malnutrition and nutritional assessment Flashcards
what is the definition of malnutrition?
a state resulting from lack of uptake or intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease”.
highest prevalence is in the youngest and oldest age groups (distribution like a halfpipe)
higher prevalence in women, especially onlder
also highest prevalence in oncology
what is a general person who would have malnutrition like?
someone how is admitted to hospital who is: over 65 with a long term condition people with progressive condition people with drug or alcohol problems people with and GI disorders
1/3 people admitted to hospital are malnourished
what is the impact of malnutrition?
- Surgeon Hiram Studley.
Surgery for perforated duodenal ulcer.
Postoperative mortality 10 x greater in those who had lost 20% bodyweight preoperatively, compared with those who had lost less.
- England and Wales (ONS). Malnutrition:
Direct cause 66 hospital deaths
Contributory factor 285 hospital deaths
the cost of malnutrition every year is £ 19.6 billion 15% of the total public expenditure on health and social care.
why does malnutrition have an impact, what does it do to the body?
Physical and functional decline and poorer clinical outcomes
↑ Mortality, septic and post surgical complications, length of hospital-stay, pressure sores, re-admissions, dependency
↓ Wound healing, response to treatment, rehabilitation potential, quality of life
how do we identify and diagnose malnutrition in the clinical setting?
Screen
assess - dietician
diagnose:
nutrition diagnosis
Plan
Implement
Monitor
Evaluate
what happens during the screen for malnutrition?
A simple tool to identify risk.
Carried out by any HCP.
This is not assessment or diagnosis.
“MUST” - malnutrition universal screening tool
what happens during the assessment for malnutrition?
by a dietician A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance. (BMI plays very little role) anthropometry biochemistry clinical dietary social and physical nutrition requirements |(estimations of resting metabolic rate)
what are the indications for nutritional support?
Nutrition support should be considered in people who are either:
- Malnourished =
BMI < 18.5 kg/m2 or
Unintentional weight loss >10 % past 3 - 6 / 12 or
BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.
- At risk of malnutrition =
Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or
Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
what is artificial nutrition support?
The provision of enteral or parenteral nutrients to treat or prevent malnutrition.
there is an algorithm for this (stratton and elia)
enteral (intestines) is superior to parenteral (veins)
what are the methods of enteral artificial nutrition support?
Route:
Enteral nutrition (EN) is superior to parenteral nutrition (PN).
Where parenteral nutrition is used, the aim is to return to enteral → oral feeding as soon as (where) clinically possible.
Access:
Is gastric feeding possible?
Yes = Naso-gastric tube (NGT) No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)
Long term (> 3 months) = Gastrostomy/jejunstomy
Nutritional feeds → renal, low sodium, respiratory, immune, elemental, peptide.
Gastric outlet obstruction = NGT feeding contraindicated → NJT
What are the complications associated with enteral feeding?
Mechanical: misplacement, blockage, buried bumper
Metabolic: hypergylcaemia, deranged electrolytes
GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea.
Misplaced NGTs
2005 – 2011 = 21 deaths + 79 cases of harm, National Patient Safety Agency (NPSA).
Aspirate pH 5.5
If pH > 5.5 → chest x-ray, interpreted by trained professional following NPSA guidelines.
what are the methods of parenteral artificial nutrition support?
Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.
Indications:
An inadequate or unsafe oral and/or enteral nutritional intake
OR
A non-functioning, inaccessible or perforated gastrointestinal tract
Composition:
Ready made / bespoke “scratch” bags.
MDT → fluid and electrolyte targets
Access:
Central venous catheter (CVC): tip at superior vena cava and right atrium.
Different CVCs for short / long term use.
What are the complications associated with parenteral nutrition?
Metabolic:
Deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia
Mechanical:
(when inserting catheter)
Pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion
Catheter related infections
Does Nutrition Support Benefit the Malnourished Patient?
yes, reduced mortality
what is albumin?
Albumin synthesised in the liver.
most. abundant circulating protein in the plasma
Low plasma albumin = poor prognosis.
A negative acute phase protein = ↓ plasma albumin when ↑ inflammation. (Pretty sure this is wrong)
The acute phase response:
Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
Cytokines act on liver to stimulate production of some proteins whilst downregulating production of others e.g. albumin.
LESS ALBUMIN
A moderate inflammatory stimulus will induce plasma acute phase protein changes.
The negative acute phase protein, albumin, will↓.
