Nutritional support 1 Flashcards
What is malnutrition?
A state of nutrition in which deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/ body form (size, shape and composition) and function and clinical outcome. The term malnutrition does include obesity, however BAPEN is focused on the problem of ‘undernutrition’.
What is the phenotypic criteria for malnutrition?
(Global leadership initiative on malnutrition)
Weight loss:
- >5% in last 6 months
- 10% in over 6 months
Low BMI:
- <20 if <70 years
- <22 if >70 years
Reduced muscle mass:
- Using validated method of measurement
Why would you still feed an obese person in hospital?
Prevent deficiency
Aid recovery
Prevent utilisation of lean muscle mass
What is the etiological criteria for malnutrition?
(Global leadership initiative on malnutriton)
Reduced food intake or absorption:
- <50% of energy requirements
- Any reduction >2 weeks
- Any chronic gastrointestinal condition impacting on absorption
Inflammation:
- Acute disease or injury
- Chronic disease states
How would you detect malnutrition?
MUST score
- validated malnutrition screening tool
- first line tool
Blood tests
- any deficiencies e.g. iron, B12
Weight loss
- over a time period
- % loss
Physical examination
- loose clothing
- loose jewellery/ watches etc
- anthropometric measures
- dehydration –> skin
- paleness –> anaemia
BMI
- Low BMI
- Big change in BMI
Reduced muscle mass
Reduced dietary intake
- altered food patterns
- altered food amount
- appetite levels
- mood
Concentration levels?
- brain fog
Feeling cold all the time?
Faltering growth of children/ adolescents
- growth, weight charts
Who is at risk of malnutrition?
Older adults
- at hospital
- home alone
- care home
Mental health conditions
Lower socioeconomic status
Those on appetite affecting medications
Eating disorders
Chronic illnesses
- diabetes
- liver disease
Progressive illness
- cancer
- dementia
Drug/ alcohol addiction
What are the grading of malnutrition in terms of different phenotypic criteria?
(GLIM)
Moderate
- Weight loss –> 5-10% in last 6 months OR 10-20% in over 6 months
- Low BMI –> <20 if <70 years old OR <22 if >70 years
- Low muscle mass –> mild to moderate deficit
Severe
- Weight loss –> >10% in last 6 months OR >20% in. over 6 months
- Low BMI –> <18.5 if <70 years OR <20 if >70 years
- Low muscle mass –> severe deficit
What is the Patient’s Association Nutrition Checklist?
A checklist used in primary care setting/ community
Staff and patient lists
Asks simple questions to screen for malnutrition risk.
Easy to use
Multiple sections
- initial assessment
- gives advice for food and eating
- identifies needs
- signpost other MDT e.g. speech and language therapist, dentist
- social support e.g. having trouble shopping
- follow up steps
Is malnutrition a new problem?
No
McWhirter and Pennington, 1994)
- 40% of patients admitted to hospital were undernourished
- Less than 50% of patients had their nutritional status noted in their hospital case notes
- 64% of the patients reassessed on discharge from hospital had lost weight
Kelly et al 2000
- Malnutrition in acute hospital goes unrecognised in 70% if cases
Stratton 2004
- Between 10-60% of adults admitted to hospital are at risk of malnutrition when screened using MUST
Stratton et al 2003
- Between 30-90% of adults and children lose weight in hospital
Elia 2004
- Estimated 5-23% of patients visiting of their GP, 25% patients receiving district nursing care and 16-29% of patients in institutions are malnourished
Why does malnutrition matter?
- Increased fall risk
- Poor quality of life
- Muscle wastage –> organ damage
- Slower wound healing
- Poor mobility
- Poor immunity –> increased infections
- Increased morbidity and mortality
- Longer hospital stay –> increased cost to NHS
- Impact on growth and development of children
What is the malnutrition carousel?
25-34% of hospital admissions are at risk of malnutrition
|
Longer stay, more complications
More support needed after discharge from hospital
More likely to need care
|
70% of patients weigh less on hospital discharge
|
More GP visits
More prescriptions
More hospital admissions
|
Repeat cycle
What nutritional support is given those with different levels of gastro-intestinal function?
Full
- Food first
Partial
- Enteral and/ or parenteral nutrition
None
- Parenteral nutrition
What are the complications of enteral nutrition?
- Blockages –> require flushing
- Drug/ nutrient interactions –> timings of feed and medications
- Patients preferences –> patients may not want feed4
- Site infections
- Constipation/ diarrhoea –> add in fibre
- Nausea/ fullness
What monitoring is required during enteral nutrition?
5- Patients views –> hunger? feed timings?
- Biochemistry
- Stools/ output
- Tolerance
- Anthropometric measures
- Amount of feed the patient is receiving
What are the types of enteral nutrtion?
Nasogastric
Nasoduodenal
Nasojejunal
- temporary (2-4 weeks maximum)
- different tube thickness depending on patients and their circumstances
Gastrostomy
- Percutaneous endoscopic gastrostomy (PEG)
- Radiologically inserted gastrostomy (RIG)
Jejunostomy
What is parenteral nutrition?
Why is is used?
Parenteral nutrition bypasses the normal digestion in the GI tract. Nutrition is given directly into the bloodstream through intravenous catheter.
Usage
- Gut rest required e.g. paralytic ileus, anastomotic leaks, small bowel fistulae, gastroparesis
- Bowel obstruction
- Ischaemic bowel
- Nutritional requirements cannot be met using enteral route e.g. short bowel syndrome, hypermetabolic states (multiple trauma)
What are the routes of access for parenteral nutrition?
Consequences?
- Peripheral catheters (short term feeding <14 days) –> veins tissues and breaks down causing leakage
- Central venous catheters –> e.g Hickman line
- Peripherally inserted central catheters (PICCs) –> short to medium term feeding
High infection rate –> sepsis in central veins/ lines
What are come complications of using parenteral nutrition?
- Infection
- Mechanical complications after line insertion e.g. pneumothorax, air embolism
- Re-feeding syndrome
- Electrolyte imbalance
- Hyperglycaemia
- Hepatic dysfunction
- Cell/ tissue atrophy of gastrointestinal tract –> can lead to gastroparesis
What is the formulation of parenteral nutrition?
- Three chamber All-in-one-bags (AIO)
- Ready made non-chamber AiO bags
- Tailored bags
What are the source of nutrients in parenteral nutrients?
- Dual energy –> glucose and fat
- Nitrogen –> mix of essential and non-essential amino acids
- Electrolytes
- Vitamins
- Minerals
Enteral VS Parenteral
- Cheaper
- More physiological ‘if the gut works use it’
- Less risk to the patient –> infection, bacteria, translocation
