Malnutrition

Question 1

what is malnutrition

Answer 1

a state of nutrition in which a deficiency, excess or imbalance of energy, protein, nutrients (vitamins or minerals) causes measurable adverse effects on tissue, body form, function and clinical outcome

Question 2

what are the disease related causes of malnutrition

Answer 2

decreased intake, impaired digestion/ absorption, increased requirements/ losses

Question 3

what can cause a decreased intake of food

Answer 3

poor appetite, pain on eating, medication side effects, dysphagia, sore mouth

Question 4

what can cause impaired digestion and/or absorption

Answer 4

problems affecting stomach, intestine, pancreas and liver

Question 5

what causes an increase in nutritional requirements

Answer 5

catabolism infection, trauma, burns, surgery

Question 6

what causes increase nutrient losses

Answer 6

vomiting, diarrhoea, stoma losses, crohns

Question 7

how prevalent is malnutrition and why is it such a big problem

Answer 7

30-40% of hospital admissions identified as malnourished (under nourished)
27% severely malnourished
75% continue to lose weight in hospital
50 % unrecognised

Question 8

what groups of patients are at high risk of malnutrition

Answer 8

care home residents, mental health unit admissions, hospital admissions

Question 9

how much is public expenditure on disease related malnutrition

Answer 9

£13 billion per year

Question 10

how would the cost of malnutrition be managed

Answer 10

improving the systemic screening, assessment and treatment of malnourished patients

Question 11

what chronic conditions can lead to poor food intake

Answer 11

anorexia, asthenia, depression, dysphagia, malabsorption, fistula, diarrhoea, infection (TB, HIV), immobility

Question 12

what acute event can lead to Gi dysfunction, increased infection rate, decreased wound healing, physical weakness

Answer 12

sepsis, pneumonia, fever, surgery, trauma, radiotherapy, radiotherapy, chemotherapy

Question 13

what can lead to stress related metabolism

Answer 13

hypermetabolism, inflammatory response, insulin resistance

Question 14

how can chronic and acute conditions interact to exacerbate malnutrition and increase the length of stay

Answer 14

Chronic condition often result in poor food intake which in turn leads to malnutrition, which increases the likelihood of GI dysfunction, infections and poor wound healing which can further decrease food intake. At same time may have acute events feeding into this such as sepsis or surgery or treatment side-effects, which result in increased nutritional requirements due to stress-induced catabolism

Question 15

what are the psychosocial causes of nutrition

Answer 15

inappropriate food provision, lack of assistance, poor eating environment, self neglect, bereavement, inability to access food, deprivation, loneliness, lack of cooking skills or facilities

Question 16

how does starvation and injury affect metabolic rate

Answer 16

starvation decreases

injury increases

Question 17

how does starvation and injury affect weight

Answer 17

starvation: slow loss, almost all from fat stores
injury: rapid loss, 80% from fat stores, remainder from protein

Question 18

how does injury and starvation affect nitrogen losses

Answer 18

starvation: decreases losses
injury: increases losses

Question 19

how does starvation affect hormones

Answer 19

Early small increases in catecholamines, cortisol, GH, then slow fall. Insulin decreased

Question 20

how does injury affect hormones

Answer 20

Increases in catecholamines, cortisol, GH. Insulin increased but relative insulin deficiency

Question 21

how does starvation and injury affect water and sodium

Answer 21

starvation: initial loss, late retention
injury: retention

Question 22

what are the adverse effects of malnutrition

Answer 22

impaired immune responses and wound healing, reduced muscle strength (including respiratory muscle) and fatigue, inactivity, water and electrolyte imbalance, impaired thermoregulation, menstrual irregularities/ amenorrhoea (absence of periods), impaired psycho-social function

Question 23

when and using what are admitted patients screened from malnutrition

Answer 23

within 1 day of admission

MUST score

Question 24

what are the subjective (in the absence of height and weight) indicators used to identify malnutrition

