Malnutrition and Nutritional Assessment Flashcards

Question

What biochemistry is used?

Answer 1

Forms part of nutritional assessment Tests used to estimate nutrient availability in fluid and tissues = critical to assess clinical nutrient deficiencies Measurements of micronutrients - expensive, therefore must have justified reason to request this

Answer 2

Acute inflammatory response skews response Therefore, not measured until CRP =< 10 micrograms /L

Answer 3

``` Alcohol and drug use Increased metabolic needs Increased nutritional losses Chronic disease Recent major surgery or illness Surgery of GI tract esp. ``` ``` Anorexia Loss of sense of taste / smell Excessive alcohol intake Poor fitting dentures Allergies Fad dieting Usual patterns of food intake Chewing or swallowing problems Aversions Cultural, religious, ethical Dietary restrictions ```

Answer 4

Socioeconomic status = ability to purchase food independently Physical or mental disabilities Eating alone

Answer 5

Most reliable method to measure energy expenditure and guide energy prescription Measurement of resting metabolic rate using a respirator gas exchange canopy

Answer 6

Restricting in clinical practice Predictive equations estimating metabolic rate are used in clinical practice instead, to determine estimated energy requirement

Answer 7

Predict (estimate) resting metabolic rate = used to calculate nutritional requirement based on patient's gender, weight, height, and level of physical activity

Answer 8

Low to moderate performance = best reaching accuracy of 70% Used as a baseline to determine first set of nutrition requirements - assessment of status determined nutritional diagnosis, outcomes, and intermediate goals

Answer 9

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

Answer 10

Plan Implement Monitor Evaluate

Answer 11

1. Patients who are malnourished = - A BMI of < 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. 2. At risk of malnourishment = - 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.

Answer 12

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

Answer 13

Stratton and Elia flowchart is used If oral route is safe and possible - always first and preferred approach Cases where oral route is not possible - is GI tract function and accessible? If so, enteral (tube to gut) feeding needs to be considered. If GI tract = non functional or accessible, parenteral (drip into blood)nutrition is then considered

Answer 14

Ethical and Legal | ESBEN have guidelines on the ethical aspects of artificial nutrition and hydration

Answer 15

Enteral = uses the gut | Where parental nutrition is used, aim to return to enteral (oral feeding) as soon as clinically possible

Answer 16

Is gastric feeding possible? ``` Yes = Naso-gastric tube (NGT) No = Naso-duodenal (NDT) / naso-jejunal tube (NJT) ``` Long term (> 3 months) = Gastrostomy / jejunstomy tube can be inserted

Answer 17

Dietitian Nutritional feed dependent on multiple factors --> renal, low sodium, respiratory, immune, elemental, peptide

Answer 18

Misplaced NGTs (21 deaths and 79 cases of harm between 2005-2011) Mechanical - misplacement, bloackage, buried bumper Metabolic - hyperglycaemia, deranged electrolytes GI -aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Answer 19

When an NGT is placed, an aspirate needs to be obtained from the tube indicating a pH of 5.5 or less = reflects gastric contents (acidity) in the stomach If pH >5.5, a chest x-ray is indicated

Answer 20

Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood

Answer 21

An inadequate or unsafe oral and/or enteral nutritional intake OR A non-functioning, inaccessible or perforated gastrointestinal tract

Answer 22

Central venous catheter (CVC): inserted into the subclavian, jugular or femoral veins, with tip at superior vena cava and right atrium Or peripherally inserted CVCs at the antecubital dossea, with tip still at the superior vena cava Different CVCs for short / long term use

Answer 23

Subclavian Jugular Femoral Antecubital fossa

Answer 24

Composed by dietitian Ready made or prescribe a “scratch” bag MDT and dietitian decide on fluid and electrolyte targets for that day

Answer 25

``` Mechanical = begins during insertion Pneumothorax Haemothorax Thrombosis Cardia arrhythmias Thrombus Catheter occlusion Thermophlebitis Extravasion ``` ``` Metabolic = begins once starting the feed Deranged electrolytes Hyperglycaemia Abnormal liver enzymes Oedema Hypertriglycerideamia ``` Catheter-related = Infections / septicemia

