Nutrition Flashcards
What is malnutrition?
A deficiency or excess (or imbalance) of energy, protein and other nutrients
Causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome
What are the causes of malnutrition
Altered nutrient processing:
- Increased and changed metabolic demands
- Liver dysfunction
Excess losses
- Vomiting
- Nasogastric tube drainage
- Diarrhoea
- Surgical drains
- Fistulae
- Stomas
Impaired intake
- Poor diet
- Poor hospital catering
- Poor appetite
- Missed meals
- Pain and nausea with food
- Mucositis
- Dysphagia
- Depression and psychological
- Unconsciousness
Impaired digestion and absorption
- Problems of stomach, intestine, pancreas and liver
What are the symptoms of malnutrition
Loss of appetite
Weight loss- appearance of skin, pale, facial features, excess skin, boney, loose clothing, bracelets don’t fit, dentures don’t fit
Poor growth in children
Fatigue
Altered mood
What is the impact of malnutrition
Uses up glycogen storages in liver, then muscle, then fat
Psychology, depression and apathy
Ventilation-loss of muscle and hypoxic responses
Decreased liver function, fatty change and necrosis
Impaired wound healing
Impaired gut integrity and immunity
Loss of strength
Hypothermia
Renal function- loss of ability to excrete sodium and water
Decreased cardiac output and immunity and resistance to infection
What are the impacts to primary and secondary care of malnutrition
Primary: GP visits Prescription costs Referral to hospital Care home admissions
Secondary: Complications Length of hospital stay Readmissions Deaths
What do the NICE guidelines say about what is classed as malnourished patient
BMI of less than 18.5kg/m2
Unintentional weight loss greater than 10% within the last 3-6 months
BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within last 3-6 months
What do NICE guidelines say about people that are at risk of malnutrition
- Eaten little or nothing for more then 5 days and/or are likely to eat little or nothing for 5 days or longer
- Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs form causes like catabolism
What is the nutritional screen (BAPEN) 5 steps measured
- Height and weight for BMI
- Note unplanned weight loss and score
- Establish acute disease score
- Add scores 1-3 for complete score
- Use management guidelines or local policies to create action plan
What is the nutritional assessment
Anthropometry
Biochemistry- electrolyse (K, Mg, Ca, Phosphate)
Clinical- disease states may increase risk of malnutrition like cancer, GI disorders (gastric reflux, altered bowel movements), burns, mental health
Dietary- energy requirements, fluid requirements, dietary assessment
Environment- home or hospital?
Describe the energy requirements for malnutrition
Basal metabolic rate- amount of energy expended by the body to maintain basic physiological functions over 24 hours
60-75% energy expenditure
Does not include physical activity expenditure
Depends on gender, age, height
What is re-feeding syndrome
- Caused when a person is in a state of prolonged starvation that is given nutrition
- Serious complication
- Person eats, a sudden shift in energy sources leads to
- insulin secretion
- Glycogen, fat and protein synthesis for which phosphate, magnesium, thiamine are required
- increased absorption of potassium and magnesium into cells
Leads to decrease in serum levels of K, Po4 and magnesium
If a person is at high risk of re-feeding syndrome, what do you do
- Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4-7 days
- Restore circulatory volume and monitoring fluid balance and overall clinical status closely
- Provide immediately before and during first 10 days of feeding:
- Oral thiamine 200-300mg daily
- Vitamin B compound strong 1 or 2 tablets, three times a day (full dose daily intravenous vitamin B preparation if necessary)
- Balanced multi-vitamin and trace element supplement if necessary - Provide oral, enteral or intravenous supplements of potassium (likely 2-4 mmol/kg/day)
Phosphate (0.3-0.6 mmol/kg/day)
