Malnutrition and nutrition intervention Flashcards
Define malnutrition
State of deficiency or excess (imbalance) of energy/protein/nutrients resulting in adverse effects on body composition and function
Groups most at risk of malnutrition
> 65yrs
Gastrointestinal dysfunction
Chronic disease e.g. DM
Progressive disease e.g. cancer
substance abuse
Causes of hospital malnutrition
- Reduced intake e.g. due to anorexia, Nil by mouth, inactivity, depression
- maldigestion/malabsorption
- altered metabolism (may be in the catabolic phase of their condition)
What is the impact of malnutrition
Increased: mortality, sepsis, complications
Decreased: wound healing, rehab, QOL
How would you diagnose malnutrition?
- Screen tool (with weight loss and height)
- Dietitian assesses with examinations (det. nature and cause of nutrient imbalance)
- Diagnosis
What are the examinations involved in diagnosing malnutrition?
Anthropometry - body measurements e.g. height
body composition - fat distribution
function - using hand grip
biochemistry - check K+ and other electrolytes
Clinical - PMH, surgical history etc
Dietary - eating habits
Social - socioeconomics, isolation
Physical - hair, teeth, nails
Nutritional rq using calorimetry
Who should nutritional support be considered for?
Low BMI (<18.5) or Weight Loss (>10% in 6 months)
Those at risk (not eaten in 5 days/poor absorption/high nutrient losses/increased rq due to catabolism)
What are the different types of nutritional support?
Oral
Enteral tube feeding
Parenteral tube feeding
What is the order of preferential options nutritional support?
Oral - Enteral - Parenteral
What is oral nutritional support?
Dietetic counselling,
fortification,
oral supplements,
Who is oral nutritional support geared towards
Inadequate food and fluid intake
unless they cannot swallow/have GI issues
If oral nutritional support is inadequate, what is the next step?
Enteral Tube feeding
How does enteral tube feeding work
Bypass the mouth, feed the stomach/duodenum/jejunum
What are the different access points for enteral nutrition?
If Gastric Feeding Possible - nasogastric tube
If not: naso-duodenal or naso-jejunal
What are the options for longer term enteral nutrition?
> 3months: gastrostomy or jejunostomy
What is a contraindication for the nasogastric tube and what is the alternative?
Gastric outlet obstruction
Naso-jejunal tube
What are the complications associated with enteral feeding?
Mechanical (blockage, misplacement)
Metabolic (hyperglycaemia, deranged electrolytes)
GI (aspiration, ulceration, D&V)
What is parenteral nutrition
Delivery of nutrients, electrolytes and fluids directly into venous blood
When would you choose parenteral nutrition?
- Enteral not adequate
- Limited tube feeding not possible
- GI tract not functional or accessible
Where is the access for parenteral nutritional support?
Directly into venous bloods - central venous catheter at tip of SVC or others
What are the complications associated with parenteral feeding?
Mechanical (pneumothorax, thrombosis, arrythmias)
Metabolic (deranged electrolytes, abnormal liver enzymes, hyperglycaemia)
Catheter-related infections
Is albumin a good marker of malnutrition in an acute hospital setting?
No - low albumin levels in inflammation as it is a negative acute phase protein
What is the acute phase response?
Inflammatory stimulus releases cytokines Cytokines stimulate the synthesis of some proteins (CRP) / downregulate others (e.g. albumin) in liver
What is RFS?
Refeeding Syndrome - clinical symptoms occurring in malnourished individuals on the reintroduction of oral/enteral/parenteral nutrition
Explain the pathophysiology of RFS
Starvation - decreased insulin secretion, use of protein/fat stores in body and salt/water intolerance. Cells will give up intracellular ions (K+, Mg+) to account for low extracellular levels.
Once nutrition restarted + insulin secretion is upregulated, ions will move back into cells causing hypokalaemia, hypomagnesaemia, thiamine deficiency
What are the clinical symptoms of RFS?
Cardio - arrythmias, tachy, CA
Neuro - encephalopathy, coma, seizures, wernicke’s encephalopathy
Resp - respiratory depression
Who is at risk for RFS according to NICE?
Little or no food intake for > 5 days
Who is at high risk for RFS according to NICE?
BMI < 16, weight loss >15% in 6 months, little nutrition
What is the management for RFS?
- Administer thiamine 30mins b4 feeding (to avoid encephalopathy)
- Monitor electrolytes daily
- Diet - 10/20kcal per kg, micronutrients
- Monitor fluid shifts and minimise hypernatraemia
