Malnutrition

Question 1

What are the risk factors for malnutrition?

Answer 1

over 65
in residential care or hospital
Long term conditions - eg cancer, dementia
Alcohol or drug dependency

Question 2

What are the three main ways that someone may become malnourised?

Answer 2

reduced nutritional intake
increased nutritional requirements
inability to utilise nutrients ingested

Question 3

Why might someone have reduced nutrient intake?

Answer 3

poverty 
low mood 
dysphagia 
repeated nil by mouth 
reduced appetite 
nausea eg from medications

Question 4

Why might someone have increased nutritional requirements?

Answer 4

infection
surgery
wound healing

Question 5

Why might someone be unable to use the nutrients they are ingesting?

Answer 5

diarrhoea 
vomiting 
drains 
wounds 
pancreatic insufficiency

Question 6

How might someone with malnutriton present?

Answer 6

Low or high BMI
history of significant weight loss
comorbidities

Question 7

What are the complications of malnutrition?

Answer 7

poor immunity and recurrent infections
muscle wasting, reduced mobility, increased falls,
imapried wound healing
micronutrient deficiencies - eg selinium, zinc, vit D deficiency
Osteomalacia
irone deficiency anaemia

Question 8

How would you investigate malnutrition?

Answer 8

Bloods - FBC, U+Es, haematinics
MUST tool
Dietician assessment

Question 9

What are the 3 key measurements/info needed for the MUST screening tool?

Answer 9

1. BMI
2. Percentage unplanned weight loss in last 3-6 months
3. Acute disease effect - is the pt acutely ill and there is likely to be/has been no nutritional intake for 5 days
   (Add scores from step 1-3 together)

Question 10

How can you manage malnutrition?

Answer 10

Treat underlying condition if any
Provide help and advice on food and drink
Record needs for special diets, follow local policy
1. Food first - snacks, drinks, food fortification
2. oral nutrient supplements
- liquid, powder or semi-solid
- macro or micronutrients
- Milkshake, juice, pudding, powders, soup, jelly- style (fortisip, fortijuice, forticreme)
3. Enteral feeding
- directly into the stomach, jejunum or duodenum
-Short term: NG tube, NJ tube
- long term: PEG tube, PEJ tube
4. Parenteral - IV

Question 11

What are the short term methods of enteral feeding?

Answer 11

Nasogastric tube - into stomach

Nasojejunal tube - into jejunum

Question 12

What are long term methods of enteral feeding?

Answer 12

PEG – percutaneous endoscopic gastrostomy

PEJ – percutaneous endoscopic jejunostomy (Post pyloric/surgical JEJ)

Question 13

What are the advantages of enteral vs parenteral feeding?

Answer 13

Enteral is cheaper

Enteral perseveres gut mucosa and integrity

Question 14

What are the disadvantages of enteral feeding?

Answer 14

tube can be uncomfortable to place

nausea, satiety, constipation or diarrhoea

Question 15

How do you check that an NG tube is in the right place?

Answer 15

aspirate pH measurement - gold standard - <5.5

second line - Xray confirmation

Question 16

How do you check that an NJ tube is in the right place?

Answer 16

needs X-ray

Can’t check position using pH (as not going to stomach)

Question 17

How is an NG tube inserted?

Answer 17

On a ward

Question 18

How is an NJ tube inserted?

Answer 18

Under radiological guidance

Question 19

Give 3 uses of a PEG tube

Answer 19

dysphagia eg stroke 
head and neck surgery
neurological conditions
Cystic fibrosis 
oral intake inadequate and likely to be long term

Question 20

Give 3 uses of a PEJ tube

Answer 20

delayed gastric emptying
Upper GI or pancreatic surgery
in pts with high risk of aspiration
severe acute pancreatitis

Question 21

When is parenteral feeding used?

Answer 21

when the gut is inaccessible or unable to absorb sufficient nutrients to sustain nutritional status

Question 22

Give 3 conditions where parenteral nutrition is used

Answer 22

short gut syndrome 
Gastrointestinal fistula 
Bowel obstruction (bowel rest)
Severe malnutrition, significant weight loss

Question 23

How is MUST scored?

Answer 23

0- low risk
1- medium risk
≥ 2- high risk

Question 24

What would you do if a patient scored 0 (low risk) on the must tool?

Answer 24

Monitor MUST level:

• Hospital – weekly
• Care Homes – monthly
• Community – annually for special groups e.g. those >75 yrs

Question 25

What would you do if a patient scored 1 (medium risk) on the must tool?

Answer 25

Document dietary intake for 3 days:

1. If adequate – little concern and repeat screening
   - Hospital – weekly
   - Care Home – at least monthly
   Community – at least every 2-3 months
2. If inadequate and there is clinical concern
   - follow local policy, set goals, improve and increase overall nutritional intake, monitor and review care plan regularly

Question 26

What would you do if a patient scored ≥2 (high risk) on the must tool?

Answer 26

1. Refer to dietitian, Nutritional Support Team or implement local policy
2. Set goals, improve and increase overall nutritional intake
3. Monitor and review care plan
   - Hospital – weekly
   - Care Home – monthly
   - Community – monthly

Question 27

What is the alternative measurements to estimate BMI?

Answer 27

mid upper arm circumference

Question 28

What is the alternative measurements to estimate height?

Answer 28

ulnar length

Question 29

What are the different ways we can support normal food intake eg in pts with dementia?

Answer 29

Red tray
Background music
Meal time assistance
Social elements of eating

Question 30

Do PEG tubes have any benefit in advanced dementia for the long-term?

Answer 30

No

Question 31

What are the considerations before inserting a PEG tube for a patient with dementia?

Answer 31

• Can the PEG tube be managed at home or do they need to go to a nursing home?
• Are you taking away the quality of life aspect of eating
• no long term benefit in advanced dementia