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Flashcards in Nutrition Deck (42):
1

What is malnutrition?

A deficiency or excess (or imbalance) of energy, protein and other nutrients

Causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome

2

What are the causes of malnutrition

Altered nutrient processing:
- Increased and changed metabolic demands
- Liver dysfunction

Excess losses
- Vomiting
- Nasogastric tube drainage
- Diarrhoea
- Surgical drains
- Fistulae
- Stomas

Impaired intake
- Poor diet
- Poor hospital catering
- Poor appetite
- Missed meals
- Pain and nausea with food
- Mucositis
- Dysphagia
- Depression and psychological
- Unconsciousness

Impaired digestion and absorption
- Problems of stomach, intestine, pancreas and liver

3

What are the symptoms of malnutrition

Loss of appetite

Weight loss- appearance of skin, pale, facial features, excess skin, boney, loose clothing, bracelets don't fit, dentures don't fit

Poor growth in children

Fatigue

Altered mood

4

What is the impact of malnutrition

Uses up glycogen storages in liver, then muscle, then fat

Psychology, depression and apathy

Ventilation-loss of muscle and hypoxic responses

Decreased liver function, fatty change and necrosis

Impaired wound healing

Impaired gut integrity and immunity

Loss of strength

Hypothermia

Renal function- loss of ability to excrete sodium and water

Decreased cardiac output and immunity and resistance to infection

5

What are the impacts to primary and secondary care of malnutrition

Primary:
GP visits
Prescription costs
Referral to hospital
Care home admissions

Secondary:
Complications
Length of hospital stay
Readmissions
Deaths

6

What do the NICE guidelines say about what is classed as malnourished patient

BMI of less than 18.5kg/m2

Unintentional weight loss greater than 10% within the last 3-6 months

BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within last 3-6 months

7

What do NICE guidelines say about people that are at risk of malnutrition

1. Eaten little or nothing for more then 5 days and/or are likely to eat little or nothing for 5 days or longer

2. Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs form causes like catabolism

8

What is the nutritional screen (BAPEN) 5 steps measured

1. Height and weight for BMI

2. Note unplanned weight loss and score

3. Establish acute disease score

4. Add scores 1-3 for complete score

5. Use management guidelines or local policies to create action plan

9

What is the nutritional assessment

Anthropometry

Biochemistry- electrolyse (K, Mg, Ca, Phosphate)

Clinical- disease states may increase risk of malnutrition like cancer, GI disorders (gastric reflux, altered bowel movements), burns, mental health

Dietary- energy requirements, fluid requirements, dietary assessment

Environment- home or hospital?

10

Describe the energy requirements for malnutrition

Basal metabolic rate- amount of energy expended by the body to maintain basic physiological functions over 24 hours

60-75% energy expenditure

Does not include physical activity expenditure

Depends on gender, age, height

11

What is re-feeding syndrome

1. Caused when a person is in a state of prolonged starvation that is given nutrition

2. Serious complication

3. Person eats, a sudden shift in energy sources leads to
- insulin secretion
- Glycogen, fat and protein synthesis for which phosphate, magnesium, thiamine are required
- increased absorption of potassium and magnesium into cells

Leads to decrease in serum levels of K, Po4 and magnesium

12

If a person is at high risk of re-feeding syndrome, what do you do

1. Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4-7 days

2. Restore circulatory volume and monitoring fluid balance and overall clinical status closely

3. Provide immediately before and during first 10 days of feeding:
- Oral thiamine 200-300mg daily
- Vitamin B compound strong 1 or 2 tablets, three times a day (full dose daily intravenous vitamin B preparation if necessary)
- Balanced multi-vitamin and trace element supplement if necessary

4. Provide oral, enteral or intravenous supplements of potassium (likely 2-4 mmol/kg/day)
Phosphate (0.3-0.6 mmol/kg/day)
Magnesium (0.2 mol/kg/day intravenously, 0.4mmol/kg/day oral)
Unless pre-feeding plasma levels are high

13

Describe the nutritional support given

Oral
Food first- encourage them to eat more, cannot physically eat more
Oral nutritional supplements

