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Clinical Teaching > Under Nutrition > Flashcards

Under Nutrition Flashcards

1
Q
A
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1
Q

Define malnutrition.

A

A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome.

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2
Q

How many people are estimated to be affected by malnutrition in the UK?

A

3 million

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3
Q

Which patients are at risk of malnutrition?

A
  • 25-34% of those admitted to hospital
  • 30-42% of those admitted to care homes
  • 18-20% of those admitted to mental health units
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4
Q

What are the main causes of malnutrition?

A
  • Decreased intake
  • Impaired digestion and/or absorption
  • Increased nutritional requirements
  • Increased nutrient losses
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5
Q

What are the psychosocial causes of malnutrition?

A
  • Self-neglect
  • Bereavement
  • Inability to access food
  • Deprivation
  • Loneliness
  • Poor eating environment
  • Lack of assistance
  • Inappropriate food provision
  • Lack of cooking skills of facilities
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6
Q

Who is at risk of malnutrition?

A
  • Those with chronic disease - cancer, COPD.
  • Those with progressive neurological diseases - Parkinsons, MND.
  • Those acutely unwell - infection, stroke.
  • Those over the age of 65 years, particularly if admitted to hospital, or living in a care home/nursing home.
  • Hip fracture patients - 30% are nutritionally at risk.
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7
Q

What are the adverse effects and consequences of malnutrition?

A

Adverse Effect

Consequence

Impaired immune responses

Increase risk of infection and impaired recovery when infected.

Impaired wound healing

Surgical wound dehiscence, anastomotic breakdown, development of post-surgical fistulae.

Reduced muscle strength and fatigue

Inactivity, poor self-care, increased risk of falls.

Reduced respiratory muscle strength

Increased risk of chest infection, difficult to wean from ventilator.

Inactivity, especially in bed bound patient

Increased risk of pressure sores and thromboembolism.

Water and electrolyte disturbances

Decreased ability to excrete sodium and water.

Impaired thermoregulation

Hypothermia.

Menstrual irregularities / amenorrhoea

Infertility and osteoporosis.

Impaired psychosocial function

Apathy, depression, self-neglect.

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8
Q

Describe the cost of malnutrition to primary care.

A
  • Results in increased:
    • Dependency
    • GP visits
    • Prescription costs
    • Referrals to hospital
    • Admission to care homes
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9
Q

Describe the cost of disease-related malnutrition to secondary care.

A
  • Results in increased:
    • Complications e.g. infections, pressure ulcers
    • Length of stay
    • Readmissions
    • Mortality
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10
Q

Describe the management plan for patients at low risk of malnutrition.

A
  • 0 - Low Risk. Require rountine clinical care​.
  • Repeat screening
    • In hospital - weekly
    • In care homes - monthly
    • In the community - annually for specific groups (eg those >75 years)
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11
Q

Describe the management plan for a patient at medium risk of malnutrition.

A
  • 1 - Medium Risk. Requires observation.​
  • Document dietary intake for 3 days
  • If adequate - little concern and repeat screening.
    • In hospital - weekly
    • In a care home - at least monthly
    • In the community - at least every 2-3 months
  • If inadequate - clinical concern. Follow local policy, set goals, improve and increase overall nutritional intake, monitor and review care plan regularly.
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12
Q

Describe the management plan for a patient at high risk of malnutrition.

A
  • 2 or more - High Risk. Requires treatment.
  • Refer to dietician, nutritional support team or implement local policy.
  • Set goals, improve and increase overall nutritional intake.
  • Monitor and review care plan:
    • In hospital - weekly
    • In a care home - monthly
    • In the community - monthly
  • *Unless detrimental or no benefit is expected from nutritional support, for example imminent death.
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13
Q

What are the alternative measures of malnutrition?

A
  • Recently documented or self-reported height/weight.
  • Ulna length, knee height or demispan to estimate height.
  • If weight and height cannot be obtained, BMI range can be estimated using mid upper arm circumference.
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14
Q

What are the subjective criteria used to assess malnutrition?

A
  • MUAC - estimated BMI range.
  • Eyeball assessment:
    • Loose fitting jewellery or clothing
    • Any underlying disease
    • History of decreased food intake
    • Swallowing problems that may indicate weight loss
    • Clinical condition - acute disease score
  • Use to estimate risk category as low, medium or high.
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15
Q

Describe a nutritional assessment.

A
  • Anthropometry - collected on admission / outpatient clinic and at regular intervals.
  • Biochemical - collected by medical staff on admission and as appropriate.
  • Clinical condition including reason for admission and past medical history - collected by the medical team on admission.
  • Dietary - nutritional requirements and diet history / 24 hour recall / 3 day food and fluid record chart.
  • Environmental, social and physical - collected on admission / outpatient clinic.
16
Q

Which groups of people need nutritional support?

A
  • BMI <18.5
  • Unintentional weight loss >10% within the last 3-6 months
  • BMI <20 and unintentional weight loss >5% within the last 3-6 months.
  • Have eaten or are likely to eat little or nothing for more than 5 days or longer.
  • Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.
17
Q

What are the options for nutrition support?

A
  • Oral nutrition support - eg. dietary counselling including food fortification, additional snacks and/or sip feeding.
  • Enteral tube feeding - the delivery of a nutritionally complete feed directly into the gut via a tube.
  • Parenteral nutrition - the delivery of nutrition intravenously.
18
Q

Describe the food first approach.