Magnesium (0.2 mol/kg/day intravenously, 0.4mmol/kg/day oral)
Unless pre-feeding plasma levels are high
Describe the nutritional support given
Oral
Food first- encourage them to eat more, cannot physically eat more
Oral nutritional supplements
Enteral
Parenteral
Need to know daily requirements for patients
Protective meal times- strictly dinner, lunch, breakfast
Developing care plans, assessments before admission and throughout patient stay, monitor plan more carefully
Who is part of the nutritional support team
Pharmacist Nurse Dietician General Practitioner Translator- elderly foreign women, wants a certain type of food
What oral nutritional supplements are there available
Juice type
Milkshake type
High energy powders
Soup type
High protein
Semi-solid and dysphagia ranges
What is enteral nutrition
- Necessary when oral nutrition is not possible or insufficient to meet their requirements
- Made up of a liquid mixture of all the needed nutrients
- Given via a tube in the stomach or small intestine
- Oral feeding is not possible, extended nil-by-mouth period is anticipated, an access device for enteral feeding should be inserted at time of surgery
Conditions like swallowing difficulty, ITU and unconsciousness
Describe what are the different enteral feeding routes and what important points should you consider
Jejunal tubes:
Nasojejunal- most common- tube passed through nose and down into stomach- usually short term feeding for 4 weeks to provide support for patient to recover via illness
Orojejunal
Jejunostomy
PEGJ (combined gastric and jejunal tube)
Gastric tubes: Nasogastric Orogastric Gastrostomy- depends on placement technique PEGJ- combined gastric and jejunal tube
Other: caecostomy tube into caecum
Consider:
- Current anatomy as bypasses, fistulae and drains may affect suitability of any enteral feeding tube for its intended purpose
- Long term enteral tube access include PEG tubes that require considerable post insertion commitment and this should be borne in mind at the initial assessment
What are the four main routes of enteral administration and describe them
Nasogastric
- Good for short term feeding and is less than 4 weeks
- Soft and fine bore size
- High aspiration risk so need to feed patient at 30-45 degree angle for at least 30 minutes
Nasojejunal tubes- post surgery recovery
- Reduced aspiration risk
- Important feed is sterile so no gastric acid protection
Gastrostomy
- Good for longer term feeding
- PEG (percutaneous endoscopic gastrostomy)
- Surgical or open gastrostomy
- RIG
Jejunostomy
- PEJ (Percutaneous endoscopic jejunostomy)
- Surgical or open jejunostomy
What are the indications to consider for small bowel access rather than the stomach
- Gastroparesis/ gastric ileus- when the stomach stop working or slows down- caused by neurological activity to stomach sedation or particular drugs- post op or injury
- Recent abdominal surgery
- Sepsis
- Significant gastro-esophageal reflux
- Pancreatitis
- Aspiration
- Ileus
- Proximal enteric fistula or obstruction
How do you select the most appropriate enteral feed
Estimation of energy, protein (nitrogen) and fluid needs
Select most appropriate enteral formula
Determine continous vs bolus feeding
Determine goal rate to meet estimated needs
Write and recommend enteral nutrition prescription
What are the types of enteral feed available
Polymeric
- Whole protein
- Patients with normal GI function
Pre-digested
- Peptide/semi elemental/ elemental (
- Patients with severely impaired GI function
Disease specific
- Formulas for respiratory disease, diabetes, renal failure, hepatic failure and immune compromise
What are the different types of enteral nutrition modes available
Enteral syringe:
- With plunger
- Gravity with plunger removed
Electronic Feeding Pump
- Via giving set through pump attached to enteral feeding tube
- Set amount over predetermined time
- Continuous or intermittent
What are the complications of enteral nutrition
Oral discomfort (no salvia- dry mouth, must replace with artificial saliva) or infection
