Y4 - Nutritional Care

Question 1

What are the groups of reasons why patients become malnourished?

Answer 1

Poor food intake Food provision problems Increased requirement Excess losses

Question 2

Give examples of what make lead to poor food intake

Answer 2

Nausea/vomiting Pain, constipation Symptoms of treatment Mechanical (limb weakness, co-ordination, chewing) Depression/anxiety Texture modification

Question 3

Give examples of issues with food provision

Answer 3

Shopping/cooking/preparing Poverty/deprivation Dislikes

Question 4

Give examples of situations that may lead to increased food requirement

Answer 4

Disease/treatment related Cancer Infection Surgery Burns Respiratory (esp. COPD (increased effort of breathing))

Question 5

How common is malnutrition?

Answer 5

4% general population 30% nursing home residents

Question 6

What are the consequences of malnutrition?

Answer 6

Impaired immune function, delayed wound healing, pressure sores Muscle wasting and weakness General weakness/lethargy Leading to longer hospital stays, increased risk of complications, mortality (e.g. depression) & increased risk of admission/re-admission and post-discharge care

Question 7

How can we recognise patients at risk of malnutrition?

Answer 7

Nutritional screening MUST tool

Question 8

What is involved in the MUST screening tool?

Answer 8

BMI score: >20 = 0; 18.5-20 = 1; <18.5 = 2 Weight loss score: unplanned in last 3m - <5% = 0, 5-10% = 1, >10% = 2 Acute disease score: patient acutely unwell & likely to have had no nutritional intake for 5+ days = 2 Score 0 = low risk Score 1 = medium risk Score >1 = high risk

Question 9

How do you manage patients according to the MUST tool?

Answer 9

Question 10

How do you manage a MUST 1?

Answer 10

3 day accurate total intake charts 2 additional snacks from 1st line options (e.g. Meritene milkshake, fortified milk drink, cheese and biscuits) If concerns refer to dietician

Question 11

How do you manage a MUST 2?

Answer 11

Refer to dietician

Question 12

What should be your approach when feeding the elderly?

Answer 12

Little and often - big meals can be daunting and unmanageable May req. extra nourishing drinks Choose energy and protein rich foods Add extra protein & energy (e.g. milk powder, milk, cheese)

Question 13

What are the benefits of giving nutritional supplements?

Answer 13

Reduces complications, e.g. wound breakdown

Question 14

What are the kinds of nutritional supplements?

Answer 14

Milkshake, e.g. ensure plus milkshake style Yoghurt flavoured - ensure plus yoghurt style Fruit juice - ensure plus juice Higher calorie - ensure two cal Small volume - ensure compact Dessert style - ensure plus crème Savoury - build up soups, ensure plus savoury

Question 15

Define enteral tube feeding

Answer 15

Nutrition provided by enteric tube into GIT

Question 16

What are the kinds of enteral tube feeds?

Answer 16

Nasogastric tube Gastrostomy tube Jejunostomy tube

Question 17

What tends to be used for short and long enteral tube feeds?

Answer 17

Short - NG tube Long - gastrostomy

Question 18

When would you use a jejunostomy tube?

Answer 18

If problems with the stomach

Question 19

What are the benefits of enteral feeding?

Answer 19

Maintains gut integrity Low risk Physiologically normal Increases muscle strength Reduces LOS Relatively low cost Decreases mortality

Question 20

When are NG tubes used?

Answer 20

Acute setting For SHORT term use

Question 21

How do you monitor the position of the NG tube?

Answer 21

Aspirate pH <5 Must check prior to feeds, also after sneezing, hiccups etc.

Question 22

What is a gastrostomy?

Answer 22

An artificial opening through the abdominal wall into the stomach, through with a feeding tube can be passed

Question 23

What are the types of gastrostomy tubes?

Answer 23

Percutaneous endoscopic gastrostomy (PEG), e.g. Freka/Corflo Temporary or primary placement radiological placement, e.g. Wills Oglesby Balloon gastrostomy, e.g. Kangaroo Low profile button gastrostomy, e.g. Mickey

Question 24

What is the choice of feed in tube feeding determined by?

Answer 24

Clinical deterioriation Period of nill by mouth prior to commencing feeds Fluid restriction Nutritional requirements Ability to eat orally Continuous pump assisted or bolus feeding

Question 25

What are the possible complications of enteral feeding?

