Malnutrition And Nutritional Assessment Flashcards
Define malnutrition
A state resulting from lack of uptake/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
How does prevalence of malnutrition change by age?
Curvilinear relationship where highest rates of malnutrition are in youngest and oldest age groups
More common in women than men
1/3 are malnoursihed at acute admission and hospitilisation exacerbates nutrition risk
How does prevalence of malnutrition differ in wards?
Oncology and care of elderly wards have highest rates
How many people on admission to hospital have malnutrition?
1 in 3 → shows a lot of malnutrition occurs in community
What % of people have lost weight at discharge and what is the weight loss in?
70% and mainly muscle mass
Most weight loss seen in those who were initially malnourished at admission
What are causes of malnutrition in hospital? (13)
Reduced intake
Contraindicated
Disease related anorexia
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue
Maldigestion or malabsorption:
Function
Length
Loses
Drug nutrient interactions
Altered metabolism
Early flow phase where lean muscle mass is used with the nutritional goal being survival. Late flow phase where goal changes to cover metabolic needs ( catabolism)and then muscle recovery (anabolism)
- The belief that being in hospital is associated with loss of appetite and that it’ll come back once they’ve left
- The belief by both patients and staff that medical treatment is the main priority and food is of secondary importance
Generally, which groups are affected most by malnutrition? (5)
- Old people over 65, particularly if admitted to hospital
- People with long term conditions like diabetes, kidney disease and chronic lung disease
- People with chronic progressive conditions like cancer or dementia
- Those who abuse drugs or alcohol
- Patients with GI dysfunction
What is the impact of malnutrition on postoperative mortality?
was found in 1936 that post op mortality was 10x greater in those who had lost ≥20% body weight pre op compared with those who lost less
Yes- malnutrition in 2022 directly caused 77 hospital deaths and contributed to 436 hospital deaths
What does malnutrition increase? (6)
- Mortality
- Septic and post surgical complications
- Length of hospital stay
- Pressure sores
- Readmissions
- Dependency
What does malnutrition decrease? (4)
- Wound healing
- Response to treatment
- Rehab potential
- Quality of life
How much does malnutrition cost England per year?
- £19.6 bil → 15% of total expenditure on health and social care
- Most of costs are in secondary health care
- Health costs said to be 3x greater for malnourished than well nourished patients
How do we screen for it?
- MUST (Malnutrition Universal Screening Tool) used- it’s based on BMI, unplanned weight loss and presence of acute disease
- Categorises patients as being low, medium or high risk and gives guidelines for treating each
- Carried out by any HCP
Limitions of MUST screening
Can miss malnourished populations e.g. where overhydration is common like in ascites and oedema or where specific screening for functional impairment is desired
Indications for nutrition support
1)Malnourished
BMI<18.5 or unintentional weight loss past 3x6/12 months. Or BMI <20 and unintentional weight loss >5% past 3-6/12 months
2)at risk of malnutrition have eaten nothing or little to nothing in the past 5 days and will continue for next 5days
Or have a poor absorptive capacity or have increased nutritional needs due to catabolism or high nutrient loss
Why is enteral tube feeding preferred to parenteral
To prevent atrophy of GI tract allowing it to continue working
Nutritional support available via oral route
Fortification if meals and snacks
Altered meal patterns
Practical support
Oral nutritional supplements
Tailored dietary counseling
Considered in pt with inadequate food or fluid intake to meet requirements unless inadequate GI function or no benefit anticipated eg end of life
Antficial nutrtion support enteral
Enteral nutrition superior to parenteral nutrition
Where parenteral used the aim to to return to oral feeding as soon as possible
Access is gastric feeding possible
If yes use nasogastric tube
If no then nasoduodenal or nasojejunal
If long term >3 months then use gastrostomy or jejunostomy
When is NGT contraindicated
Gastric outlet obstruction
Use NJT
Enteral nutritional feeds
Renal
Low sodium
Respiratory
Immune
Elemental
Peptide
High energy
High protein
Complications with enteral nutrition
mechanical-misplacement blockage or buried bumper
metabolic-hyperglycaemia,deranged electrolytes
GI-aspirtation,nasopharyngeal pain laryngeal ulceration vomiting or diarrhea
Parenteral nutrition
The delivery of nutrients electrolys fluids directly to venous blood
More high risk that enteral
given when theres an inadequate or unsafe oral and or enteral intake or there is a non functioning inaccesible/perforated gi tract
ready made bespoke ‘scratch’ bags
Parenteral nutrition complications
catheter realted infections
mechanical-
pneumothorax
haemothorax
thrombosis
cardiac arrythmias
thrombus
catheter occlusion
thrombophlebitits
extravasion
metabolic-
deranged electrolytes
hyperglycaemia
abnormal liver enzymes
odema
hypertriglycerideaemia
How do we obtain access for parenteral feeding
Central venous catheter tip at superior vena cava and right atrium
Different cvcs for short or long term use
Albumin
Synthesized in liver
Hypoalbuminaemka has a poor prognosis
A negative acute phase protein- decreased plasma albumin when inflammation is increased
Acute phase response
Inflammatory stimulus-activation of monocytes and macrophages cause cytokine release
Cytokine act in liver to cause release of CRP whilst down regulating others such S albumin
Refeeding syndrome
A group of biochemical shifts and clinical symptoms that occur in the malnourished or starved individual when reintroduced oral enteral or parenteral nutrition
Consequence of RFS
Arrhythmia,tachycardia,CHF->cardiac arrest and sudden death
Respiratory depression
Encephalopathy coma seizures rhabdomyolosis
Wernickes encephalopathy
RFS management
Administer thiamine 30 mins before and after reseeding for the first ten days
Correct and monitor electrolytes daily
Start 10-20 kcal/kg . CHO 40-50% of energy. Micronutrients from onset of feeding
Monitor fluid shifts and minimise risk of fluid and Na+ overload
Whi does refeeding syndrome occur commonly in
In overweight pts esp this who have eaten nothing for long period of time
Pt with normal levels of potassium phosphate and magnesium can still develop refeeding syndrome
is albumin a valid marker of malnutrition
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. Anderson and Wochos, 1982
criteria defining 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 this
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
in pts with demenetia what would we do
in severe dementia it is contrainidcated to everteral feed as it causes distress and theres a risk of misplacement. As well as that it doesnt prolong survival or improve qol ,decrease risk of pressure sores
clear fluids
transparent containing minimal fat and sometimes minimal protein to reduce stimulation of the gut for digestion
eg water
clear juice
squashes
tea or coffee no milk
jelly no lumps
herbal tea
free fluids
food and fluids that are liquid at rtp and contain protein fat and carbs
all clear fluids and smooth soup
custard
smooth yoghurt
ice cream
RFS mechanism
Starvation causes increased glycogenolysis and gluconeogenesis which decreases proteins fats and electrolytes
Trying to refeeding switches from catabolic state (breaking down) to anabolic state which causes the release of salts and nutrients (CHO major energy source)
This causes insulin secretion insulin enters ICF with Po4,K+,glucose and thiamine thus reduced levels in the ecf
Thus causes increased protein and glycogen synthesis
Thus RFS due to hypokalaemia hypomagnesaemia hypophosphateamia thiamine deficiency salt and water retention which leads to odema
How do we diagnose misplaced ngts
Aspirate ph is less than 5.5
If ph greater then do c X-ray
