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Year 2 Gastro > Malnutrition and Nutritional Assessment > Flashcards

Malnutrition and Nutritional Assessment Flashcards

1
Q

Define malnutrition

A

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

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2
Q

In who is malnutrition most prevalent in?

A

Youngest and oldest adult age groups (over 65)
Curvilinear relationship

More common in women than men

Oncology and care of the elderly walls

Those with Gastrointestinal disease

Long term condtions e.g. diabetes

Chronic progressive conditions e.g. cancer or dementia

Those who abuse drugs or alcohol

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3
Q

What percentage of people admitted to hospital are malnourished?

A

1 in 3

33%

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4
Q

What percentage of people loose weight after discharge?

A

70%

Mainly muscle mass

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5
Q

What is disease related anorexia?

A

Loss of appetite as a result of pathophysiological mechanisms observed in the presence of disease

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6
Q

Why do people loose weight in hospital?

A 
40% of food left on plate
GI symptoms
Depression/Low mood
Quality of food
Lack of motivation
Food of secondary importance
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7
Q

What was the impact of malnutrition on recovery from surgery for duodenal cancer?

A

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

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8
Q

What did the ONS reveal about hospital deaths and malnutrition in 2016?

A

Direct cause 66 hospital deaths

Contributory factor 285 hospital deaths

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9
Q

What increases as a result of malnutrition?

A 
Mortality
septic and post surgical complications
length of hospital-stay
pressure sores
re-admissions
dependency
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10
Q

What decreases as a result of malnutrtion?

A

Wound healing, response to treatment, rehabilitation potential, quality of life

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11
Q

What is the cost of malnutrition in England per year?

A

£ 19.6 billion

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12
Q

How is malnutrtion diagnosed in acute settings?

A

Malnutrition universal screening tool (MUST)

A simple tool to identify risk.
Carried out by any HCP.
This is not assessment or diagnosis.

Clasfies as low, medium and high risk of malnutrition

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13
Q

What is nutrition assessment?

A

A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance.

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14
Q

What is anthropometry?

A

Measurement of body

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15
Q

What is conducted in a anthropometry assessment?

A

Scale for weight
BMI is insignificant

Midarm muscle circumference

Multifrequency bioelectrical impedance analysis - renal and haematology patients

CT for muscle content and fat - expensive and radiation

Hand grip strength - response earlier to malnutrition

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16
Q

What biochemistry is used?

A

Measurements of micronutrients - expensive

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17
Q

With inflammation what must be achieved before measuring micronutrients?

A

CRP below 10 micrograms per litre

Otherwise skewed results

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18
Q

What is included in a dietary history?

A 
Anorexia
Allergies
Fad dieting 
Aversions
Cultural, religious, ethical Dietary restrictions
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19
Q

How are nutritional requirements calculated?

A

Predictive equations that estimate resting metabolic rate

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20
Q

What is nutritional requirement?

A

Average dietary intake that is predicted to maintain energy balance in an adult of a defined age, gender, weight, height and physical activity

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21
Q

What is done once malnutrition has been diagnosed?

A

Plan
Implement
Monitor
Evaluate

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22
Q

How is malnourished defined by NICE?

A

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.

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23
Q

How is at risk of malnutrition defined by NICE?

A

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.

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24
Q

What is artificial nutrition support?

A

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

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25
Q

What is used to decide how malnutrition is treated?

A

Stratton and Elia flowchart

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26
Q

What is always considered first in treatment?

A

Oral route

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27
Q

What implications does enteral nutrition have?

A

Ethical and Legal

ESBEN have guidelines on the ethical aspects of artificial nutrition and hydration

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28
Q

What are the features of the route of feeding?

A

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.

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29
Q

How is access decided for feeding?

A

Is gastric feeding possible?

Yes	=  Naso-gastric tube (NGT) 
No  	=  Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Long term (> 3 months) = Gastrostomy/jejunstomy

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30
Q

What are the complications associated with enteral feeding?

A

Misplaced NGTs (21 deaths between 2005-2011)

Mechanical

Metabolic

GI

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31
Q

What must be done when an NG tube has been placed?

