MALNUTRITION AND NUTRITION ASSESSMENT

Question 1

What is the definition of malnutrition?

Answer 1

A state resulting from lack of uptake/intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from diseas

Question 2

Why might malnutrition occur in hospital?

Answer 2

Co-morbidities
Disease related anorexia
Metabolic response to illness/injury
Excess nutritional loss
Low mood/depression
Inactivity
Dysphagia
Quality of food
Inflexibility of mealtimes

Question 3

What is the impact of malnutrition in hospital environments?

Answer 3

Increased mortality, complications (septic/post surgical), hospital stay, pressure sores, re-admissions, dependency

Decreased wound healing, response to treatment, rehabilitation potential, QOL

Question 4

How is malnutrition diagnosed and who by?

Answer 4

Screen to identify risk by any HCP
Assess to determine cause by dietitian
Diagnosis

Question 5

What are some ways malnutrition can be diagnosed?

Answer 5

Anthropometry (physical properties of body)
Biochemistry
Clinical (history, symptoms)
Dietary
Social/physical
Nutrition requirements

Question 6

In which individuals should nutrition support be considered?

Answer 6

Malnourished

At risk of malnutrition

Question 7

What qualifies a person to be malnourished?

Answer 7

BMI < 18.5
or
Unintentional weight loss > 10% in past 3-6 months
or
BMI < 20 and unintentional weight loss > 5% in past 3-6 months

Question 8

What qualifies a person to be at risk of malnutrition

Answer 8

Eaten little/nothing for > 5 days and/or likely to eat little/nothing for next 5+ days
Or
Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes e.g. catabolism

Question 9

What is artificial nutrition support?

Answer 9

The provision of enteral or parenteral nutrients to treat or prevent malnutrition

Question 10

What is the aim of parental nutrition?

Answer 10

Return to enteral then oral feeding as soon as clinically possible

Question 11

If gastric feeding is possible, what should a patient on enteral nutrition use?

Answer 11

Naso-gastric tube (NGT)

Question 12

If gastric feeding isn’t possible, what should a patient on enteral nutrition use?

Answer 12

Naso-duodenal tube (NDT)

Naso-jejunal tube (NJT)

Question 13

When should gastrostomy/jejunstomy be done?

Answer 13

Patient on enteral nutritional support for > 3 months

Question 14

What are the complications associated with enteral nutrition support?

Answer 14

Mechanical - misplacement, blockage, buried bumper

Metabolic - hyperglycaemia, deranged electrolytes

GI - aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Question 15

What must be done after placing a NGT?

Answer 15

Obtain an aspirate from it.
If aspirate pH =< 5.5 then NGT placed correctly (stomach)

If aspirate pH > 5.5 need to do a chest Xray to see where NGT is

Question 16

What is parental nutrition?

Answer 16

Delivery of nutrients, electrolytes and fluid directly into venous blood

Question 17

When should parental nutrition be done?

Answer 17

An inadequate/unsafe oral/enteral nutritional intake
Non-functioning, inaccessible GI tract
Perforated GI tract

Question 18

What is the composition of parenteral nutrition delivered to patients?

Answer 18

Ready made/bespoke bags by dietician

Fluid and electrolyte targets by MDT

Question 19

How is parental nutrition administered?

Answer 19

Central venous catheter at subclavian, jugular or femoral vein with tip at SVC and right atrium

Question 20

What are the complications of parental nutrition?

Answer 20

Mechanical - pneumothorax, haemothorax, thrombosis, arrhythmias, catheter occlusion, thrombophlebitis, extravasion

Metabolic - deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia

Catheter related infections

Question 21

Where is albumin synthesised?

Answer 21

Liver

Question 22

What increases albumin synthesis?

Answer 22

Insulin, cortisol, GH

Question 23

Why is albumin measured?

Answer 23

It is a negative acute phase protein so;

- Less plasma albumin when increased inflammation

Question 24

Why is albumin decreased in inflammation?

Answer 24

Cytokines released act on liver to downregulate albumin production

Question 25

What is refeeding syndrome?

Answer 25

A group of biochemical shifts and clinical symptoms that can occur in malnourished/starved individual upon oral, enteral or parenteral nutrition.

Question 26

What are the consequences/signs of refeeding syndrome?

Answer 26

Arrhythmia, tachycardia, CHF –> cardiac arrest/sudden death

Respiratory decompression
Encephalopathy, coma, seizures, rhabdomyolysis
Wernicke’s encephalopy

Question 27

Describe the NICE criteria for risk of refeeding syndrome?

Answer 27

At risk:
- Very little/no food intake > 5 days

High risk:
(1 of the following):
- BMI < 16
- Unintentional weight loss > 15% in 3-6 months
- Very little/no nutrition > 10 days
- Low K+, Mg2+, PO4 prior to feeding

Or

(2 of the following):

• BMI < 18.5
• Unintentional weight loss > 10% in 3-6 months
• Very little/no nutrition > 5 days
• Alcohol abuse/drugs

Extremely high risk:

• BMI < 14
• Negligible intake > 15 days

Question 28

What is the management for avoiding refeeding syndrome?

Answer 28

Start:

• 10-20 kcal/kg
• carbohydrates 40-50% energy
• micronutrients

Correct and monitor electrolytes daily following trust policy
Administer thiamine from onset of feeding following trust policy
Monitor fluid shifts and minimise risk of fluid/Na+ overload