Nutritional Management Of Patients With Long-term Neurodisability

Question 1

Types of neurodisability (2) and prolonged disorder of consciousness states (4)

Answer 1

• types of neurodisability: acquired brain injury (traumatic, hypoxia, vascular, infection, tumour), neurodegenerative disease (multiple sclerosis, motor neuron disease, Huntingdon’s disease)
• prolonged disorder of consciousness: vegetative state (awake but not aware), minimally conscious state (awake with minimal awareness), emerged (severe cognitive and communication difficulties), locked-in syndrome (awake and aware but unable to move or communicate except from eye movements and blinking)

Question 2

How severe brain injury impacts nutrition

Answer 2

• GI: difficulties swallowing, vomiting, diarrhoea, constipation
• physical: loss of of muscle tone, taste, smell, mobility
• cognitive: memories of food, attention to food, initiating eating
• communication: dyspraxia (reading and writing problems), dysarthria (reduced control and clarity of speech)

Question 3

Nutritional challenges in enterally fed patients

Answer 3

• weight gain: energy requirements can change rapidly once stable and no longer in catabolic phase
• weight loss: rapid changes in metabolism such as ‘storming’, may have infections or increased activity or agitation
• increased fluid losses: sweating in storming, vomiting perhaps due to medication
• GI disorders: constipation, vomiting, diarrhoea
• barriers to delivery of feed: if very violent dont want to endanger nurses doing a bolus feed, dont want them to get tangled in tubes at night
• when transitioning to an oral diet may require a ‘mealmat’ which depicts the kinds of foods they can eat

Question 4

Managing energy requirements and fluid requirements in brain injuries

Answer 4

• start with EI that was having in acute setting and assess if they are gaining or losing weight
• can use PENG guidelines as a rough rule, but need to use clinical judgement i.e may need to rapidly increase EI if storming or infection then rapidly decrease once stable
• for fluid, recommends 30-35 ml/kg/day due to hypersalivation, need to monitor electrolytes closely and change accordingly

Question 5

Sodium balance disorders common in brain injury

Answer 5

• syndrome of inappropriate ADH secretion: low serum Na, high urine Na but low urine output, may be caused by total brain injury/SAH. Treat with electrolyte free water restriction of 800-1000mL per day
• cerebral salt wasting syndrome: low serum Na, high urine output and high urine Na. Caused by brain tumour/TBI/SAH. Treat with 0.9% saline
• diabetes insipidus: high serum Na, high urine output (>3L), low urine Na. Caused by TBI/SAH/intracerebral haemorrhage/pituitary surgery. Treat with vasopressin and increased fluid provision

Question 6

GI disorders associated with brain injury

Answer 6

• vomiting, diarrhoea, constipation, abdominal distention, reflux
• use Nestle tool for information on patient pathway
• may need to perform a vomit diary to ascertain where the issue is i.e could it be a side effect of new medication? Sorbitol containing medications?