Answer 25

Refeeding syndrome Aspiration - tube may migrate to lungs, more common with NG tube Diarrhoea Tube blockage (commonly with meds, ensure regular flushing) Infection (insertion site)

Question 26

If there are complications of enteral feeding what can you do?

Answer 26

Reduce feeding rate Stop/start fibre for diarrhoea Change feed (e.g. if protein feed, can give peptide feed instead)

Question 27

When should you use TPN?

Answer 27

Gut failure/gut inaccessible

Question 28

What line should you use for TPN?

Answer 28

Central (hickman/PICC) or peripheral

Question 29

What are the downsides to TPN?

Answer 29

Very expensive Complications - blocked catheter, thrombosis, sepsis

Question 30

Define refeeding syndrome

Answer 30

Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding

Question 31

What causes refeeding syndrome?

Answer 31

Starvation adaptations take place to reduce cellular activity & organ function to save energy –> mineral/vitamin deficiency Introduction of nutrition –> rapid rise in insulin, rapid generation of ATP, phosphate moves into cells, hypophosphataemia rapidly develops Movement of Mg, Ca, K from extracellular to intracellular compartments

Question 32

What are the consequences of refeeding syndrome?

Answer 32

Rhabdomyolysis Respiratory failure Cardiac failure Leucocyte dysfunction Hypotension Arrhythmias Seizures Coma Sudden death

Question 33

Who is at risk of refeeding syndrome?

Answer 33

Those with 1 of: - BMI <16kg/m2 - Unintentional weight loss >15% within 3-6m - Low levels of K, Mg, PO4 before feeding Or 2 of: - BMI <18.5kg/m2 -Unintentional weight loss >10% in last 3-6m - Very little nutrition in >5 days - Hx of alcohol abuse

Question 34

What are the recommendations to avoid refeeding syndrome?

Answer 34

Be aware of at risk patients Commence on thiamine, vitamin B co-strong and Forceval daily for 10 days Increase Kcal slowly Check and correct K, Mg, PO4 regularly for 1st week of feeding Give thiamine 20m before feeding

Question 35

Why do you give B vitamins to those at risk of refeeding syndrome?

Answer 35

B vitamins involved in metabolism and so need more to cope with extra food

Question 36

How do you work out someone’s nutritional requirements?

Answer 36

Work out basal metabolic rate Add combined factor for activity and diet induced thermogenesis (0% if sedated & ventilated, 10% if bed bound immobile, 15-20% if bed bound mobile/sitting, 25% if mobile on the ward) Adjust for weight change - if weight change an aim & patient metabolically stable add or subtract 400-1000 calories/day

Question 37

What is the normal nitrogen requirements per day and how do you change this to protein requirement?

Answer 37

0.17 if normal x6.25 to convert to protein

Question 38

How do you estimate fluid requirements?

Answer 38

Maintenance - 35ml/kg/day (if over 60 - 30ml/day) Add 2-2.5ml/kg/24h for each 1C rise in temp Be careful in very thin/obese patients

Question 39

What things are depleted intracellularly during starvation?

Answer 39

K, Mg, PO4 But intracellular Na and water are increased

Question 40

Levels of what hormone are low during starvation and why?

Answer 40

Insulin as body adapts from carbohydrate metabolism to fat burning metabolism producing ketones

Question 41

What organs may be affected by starvation?

Answer 41

Cardiac and renal function may be impaired as there is reduction in excretion of salt and water load Liver abnormalities may occur

Question 42

What are clinical indicators of refeeding syndrome?

Answer 42

Cardiac failure, pulmonary oedema, dysrhythmias Acute circulatory fluid overload or circulatory fluid depletion Hypophosphataemia Hypokalaemia Hypomagnesaemia and occasionally hypocalcaemia Hyperglycaemia

Question 43

What are the baseline blood measurements prior to feeding?

Answer 43

Serum urea, electrolytes, calcium, Mg, PO4, glucose FBC LFTs Cardiac monitoring if appropriate

Question 44

When feeding someone at risk of refeeding how many calories should you start with?

Answer 44

No more than 10kcal/kg body weight/day

Question 45

What should be monitored in refeeding on a daily basis?

Answer 45

Tolerance of feed, e.g. bowels, vomiting, nausea, biochemical markers

Question 46

What is the aim of refeeding?

Answer 46

Meet nutritional requirements within 4-7 days of commencing feed