Reflux or vomiting- 30 to 45 degrees sit them upright, consider clinical assessment
- Prolonged vomiting = risk of dehydration (iv fluids needed)
Abdominal distension or pain- intolerance to the feeds, trapped gas, check bowel function, volume rate, gastric venting
Diarrhoea- manage dehydration and electrolytes, give patient break from feed or change it- allow patient to recover
Constipation- more fibre in diet, fluid, immobile
What do you monitor in enteral nutrition
- Aim is to reduce the risks of complications, electrolytes and metabolic abnormalities
- Ensure adequate nutrition
- Watch out for other people pulling it out, prevention of tube blocking and infections
- Compliance issues
Describe what is parenteral nutrition
Also known as total parenteral nutrition (TPN) or intravenous infusion
A special liquid mixture given into the blood via a catheter in a vein
Who needs parenteral nutrition and what conditions may require it
Required when:
- Inadequate or unsafe oral and/or enteral nutritional intake
- Non-functional, inaccessible or perforated (leaking) GI tract
- Intestinal failure- temporary or permanent
Should not be used to correct serum albumin levels
Used short term in small bowel dysfunction, fistula, obstruction
Used long term in short bowel, small bowel dysfunction from crohn’s disease, gut bypass
What is intestinal failure
What is intestinal failure
Reduction of gut function below minimum necessary for the absorption of macronutrients and/or water and electrolytes
Such that intravenous supplementation (IVS) is required to maintain health and/or growth
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What is type I , type II and type III intestinal failure
Type I- acute, short term and usually self limiting condition- post operative ileum
Type II- prolonged acute condition, often in metabolically unstable patients, that require a multi-disciplinary care and parenteral nutrition over periods of weeks or months
Type III- chronic condition, in metabolically stable patients that require parenteral nutrition over months or years- may be reversible or irreversible
What are the specific conditions that may require parenteral nutrition? (9)
- Pre-operative nausea and vomiting
- Mucositis from chemotherapy and radiotherapy
- Major abdominal surgery- colonic resection and small bowel resections
- Bowel obstruction
- SB perforation
- Severe acute pancreatitis
- Persistent paralytic ileus post operatively
- Post operative anastomosis breakdown/ abdominal sepsis. small bowel fistulae and adhesions
- Severe burns
What are the clinical factors to consider for PN?
Duration of intestinal failure
Aetiology
- Post op ileus
- Bowel injury
- GI fistulae
- Short bowel
- Motility disorder
Co-morbidity (sepsis etc), renal (dialysis required?), cardiac (CCF need to consider amount of fluid going in and Na levels), liver and sepsis
Prognosis
Available intravenous access
What is the formulation of parenteral nutrition
All in one Multi chamber Standardised Tailor made Macronutrients- carbohydrates, nitrogen, lipids Micronutrients
What is involved in prescribing for parenteral nutrition
Clinical assessment is necessary for:
Indication of Parenteral Nutrition- can the patient eat, swallow, digest and absorb food
Patient medication history
Drug history and current medications
- Oral antidiaetics
- Any medicines that may not be needed with TPN
- Medicines that need to be given parenterally- parbinex etc
- Review opiate drugs
SHx
Nutritional history
Current body weight, weight loss and BMI
Nutritional requirements and refeeding risk
Bio-chemistry- Liver function tests (ability to metabolise TPN), U + Es, CRP and WCC signs of infection, Mg, Ca, PO4
Fluid balance records
Current clinical status and observations
Respiratory problems- don’t overfeed patient as that will increase O2 demand and CO2 production
Any cardiac problems- think about Na+ content and fluids if CCF
Intravenous access for administration
What is involved in the selection of parenteral nutrition?
