Nutrition Assessment In Malnourished Patients

Question 1

Key components of malnutrition assessment

Answer 1

Questioning and proving to identify issues
Be responsive to cues
Gather a picture of where the patient is currently and what has changed (recently or over a longer period of time)
Therefore time frame is important in asking questions eg. About weight changes, appetite, and dietary intake
Note: this may be quite different from assessing someone in whom diet and lifestyle have been stable for approx 1 year or more

Question 2

Elements of a system

Answer 2

Screening- to identify those most at risk of malnutrition

Identification of those patients with malnutrition- involves nutrition assessment- diagnosis

Systems and tools for treating malnutrition

• includes interventions such as oral nutritional supplements and enteral nutrition, micronutrient supplementation
• includes addressing the factors contributing to malnutrition eg. Nausea, vomiting, malabsorption

Evaluation and monitoring
- is the patients nutritional status improving over time

Question 3

Tools for detecting malnutrition: individual dietetic case management

Answer 3

Individual dietetic case management:
Adopts an individualised approach
Collect range of data- nutrition diagnosis- management plan
This approach is commonly used by dietitians in detection of malnutrition
Advantages:
Individually tailored
Comprehensive
Detect other nutrition issues as well
Identifies factors contributing to malnutrition (helps target management) eg social factors

Limitations:
Time consuming

Question 4

Tools for detecting malnutrition: mini nutritional assessment

Answer 4

Subjective goal assessment
ICD-10 diagnostic codes for malnutrition
Evolving and novel criteria/ algorithms for malnutrition
Individual nutrition assessment:
- discussion of weight history- unintentional LOW
- quantify amount % of weight loss
- explore time frame of weight loss- rapid, progressive, fluctuating
Many patients will not weigh self or be weighed regularly
- may not weight from younger years or report clothing size changes

Question 5

Quantifying weight lozz

Answer 5

Mild- moderate
6 months 5-10%
Over 1 month 2-5%
Over 1 week 1-2%

Severe
6 moths 5-10%
Over 1 month 2-5%
Over 1 week 1-2%

A recent low is not a necessary criterion as may be chronically malnourished. However, thinness does not equal malnutrition.

Question 6

Link all assessment of signs of malnutrition in mini nutrition sdddssment

Answer 6

• muscle wasting: temples, clavicles, shoulders, interosseous muscle (be thumb and forefinger), scapula, thigh, calf
• loss of subcutaneous fat: orbital fat loss, triceps, fat overlying the ribs, deconditioning
• fluid retention (oedema): in severe malnutrition, many acutely ill patients have oedema independent of malnutrition. Presence may ask severity of malnutrition as it contributes to kgs. If push affected area, it will leave a dint.

Question 7

Exploration of factors that might contribute to negative energy balance

Answer 7

Loss of appetite due to long or short term factors
Energy losses- vomiting
Maldigestion and malabsorption - loss of nutrients before they are absorbed into body eg pancreatic dysfunction, some for of liver disease, small vowel resection
Increased energy expenditure as a result of illness/ injury, hypermetabolism, stress/ illness factors
Stress/ injury factors represent the % by which the illness / stress is thought to increase BMR, important to understand the factors which may result in increased stress factor

Question 8

Subjective global assessment (SGA)

Answer 8

Includes weight loss, intake (in relation to change from usual), GI symptoms, functional capacity and physical examination

Patient categorised as
SGA-A- normal
SGA-B- mild- moderate
SGA-C- severe malnutrition

Limitations
Subjective rating of individual components and overall rating
Low sensitivity for detecting small changes in nutritional status
Intake only assessed in relation to change from usual.

Question 9

Patient generated SGA

Answer 9

First part completed by patient
Provides a category and numerical scoring

Limitations:
Complex scoring, may be subjectivity
More of an indicator of need for intervention that a malnutrition diagnostic tool. If in hospital, would be done on a weekly basis.

Question 10

New ASPEN criteria for malnutrition

Answer 10

First malnutrition tool is to distinguish the different forms of malnutrition. Starvations vs chronic of acute disease related malnutrition (which includes cachexia), distinguished by presence of inflammation - no/yes, mild/ marked, also had separate categories for severe and mild- moderate

Elements of criteria: 2 or more of the following are required to categorise a patient as malnourished:

• insufficient energy intake
• weight loss (doesn’t take stable low BMI into account- limitation)
• loss of muscle mass
• loss of subcutaneous fat
• oedema that may ask weight loss
• reduced functional status