Malnutrition and nutritional assessment Flashcards
What is the definition of malnutrition?
A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome
What age is malnutrition more prevalent in?
What gender?
What ward?
Those aged 65 and over or younger than 18
Women
Orthopedic/trauma, surgery, medical
What are the causes of malnutrition in the hospital
Reduced intake
Maldigestion, malabsorption
Altered metabolism
What are reasons for reduced intake
Contraindicated
Disease related anorexia - pro inflammatory cytokines supressing hunger signals, reducing appetite
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue
What are reasons for maldigestion and malabsorption
Function
Length
Losses - drains / stomas / vomiting / diarhea
Drug-nutrient interactions
What are the reasons for altered metabolism
Ebb phase: drop in resting energy expenditure
Early flow phase: increase
Late flow phase: gradual decrease
What is the physical and functional effect as well as effect on clinical outcomes with malnutrition
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 to diagnose malnutrition
Screen
A simple tool to identify risk. This is not assessment or diagnosis - within 6 hours of hospital admission (MUST)
Limitations: Won’t trigger if they have asites or oedema
Assess – Dietitian
A systematic process of collecting and interpreting information to determine the nature and cause of the nutrient imbalance
Anthropometry - external measurement of human body
Body composition - using CT
Function - muscle body strength
Biochemistry - inflammatory state , renal (potassium etc)
Clinical
Dietary
Social
Physical
Requirements - depending on energy and proteins
Diagnose
Nutrition diagnosis.
What people should nutrition support be considered in?
- 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.
When should oral nutritional support be considered
Consider for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function or if no benefit is anticipated e.g. end of life care
What nutritional options are available via the oral route
Fortification of meals and snacks
Altered meal patterns
Practical support
Oral nutritional supplements (ONS)
Tailored dietary counselling
What is artificial nutritional support
The provision of enteral or parenteral nutrients to treat or prevent malnutrition.
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.
How is the enteral route type decided?
Access:
Is gastric feeding possible?
Yes = Naso-gastric tube (NGT)
No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)
Long term (> 3 months) = Gastrostomy / jejunostomy
What is in the nutritional feeds
renal, low sodium, respiratory, immune, elemental, peptide.
What is 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.
How are misplaced NGTs found
Aspirate pH < 5.5
If pH > 5.5 → chest x-ray, interpreted by trained professional following NPSA guidelines
What is parenteral nutrition
The delivery of nutrients, electrolytes and fluid directly into venous blood.
When would you use parenteral support
An inadequate or unsafe oral and/or enteral nutritional intake
OR
A non-functioning, inaccessible or perforated gastrointestinal tract
What is parenteral support made of
Ready made / bespoke “scratch” bags.
MDT → fluid and electrolyte targets
Where is the access point of parenteral support
Central venous catheter (CVC): tip at superior vena cava and right atrium.
Different CVCs for short / long term use.
What are complications associated with parenteral nutrition
Mechanical:
Pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion
Metabolic:
Deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia
Catheter related infections
What is albumin?
Albumin synthesised in the liver.
Hypoalbuminaemia = poor prognosis.
A negative acute phase protein = ↓ plasma albumin when ↑ inflammation
What is the acute phase response
Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin.
Is albumin a valid marker of malnutrition in the acute hospital setting
No. Albumin synthesis ↓es in response to inflammation ∴ poor predictor of malnutrition during acute phase. However, do consider the aetiology / impact of the inflammatory response on nutrition status.
What is refeeding syndrome
A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.
What are the consequences of RFS
Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis,
Wernicke’s encephalopy
According to the National Institute for Health and Care Excellence (NICE), what are the criteria for defining the risk of RFS?
At risk:
Very little or no food intake for > 5 days
High risk:
>1 of the following:
BMI < 16 kg/m2
Unintentional weight loss > 15 % 3 – 6 /12
Very little / no nutrition > 10 days
Low K+, Mg2+, PO4 prior to feeding
Or > 2 of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10 % 3 – 6 / 12
Very little / no nutrition > 5 days
PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)
Extremely high risk:
BMI < 14 kg/m2
Negligible intake > 15 days
What does the management of RFS involve
Management
Start: 10 – 20kcal/kg
CHO 40 – 50% energy
Micronutrients from onset of feeding
Correct and monitor electrolytes daily following Trust policy
Administer thiamine from the onset of feeding following Trust policy
Monitor fluid shifts and minimise risk of fluid and Na+ overload
