Malnutrition and Nutritional Assessment Flashcards
Define malnutrition
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
In who is malnutrition most prevalent in?
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
What percentage of people admitted to hospital are malnourished?
1 in 3
33%
What percentage of people loose weight after discharge?
70%
Mainly muscle mass
What is disease related anorexia?
Loss of appetite as a result of pathophysiological mechanisms observed in the presence of disease
Why do people loose weight in hospital?
40% of food left on plate GI symptoms Depression/Low mood Quality of food Lack of motivation Food of secondary importance
What was the impact of malnutrition on recovery from surgery for duodenal cancer?
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
What did the ONS reveal about hospital deaths and malnutrition in 2016?
Direct cause 66 hospital deaths
Contributory factor 285 hospital deaths
What increases as a result of malnutrition?
Mortality septic and post surgical complications length of hospital-stay pressure sores re-admissions dependency
What decreases as a result of malnutrtion?
Wound healing, response to treatment, rehabilitation potential, quality of life
What is the cost of malnutrition in England per year?
£ 19.6 billion
How is malnutrtion diagnosed in acute settings?
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
What is nutrition assessment?
A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance.
What is anthropometry?
Measurement of body
What is conducted in a anthropometry assessment?
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
What biochemistry is used?
Measurements of micronutrients - expensive
With inflammation what must be achieved before measuring micronutrients?
CRP below 10 micrograms per litre
Otherwise skewed results
What is included in a dietary history?
Anorexia Allergies Fad dieting Aversions Cultural, religious, ethical Dietary restrictions
How are nutritional requirements calculated?
Predictive equations that estimate resting metabolic rate
What is nutritional requirement?
Average dietary intake that is predicted to maintain energy balance in an adult of a defined age, gender, weight, height and physical activity
What is done once malnutrition has been diagnosed?
Plan
Implement
Monitor
Evaluate
How is malnourished defined by NICE?
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.
How is at risk of malnutrition defined by NICE?
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.
What is artificial nutrition support?
The provision of enteral or parenteral nutrients to treat or prevent malnutrition
What is used to decide how malnutrition is treated?
Stratton and Elia flowchart
What is always considered first in treatment?
Oral route
What implications does enteral nutrition have?
Ethical and Legal
ESBEN have guidelines on the ethical aspects of artificial nutrition and hydration
What are the features of the route of feeding?
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 access decided for feeding?
Is gastric feeding possible?
Yes = Naso-gastric tube (NGT) No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)
Long term (> 3 months) = Gastrostomy/jejunstomy
What are the complications associated with enteral feeding?
Misplaced NGTs (21 deaths between 2005-2011)
Mechanical
Metabolic
GI
What must be done when an NG tube has been placed?
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
What are the mechanical complications of NG feeding?
Misplacement
Blockage
Buried bumper
What are the metabolic complications of NG feeding?
Hyperglycaemia
Deranged electrolytes
What are the GI complications of NG feeding?
Aspiration Nasopharyngeal pain Laryngeal ulceration Vomiting Diarrhoea
What is parenteral nutrition?
Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.
What are the indications for parenteral nutrition?
An inadequate or unsafe oral and/or enteral nutritional intake
OR
A non-functioning, inaccessible or perforated gastrointestinal tract
How is access for parenteral nutrition gained?
Central venous catheter (CVC): tip at superior vena cava and right atrium.
Different CVCs for short / long term use.
Where can CVCs be inserted?
Subclavian
Jugular
Femoral
Antecubital fossa
What composes parenteral nutrition?
Ready made / bespoke “scratch” bags.
MDT → fluid and electrolyte targets
What are the complications associated with parenteral nutrition?
Mechanical
Metabolic
Catheter-related
What are the metabolic complications of parenteral nutrition?
Deranged electrolytes Hyperglycaemia Abnormal liver enzymes Oedema Hypertriglycerideamia
What are the mechanical complications of parenteral nutrition?
Pneumothorax Haemothorax Thrombosis Cardia arrhythmias Thrombus Catheter occlusion Thermophlebitis Extravasion
Does nutrition support benefit the malnourished patient?
