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Year 2 Gastro > Malnutrition and Nutritional Assessment > Flashcards

Malnutrition and Nutritional Assessment Flashcards

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1
Q

Define malnutrition

A

a state resulting from lack of uptake or intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease

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2
Q

In who is malnutrition most prevalent in?

A

Youngest and oldest adult age groups (over 65)
Curvilinear relationship

More common in women than men

Oncology and care of the elderly walls

Those with Gastrointestinal disease

Long term condtions e.g. diabetes

Chronic progressive conditions e.g. cancer or dementia

Those who abuse drugs or alcohol

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3
Q

What percentage of people admitted to hospital are malnourished?

A

1 in 3

33%

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4
Q

What percentage of people loose weight after discharge?

A

70%

Mainly muscle mass

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5
Q

What is disease related anorexia?

A

Loss of appetite as a result of pathophysiological mechanisms observed in the presence of disease

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6
Q

Why do people loose weight in hospital?

A 
40% of food left on plate
GI symptoms
Depression/Low mood
Quality of food
Lack of motivation
Food of secondary importance
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7
Q

What was the impact of malnutrition on recovery from surgery for duodenal cancer?

A

a state resulting from lack of uptake or intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease

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8
Q

What did the ONS reveal about hospital deaths and malnutrition in 2016?

A

Direct cause 66 hospital deaths

Contributory factor 285 hospital deaths

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9
Q

What increases as a result of malnutrition?

A 
Mortality
septic and post surgical complications
length of hospital-stay
pressure sores
re-admissions
dependency
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10
Q

What decreases as a result of malnutrtion?

A

Wound healing, response to treatment, rehabilitation potential, quality of life

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11
Q

What is the cost of malnutrition in England per year?

A

£ 19.6 billion

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12
Q

How is malnutrtion diagnosed in acute settings?

A

Malnutrition universal screening tool (MUST)

A simple tool to identify risk.
Carried out by any HCP.
This is not assessment or diagnosis.

Clasfies as low, medium and high risk of malnutrition

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13
Q

What is nutrition assessment?

A

A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance.

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14
Q

What is anthropometry?

A

Measurement of body

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15
Q

What is conducted in a anthropometry assessment?

A

Scale for weight
BMI is insignificant

Midarm muscle circumference

Multifrequency bioelectrical impedance analysis - renal and haematology patients

CT for muscle content and fat - expensive and radiation

Hand grip strength - response earlier to malnutrition

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16
Q

What biochemistry is used?

A

Measurements of micronutrients - expensive

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17
Q

With inflammation what must be achieved before measuring micronutrients?

A

CRP below 10 micrograms per litre

Otherwise skewed results

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18
Q

What is included in a dietary history?

A 
Anorexia
Allergies
Fad dieting 
Aversions
Cultural, religious, ethical Dietary restrictions
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19
Q

How are nutritional requirements calculated?

A

Predictive equations that estimate resting metabolic rate

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20
Q

What is nutritional requirement?

A

Average dietary intake that is predicted to maintain energy balance in an adult of a defined age, gender, weight, height and physical activity

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21
Q

What is done once malnutrition has been diagnosed?

A

Plan
Implement
Monitor
Evaluate

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22
Q

How is malnourished defined by NICE?

A

BMI < 18.5 kg/m2 or

Unintentional weight loss >10 % past 3 - 6 / 12 or

BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.

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23
Q

How is at risk of malnutrition defined by NICE?

A

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or

Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

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24
Q

What is artificial nutrition support?

A

The provision of enteral or parenteral nutrients to treat or prevent malnutrition

