Nutrition in practice

Question 1

What is the annual cost of malnutrition to NHS England?

14.7 million
4.3 billion
23.5 billion

Answer 1

What is the annual cost of malnutrition to NHS England?

14.7 million
4.3 billion
23.5 billion

Question 2

Name 5 reasons why someone might have reduced intake of food [5]

Answer 2

Dysphagia
Prolonged periods NBM
Side effects of treatment
Pain/constipation
Psychological e.g. depression
Social e.g. low income, isolation, cost of living
Poor dentition
Reflux/feeding problems/food intolerance’s

Question 3

Name 3 reasons why someone might have increased requirement of food that causes malnutrition? [3]

Answer 3

Infections
Involuntary movements
Wound healing

Question 4

Name 3 reasons why someone might have increased losses of food that causes malnutrition? [3]

Answer 4

Malabsorption from gut
Diarrhoea and vomiting
High stoma output

Question 5

Name 5 consequences of malnutrition

Answer 5

decreased respiratory function
decreased Cardiac function
decreased Mobility
increased risk of pressure sores
increased risk of infection
decreased wound healing
increased risk of malabsorption
Apathy and depression

CAUSES FURTHER MALNUTRITION

Question 6

Name 2 sreening methods used (by Bart’s Health Trust) for nutritional screening for adults [1] and children [1]?

Answer 6

MUST (adults) and STAMP (paedatrics)

Question 7

How would you calculate a MUST score? [3]

How do you work out an Action Plan for MUST? [1]

Answer 7

MUST:
1. BMI
2. Weight Loss
3. Acute disease effect
4. Add scores for 1-3
5. Action Plan

Question 8

How often should you repeat MUST assessment? [1]

Answer 8

weekly

Question 9

How do you calculate BMI? [1] Unit? [1]

What score would indicate underweight? [1]
normal? [1]
overweight? [1]

Answer 9

Weight (kg)
BMI = ——————
Height (m2)

less than 19 underweight
20 – 25 Normal
more than 25 overweight

Question 10

Whats important to think when assessing malnutrition? [1]

Answer 10

Often missed in overweight patient (high BMI would be scored agaisnt in MUST)

Question 11

ABCDE of dietary screening? [5]

Answer 11

Anthropometrics
* Weight (Dry/Oedema/Ascites)
* Height (ulna, knee length, full body length),
* BMI (Actual or estimate)
* Weight history (?recent weight loss)
* Other measurements – MUAC, MUAMC

Biochemistry
* Pre-existing malnutrition consider evidence of depletion/risk of RFS

Clinical status
* Diagnosis, medications, PMH will impact on nutritional intervention

Dietary intake
* Routes available for feeding
* Pre-admission nutritional intake
* Allergies

Estimated Requirements

Question 12

Name 3 surrogate measures for height [3]

What is a superior meaurement than ^ ? [1]

Answer 12

-Knee height
-Demispan
-Ulna length

Reported height is superior

Question 13

What is a surrogate measure for measuring weight? [1]

Answer 13

Mid upper arm circumference (MUAC) [1] (can measure in supine position)

Question 14

If MUAC is over [], BMI is likely to be over []

If MUAC IS over [], BMI is likely to be >[]

Answer 14

If MUAC is over 23.5, BMI is likely to be over 20 (underweight)

If MUAC IS >32, BMI is likely to be >30 (overweight)

Question 15

How do you estimate dry weight for ascites and peripheral oedema?

Answer 15

Subtract the following

Question 16

Other Anthropometric Measures

Question 17

What does Handgrip Dynamometry (HGD) or Grip Strength measure? [1]

How do you take? [3]

Answer 17

Measures muscle strength & endurance: predictor of mortatility

Can be measured
* -supine or sitting position
* -dominant or non-dominant side
* -repeated measures to mirror original position

Question 18

It is a widely held belief that low albumin arises because of inadequate protein intake.

