Malnutrition and feeding

why does nutrition matter

essential for growth, repair and normal physiological function

why does nutrition status get worse when admitted to hospital

reduced intake, fasting and procedures

why might patients have an impaired intake

poor appetite, pain, nausea, dysphagia, mucositis, depression

why might nutrition drop de to increased or altered metabolic demands

sepsis, trauma, post-operative state

why might nutrition be a threat due to excess losses

vomiting, diarrhoea, NG drainage, stomas, fistulae

why might nutrition be a threat due to impaired digestion and absorption

gastric, intestinal, pancreatic or liver disease

what are the 4 nutrition threats to patients

impaired intake

increased or altered metabolic demands

excess loses

impaired digestion/absorption

what are some effects of malnutrition

weight loss of fat and muscle mass

reduced immune function and increased infection risk

fatigue, weakness and impaired wound healing

what factors are considered when taking a nutrition history on a patients intake

dietary intake and recent changes

appetite and factors limiting intake

ability to swallow, chew, shop, prepare food and self feed

what factors are considered when taking a nutrition history on a patients losses and requirements

vomiting, diarrhoea, stomach outputs fistulae, drains

fever, sepsis, surgery or inflammation

alcohol intake and relevant past medical history

what does the anthropometry section of a nutrition history involve

weight, height, ethnic background

calculate BMI

assess recent unintentional weight loss

what does the examination section of a nutrition history involve

hair, skin, mucosal changes

muscles wasting and loss of subcutaneous fat

behaviour, apathy or confusion

mobility and fluid balance

what does the functional assessment section of a nutrition history involve

functional decline can be a marker for nutritional compromise

reduced grip strength or exercise tolerance

what does the lab tests section of a nutrition history involve

baseline tests often include

U&Es

LFTs

calcium and bone profile

magnesium

phosphate

glucose

what are the lab limitations in nutrition

measured values may not reflect intracellular stores

short term redistribution can distort interpretation

what does the drug history section of a nutrition history involve

digoxin, tricyclic antidepressants and ACE inhibitors can reduce taste or intake

aspirin may contribute to iron deficiency

laxatives and diuretics may lower potassium

metformin can contribute to to B12 deficiency

what effect might metformin have on nutrition

B12 deficiency

what effect might laxatives and diuretics have on nutrition

lower potassium

what effect might aspirin have on nutrition

iron deficiency

what effect might digoxin, tricyclic antidepressants and ACE inhibitors have on nutrition

reduce taste or intake

why is albumin not a good marker of nutritional status

low albumin is more often reflecting inflammation, sepsis, dilution, increased loss or altered distribution

who needs nutritional support

underweight, losing weight or unable to eat for prolonged periods

high loss states, poor absorptive capacity and increased metabolic demand

what is the NICE criteria for concern

BMI <18.5kg/m²

unintentional weight loss greater than 10% in the last 3-6 months

BMI <20kg/m² AND unintentional weight loss greater than 5% in last 3-6 months

little or no intake for 5 days or likely over the next 5 days

what does the malnutrition universal screening tool predict

length of stay, mortality, discharge destination

what is the first step using the malnutrition universal screening tool

calculate BMI

low BMI increases the MUST score and the likelihood of malnutrition risk

assign a score 0-2

what is the second step using the malnutrition universal screening too

calculate percentage unplanned weight loss over the past 3-6 months

greater weight loss will score more highly

assign a score 0-2

what is the third step using the malnutrition universal screening too

assess the acute disease affect

if the patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days, add 2 points

what does a MUST score of 0 mean

low risk

what does a MUST score of 1 mean

medium risk

what does a MUST score of 2 or more mean

high risk

what are the principles of support for those with poor nutrition

maintain weight and function

match ongoing losses

treat underlying disease affect

replete specific nutrient deficits and avoid both underfeeding and overfeeding

what are the three methods of nutritional support

oral support

enteral tube feeding when gut works but oral intake is inadequate or unsafe

parenteral nutrition when the gut cannot be used effectively or safely

what does enteral feeding help with

maintain gut structure and function

what are common routes for enteral feeding

NG or NJ

what are the indications for parenteral nutrition

non-functioning gut

obstruction or paralytic ileus

short bowel or major bowel resection

selected fistulae/severe malabsorption

how to monitor nutritional support

route/tube/line issues

weight and fluid balance

baseline and repeat bloods including electrolytes and glucose

med review

what is an early complication of feeding

refeeding syndrome

what is a complication of enteral feeding

aspiration, diarrhoea, metabolic issues

what is a complication of parenteral feeding

line sepsis, pneumothorax, air embolism, metabolic complications

who is at risk of refeeding syndrome

prolonged starvation or very poor intake

alcohol excess

malignancy

post op patients

what is the pathophysiology of refeeding syndrome

Starvation leads to reduced basal metabolic rate and reduced insulin secretion.

 

Refeeding, especially carbohydrate, stimulates insulin, leads to electrolyte shifts

 

Potassium and magnesium move intracellularly and phosphate is consumed for high-energy phosphate production.

 

This produces hypophosphataemia, hypokalaemia and hypomagnesaemia.

 

Leads to; weakness/muscle dysfunction, confusion/seizures, heart failure, respiratory failure, fluid shifts, death

what can starvation lead to

reduced basal metabolic rate and reduced insulin secretion

what does refeeding produce

hypophosphataemia, kypokalaemia, hypomagnesaemia

what can refeeding syndrome lead to

weakness/muscle dysfunction

confusion/seizures

heart failure

resp failure

fluid shifts

death

how to prevent refeeding syndrome

start nutrition gradually

monitor electrolytes closely

replace phosphate, potassium and magnesium as required

start thiamine replacement