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25
What is used to decide how malnutrition is treated?
Stratton and Elia flowchart
26
What is always considered first in treatment?
Oral route
27
What implications does enteral nutrition have?
Ethical and Legal | ESBEN have guidelines on the ethical aspects of artificial nutrition and hydration
28
What are the features of the route of feeding?
Enteral nutrition (EN) is superior to parenteral nutrition (PN). Where parenteral nutrition is used, the aim is to return to enteral → oral feeding as soon as (where) clinically possible.
29
How is access decided for feeding?
Is gastric feeding possible? ``` Yes = Naso-gastric tube (NGT) No = Naso-duodenal (NDT) / naso-jejunal tube (NJT) ``` Long term (> 3 months) = Gastrostomy/jejunstomy
30
What are the complications associated with enteral feeding?
Misplaced NGTs (21 deaths between 2005-2011) Mechanical Metabolic GI
31
What must be done when an NG tube has been placed?
An aspirate needs to be obtained from the tube indicating a pH of 5.5 or less Reflecting gastric contents If pH is greater, CXR is indicated
32
What are the mechanical complications of NG feeding?
Misplacement Blockage Buried bumper
33
What are the metabolic complications of NG feeding?
Hyperglycaemia | Deranged electrolytes
34
What are the GI complications of NG feeding?
``` Aspiration Nasopharyngeal pain Laryngeal ulceration Vomiting Diarrhoea ```
35
What is parenteral nutrition?
Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.
36
What are the indications for parenteral nutrition?
An inadequate or unsafe oral and/or enteral nutritional intake OR A non-functioning, inaccessible or perforated gastrointestinal tract
37
How is access for parenteral nutrition gained?
Central venous catheter (CVC): tip at superior vena cava and right atrium. Different CVCs for short / long term use.
38
Where can CVCs be inserted?
Subclavian Jugular Femoral Antecubital fossa
39
What composes parenteral nutrition?
Ready made / bespoke “scratch” bags. MDT → fluid and electrolyte targets
40
What are the complications associated with parenteral nutrition?
Mechanical Metabolic Catheter-related
41
What are the metabolic complications of parenteral nutrition?
``` Deranged electrolytes Hyperglycaemia Abnormal liver enzymes Oedema Hypertriglycerideamia ```
42
What are the mechanical complications of parenteral nutrition?
``` Pneumothorax Haemothorax Thrombosis Cardia arrhythmias Thrombus Catheter occlusion Thermophlebitis Extravasion ```
43
Does nutrition support benefit the malnourished patient?
Lowers mortality Reduction in readmission Weight increase Better outcomes
44
What is albumin?
most abundant circulating protein Albumin synthesised in the liver. Low plasma albumin = poor prognosis. A negative acute phase protein = ↓ plasma albumin when ↑ inflammation.
45
What happens in acute inflammatory phase?
Inflammatory stimulus → activation of monocytes & macrophages → release cytokines. Cytokines act on liver to stimulate production of some proteins whilst downregulating production of others e.g. albumin. Albumin levels decrease
46
What is refeeding syndrome?
A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.
47
What are the consequences of Refeeding syndrome?
Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death Respiratory depression Encephalopathy, coma, seizures, rhabdomyolysis, Wernicke’s encephalopy
48
What happens when carbohydrate is reintroduced after starvation?
Secretion of insulin Na/K ATPase activation Increased uptake of solutes Low electrolytes in plasma
49
What are the criteria for defining the risk of RFS?
At risk: very little or no food intake for > 5 days High risk: one or more of BMI less than 16 kg/m2 unintentional weight loss greater than 15% within the last 3–6 months little or no nutritional intake for more than 10 days low levels of potassium, phosphate or magnesium prior to feeding. BMI less than 18.5 kg/m2 unintentional weight loss greater than 10% within the last 3–6 months little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.
50
What defines extremely high risk of RFS?
BMI < 14 | Negligible intake for more than 15 days
51
How is RFS managed at the start?
Start with 10-20 kcal/kg Carbohydrates 40-50% Micronutrients from onset of feeding Correct and monitor electrolytes daily following Trust policy Administer thiamine from the onset of feeding following Trust policy Monitor fluid shifts and minimise risk of fluid and Na+ overload
52
What can you use to estimate height and weight if the patients is unable to tell you?
Ulnar length Mid arm circumference e.g. Ulna length: 27 cm = height 1.71m Mid upper arm circumference 21cm = BMI 18 kg / m2. Weight est. 60 kg
