Malnutrition and Nutritional Assessment Flashcards by Fara A

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.

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What conditions can cause reduced intake in hospital?

Contraindicated
Disease related anorexia
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue

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What aspects of hospitals encourage malnutrition?

inflexible meal timings
poly-pharmacy
inactivity
altered metabolism

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What is the impact of malnutrition?

physical and functional decline and poorer clinical outcomes

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What does malnutrition increase?

mortality
sepsis
post surgical complications
length of hospital stay
pressure sores
re-admissions
dependency

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What does malnutrition decrease?

wound healing
response to treatment
rehab
quality of life

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How do you diagnose malnutrition?

screen
assess
diagnose
plan
implement
monitor
evaluate

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What is involved in a screen when looking to diagnose malnutrition?

tool used to identify risk
any HCP
NOT an assessment or diagnosis

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What is needed to assess malnutrition?

dietitian
a process to determine the cause of the nutrient imbalance
anthropometry
biochemistry
clinical implications
dietary restrictions
social and physical history
nutrition requirements

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When should nutrition support be considered?

in those that are:

malnourished
at risk of malnutrition

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What values would result in a classification of malnourished?

BMI < 18.5
OR
unintentional weight loss > 10% over the past 3-6 months
OR
BMI <20, unintentional weight loss >5% in the past 3-6 months

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What would result in a classification of at risk of malnutrition?

have eaten very little for >5 days and/or are likely to eat little/nothing for the next 5 days
poor absorptive capacity
high nutrient losses
increased nutritional needs from causes such as catabolism

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What is artificial nutrition support?

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

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What is the best form of artificial nutrition support?

enteral

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Which tube is used for enteral nutrition when gastric feeding is possible?

naso-gastric tube

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Which tube is used for enteral nutrition when gastric feeding is not possible?

naso-duodenal
naso-jejunal tube

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What is are possible forms of long term (>3 months) enteral nutrition?

gastrostomy
jejunstomy

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What are the different types of nutritional feeds?

renal
low sodium
respiratory
immune
elemental
peptide
high energy
high protein

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When is an NGT contraindicated?

gastric outlet obstruction

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What can be used as a substitute when NGT is contraindicated?

NJT

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What are the mechanical complications associated with enteral feeding?

misplacement
blockage
buried bumper

What are the GI complications associated with enteral feeding?

aspiration
nasopharyngeal pain
laryngeal ulceration
vomiting
diarrhoea

How do you test for a misplaced NGT?

aspirate pH < 5.5
if >5.5, CXR

What is parenteral nutrition?

the delivery of nutrients, electrolytes and fluid and directly into venous blood

What are the indications for parenteral nutrition?

- inadequate or unsafe oral and/or enteral nutritional intake - non-functioning, inaccessible or perforated gastrointestinal tract

What is the composition of parenteral nutrition?

- ready made/bespoke 'scratch bags' - MDT decides on fluid and electrolyte targets

What are the access points for parenteral nutrition?

- central venous catheter: tip at the superior vena cava and right atrium - different CVCs for different length of use

What is a PICC line?

Peripherally Inserted Central Catheter

What are the mechanical complications associated with parenteral feeding?

- pneumothorax - haemothorax - thrombosis - cardiac arrhythmias - thrombus - catheter - occlusion - thrombophlebitis - extravasion

What are the metabolic complications associated with enteral feeding?

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

What are the other complications associated with enteral feeding?

catheter related infections

What does albumin indicate?

low albumin tends to indicate high inflammation and therefore a poor prognosis

What is albumin?

a negative acute phase protein

Why does albumin decrease when inflammation increases?

- activation of monocytes and macrophages in inflammation causes cytokine released - cytokines down regulate the production of some proteins, such as albumin

Is albumin a valid marker of malnutrition in the acute hospital setting?

What is refeeding syndrome?

a group of biochemical shifts and clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition

What is the impact of refeeding syndrome?

- arrhythmia, tachycardia, cardiac arrest, sudden death - respiratory depression - encephalopathy, comma, seizures, rhabdomyolysis - wernicke's encephalopathy

What tends to happen refeeding syndrome?

- hypokalaemia - hypomagnesaemia - hypophosphataemia - thiamine deficiency - salt and water retention, odema

According to the National Institute for Health and Care Excellence (NICE), what are the criteria for defining the risk of RFS?

- at risk - high risk - extremely high risk

What would classify someone as at risk of RFS?

Very little or no food intake for > 5 days

What would classify someone as high risk of RFS?

``` >/= 1 of the following: BMI < 16 kg/m2 Unintentional weight loss > 15 % 3 – 6 months 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 months Very little / no nutrition > 5 days PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)

What would classify someone as very high risk of RFS?

BMI < 14 kg/m2 Negligible intake > 15 days

How do you manage RFS?

- start on 10-20cal/kg, CHO 40-50% energy - correct and monitor electrolytes daily - administer thiamine 30 mins before refeeding and for first 10 days - monitor fluid shifts and reduce the risk of fluid and Na* overload - micronutrients from onset of feeding

What groups are most at risk of malnutrition?

- elderly - cancer - chronic illness - drug/alcohol abuse

What is the effect of Enteral nutrition?

- supports the function and structural mobility of the gut - modulates the system immune response - attenuates disease severity

When is there a risk of refeeding syndrome?

- low BMI - poor nutrition for greater than 5 days - low potassium - alcohol history

What is taken into a nutritional assessment?

- body composition and function - bloods - clinical features - DHx - diet Hx - social Hx

What is oral nutritional support?

Fortification of meals and snacks Altered meal patterns Practical support Oral nutritional supplements (ONS) Tailored dietary counselling

When should oral nutrition support be considered?

Patients with inadequate food and fluid intake to meet requirement

When should oral nutrition support not be considered?

- can't swallow safely - inadequate GI function - no benefits e.g. in end of life care

What is enteral nutrition support?

Nutrition support through the GI tract, bypassing the mouth