Assess re-feeding syndrome risk
Assess basal metabolic rate (BMR) and additional stress factors, nitrogen, fluid and electrolyte requirements
Assess route of administration available
Work out rate of administration
Select parenteral nutrition bag
Prescribe parenteral nutrition on chart
Document in medical notes
Order from aseptic services unit
Describe peripheral administration in parenteral nutriton
Duration of parenteral nutrition: 4-7 days
Line type: Venflon
Advantages: nurse can insert and avoid risks of central lines
Disadvantages: incomplete parenteral nutrition, re-site ater 1-2 days, thrombophlebitis, osmolarity of PN
Describe central administration in parenteral nutriton
Duration of parenteral nutrition: long term > 2 weeks
Line type:
Multi-lumen central line
Tunnelled
PICC
Advantages:
Complete parenteral nutrition
Multi-Lumen- other medications
Single lumen- infection chance decreases
Disadvantages: Theatre procedure Risk Line infections Catheter related complications- brachial nerve injury, sepsis, venous thrombosis
What are the considerations for parenteral nutrition (3)
- Glucose infusion rate should be <5mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosis (infiltration of hepatocytes with fat) and respiratory distress
- Lipid infusion should be <0.1g/kg/hour
(ideally 0.4g/kg/day to minimise/prevent parenteral nutrition induced liver dysfunction)- important as careful how much fat is processed by liver - Initiate parenteral nutrition at 1/2 of goal rate/concentration and gradually increase to goal over 2-3 days to optimise serum glucose control
What do we monitor in parenteral nutrition
Current parenteral prescription
Biochemistry
- U and Es, LFTs, FBC, Ca, Mg and PO4
Fluid balance
- Ensure that fluid intake from all sources is recorded such as oral, enteral, drug administration, flushes, IV medication
Capillary blood sugars
Administration line and patency
Clinical signs of infection
GI function
- Bowel function, nasogastric tube aspirate, bowel sounds, can the patient try oral or enteral, drug administration, flushes, IV medication
Nutrient intake and current nutritional status
Drug chart
Weekly weights
Trace elements
Clinical observations
Intravenous catheter inspection
What are the parenteral nutrition complications
Insert complications
- bleeding
- misplacement
Line complications
- line sepsis
- Thrombosis
- Dislodgement
- Fracture, leaking
Metabolic feed complications (Acute) - Refeeding syndrome - Hyper/hypoglycaemia - Electrolyte disturbances - Hypertriglyceridemia - Acute cholestasis
(Chronic)
- Liver disease
- Metabolic bone disease
- micronutrient imbalances
What are the complications of parenteral nutrition
Hepatic steatosis (infiltration of hepatocytes with fat)
- Occurs within 1-2 weeks after starting PN
- Reversible in patients on short term parenteral nutrition and typically resolves within 10-15 days
- Limitation (<1g/kg/day) or remove fat content of parenteral nutrition or cyclical parenteral nutrition over 12 hours per day in long term PN patients
Cholestasis
- Occurs within 2-6 weeks after starting PN
- Indicated by progressive increase in bilirubin and an elevated serum alkaline phosphatase
- Occurs due to no intestinal nutrients to stimulate hepatic bile flow
- Bilrubin is > 5 to 10mg/dL due to hepatic dysfunction, consider stoping trace elements- can cause toxicity of manganase and copper
Gastrointestinal atrophy
- Lack of enteral stimulation associated with villus hypoplasia, colonic mucosal atrophy, decrease GI function, impaired GI immunity, bacterial overgrowth
- Trophic enteral feeding to minimise and prevent it
What is home parenteral nutrition (HPN)
Needed for patients with acute or chronic intestinal failure in whom nutritional and/or water and electrolyte balance cannot be corrected by oral or enteral feeding and whom PN is feasible in home
What is transitional feeding
Switching from parenteral to enteral
Introduction of enteral feeding at a low rate to establish tolerance
Decrease parenteral nutrient levels slowly to keep nutrient levels at same prescribed amount
Enteral rate increased every 4-8 hours, parenteral can be reduced
Discontinue parenteral solution when 50-75% of nutrient needs are met by enteral route
Describe the drug and nutrient interactions during these methods of feeding
Absorption:
Mg or Al antacids with phosphate
Tetracyclines chelate with Ca, Mg, Fe
Quinolones- ciprofloxacin absorption reduced by 50% if given by enteral feed
Metabolism:
Grapefruit juice- cytochrome p450 inhibitor, reduce metabolism of certain drugs hence increased plasma concentrations of amiodarone, cyclosporin, simvastatin
Folate
Pyridoxine (vitamin B6)
Excretion
Diuretics
Amphotericin
Changes feed consistency
Physical interaction between drug and feed product
Enteral feeding tubes can be blocked
Examples: Phenytoin, digoxin, carbamazepine Antacids bind to proteins Penicillins- feed can reduce absorption Never add drug to feed