A
  • Encourage small, frequent meals and snacks / nourishing drinks.
  • Adjust choices of everyday foods added to the diet to increase energy and protein content (full fat milk, cheese, yoghurts).
  • Overcome potential barriers to oral intake (physical, mechanical, environmental - consider referral onto other healthcare professionals as required in line with local guidelines).
  • Dietary counselling has potential advantages in that it can offer greater variety, however, data on clinical outcomes is limited.
19
Q

What are the indications for oral nutritional supplements?

A
  • Standard ACBS indications:
    • Disease-related malnutrition
    • Intractable malabsorption
    • Per-operative preparation of malnourished patients
    • Dysphagia
    • Proven IBD
    • Post total gastrectomy
    • SBS - short bowel syndrome
    • Bowel fistulae
20
Q

What is the evidence for the use of oral nutritional supplements?

A
  • Benefits, particularly in acutely ill older patients.
  • Can increase protein and energy intake, improve weight and have functional benefits.
  • Clinical benefits include reductions in complications, hospital admissions and readmissions.
  • Cost effective if used appropriately.
21
Q

What are the indications for enteral tube feeding?

A
  • Inadequate or unsafe oral intake, and a functional, accessible GI tract.
  • Unconscious patients.
  • Neuromuscular swallowing disorder.
  • Upper GI obstruction.
  • GI dysfunction.
  • Increased nutritional requirements.
22
Q

What is enteral tube feeding?

List the different types.

A
  • Delivery of a nutritionally complete feed via a tube into the stomach, duodenum or jejunum.
    • Nasogastric (NG)
    • Nasojejunal (NJ)
    • Percutaneous endoscopic gastrostomy PEG
    • Percutaneous jejunostomy
    • Surgical jejunostomy
23
Q

What are the contra-indications for enteral tube feeding?

A
  • Lower GI obstruction
  • Prolonged intestinal ileus
  • Severe diarrhoea or vomiting
  • High enterocutaneous fistula
  • Intestinal ischaemia
24
Q

What are the complications of insertion in enteral tube feeding?

A
  • Nasal damage
  • Intra-cranial insertion
  • Pharyngeal/oesophageal pouch perforation
  • Bronchial placement
  • Precipitate variceal bleeding
  • Bleeding
  • Intestinal / colonic perforation
25
Q

What are the post-insertion traumas associated with enteral tube feeding?

A
  • Discomfort
  • Erosions
  • Fistulae
  • Strictures
26
Q

What are the indications for parenteral nutrition?

A
  • Healthcare profesionals should consider parenteral nutrition in people who are malnourished or at risk of malnutrition and meet either of the following criteria:
    • Inadequate or unsafe oral and/or enteral nutritional intake.
    • A non-functional, inaccessible or perforated GI tract:
      • IBD with severe malabsorption
      • Radiation enteritis
      • Short bowel syndrome
      • Motility disorders
27
Q

Describe the access routes used for parenteral nutrition.

A
  • Secure venous access required for the safe delivery of parenteral nutrition:
    • Peripheral access
    • Central access
  • In considering the type of venous access, it is important to consider:
    • The duration parenteral nutrition support is likely to be required
    • Nutritional requirements
28
Q

What are the complications of line insertion in parenteral nutrition?

A
  • Pneumothorax
  • Misplacement
29
Q

What are the complications of the line itself in parenteral nutrition?

A
  • Line sepsis
  • Thrombosis
30
Q

What are the acute metabolic complications of parenteral nutrition?

A
  • Refeeding syndrome
  • Hyperglycaemia
  • Hypoglycaemia
31
Q

What are the chronic metabolic complications of parenteral nutrition?

A
  • Liver disease
  • Micronutrient imbalances
32
Q

When designing a feeding regimen, what factors should be taken into account?

A
  • Energy, protein, fluid, electrolyte, mineral, micronutrient and fibre needs.
  • Activity levels and the underlying condition, eg. catabolism, pyrexia.
  • GI tolerance, potential metabolic instability and risk of refeeding syndrome.
  • Likely duration of nutrition support
  • Other aspects of care
33
Q

What is refeeding syndrome?

A
  • Potentially fatal shifts in fluids and electrolytes and disturbances in organ function and metabolic regulation that may result from rapid initiation of refeeding after a period of undernutrition.
  • Less likely to occur with oral feeding as intake is usually limited but excessive feeding can easily be administered by parenteral nutrition or enteral nutrition.
34
Q

What are the metabolic features of refeeding syndrome?

A
  • Hypokalaemia
  • Hypophosphataemia
  • Hypomagnesaemia
  • Altered glucose metabolism
  • Fluid overload
35
Q

What are the physiological features of refeeding syndrome?

A
  • Arrhythmias
  • Altered level of consciousness
  • Seizure
  • Respiratory failure
  • Cardiovascular collapse
  • Death
36
Q

Describe the prevention and management of refeeding syndrome in high risk patients.

A
  • Check PO4, Mg2+, K+, and Ca2+
  • Provide immediately before and during the first 10 days of feeding:
    • Thiamin
    • Vitamin B compound
    • Multivitamin and mineral supplement
  • Start feeding at 5-10kcal/kg/day
  • Slowly increase feeding over 4-7 days
  • Rehydrate carefully and supplement/correct levels of PO4, Mg2+, K+, and Ca2+.
  • Monitor PO4, Mg2+, K+, and Ca2+ for the first 2 weeks and amend supplementation as appropriate.

Clinical Teaching (12 decks)

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