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 conditions can cause reduced intake in hospital?
Contraindicated
Disease related anorexia
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue
What aspects of hospitals encourage malnutrition?
- inflexible meal timings
- poly-pharmacy
- inactivity
- altered metabolism
What is the impact of malnutrition?
physical and functional decline and poorer clinical outcomes
What does malnutrition increase?
- mortality
- sepsis
- post surgical complications
- length of hospital stay
- pressure sores
- re-admissions
- dependency
What does malnutrition decrease?
- wound healing
- response to treatment
- rehab
- quality of life
How do you diagnose malnutrition?
- screen
- assess
- diagnose
- plan
- implement
- monitor
- evaluate
What is involved in a screen when looking to diagnose malnutrition?
- tool used to identify risk
- any HCP
- NOT an assessment or diagnosis
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
When should nutrition support be considered?
in those that are:
- malnourished
- at risk of malnutrition
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
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
What is artificial nutrition support?
the provision of enteral or parenteral nutrients to treat or prevent malnutrition
What is the best form of artificial nutrition support?
enteral
Which tube is used for enteral nutrition when gastric feeding is possible?
naso-gastric tube
Which tube is used for enteral nutrition when gastric feeding is not possible?
- naso-duodenal
- naso-jejunal tube
What is are possible forms of long term (>3 months) enteral nutrition?
- gastrostomy
- jejunstomy
What are the different types of nutritional feeds?
- renal
- low sodium
- respiratory
- immune
- elemental
- peptide
- high energy
- high protein
When is an NGT contraindicated?
gastric outlet obstruction
What can be used as a substitute when NGT is contraindicated?
NJT
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?
no
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
