Nutrition

Question 1

Causes of malnutrition?

Answer 1

o Reduced Dietary Intake: Depression, dementia, schizo
o Malabsorption: Coeliac, chronic pancreatitis, Crohn’s disease
o Increased losses or altered requirements: e.g., enterocutaneous fistulae or burns
o Energy expenditure: major trauma, head injury or burns

Question 2

Consequence of malnutrition?

Answer 2

o Muscle function - Reduced muscle function and mass.
o Cardio-respiratory function- Reduced cardiac muscle mass –> reduced cardiac output. Also micronutrient and electrolyte deficiencies may reduce cardiac function.
o Gastrointestinal function
 Changes in pancreatic exocrine function, intestinal blood flow, villous architecture and intestinal permeability.
 colon loses its ability to reabsorb water and electrolytes, and secretion of ions and fluid occurs in the small and large bowel.
o Immunity and wound healing - Increased risk of infection (impaired cell-mediated immunity and cytokine, complement and phagocyte function) and delayed wound healing
o Psychosocial effects - e.g. apathy, depression, anxiety, self neglect

Question 3

Process of wound healing??

Answer 3

1. Hemostasis: action of platelets and cytokines forms a haematoma and causes vasoconstriction, limiting blood loss at the affected area
2. Inflammation: a cellular inflammatory response acts to remove any cell debris and pathogens present
3. Proliferation: cytokines released by inflammatory cells drive the proliferation of the fibroblasts and the formation of granulation tissue – angiogenesis promoted by the presence of growth mediators (e.g VEGF), allowing for further maturation of the granulation tissue
4. Remodelling: collagen fibres are deposited within the wound to provide strength in the region, with the fibroblasts subsequently undergoing apoptosis

Question 4

Score used to assess nutrition?

Answer 4

MUST

Question 5

If height is not known, how to estimate it?

Answer 5

o Ulna length –
 bend an arm (left side if possible), palm across chest, fingers pointing to opposite shoulder.
 Using a tape measure, measure the length in centimetres (cm) to the nearest 0.5 cm between the point of the elbow (olecranon) and the mid-point of the styloid process

o Knee height – Measure left leg if possible.
 The subject should sit on a chair, without footwear, with knee at a right angle.
 Hold tape measure between 3rd and 4th fingers with zero reading underneath fingers. Place your hand flat across the subject’s thigh, about 4 cm (11⁄2 inches) behind the front of the knee.
 Extend the tape measure straight down the side of the leg in line with the bony prominence at the ankle (lateral malleolus) to the base of the heel. Measure to nearest 0.5 cm.

o Demispan - midpoint of the sternal notch to between the middle and ring finger of subjects right hand

Question 6

How to estimate the BMI for use in the MUST score?

Answer 6

o mid upper arm circumference (MUAC): -  The subject should be standing or sitting.
 Use left arm if possible and ask subject to remove clothing so arm is bare.
 Locate the top of the shoulder (acromion) and the point of the elbow (olecranon process).
 Measure the distance between the 2 points, identify the mid point and mark on the arm.
 Ask subject to let arm hang loose and with tape measure, measure circumference of arm at the mid point.
 Do not pull the tape measure tight - it should just fit comfortably round the arm.
 If MUAC is less than 23.5 cm, BMI is likely to be less than 20 kg/m2 i.e. subject is likely to be underweight. If MUAC is more than 32.0 cm, BMI is likely to be more than 30 kg/m2 i.e. subject is likely to be obese

Question 7

Recommendations for MUST scores?

Answer 7

• MUST score = 0 – Repeat screening (hospital – weekly; care home – monthly; Community – annually)
• MUST Score = 1
o Document dietary intake for 3 days
o If adequate – little concern and repeat screening (Hospital – weekly; Care Home – at least monthly; Community – at least every 2-3 months)
• MUST = 2 or higher
o Refer to dietitian, Nutritional Support Team or implement local policy
o Set goals, improve and increase overall nutritional intake
o Monitor and review care plan (Hospital – weekly; Care Home – monthly; Community – monthly)
• Obesity - Record presence of obesity. For those with underlying conditions, these are generally controlled before the treatment of obesity.

Question 8

Define acute disease effect in MUST score?

Answer 8

• Acute disease effect = Acutely ill and no nutritional intake or likelihood of no intake for more than 5 days

Question 9

Metabolic consequences of refeeding syndrome?

Answer 9

Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance

Question 10

Define high risk of re-feeding problems?

Answer 10

If one or more of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% over 3-6 months
Little nutritional intake > 10 days
Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

If two or more of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10% over 3-6 months
Little nutritional intake > 5 days
History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Question 11

Mx of someone at risk of re-feeding syndrome?

Answer 11

Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days

Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements

Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

Question 12

Define malnutrition?

Answer 12

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 13

When to do the MUST score?

Answer 13

it should be done on admission to care/nursing homes and hospital, or if there is concern. For example an elderly, thin patient with pressure sores

Question 14

What is the food first approach?

Answer 14

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 15

What conditions is refeeding syndrome associated with? Features?

Answer 15

malnourished patients in e.g. malignancy, chronic organ dysfunction, inflammatory conditions (e.g. pancreatitis, colitis), the perioperative period as well as anorexia nervosa.

Sequelae of hypophosphataemia, hypokalaemia, hypocalcaemia, hypomagnesaemia, e.g.
Congestive heart failure, peripheral oedema, rhabdomyolysis, seizures, haemolysis

Question 16

Mx of refeeding syndrome?

Answer 16

Involvement of a dietitian
Daily monitoring & replacing electrolytes (hypophosphataemia, hypomagnesaemia, hypocalcaemia)
Vitamin replacement as per trust guidelines (typically IV Pabrinex for 3 days followed by oral vitamin b co strong & thiamine)
A slow introduction of nutrition as guided by the dietetics team

Question 17

Complications of TPN?

Answer 17

If infused peripherally - Thrombophlebitis

Complications are related to sepsis, re-feeding syndromes and hepatic dysfunction.

Question 18

Define pressure ulcers?

Answer 18

• an area of damaged skin and/or the tissues below as a result of being placed under pressure.

Question 19

Describe the types of pressure ulcer?

Answer 19

Stage 1: Non-blanchable redness of intact skin

Stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough - May also present as an intact or open/
ruptured sero-sanguinous blister.

Stage 3: full thickness skin loss with visible subcutaneous fat. Bone, tendon, or muscle are not exposed.

Stage 4: full thickness tissue loss wth exposed bone, tendon, or muscle

Question 20

Causes of pressure ulcer?

Answer 20

o Pressure from a hard surface (eg. Bed or wheelchair)
o Pressure that is placed on the skin through involuntary muscle movements – such as muscle spasms
o Moisture – can break down outer layer of skin

Question 21

Common sites of pressure ulcer?

Answer 21

Heels, Elbows, Hips, Base of spine, Shoulder blades

Question 22

Pressure ulcer screening tools?

Answer 22

Braden scale, waterlow scale

Question 23

RFs for pressure ulcers?

Answer 23

Weight: Obese or underweight
Elderly
Mulnutrition
Urinary and faecal incontinence
Reduced mobility

Tissue malnutrtion: Terminal cachexia, organ failure, peripheral vascular disease, anaemia, smoking

Neuro deficit: Diabetes, MS, CVA, paraplegia

Major surgery/trauma: Orthopaedic/spinal, prolonged time on the table.

Question 24

Mx of patients at risk of pressure ulcers?

Answer 24

 change their position frequently and at least every 6 hours
 Consider the seating needs of people – if sitting for prolonged period of time eg. high-specification foam or equivalent pressure redistributing cushion