Nutrition

Question 1

how might we identify those at nutritional risk?

Answer 1

• Weight changes - sudden loss or gain
• BMI
• Dietary assessment
• Physical symptoms - fatigue, muscle weakness, thinning hair, brittle nails, dry skin, dental issues
• PMH
• DHx - affect appetite, digestion etc
• Functional assessment - mobility, strength, ADL
• Social factors - live alone
• biochemical markers
• psychological factors
• hydration status

Question 2

what are some causes of nutritional decline?

Answer 2

• reduced appetite
• chronic health conditions
• medications due to side effects
• physical limitations to meet ADL
• dental problems
• social isolation
• finances
• MH
• cognitive decline
• alcohol and substance misuse
• limited access to nutritious food

Question 3

what things would you focus on when examining someone for their nutrition?

Answer 3

• hands & arms: clubbing, leukonychia, koilonychia, xanthoma, bruising, rash, BP
• HNN: corneal arcus, sunken eyes, pallor, glossitis, stomatitis, aphthous ulcers, JVP, goitre
• chest: skin turgor, CRT
• abdo: ascites, adiposity, loose skin or striae
• legs: oedema, bowed legs, peripheral neuropathy

Question 4

what screening tools can you use to assess nutrition? and when is it used?

Answer 4

MUST (Malnutrition Universal Screen Tool)

• it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores
• it takes into account BMI, recent weight change and the presence of acute disease
• categorises patients into low, medium and high risk

Question 5

how does NICE define malnutrition?

Answer 5

• a Body Mass Index (BMI) of less than 18.5; or
• unintentional weight loss greater than 10% within the last 3-6 months; or
• a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months

Question 6

what are 3 main broad causes for malnutrition?

Answer 6

• inadequate amount of nutrients eg: poor variety in diet
• difficulty absorbing nutrients eg: GI dysfunction, coeliac etc
• increased nutritional demands eg: post-surgery for healing

Question 7

how might someone with malnutrition present?

Answer 7

• high susceptibility or long durations of infections
• slow or poor wound healing
• altered vital signs eg: brady, hypotension, hypothermia
• depleted subcutaneous fat stores
• low skeletal mass*children may be smaller compared to others same age

Question 8

how is malnutrition managed?

Answer 8

MDT care
- consider underlying condition mx
- focus on reversible
- methods of feeding
- oral nutrition, NGT, long term PEG or RIG or jejunostomy, parenteral for intestinal failure or inaccessible digestive tract

Question 9

what is a ‘food-first’ approach?

Answer 9

a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as Ensure

*if ONS are used they should be taken between meals, rather than instead of meals

Question 10

what is the pathophysiology of Refeeding syndrome?

Answer 10

• patient’sintracellular storesof key electrolytes such aspotassiumandphosphate becomedepleted
• if a patient is suddenly provided with normal levels of nutrition, there is asudden shift of these electrolytesfrom the extracellular to the intracellular compartment driven by alarge insulin response
• This can ultimately lead to asudden drop in extracellular levels of key electrolytesresulting inhypokalaemiaandhypo-phosphataemia
• This can subsequently lead tocardiac complications(e.g. arrhythmias) andseizures

Question 11

how is referring syndrome managed?

Answer 11

Frequent monitoring of blood levels of phosphate, magnesium, and potassium

Slow reintroduction of food and fluids to avoid sudden shifts in electrolytes

Thiamine replacement for all at-risk patients to prevent Wernicke’s encephalopathy, a neurological complication of severe thiamine deficiency