A

An aspirate needs to be obtained from the tube indicating a pH of 5.5 or less

Reflecting gastric contents

If pH is greater, CXR is indicated

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32
Q

What are the mechanical complications of NG feeding?

A

Misplacement
Blockage
Buried bumper

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33
Q

What are the metabolic complications of NG feeding?

A

Hyperglycaemia

Deranged electrolytes

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34
Q

What are the GI complications of NG feeding?

A 
Aspiration
Nasopharyngeal pain
Laryngeal ulceration
Vomiting 
Diarrhoea
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35
Q

What is parenteral nutrition?

A

Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.

36
Q

What are the indications for parenteral nutrition?

A

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

37
Q

How is access for parenteral nutrition gained?

A

Central venous catheter (CVC): tip at superior vena cava and right atrium.

Different CVCs for short / long term use.

38
Q

Where can CVCs be inserted?

A

Subclavian
Jugular
Femoral
Antecubital fossa

39
Q

What composes parenteral nutrition?

A

Ready made / bespoke “scratch” bags.

MDT → fluid and electrolyte targets

40
Q

What are the complications associated with parenteral nutrition?

A

Mechanical
Metabolic
Catheter-related

41
Q

What are the metabolic complications of parenteral nutrition?

A 
Deranged electrolytes 
Hyperglycaemia
Abnormal liver enzymes
Oedema
Hypertriglycerideamia
42
Q

What are the mechanical complications of parenteral nutrition?

A 
Pneumothorax
Haemothorax
Thrombosis
Cardia arrhythmias
Thrombus
Catheter occlusion
Thermophlebitis
Extravasion
43
Q

Does nutrition support benefit the malnourished patient?

A

Lowers mortality
Reduction in readmission
Weight increase
Better outcomes

44
Q

What is albumin?

A

most abundant circulating protein
Albumin synthesised in the liver.
Low plasma albumin = poor prognosis.
A negative acute phase protein = ↓ plasma albumin when ↑ inflammation.

45
Q

What happens in acute inflammatory phase?

A

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.

Albumin levels decrease

46
Q

What is refeeding syndrome?

A

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.

47
Q

What are the consequences of Refeeding syndrome?

A

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis,
Wernicke’s encephalopy

48
Q

What happens when carbohydrate is reintroduced after starvation?

A

Secretion of insulin
Na/K ATPase activation
Increased uptake of solutes
Low electrolytes in plasma

49
Q

What are the criteria for defining the risk of RFS?

A

At risk: very little or no food intake for > 5 days

High risk: one or more of
BMI less than 16 kg/m2

unintentional weight loss greater than 15% within the last 3–6 months

little or no nutritional intake for more than 10 days

low levels of potassium, phosphate or magnesium prior to feeding.

BMI less than 18.5 kg/m2

unintentional weight loss greater than 10% within the last 3–6 months

little or no nutritional intake for more than 5 days

a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.

50
Q

What defines extremely high risk of RFS?

A

BMI < 14

Negligible intake for more than 15 days

51
Q

How is RFS managed at the start?

A

Start with 10-20 kcal/kg
Carbohydrates 40-50%
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

52
Q

What can you use to estimate height and weight if the patients is unable to tell you?

A

Ulnar length
Mid arm circumference

e.g.
Ulna length: 27 cm = height 1.71m

Mid upper arm circumference 21cm = BMI 18 kg / m2.
Weight est. 60 kg

53
Q

What do you have to be mindful of when giving propofol?

A

Contributes additional energy of 1 kcal/mL

Risk of fat overload

54
Q

What do pro-kinetics do?

A

Promote gastric emptying

55
Q

What must be monitored when feeding?

A

Bowel frequency

Bristol stool chart

56
Q

What can be used when bowel frequency is high?

A

Pancreatic enzymes to help with absorption

57
Q

What is PICC?

A

Peripherally inserted central catheter

58
Q

What are the two main nutritional goals for all patients?

A

Prevent dehydration

Improve nutritional status

59
Q

What are some of the implications nutritionally of commonly prescribed ICU medications?

A

Slow gut motility

Reduce blood flow to gut increasing risk of gut ischaemia

60
Q

What often happens during ICU admission?

