Malnutrition Flashcards
what is malnutrition
a state of nutrition in which a deficiency, excess or imbalance of energy, protein, nutrients (vitamins or minerals) causes measurable adverse effects on tissue, body form, function and clinical outcome
what are the disease related causes of malnutrition
decreased intake, impaired digestion/ absorption, increased requirements/ losses
what can cause a decreased intake of food
poor appetite, pain on eating, medication side effects, dysphagia, sore mouth
what can cause impaired digestion and/or absorption
problems affecting stomach, intestine, pancreas and liver
what causes an increase in nutritional requirements
catabolism infection, trauma, burns, surgery
what causes increase nutrient losses
vomiting, diarrhoea, stoma losses, crohns
how prevalent is malnutrition and why is it such a big problem
30-40% of hospital admissions identified as malnourished (under nourished)
27% severely malnourished
75% continue to lose weight in hospital
50 % unrecognised
what groups of patients are at high risk of malnutrition
care home residents, mental health unit admissions, hospital admissions
how much is public expenditure on disease related malnutrition
£13 billion per year
how would the cost of malnutrition be managed
improving the systemic screening, assessment and treatment of malnourished patients
what chronic conditions can lead to poor food intake
anorexia, asthenia, depression, dysphagia, malabsorption, fistula, diarrhoea, infection (TB, HIV), immobility
what acute event can lead to Gi dysfunction, increased infection rate, decreased wound healing, physical weakness
sepsis, pneumonia, fever, surgery, trauma, radiotherapy, radiotherapy, chemotherapy
what can lead to stress related metabolism
hypermetabolism, inflammatory response, insulin resistance
how can chronic and acute conditions interact to exacerbate malnutrition and increase the length of stay
Chronic condition often result in poor food intake which in turn leads to malnutrition, which increases the likelihood of GI dysfunction, infections and poor wound healing which can further decrease food intake. At same time may have acute events feeding into this such as sepsis or surgery or treatment side-effects, which result in increased nutritional requirements due to stress-induced catabolism
what are the psychosocial causes of nutrition
inappropriate food provision, lack of assistance, poor eating environment, self neglect, bereavement, inability to access food, deprivation, loneliness, lack of cooking skills or facilities
how does starvation and injury affect metabolic rate
starvation decreases
injury increases
how does starvation and injury affect weight
starvation: slow loss, almost all from fat stores
injury: rapid loss, 80% from fat stores, remainder from protein
how does injury and starvation affect nitrogen losses
starvation: decreases losses
injury: increases losses
how does starvation affect hormones
Early small increases in catecholamines, cortisol, GH, then slow fall. Insulin decreased
how does injury affect hormones
Increases in catecholamines, cortisol, GH. Insulin increased but relative insulin deficiency
how does starvation and injury affect water and sodium
starvation: initial loss, late retention
injury: retention
what are the adverse effects of malnutrition
impaired immune responses and wound healing, reduced muscle strength (including respiratory muscle) and fatigue, inactivity, water and electrolyte imbalance, impaired thermoregulation, menstrual irregularities/ amenorrhoea (absence of periods), impaired psycho-social function
when and using what are admitted patients screened from malnutrition
within 1 day of admission
MUST score
what are the subjective (in the absence of height and weight) indicators used to identify malnutrition
physical appearance, history of unplanned weight loss, loose fitting clothing/ jewellery, need for assistance, current illness posing risk of malnutrition or increasing nutritional needs, swallowing difficulties
what are the physical assessment for nutrition
bmi, anthropometry (mid-arm circumference, triceps, grip strength)
what are the biochemical assessments of nutritional status
albumin,
transferrin (synthesis reduced in protein restriction and affected by abdominoperineal resection, iron deficiency and liver disease),
transthyretin (prealbumin) (reflects dietary intake, increased in uraemia and dehydration, decreased in fasting),
retinol binding protein (reflects recent dietary intake),
urinary creatinine (excretion rate reflects muscle mass),
IGF1 (reduced in malnutrition),
micronutrients
what biochemical measures should be taken for older people in the community
vitamins A,B,C,D and E, albumin and zinc all lower in high risk groups
what parameters means a patient requires nutritional suppport
BMI <18.5
Unintentional weight loss >10% within the last 3–6 months
BMI <20 and unintentional weight loss >5% within the last 3–6 months
Have eaten or are likely to eat little or nothing for more than 5 days or longer
Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism
what are the different types of nutritional support
Food fortification & dietary counselling
oral nutritional support
enteral tube feeding
parental nutrition
what is enteral tube feeding
Delivery of a nutritionally complete feed via a tube into the stomach, duodenum or jejunum
what should be the first step in managing malnutrition
food first: increase energy and protein of diet without increasing volume (food fortification)
what issues can interfere with a patient eating an drinking on a ward
Presentation of food/drink Difficulty swallowing Unpleasant smells on the ward Treatment/ scans at mealtimes Lack of privacy Hospital crockery or cutlery
what alerts staff to patients that require physical assistance with eating and drinking
coloured tray
why might someone need help eating and drinking
cognitive impairment, swallowing difficulties, learning disabilities
what are some oral nutritional supplements
ready made drinks, powders, puddings, carb fat and protein supplements
what are the indications for ETF
inadequate or unsafe oral intake,
afunctional, asseccible gastrointestinal tract
in what patients should ETF be used instead of PN
‘if the gut works, use it’ Unconscious patients Neuromuscular swallowing disorder Upper GI obstruction GI dysfunction Increased nutritional requirements
what are the contraindications of ETF
Lower gastrointestinal obstruction Prolonged intestinal ileus Severe diarrhoea or vomiting High enterocutaneous fistula Intestinal ischaemia
what are the complications of enteral tube feeding
insertion (nasal damage, perforation, bleeding)
post insertion trauma
displacement (bronchial administration of food)
reflux (oesophagitis, aspiration)
GI intolerance (nausea, bloating, pain, diarrhoea)
metabolic (Refeeding syndrome, hyperglycaemia, fluid overload, electrolyte disturbance)
describe PN
The administration of nutrient solutions via a central or peripheral vein
what are the negatives of parental nutrition
Expensive Complications are life-threatening Needs specialist skills Not physiological Psycho-social disturbance
what are the indications for PN
inadequate or unsafe oral and/or enteral nutritional intake
a non-functional, inaccessible or perforated (leaking) gastrointestinal tract
- IBD with severe malabsorption
- Radiation enteritis
- Short bowel syndrome
- Motility disorders
what are the indications for PN feeding in type 1 intestinal failure
Severe malnutrition pre-op Post-op feeding: ileus/organ failure/5 day rule Intestinal fistulae Multi-organ failure Post chemo mucositis
what are the ethical considerations of nutritional support
Food & fluids essential to life
- Social and psychological role
- Viewed as symbols of caring
Withholding nutrition can be perceived as neglect