53
What do you have to be mindful of when giving propofol?
Contributes additional energy of 1 kcal/mL | Risk of fat overload
54
What do pro-kinetics do?
Promote gastric emptying
55
What must be monitored when feeding?
Bowel frequency | Bristol stool chart
56
What can be used when bowel frequency is high?
Pancreatic enzymes to help with absorption
57
What is PICC?
Peripherally inserted central catheter
58
What are the two main nutritional goals for all patients?
Prevent dehydration Improve nutritional status
59
What are some of the implications nutritionally of commonly prescribed ICU medications?
Slow gut motility | Reduce blood flow to gut increasing risk of gut ischaemia
60
What often happens during ICU admission?
Many become insulin resistant showing hyperglycaemia Give insulin but must be mindful of hypoglycaemia
61
What needs to happen if a patients it taking the anticonvulsant phenytoin?
If given via the enteral route requires a break from feed for drug absorption
62
What does the Penn State equation for feeding take into account?
``` Gender Age Height Temperature Ventilation settings ```
63
How can you feed into the gut if there is stenosis in the duodenum?
Naso-jejunal tube Can be place via endoscopy or also at the bedside
64
What is 'trophic' NG feeding?
Minimal amount
65
Why do you always want to prioritise enteral feeding?
Used alongside parenteral | To challenge the gut, stop gut becoming leaky, high risk of bacterial translocation - maintain integrity
66
What is an early indicator of adequate nutritional support?
Hand grip | Indicative of muscle function improving
67
What is small bowel syndrome?
Short-bowel syndrome-intestinal failure results from surgical resection, congenital defect or disease-associated loss of absorption Characterised by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balances when on a conventionally accepted, normal diet
68
What does outcome for patient after resection depend on?
Type Length Quality or remnant small bowel Colon present or not?
69
In what resection is there no colon present?
End-Jejunostomy | Ends in stoma at abdomen
70
In which resections is the colon preserved?
Ileocolonic anastaomosis | Jejunocolonic anastamosis
71
What are the benefits of preserving the colon?
Allows for the reabsorption of sodium, fluid and fatty acids Slows intestinal transit Allows for intestinal readaption
72
What define short bowel syndrome?
less than 2 metres from duodenojejunal flexure.
73
What are the critical lengths in short bowel syndrome?
< 100cm of jejunum = long term intravenous fluid + e- < 75 cm of jejunum = long term PN, fluid + e- < 50 cm of jejunum + colon = long term PN, fluid + e-
74
What happens to fluid after a resction?
Daily secretions 4L a day arriving at the upper jejunum for reabsorption Fluid reabsorbed if colon is present If not high fluid losses
75
What is the target stoma output 6 weeks post op?
1.5L a day
76
What oral fluid advice would you give to prevent further dehydration and electrolyte balance?
Decrease oral fluids Misconception that it should be increased Drinking hypotonic fluids (Na 90mmol or less) results in high stoma output as sodium is dragged into gut lumen Anything very concentrated as the same impact e.g. fruit juice - fluid dragged into lumen to balance solute
77
What should patients have when they are dehydrated?
Oral rehydration solution | 1L of electrolyte mix
78
What is the recipe for ORS?
``` 20g (6 teaspoons) glucose 3.5g (1 level 5ml teaspoon) salt 2.5g (1 heaped 2.5ml spoon) sodium bicarbonate 1L water Add cordial, chill, sip through straw ```
79
What is the dietetic intervention for jejunostomy?
Hyperphagic diet Absorb half of food they eat Calories requirements and nitrogen doubled High fat- for energy and essential fatty acids Low fibre - lowers intestinal gut transit Additional NaCl given Additional selenium and magnesium
80
What do you do if appetite in a jejunostomy patient decreses?
Food fortification | Oral nutritional supplements
81
What strategies can be used to overcome thirst?
Strategies to overcome thirst: Ice chips, smaller cup, drink between rather than with meals
82
What urinary sodium value indicates dehydration?
>20mmol/L
83
What are the two main nutrition goals?
Prevent dehydration | Improve nutritional status
84
How can dehydration be prevented?
Aiming for urine sodium >20 mmol/L by encouraging adherence to fluid restriction and consumption of an oral rehydration solution over the next 2 wks.
85
How is nutritional status improvement measured?
by showing an ↑ in lean body mass evidenced by ↑ mid-arm muscle circumference & handgrip strength over next 4 wks

Year 2 Gastro (10 decks)

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