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.
How are RIG and RIG-J inserted?
With radiological assistance.
They also require to puncture the stomach with a trocar making them invasive as well.
What is parenteral nutrition?
Nutrition and fluid directly into a patient’s veins.
When is parenteral nutrition indicated?
When the GI tract is either not accessible i.e. blocked or not working i.e. short, leaking or diseased and unlikely to function for at least 7 days.
It is not without its risks, even in GI disease studies show that enteral nutrition is safer, cheaper and at least as efficacious as parenteral.
Administration of parenteral feeding.
Must be given via a dedicated central line usch as a PICC (Peripheral Parenteral Nutrition (PPN)) or a Hickman line (Total Parenteral Nutrition (TPN)).
Complications of parenteral feeding.
Sepsis (S. epidermidis, aureus, candida, pseudomonas and infective endocarditis)
Thrombosis
Metabolic imbalance
Mechanical - pneumothorax and embolism of IV line tip
Liver dysfunction due to refeeding syndrome
Give examples of nutritional disorders.
Scurvy
Beriberi
Pellagra
Xeropthalmia
Explain scurvy.
Vit C def.
Signs of scurvy.
Listlessness, anorexia and cachexia
Gingivitis, loss of teeth, foul breath
Bleeding from guns, nose, hair follicles or into joints, bladder and gut.
Muscle pain and weakness
Oedema
Diagnosis of scurvy.
No test is completely satisfactory
WBC and ascorbic acid might be decreased
Treatment of scurvy.
Ascorbic acid (Vit C)
What is Beriberi?
Heart failure with general oedema (Wet beriberi), or neuropathy (dry beriberi).
Due to lack of vitamin B1 (thiamine).
Diagnosis is usually clinical.
Treatment is thiamine.
What is Pellagra?
Lack of nicotinic acid.
It may occur in carcinoid syndrome and anti-TB drugs like isoniazid.
It is endemic in China and Africa.
Clinical features of Pellagra.
Triad = Diarrhoea, Dementia, Dermatitis
Neuropathy, depression, insomnia, tremor, rigidity, ataxia, fits.
Treatment of Pellagra.
Education
Electrolyte replacement
Nicotinamide
What is xerophthalmia?
Vitamin A def. syndrome that is a big cause of blindness in the tropics.
Clinical features of xerophthalmia.
It is in the name.
Blindness
Conjunctivae become dry and develop oval/triangular spots
Corneas become cloudy and soft.
Treatment of xerophthalmia.
Give vitamin A.
If they are pregnant get special help as vitamin A embryopathy must be avoided.
