Malnutrition Flashcards
What causes malnutrition
Poor intake
Provision - shopping / poverty / fussy
Increased requirement
Excess loss
What causes increased requirements
Disease - cancer / infection
Respiratory disease / liver = very high requirement
Surgery
Treatment
What causes excess loss
Burns
Malabsorption
Intolerances
High output stoma
What are complications of malnutrition
Poor immune system Pour wound healing Pressure sores Muscle wasting Weakness Lethargy Increased hospital risk and readmission
How do you prevent malnutrition
MUST screening within 24 hours and then weekly
Weight on admission
What does MUST take in
BMI
Unexplained weight loss
Acute disease where no intake for >5 days
What do you do for a score of 1
3 day food diary
1st line support e.g. extra snacks
What do you do if the score is 2
Refer for dietician input
Food fortification = 1st line to make what eating higher calories
Nutritional supplement on top of oral
Estimate energy and protein requirement
What should you be careful with when prescribing nutirional supplement
U+E
Can put potassium etc wrong
What is enteral feeding
Enteric tube direct into gut
If can’t maintain oral intake e.g. aspiration after stroke
What are types of enteral feeding
NG tube
Gastrostomy
Jejunostomy
When would you do a NG tube
Quick and easy Acute setting <6 weeks Easy to pull out / move Aspirate before and feed if PH <5.5 CXR to check it is in stomach
What is a gastrostomy
Inserted surgically / radiologically / endoscopic
PEG = most common if need feed long term / NG dislodge
When is a jejunostomy used
If blockage below gastrostomy
Less likely to dislodge
Common after surgery
What are the benefits of enteral feeding
Maintains gut integrity so no difficulty when restart on oral Low risk and low cost Physiologically normal Increased muscle strength Decreased hospital and mortality
What are the complications of enteral feeding
Refeeding syndrome Aspiration - 30 degree angle Diarrhoea Tube blockage Infection
What does the type of feed depend on
Clinical condition Period of NBM prior Requirement Fluid restriction Oral intake Continous vs bolus
When is TPN used
ONLY in gut failure or inaccessible
Given via a central venous line or PICC
If gut works = use
What is refeeding syndrome
Severe fluid and electrolyte shift and related metabolic concentration disturbance when feed restarted in malnourished patient
Can occur with oral as well as enteral / parenteral
What happens in refeeding syndrome
Dangerous change due to increased insulin + ATP when switch from fat to carb metabolism
Intracellular Na and H20 shift out of cells
Glucose, K, phosphate taken up by cells
Increased demand for electroyltes and nutrients
What are indicators of refeeding syndrome
CF - pulmonary oedema / arrthymia Acute circulatory overload or depletion Hypophosphate / K and Mg Hyperglycaemia Rhabdomyolysis Resp failure Leucocyte dysfunction Hypotension Seizure Coma
You are at risk with 1+ of
BMI <18
Unintentional weight loss >15% 3-6 months
Little or no intake >10 days
Low K, phosphate or Mh prior to feed
At risk if 2+ of
BMI <18.5
Weight loss >10% 3-6 months
Little or no intake >5 days
Alcohol / drug abuse Hx
How do you manage the risk of refeeding syndrome
Calculate additional requirement
Baseline blood prior - U+E, FBC, LFT, Ca, Mg, phosphate, glucose
Monitor DAILY
Supplement as need
Delivery slowly if high risk (10cal/kg/day)
Aim to meet needs 4-7 days
Cardiac monitor where appropriate
Thiamine / Paprinix prior to feed
Vit B compound and forceval + thiamine first 10 days
How do you monitor tolerance to feed
Bowel
N+V
Biochemical
What do you require if artificial feed
Daily bloods
What are complications of TPN
Sepsis Thrombophlebitis LFT abnormality Central vein thrombosis leading to PE Metabolic imbalance Pneumothorax
How do you deal
Sterile technique
Review fluid balance 2x daily
Check weight, glucose, U+E and FBC daily
Check LFT 3x