Enteral

Parenteral

Need to know daily requirements for patients

Protective meal times- strictly dinner, lunch, breakfast

Developing care plans, assessments before admission and throughout patient stay, monitor plan more carefully

14

Who is part of the nutritional support team

Pharmacist
Nurse
Dietician
General Practitioner
Translator- elderly foreign women, wants a certain type of food

15

What oral nutritional supplements are there available

Juice type

Milkshake type

High energy powders

Soup type

High protein

Semi-solid and dysphagia ranges

16

What is enteral nutrition

1. Necessary when oral nutrition is not possible or insufficient to meet their requirements

2. Made up of a liquid mixture of all the needed nutrients

3. Given via a tube in the stomach or small intestine

4. Oral feeding is not possible, extended nil-by-mouth period is anticipated, an access device for enteral feeding should be inserted at time of surgery

Conditions like swallowing difficulty, ITU and unconsciousness

17

Describe what are the different enteral feeding routes and what important points should you consider

Jejunal tubes:
Nasojejunal- most common- tube passed through nose and down into stomach- usually short term feeding for 4 weeks to provide support for patient to recover via illness
Orojejunal
Jejunostomy
PEGJ (combined gastric and jejunal tube)

Gastric tubes:
Nasogastric
Orogastric
Gastrostomy- depends on placement technique
PEGJ- combined gastric and jejunal tube

Other: caecostomy tube into caecum

Consider:
- Current anatomy as bypasses, fistulae and drains may affect suitability of any enteral feeding tube for its intended purpose
- Long term enteral tube access include PEG tubes that require considerable post insertion commitment and this should be borne in mind at the initial assessment

18

What are the four main routes of enteral administration and describe them

Nasogastric
- Good for short term feeding and is less than 4 weeks
- Soft and fine bore size
- High aspiration risk so need to feed patient at 30-45 degree angle for at least 30 minutes

Nasojejunal tubes- post surgery recovery
- Reduced aspiration risk
- Important feed is sterile so no gastric acid protection

Gastrostomy
- Good for longer term feeding
- PEG (percutaneous endoscopic gastrostomy)
- Surgical or open gastrostomy
- RIG

Jejunostomy
- PEJ (Percutaneous endoscopic jejunostomy)
- Surgical or open jejunostomy

19

What are the indications to consider for small bowel access rather than the stomach

- Gastroparesis/ gastric ileus- when the stomach stop working or slows down- caused by neurological activity to stomach sedation or particular drugs- post op or injury

- Recent abdominal surgery

- Sepsis

- Significant gastro-esophageal reflux

- Pancreatitis

- Aspiration

- Ileus

- Proximal enteric fistula or obstruction

20

How do you select the most appropriate enteral feed

Estimation of energy, protein (nitrogen) and fluid needs

Select most appropriate enteral formula

Determine continous vs bolus feeding

Determine goal rate to meet estimated needs

Write and recommend enteral nutrition prescription

21

What are the types of enteral feed available

Polymeric
- Whole protein
- Patients with normal GI function

Pre-digested
- Peptide/semi elemental/ elemental (
- Patients with severely impaired GI function

Disease specific
- Formulas for respiratory disease, diabetes, renal failure, hepatic failure and immune compromise

22

What are the different types of enteral nutrition modes available

Enteral syringe:
- With plunger
- Gravity with plunger removed

Electronic Feeding Pump
- Via giving set through pump attached to enteral feeding tube
- Set amount over predetermined time
- Continuous or intermittent

23

What are the complications of enteral nutrition

Oral discomfort (no salvia- dry mouth, must replace with artificial saliva) or infection

Reflux or vomiting- 30 to 45 degrees sit them upright, consider clinical assessment
- Prolonged vomiting = risk of dehydration (iv fluids needed)

Abdominal distension or pain- intolerance to the feeds, trapped gas, check bowel function, volume rate, gastric venting

Diarrhoea- manage dehydration and electrolytes, give patient break from feed or change it- allow patient to recover

