Scotland for nutritional screening and is a standard of care?
MUST- malnutrition universal screening tool
What factors make up a MUST score?
- BMI >20 = 0
18.5-20 = 1
10% = 2 - Acute disease effect
Add a score of 2 is there has been or is likely to be no nutritional intake for >5 days
What MUST scores are a) low risk, b) medium risk and c) high risk?
What actions should be taken for each category of risk?
a) 0 = low risk - normal care
b) 1= medium risk - observe and re-screen
c) 2 or more = high risk - nutritional support
What measures are used to improve nutrition?
Food first
Oral supplements
Enteral Feeding
Parenteral feeding
Describe various methods of enteral tube feeding.
Nasogastric Nasojejunal Percutaneous endoscopic gastrostomy Percutaneous jejunostomy Surgical jejunostomy
What are contraindications of enteral feeding?
Lower GI Obstruction Perforation Active ulceration Fistula Facial injury Severe diarrhoea or vomiting Prolonged intestinal ileus Intestinal ischaemia
What are complications of enteral feeding?
Patient uncooperative Malposition Blockage Diarrhoea Aspiration Metabolic disturbance
What is parenteral feeding?
The administration of nutrient solutions via a central or peripheral vein
What are negative features of parenteral feeding?
It is expensive The complications are life-threatening Needs specialist skills Not physiological Pyscho-social disturbance
Define malnutrition
A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse affects on tissue, body form, function and clinical outcome.
What is the malnutrition cycle?
Illness–> hospital –> Anorexia and weight loss –> complications –> illness
This becomes a vicious cycle
List some psychosocial causes of malnutrition
inappropriate food provision Lack of assistance Poor eating environment Lack of cooking skills or facilities Self neglect Bereavement Inability to access food Deprivation Loneliness
List the biochemical markers commonly used to assess a patients nutritional status and describe their usefulness.
Albumin: A non-specific marker of illness
Transferrin: Synthesis reduced in protein restriction. Affected by APR, iron deficiency and liver disease.
Prealbumin: Reflects recent dietary intake rather than overall nutritional status. Increased in uraemia and dehydration. Decreased by APR, fasting. More useful in measuring response to nutritional support than initial assessment.
Retinol binding protein: Reflects recent dietary intake rather than overall nutritional status. Affected more by energy than protein restriction. Levels increased by increased glomerular filtration rate and alcoholism and decreased by chronic liver disorders and vitamin A and zinc deficiency.
Urinary creatinine: If renal function is normal, excretion rate mirrors muscle mass. Expressed per unit height. 24hr urine collection is required.
IGF1: Reduced in acute and chronic malnutrition and increases with repletion. Levels reduced in liver disease and renal failure.
Micronutrients: Poor correlation between plasma values and intracellular concentrion, especially during illness, therefore measurement of related coenzymes more useful. Usually can only be analysed by a specialised centre.
List some indications for enteral feeding.
Inadequate or unsafe oral intake, and a functional, accessible GI tract (If the gut works, use it). Unconscious patients Neuromuscular swallowing disorder Upper GI obstruction GI dysfunction Increased nutritional requirements.
What are indications for parenteral feeding?
Should be considered in patients who are malnourished or at risk of malnutrition and meet either of the following criteria:
inadequate or unsafe oral and/or enteral nutritional intake
a non-functional, inaccessible, or perforated GI tract:
IBD with severe malabsorption
Radiation enteritis
Short bowel syndrome
Motility disorders
What is refeeding synrome?
When can it arise?
Potentially fatal shifts in fluids and electrolytes and disturbances in organ function and metabolic regulation that may result from a rapid initiation of re feeding after a period of under nutrition.
It is less likely to occur with oral feeding as intake is usually limited by a poor appetite, but excessive feeding can be administered by EN or PN.
What are some metabolic signs of refeeding syndrome?
Hypokalaemia Hypomagnesaemia Hypophosphataemia Salt and water retention- fluid overload and oedema Altered glucose metabolism
What are some physiological features of refeeding syndrome?
Arrhythmias Altered level of consciousness Seizure Respiratory failure Cardiovascular collapse Death
How should patients who are at moderate risk of refeeding syndrome (i.e. have had more than 5 days of little or no nutrition) be managed?
Nutritional support should be introduced at a maximum of 50% of requirements for the first 48 hours.
Their clinical and biochemical parameters should be monitored.
If monitoring reveals no problem, increase nutrition support to meet full requirements.
How should patients at high risk of refeeding syndrome be managed?
Check phosphate, magnesium, calcium and potassium.
Provide immediately before and during the first 10 days of feeding:
thiamine
vitamin B compound
multi-vitamin and mineral supplement
Start feeding at 5-10kcal/kg/day and slowly increase feeding over 4-7 days
Rehydrate carefully and supplement/correct levels phosphate, magnesium, potassium and calcium.
Monitor these levels for the first 2 weeks and amend supplementation as appropriate.