Answer 24

physical appearance, history of unplanned weight loss, loose fitting clothing/ jewellery, need for assistance, current illness posing risk of malnutrition or increasing nutritional needs, swallowing difficulties

Question 25

what are the physical assessment for nutrition

Answer 25

bmi, anthropometry (mid-arm circumference, triceps, grip strength)

Question 26

what are the biochemical assessments of nutritional status

Answer 26

albumin, transferrin (synthesis reduced in protein restriction and affected by abdominoperineal resection, iron deficiency and liver disease), transthyretin (prealbumin) (reflects dietary intake, increased in uraemia and dehydration, decreased in fasting), retinol binding protein (reflects recent dietary intake), urinary creatinine (excretion rate reflects muscle mass), IGF1 (reduced in malnutrition), micronutrients

Question 27

what biochemical measures should be taken for older people in the community

Answer 27

vitamins A,B,C,D and E, albumin and zinc all lower in high risk groups

Question 28

what parameters means a patient requires nutritional suppport

Answer 28

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

Question 29

what are the different types of nutritional support

Answer 29

Food fortification & dietary counselling oral nutritional support enteral tube feeding parental nutrition

Question 30

what is enteral tube feeding

Answer 30

Delivery of a nutritionally complete feed via a tube into the stomach, duodenum or jejunum

Question 31

what should be the first step in managing malnutrition

Answer 31

food first: increase energy and protein of diet without increasing volume (food fortification)

Question 32

what issues can interfere with a patient eating an drinking on a ward

Answer 32

``` Presentation of food/drink Difficulty swallowing Unpleasant smells on the ward Treatment/ scans at mealtimes Lack of privacy Hospital crockery or cutlery ```

Question 33

what alerts staff to patients that require physical assistance with eating and drinking

Answer 33

coloured tray

Question 34

why might someone need help eating and drinking

Answer 34

cognitive impairment, swallowing difficulties, learning disabilities

Question 35

what are some oral nutritional supplements

Answer 35

ready made drinks, powders, puddings, carb fat and protein supplements

Question 36

what are the indications for ETF

Answer 36

inadequate or unsafe oral intake, | afunctional, asseccible gastrointestinal tract

Question 37

in what patients should ETF be used instead of PN

Answer 37

``` ‘if the gut works, use it’ Unconscious patients Neuromuscular swallowing disorder Upper GI obstruction GI dysfunction Increased nutritional requirements ```

Question 38

what are the contraindications of ETF

Answer 38

``` Lower gastrointestinal obstruction Prolonged intestinal ileus Severe diarrhoea or vomiting High enterocutaneous fistula Intestinal ischaemia ```

Question 39

what are the complications of enteral tube feeding

Answer 39

insertion (nasal damage, perforation, bleeding) post insertion trauma displacement (bronchial administration of food) reflux (oesophagitis, aspiration) GI intolerance (nausea, bloating, pain, diarrhoea) metabolic (Refeeding syndrome, hyperglycaemia, fluid overload, electrolyte disturbance)

Question 40

describe PN

Answer 40

The administration of nutrient solutions via a central or peripheral vein

Question 41

what are the negatives of parental nutrition

Answer 41

``` Expensive Complications are life-threatening Needs specialist skills Not physiological Psycho-social disturbance ```

Question 42

what are the indications for PN

Answer 42

inadequate or unsafe oral and/or enteral nutritional intake a non-functional, inaccessible or perforated (leaking) gastrointestinal tract - IBD with severe malabsorption - Radiation enteritis - Short bowel syndrome - Motility disorders

Question 43

what are the indications for PN feeding in type 1 intestinal failure

Answer 43

``` Severe malnutrition pre-op Post-op feeding: ileus/organ failure/5 day rule Intestinal fistulae Multi-organ failure Post chemo mucositis ```

Question 44

what are the ethical considerations of nutritional support

Answer 44

Food & fluids essential to life - Social and psychological role - Viewed as symbols of caring Withholding nutrition can be perceived as neglect