Y4 - Nutritional Care Flashcards
What are the groups of reasons why patients become malnourished?
Poor food intake Food provision problems Increased requirement Excess losses
Give examples of what make lead to poor food intake
Nausea/vomiting Pain, constipation Symptoms of treatment Mechanical (limb weakness, co-ordination, chewing) Depression/anxiety Texture modification
Give examples of issues with food provision
Shopping/cooking/preparing Poverty/deprivation Dislikes
Give examples of situations that may lead to increased food requirement
Disease/treatment related Cancer Infection Surgery Burns Respiratory (esp. COPD (increased effort of breathing))
How common is malnutrition?
4% general population 30% nursing home residents
What are the consequences of malnutrition?
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
How can we recognise patients at risk of malnutrition?
Nutritional screening MUST tool
What is involved in the MUST screening tool?
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
How do you manage patients according to the MUST tool?
How do you manage a MUST 1?
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
How do you manage a MUST 2?
Refer to dietician
What should be your approach when feeding the elderly?
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)
What are the benefits of giving nutritional supplements?
Reduces complications, e.g. wound breakdown
What are the kinds of nutritional supplements?
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
Define enteral tube feeding
Nutrition provided by enteric tube into GIT
What are the kinds of enteral tube feeds?
Nasogastric tube Gastrostomy tube Jejunostomy tube
What tends to be used for short and long enteral tube feeds?
Short - NG tube Long - gastrostomy
When would you use a jejunostomy tube?
If problems with the stomach
What are the benefits of enteral feeding?
Maintains gut integrity Low risk Physiologically normal Increases muscle strength Reduces LOS Relatively low cost Decreases mortality
When are NG tubes used?
Acute setting For SHORT term use
How do you monitor the position of the NG tube?
Aspirate pH <5 Must check prior to feeds, also after sneezing, hiccups etc.
What is a gastrostomy?
An artificial opening through the abdominal wall into the stomach, through with a feeding tube can be passed
What are the types of gastrostomy tubes?
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
What is the choice of feed in tube feeding determined by?
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
What are the possible complications of enteral feeding?
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)
If there are complications of enteral feeding what can you do?
Reduce feeding rate Stop/start fibre for diarrhoea Change feed (e.g. if protein feed, can give peptide feed instead)
When should you use TPN?
Gut failure/gut inaccessible
What line should you use for TPN?
Central (hickman/PICC) or peripheral
What are the downsides to TPN?
Very expensive Complications - blocked catheter, thrombosis, sepsis
Define refeeding syndrome
Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding
What causes refeeding syndrome?
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
What are the consequences of refeeding syndrome?
Rhabdomyolysis Respiratory failure Cardiac failure Leucocyte dysfunction Hypotension Arrhythmias Seizures Coma Sudden death
Who is at risk of refeeding syndrome?
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
What are the recommendations to avoid refeeding syndrome?
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
Why do you give B vitamins to those at risk of refeeding syndrome?
B vitamins involved in metabolism and so need more to cope with extra food
How do you work out someone’s nutritional requirements?
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
What is the normal nitrogen requirements per day and how do you change this to protein requirement?
0.17 if normal x6.25 to convert to protein
How do you estimate fluid requirements?
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
What things are depleted intracellularly during starvation?
K, Mg, PO4 But intracellular Na and water are increased
Levels of what hormone are low during starvation and why?
Insulin as body adapts from carbohydrate metabolism to fat burning metabolism producing ketones
What organs may be affected by starvation?
Cardiac and renal function may be impaired as there is reduction in excretion of salt and water load Liver abnormalities may occur
What are clinical indicators of refeeding syndrome?
Cardiac failure, pulmonary oedema, dysrhythmias Acute circulatory fluid overload or circulatory fluid depletion Hypophosphataemia Hypokalaemia Hypomagnesaemia and occasionally hypocalcaemia Hyperglycaemia
What are the baseline blood measurements prior to feeding?
Serum urea, electrolytes, calcium, Mg, PO4, glucose FBC LFTs Cardiac monitoring if appropriate
When feeding someone at risk of refeeding how many calories should you start with?
No more than 10kcal/kg body weight/day
What should be monitored in refeeding on a daily basis?
Tolerance of feed, e.g. bowels, vomiting, nausea, biochemical markers
What is the aim of refeeding?
Meet nutritional requirements within 4-7 days of commencing feed