Lowers mortality
Reduction in readmission
Weight increase
Better outcomes
What is albumin?
most abundant circulating protein
Albumin synthesised in the liver.
Low plasma albumin = poor prognosis.
A negative acute phase protein = ↓ plasma albumin when ↑ inflammation.
What happens in acute inflammatory phase?
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
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 Refeeding syndrome?
Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis,
Wernicke’s encephalopy
What happens when carbohydrate is reintroduced after starvation?
Secretion of insulin
Na/K ATPase activation
Increased uptake of solutes
Low electrolytes in plasma
What are the criteria for defining the risk of RFS?
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.
What defines extremely high risk of RFS?
BMI < 14
Negligible intake for more than 15 days
How is RFS managed at the start?
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
What can you use to estimate height and weight if the patients is unable to tell you?
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
What do you have to be mindful of when giving propofol?
Contributes additional energy of 1 kcal/mL
Risk of fat overload
What do pro-kinetics do?
Promote gastric emptying
What must be monitored when feeding?
Bowel frequency
Bristol stool chart
What can be used when bowel frequency is high?
Pancreatic enzymes to help with absorption
What is PICC?
Peripherally inserted central catheter
What are the two main nutritional goals for all patients?
Prevent dehydration
Improve nutritional status
What are some of the implications nutritionally of commonly prescribed ICU medications?
Slow gut motility
Reduce blood flow to gut increasing risk of gut ischaemia
What often happens during ICU admission?
Many become insulin resistant showing hyperglycaemia
Give insulin but must be mindful of hypoglycaemia
What needs to happen if a patients it taking the anticonvulsant phenytoin?
If given via the enteral route requires a break from feed for drug absorption
What does the Penn State equation for feeding take into account?
Gender Age Height Temperature Ventilation settings
How can you feed into the gut if there is stenosis in the duodenum?
Naso-jejunal tube
Can be place via endoscopy or also at the bedside
What is ‘trophic’ NG feeding?
Minimal amount
Why do you always want to prioritise enteral feeding?
Used alongside parenteral
To challenge the gut, stop gut becoming leaky, high risk of bacterial translocation - maintain integrity
What is an early indicator of adequate nutritional support?
Hand grip
Indicative of muscle function improving
What is small bowel syndrome?
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
What does outcome for patient after resection depend on?
Type
Length
Quality
or remnant small bowel
Colon present or not?
In what resection is there no colon present?
End-Jejunostomy
Ends in stoma at abdomen
In which resections is the colon preserved?
Ileocolonic anastaomosis
Jejunocolonic anastamosis
What are the benefits of preserving the colon?
Allows for the reabsorption of sodium, fluid and fatty acids
Slows intestinal transit
Allows for intestinal readaption
What define short bowel syndrome?
less than 2 metres from duodenojejunal flexure.
What are the critical lengths in short bowel syndrome?
< 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-
What happens to fluid after a resction?
Daily secretions 4L a day arriving at the upper jejunum for reabsorption
Fluid reabsorbed if colon is present
If not high fluid losses
What is the target stoma output 6 weeks post op?
1.5L a day
What oral fluid advice would you give to prevent further dehydration and electrolyte balance?
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
What should patients have when they are dehydrated?
Oral rehydration solution
1L of electrolyte mix
What is the recipe for ORS?
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
What is the dietetic intervention for jejunostomy?
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
What do you do if appetite in a jejunostomy patient decreses?
Food fortification
Oral nutritional supplements
What strategies can be used to overcome thirst?
Strategies to overcome thirst: Ice chips, smaller cup, drink between rather than with meals
What urinary sodium value indicates dehydration?
> 20mmol/L
What are the two main nutrition goals?
Prevent dehydration
Improve nutritional status
How can dehydration be prevented?
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.
How is nutritional status improvement measured?
by showing an ↑ in lean body mass
evidenced by ↑ mid-arm muscle circumference & handgrip strength over next 4 wks