Constipation- more fibre in diet, fluid, immobile

24

What do you monitor in enteral nutrition

1. Aim is to reduce the risks of complications, electrolytes and metabolic abnormalities

2. Ensure adequate nutrition

3. Watch out for other people pulling it out, prevention of tube blocking and infections

4. Compliance issues

25

Describe what is parenteral nutrition
Also known as total parenteral nutrition (TPN) or intravenous infusion

A special liquid mixture given into the blood via a catheter in a vein

26

Who needs parenteral nutrition and what conditions may require it

Required when:
- Inadequate or unsafe oral and/or enteral nutritional intake
- Non-functional, inaccessible or perforated (leaking) GI tract
- Intestinal failure- temporary or permanent

Should not be used to correct serum albumin levels

Used short term in small bowel dysfunction, fistula, obstruction

Used long term in short bowel, small bowel dysfunction from crohn's disease, gut bypass

27

What is intestinal failure

What is intestinal failure
Reduction of gut function below minimum necessary for the absorption of macronutrients and/or water and electrolytes

Such that intravenous supplementation (IVS) is required to maintain health and/or growth
28

28

What is type I , type II and type III intestinal failure

Type I- acute, short term and usually self limiting condition- post operative ileum

Type II- prolonged acute condition, often in metabolically unstable patients, that require a multi-disciplinary care and parenteral nutrition over periods of weeks or months

Type III- chronic condition, in metabolically stable patients that require parenteral nutrition over months or years- may be reversible or irreversible

29

What are the specific conditions that may require parenteral nutrition? (9)

1. Pre-operative nausea and vomiting

2. Mucositis from chemotherapy and radiotherapy

3. Major abdominal surgery- colonic resection and small bowel resections

4. Bowel obstruction

5. SB perforation

6. Severe acute pancreatitis

7. Persistent paralytic ileus post operatively

8. Post operative anastomosis breakdown/ abdominal sepsis. small bowel fistulae and adhesions

9. Severe burns

30

What are the clinical factors to consider for PN?

Duration of intestinal failure

Aetiology
- Post op ileus
- Bowel injury
- GI fistulae
- Short bowel
- Motility disorder

Co-morbidity (sepsis etc), renal (dialysis required?), cardiac (CCF need to consider amount of fluid going in and Na levels), liver and sepsis

Prognosis

Available intravenous access

31

What is the formulation of parenteral nutrition

All in one
Multi chamber
Standardised
Tailor made
Macronutrients- carbohydrates, nitrogen, lipids
Micronutrients

32

What is involved in prescribing for parenteral nutrition

Clinical assessment is necessary for:
Indication of Parenteral Nutrition- can the patient eat, swallow, digest and absorb food

Patient medication history

Drug history and current medications
- Oral antidiaetics
- Any medicines that may not be needed with TPN
- Medicines that need to be given parenterally- parbinex etc
- Review opiate drugs

SHx

Nutritional history

Current body weight, weight loss and BMI

Nutritional requirements and refeeding risk

Bio-chemistry- Liver function tests (ability to metabolise TPN), U + Es, CRP and WCC signs of infection, Mg, Ca, PO4

Fluid balance records

Current clinical status and observations
Respiratory problems- don't overfeed patient as that will increase O2 demand and CO2 production
Any cardiac problems- think about Na+ content and fluids if CCF

Intravenous access for administration

33

What is involved in the selection of parenteral nutrition?

Assess re-feeding syndrome risk

Assess basal metabolic rate (BMR) and additional stress factors, nitrogen, fluid and electrolyte requirements

Assess route of administration available

Work out rate of administration

Select parenteral nutrition bag

Prescribe parenteral nutrition on chart

Document in medical notes

Order from aseptic services unit

34

Describe peripheral administration in parenteral nutriton

Duration of parenteral nutrition: 4-7 days

Line type: Venflon

Advantages: nurse can insert and avoid risks of central lines

Disadvantages: incomplete parenteral nutrition, re-site ater 1-2 days, thrombophlebitis, osmolarity of PN

35

Describe central administration in parenteral nutriton

Duration of parenteral nutrition: long term > 2 weeks

Line type:
Multi-lumen central line
Tunnelled
PICC

Advantages:
Complete parenteral nutrition
Multi-Lumen- other medications
Single lumen- infection chance decreases