Explain what causes Hypoalbuminaemia in hospital? [2]

Answer 18

Cause in hospital: is inflammation and sepsis:

• increased C-Reactive Protein
• White Cell Count
• pyrexia
• infection

In these patients capillary walls become more ‘porous’ and albumin drifts out –> low plasma albumin

Low albumin often occurs in sick, malnourished patients, but it is not caused by poor intake

Question 19

Does albumin level reflect nutritional status? [2]

Answer 19

Low albumin often occurs in sick, malnourished patients, but it is not caused by poor intake.

Patients with anorexia nervosa often have normal albumin levels on admission

Question 20

Define refeeding syndrome

Answer 20

A potentially fatal condition characterized by severe fluid and electrolyte shifts and related metabolic implications in malnourished patients undergoing refeeding (via the oral, enteral or parenteral routes)

Question 21

Describe changes that occur when refeeding occurs in refeeding sydrome

What do you become reduced in? [4]

Answer 21

Metabolism changes from fatty acids to carbohydrates

Raised insulin secretion

Insulin stimulates K+, P04-, Mg2+ to return to cells

∴ intracellular stores are replenished but at the expense of plasma concentrations.

See:
* Hypokalaemia
* Hypomagenesiumia
* Hypopohopshataemia
* Thiamine deficiency

Question 22

Refeeding syndrome: clinical consequences of

Hypophosphataemia [5]

Hypomagnesaemia [3]

Hypokalaemia [5]

Answer 22

Hypophosphataemia
Neurological—Seizures, paraesthesia
Musculoskeletal—Rhabdomyolysis, weakness, osteomalacia
Respiratory—Impaired respiratory muscle function
Cardiac—Cardiac failure
Renal—Rhabdomyolysis, fluid and salt retention

Hypomagnesaemia
Neurological—Tetany, paraesthesia, seizures, ataxia, tremor
Cardiac—Arrhythmias
Gastrointestinal—Anorexia, abdominal pain

Hypokalaemia
Neurological—Paralysis, paraesthesia
Musculoskeletal—Rhabdomyolysis
Respiratory—Respiratory depression
Cardiac—Arrhythmias, cardiac arrest
Gastrointestinal—Constipation, paralytic ileus

Question 23

Which Ptx are at risk of refeeding syndrome? [1]

Which Ptx are at high risk of refeeding syndrome? [4]

Which Ptx are at very high risk of refeeding syndrome? [4]

Answer 23

Risk
* Any ptx with very little food for more than 5 days

High risk
ONE OF:
Any one the following;
* BMI less than 16
* Unintentional weight loss >15% in last 3-6 months
* Little or no nutritional intake for more than 10 days
* Low levels of K, PO, Mg prior to feeding

Very high risk
TWO OF THE FOLLOWING:
* BMI less than 18.5
* Unintentional weight loss >10% in last 3-6 months
* Little or no nutrition for more than 5 days
* A history of alcohol abuse or drug use including chemotherapy, antacids or diuretics

Question 24

How can you provide nutritional support from supplemental drinks? [3]

Answer 24

Milkshake style
* Calorie content varies
* Ready made

Juice based
* Fat free

Powdered
* Not nutritionally complete
* Is the patient able to mix it

Question 25

What nutritonal supplements could you provide for ptx with dysphagia? [5]

Answer 25

• Pre-thickened drinks
• Thickening of supplement drinks with a thickener
• Yoghurt style drinks
• Smoothie style drinks
• Yoghurt/dessert pot type supplements

Question 26

What is Gastrotomy / enteral feeding?

Give 4 different examples of entreal access

Answer 26

Tube Inserted through skin into stomach so is inside digestive tract has a tube on phalange on the inside to stop it
coming out. Can be in for years.

Oral
Nasogastric
Orogastric
Nasojejunal
Gastrostomy
Jejunostomy

Question 27

What is parental feeding? [2]

Answer 27

Parenteral feeding is the intravenous administration of nutrients: outside of GI tract, instead straight into veins

Central (ideally) tunnelled subclavian vein central lines,

Peripheral :veins