Malnutrition Flashcards
Prevalence of malnutrition in hospital.
25-30% of patients admitted to hospital are already malnourished.
And some also leave so.
Why are so many hospital patients malnourished?
Increased nutritional requirements due to e.g. sepsis, burns and surgery
Increased nutritional losses due to e.g. malabsorption, output from stoma, diarrhoea, vomiting.
Decreased intake due to e.g. dysphagia, nausea, sedation, coma.
Effect of treatment due to e.g. nausea and diarrhoea
Enforced starvation when they are e.g. nil by mouth for surgery.
Missing meals - due to e.g. patient going for x-ray etc…
Difficulty feeding - lost dentures or no one to assist
Unappetising food
How is malnutrition identified?
History - Any recent weight loss, change in appetite, diet history, changes in oral intake, nausea, vomiting, pain and diarrhoea.
Examination - State of hydration (dehydration usually goes hand in hand with malnutrition and can even mask it)
Investigations - Generally unhelpful. Low albumin can be suggestive but is also found in other cases.
Evidence of malnutrition on examination.
Skin hanging off muscles
No fat between fold of skin
Hair rough and wiry
Pressure sores
Sores at corner of mouth
BMI < 18.5 kg/M2
Anthromorphic indices such as mid-arm circumference, skin fold measures and grip strength are also used.
Bedside tool used to assess nutrition.
MUST
Malnutrition Universal Screening Tool.
First step in managing malnutrition.
Food and encouragement.
Keep mealtime interupptions to a minimum.
Assistance when they are eating if needed, appropriate cutler and also make sure they have their dentures.
If the patient is unwell try anti-emetics.
Add food fortification if needed as it is useful to provide additional calories without increasing volume of food.
A large portion can discourage a person from eating.
If first step in managing malnutrition is not working, what should be done?
Involve a dietician.
They will often use nutritional supplements to provide large amounts of calories in small volumes.
Some are nutritionally complete which means that they provide all macro and micro nutritients required in ones diet.
They are expensive and if they need to be continued after discharge, it is a decision of the dietician.
If the patient still cannot meet their nutritional requirements, what should be considered?
Enteral nutrition
Parenteral nutrition
What types of enteral feeding methods are there?
Nasogastric tube
Nasojejunal tube
Percutaneous endoscopic gastrostromy (PEG)
Percutaneous endoscopic transgastric jejunostomy (PEG-J)
Radiologically inserted gastrostomy (RIG)
Radiologically inserted transgastric jejunostomy (RIG-J)
Explain why an NG tube might be used.
Short-term access if patient is malnutritioned and cannot be fed orally.
It also prevents aspiration of foods and liquids, however the patient can still aspirate on their own saliva
Explain NG tube.
Tube is passed into the stomach via the nose, it can be a large (16F), medium or small (10F).
Have a cup of water to hand, lubricate the tube well with aqueous gel.
Use the tube by holding it against the patient’s head to estimate the length required to get from the nostril to the back of the thraot.
Place the lubricated tube in nostril with its natural curve promoting passage down, rather than up.
When the tip is estimated to be entering the throat, rotate the tube by 180 degrees to discourage the tube passing into the mouth.
Ask the patient to swallow a sip of water and advance as they do, timing each push with a swallow, if this fails, try the other nostril.
The tube has distance markings along it; the stomach is at 35-40cm in adults, so advance further than that distance, preferably 10-20 cm beyond.
Tape securely to the nose.
How can you make sure that the NG tube is in the right place?
Check pH prior to each use, this ensures that the tip of the NG tube is in the stomach and not the lungs.
If they are on PPis this might not work, then you may have to need to perform a CXR to ensure the position of the tube.
Complications of NG tube.
Pain
Loss of electrolytes
Oesophagitis
Tracheal or duodenal intubation.
Necrosis - naso or retropharyngeal
Stomach perforation
When might PEG/RIG/PEGJ and RIGJ be used instead of NG tube?
When there is feeding difficulty, or a need to provide supplementary feeding that is likely to be medium or long term.
NG tube is more short term
NG tube can be inserted with out any assistance.
How are PEG and PEG-J tubes inserted?
They are placed endoscopically.
It requires to puncture the stomach with a trocar so it is an invasive procedure.