Disadvantages:
Theatre procedure
Risk
Line infections
Catheter related complications- brachial nerve injury, sepsis, venous thrombosis

36

What are the considerations for parenteral nutrition (3)

1. Glucose infusion rate should be <5mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosis (infiltration of hepatocytes with fat) and respiratory distress

2. Lipid infusion should be <0.1g/kg/hour
(ideally 0.4g/kg/day to minimise/prevent parenteral nutrition induced liver dysfunction)- important as careful how much fat is processed by liver

3. Initiate parenteral nutrition at 1/2 of goal rate/concentration and gradually increase to goal over 2-3 days to optimise serum glucose control

37

What do we monitor in parenteral nutrition

Current parenteral prescription

Biochemistry
- U and Es, LFTs, FBC, Ca, Mg and PO4

Fluid balance
- Ensure that fluid intake from all sources is recorded such as oral, enteral, drug administration, flushes, IV medication

Capillary blood sugars

Administration line and patency

Clinical signs of infection

GI function
- Bowel function, nasogastric tube aspirate, bowel sounds, can the patient try oral or enteral, drug administration, flushes, IV medication

Nutrient intake and current nutritional status

Drug chart

Weekly weights

Trace elements

Clinical observations

Intravenous catheter inspection

38

What are the parenteral nutrition complications

Insert complications
- bleeding
- misplacement

Line complications
- line sepsis
- Thrombosis
- Dislodgement
- Fracture, leaking

Metabolic feed complications
(Acute)
- Refeeding syndrome
- Hyper/hypoglycaemia
- Electrolyte disturbances
- Hypertriglyceridemia
- Acute cholestasis

(Chronic)
- Liver disease
- Metabolic bone disease
- micronutrient imbalances

39

What are the complications of parenteral nutrition

Hepatic steatosis (infiltration of hepatocytes with fat)
- Occurs within 1-2 weeks after starting PN
- Reversible in patients on short term parenteral nutrition and typically resolves within 10-15 days
- Limitation (<1g/kg/day) or remove fat content of parenteral nutrition or cyclical parenteral nutrition over 12 hours per day in long term PN patients

Cholestasis
- Occurs within 2-6 weeks after starting PN
- Indicated by progressive increase in bilirubin and an elevated serum alkaline phosphatase
- Occurs due to no intestinal nutrients to stimulate hepatic bile flow
- Bilrubin is > 5 to 10mg/dL due to hepatic dysfunction, consider stoping trace elements- can cause toxicity of manganase and copper

Gastrointestinal atrophy
- Lack of enteral stimulation associated with villus hypoplasia, colonic mucosal atrophy, decrease GI function, impaired GI immunity, bacterial overgrowth
- Trophic enteral feeding to minimise and prevent it

40

What is home parenteral nutrition (HPN)

Needed for patients with acute or chronic intestinal failure in whom nutritional and/or water and electrolyte balance cannot be corrected by oral or enteral feeding and whom PN is feasible in home

41

What is transitional feeding

Switching from parenteral to enteral

Introduction of enteral feeding at a low rate to establish tolerance

Decrease parenteral nutrient levels slowly to keep nutrient levels at same prescribed amount

Enteral rate increased every 4-8 hours, parenteral can be reduced

Discontinue parenteral solution when 50-75% of nutrient needs are met by enteral route

42

Describe the drug and nutrient interactions during these methods of feeding

Absorption:
Mg or Al antacids with phosphate
Tetracyclines chelate with Ca, Mg, Fe
Quinolones- ciprofloxacin absorption reduced by 50% if given by enteral feed

Metabolism:
Grapefruit juice- cytochrome p450 inhibitor, reduce metabolism of certain drugs hence increased plasma concentrations of amiodarone, cyclosporin, simvastatin
Folate
Pyridoxine (vitamin B6)

Excretion
Diuretics
Amphotericin

Changes feed consistency

Physical interaction between drug and feed product

Enteral feeding tubes can be blocked

Examples:
Phenytoin, digoxin, carbamazepine
Antacids bind to proteins
Penicillins- feed can reduce absorption
Never add drug to feed