Answer 26

Lowers mortality Reduction in readmission Weight increase Significantly better outcomes - including all-cause mortality, intensive care unit admission, non-elective hospital readmissions, major complications, and functional status at day 30

Answer 27

Most abundant circulating protein in the plasma of healthy individuals Albumin synthesised in the liver - 10-15g produced daily Low plasma albumin = poor prognosis A negative acute phase protein = decreased plasma albumin when increased inflammation

Answer 28

Albumin synthesis is stimulated by hormones e.g. insulin, cortisol and GH (growth hormone)

Answer 29

Pro-inflammatory substances eg. IL-6, tumour necrosis factor (TNF)

Answer 30

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 - additionally from degradation and transcapillary loss

Answer 31

No Albumin synthesis reduces in response to inflammation - therefore not a valid marker of nutritional statur nor an indicator for nutritional intervention in the acute setting Best evidence = hypoalbuminaemia in obese trauma patients Dietitian focused on the aetiology / impact of the inflammatory state on nutritional status rather than albumin levels

Answer 32

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

Answer 33

During starvation, body aims to utilise energy stores: - Reduction in insulin secretion - Increase in glucagon secretion to produce glucose - Glycogen stores in the liver, amino acids in the skeletal muscle = metabolised into glucose - There deplete within 24-72hrs, metabolism shifts to derive energy from ketone production due to free fatty acids being released from fat stores Decrease in basal metabolic rate - brain adapts to using ketone bodies instead of glucose - results in loss of fat mass Reduce energy expenditure by reducing action on cellular pumps - electrolytes are then able to leak across cell membrane = increase in extracellular water, total body water and Na+; but depletion in K+, Mg2+, and phosphate Serum concentrations are maintained, but intracellular stores are depleted Sodium and fluid leak into cells = leads to sodium and fluid intolerance Micronutrient stores = depleted Thiamine deficiency likely as it is water soluble and the body has limited stores

Answer 34

Shift spares skeletal muscle breakdown and fat free mass is preserved to an extent

Answer 35

Secretion of insulin - stimulates Na+/K+ ATPase pump activation - required Mg2+ as a co-factor This drives potassium and phosphate into cells, and sodium and fluid out of cells into the ECF Phosphate driven into cells = energy storage as ATP ATP = increased cellular uptake of glucose, magnesium, potassium and phosphate and subsequent reduction in extracellular concentrations Thiamine = coenzyme in carbohydrate metabolism and deficiency can occur on refeeding in a vitamin B depleted patient Increased uptake of solutes Lower electrolytes in plasma - clinical manifestations Carbohydrates = reduce sodium and fluid excretion = expansion of ECF resulting in refeeding oedema and fluid overload

Answer 36

Arrhythmia, tachycardia, Congestive heart failure - lead to cardiac arrest, sudden death Respiratory depression Encephalopathy, coma, seizures, rhabdomyolysis Wernicke’s encephalopy

Answer 37

At risk: very little or no food intake for > 5 days High risk: one or more of - BMI less than 16 kg/m"2 - Unintentional weight loss greater than 15% within the last 3–6 months - Very little or no nutritional intake for more than 10 days - Low levels of potassium, phosphate or magnesium prior to feeding OR high risk: two or more of - BMI less than 18.5 kg/m"2 - Unintentional weight loss greater than 10% within the last 3–6 months - Little or no nutritional intake for more than 5 days - A (PMH) history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Extremely high risk: - BMI less than 14 kg/m^2 - Negligible intake for more than 15 days

Answer 38

Start with 10-20 kcal/kg Of that, 40-50% of the energy will be carbohydrates Micronutrients given from onset of feeding Monitor and replace electrolytes daily following Trust policy Administer thiamine from the onset of feeding following Trust policy - first dose fiven 30 mins before onset of initial feeding Monitor fluid shifts and minimise risk of fluid and Na+ overload

Malnutrition and Nutritional Assessment Flashcards

(62 cards)