A

Many become insulin resistant showing hyperglycaemia

Give insulin but must be mindful of hypoglycaemia

61
Q

What needs to happen if a patients it taking the anticonvulsant phenytoin?

A

If given via the enteral route requires a break from feed for drug absorption

62
Q

What does the Penn State equation for feeding take into account?

A 
Gender
Age
Height 
Temperature
Ventilation settings
63
Q

How can you feed into the gut if there is stenosis in the duodenum?

A

Naso-jejunal tube

Can be place via endoscopy or also at the bedside

64
Q

What is ‘trophic’ NG feeding?

A

Minimal amount

65
Q

Why do you always want to prioritise enteral feeding?

A

Used alongside parenteral

To challenge the gut, stop gut becoming leaky, high risk of bacterial translocation - maintain integrity

66
Q

What is an early indicator of adequate nutritional support?

A

Hand grip

Indicative of muscle function improving

67
Q

What is small bowel syndrome?

A

Short-bowel syndrome-intestinal failure results from surgical resection, congenital defect or disease-associated loss of absorption

Characterised by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balances when on a conventionally accepted, normal diet

68
Q

What does outcome for patient after resection depend on?

A

Type
Length
Quality
or remnant small bowel

Colon present or not?

69
Q

In what resection is there no colon present?

A

End-Jejunostomy

Ends in stoma at abdomen

70
Q

In which resections is the colon preserved?

A

Ileocolonic anastaomosis

Jejunocolonic anastamosis

71
Q

What are the benefits of preserving the colon?

A

Allows for the reabsorption of sodium, fluid and fatty acids

Slows intestinal transit

Allows for intestinal readaption

72
Q

What define short bowel syndrome?

A

less than 2 metres from duodenojejunal flexure.

73
Q

What are the critical lengths in short bowel syndrome?

A

< 100cm of jejunum = long term intravenous fluid + e-
< 75 cm of jejunum = long term PN, fluid + e-
< 50 cm of jejunum + colon = long term PN, fluid + e-

74
Q

What happens to fluid after a resction?

A

Daily secretions 4L a day arriving at the upper jejunum for reabsorption

Fluid reabsorbed if colon is present

If not high fluid losses

75
Q

What is the target stoma output 6 weeks post op?

A

1.5L a day

76
Q

What oral fluid advice would you give to prevent further dehydration and electrolyte balance?

A

Decrease oral fluids

Misconception that it should be increased

Drinking hypotonic fluids (Na 90mmol or less) results in high stoma output as sodium is dragged into gut lumen

Anything very concentrated as the same impact e.g. fruit juice - fluid dragged into lumen to balance solute

77
Q

What should patients have when they are dehydrated?

A

Oral rehydration solution

1L of electrolyte mix

78
Q

What is the recipe for ORS?

A 
20g (6 teaspoons) glucose 
3.5g (1 level 5ml teaspoon) salt 
2.5g (1 heaped 2.5ml spoon) sodium bicarbonate 
1L water
Add cordial, chill, sip through straw
79
Q

What is the dietetic intervention for jejunostomy?

A

Hyperphagic diet
Absorb half of food they eat
Calories requirements and nitrogen doubled
High fat- for energy and essential fatty acids
Low fibre - lowers intestinal gut transit
Additional NaCl given
Additional selenium and magnesium

80
Q

What do you do if appetite in a jejunostomy patient decreses?

A

Food fortification

Oral nutritional supplements

81
Q

What strategies can be used to overcome thirst?

A

Strategies to overcome thirst: Ice chips, smaller cup, drink between rather than with meals

82
Q

What urinary sodium value indicates dehydration?

A

> 20mmol/L

83
Q

What are the two main nutrition goals?

A

Prevent dehydration

Improve nutritional status

84
Q

How can dehydration be prevented?

A

Aiming for urine sodium >20 mmol/L
by encouraging adherence to fluid restriction
and consumption of an oral rehydration solution over the next 2 wks.

85
Q

How is nutritional status improvement measured?

A

by showing an ↑ in lean body mass

evidenced by ↑ mid-arm muscle circumference & handgrip strength over next 4 wks

Year 2 Gastro (10 decks)

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