MAIN TOPIC SUB-TOPIC SUB-SUB TOPICS NDT LEC

MALNUTRITION

Malnutrition – epidemic  Depending on the staff to eat

Nutrition – balance nutrition + Cal What will happen to the patient if they are
malnourished
 No access, hunger
 Weight loss/muscle loss: fragile  fall 
Older adult risk:
fracture  disability  DEPENDENT
 Taste and smell (weak)  Protein deficiency decreased muscle
 Change dietary needs mass/strength
 GI system weakens  Protein deficiency  sarcopenia 
 Less absorption decreased skeletal muscles
 Chewing and swallowing (problems)  Not fight disease  decreased immune system
 Decreased wound healing
Chronic disease (risk)  Slow recovery  length of stay will be longer 
COST increased
 Decreased appetite
 Readmission and possible death
Treatment: Diet restriction

Side effects: vomit Treatment/Solutions

 Change metabolism and absorption  Change in the diet

 In-home support, meal delivery, and
Hospitalization community-based nutrition programs
 Don’t like the food  Oral supplement or drink
 Restriction to diet/NPO  Tube feeding (possible in some case)
 Decrease appetite  IV nutrition
 Worried and depressed  Treat underlying cause of malnutrition
 Consultation: dietician  nutritional plan 
Long term care facilities hospital  home

 Chronic disease: nutritional needs, decrease Check to signs and symptoms

ability to eat
 Isolated: depressed – decreased appetite 1. Sudden unexplained weight loss
2. Loss of appetite and decreased food intake
 MINI NUTRITIONAL ASSESSMENT

Mini Nutritional Assessment – Shortform (MNA®-SF)

A screening tool to help identify elderly patients who are malnourished or at risk of malnutrition

 User guide will assist you in completing the (MNA®-SF) accurately and consistently
 It explains each question and how to assign and interpret the score

MNA has 18 questions and covers 4 domains

 A score of ≥ than 24 indicates adequate nutritional status

 A score between 17 and 23.5 indicates risk of malnutrition
 A score <17 indicates malnutrition

Mini Nutritional Assessment; Screening

A Has food intake declined over the past 3 months, due to loss of appetite, digestive problems chewing or
swallowing difficulties?
0 = severe loss of appetite
1 = moderate loss of appetite
2 = no loss of appetite
B Weight loss during last 3 months?
0 = weight loss greater than 3kg
1 = does not know
2 = weight loss between 1 and 3kg
3 = no weight loss
C Mobility?
0 = bed or chair bound
1 = able to get out of bed/chair but does not go out
2 = goes out
D Has suffered psychological stress or acute disease in the past 3 months?
0 = yes
2 = no
E Neuropsychological problems?
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
F Body Mass Index (BMI) [weight in kg] / [height in m] 2?
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
Screening Score (subtotal max. 14 points)
12 points or greater = Normal – not at risk  no need to complete assessment
11 points or below = Possible malnutrition  continue assessment
G Lives independently (not in nursing home or hospital)?
0 = no 1 = yes
H Takes more than 3 prescription drugs per day?
0 = yes 1 = no
I Pressure sores or skin ulcers
0 = yes 1 = no
J How many full meals does the patient eat daily?
0 = 1 meal 1 = 2 meals 2 = 3 meals
K Selected consumption markers for protein intake?
At least on serving of dairy products (milk, cheese, yoghurt) per day? Yes? No?
Two or more serving of legumes or egg per week? Yes? No?
Meat, fish or poultry everyday? Yes? No?
0.0 = if 0 or 1 yes
0.5 = if 2 yes
1.0 = if 3 yes
L Consumes two or more servings or fruits or vegetables per day?
0 = no 1 = yes
Assessment score (max. 16 points)
Screening score (max. 14 points)
Total assessment (max. 30 points)
Malnutrition Indicator Score
17 to 23.5 points  at risk of malnutrition
Less than 17 points  malnourished
 GENERIC NUTRITIONAL RISK INDEX

Generic Nutritional Risk Index

An objective and simple tool, comprises just four variables:

1. Serum
2. Albumin
3. Actual body weight
4. Ideal body weight (calculated by height and gender)

The psychometric properties of the GNRI score have been tested in elderly hospitalized patients

 Sensitivity: 0.0062
 Specificity: 0.977

25 previous studies report that the GNRI score is associated with mortality and LOS in patients suffering from chronic
kidney disease, heart failure, malignancy, acute ischemic stroke and diabetes

 Patients at risk of malnutrition and related morbidity and mortality can be identified with the Nutritional Risk
Index (NRI)
 However, this index remains limited for elderly patients because of difficulties in establishing their
normal weight
 Therefore, we replaced the usual weight in this formula by ideal weight according to the Lorentz formula (WLo),
creating a new index called the Geriatric Nutritional Risk Index (GNRI)

GNRI Formula is: GNRI = 1.487 x ALB (g/L) + 41.7 x PBW/IBW (kg) 17

Nutrition risk index was calculated as follows:

NRI = (1.487 x serum albumin (g/L) + 41.7x (present weight/usual weight)

 >100 = in no risk group

 97.5 – 100 = mild risk
 83.5 – 97.5 = moderate risk
 <83.5 = severe risk groups
 MALNUTRITION UNIVERSAL SCREENING TOOLS (MUST)

Malnutrition Universal Screening Tools

‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or
obese

 Also includes management guidelines which can be used to develop a care plan
 It is for use in hospitals, community and other care settings and can be used by all care workers

This guide contains

A flow chart showing the 5 steps to use for screening and management BMI chart Weight loss tables Alternative
measurements when BMI cannot be obtained by measuring weight and height

Step 1

Measure height and weight to get a BMI score using chart provided. If unable to obtain height and weight, use the
alternative procedures shown in this guide.

Step 2

Note percentage unplanned weight loss and score using tables provided

Step 3

Establish acute disease effect and score

Step 4

Add scores from step 1, 2 and 3 together to obtain overall risk of malnutrition

Step 5

Use management guidelines and/or local policy to develop care plan

 MALNUTRITION UNIVERSAL SCREENING TOOLS (MUST)
continuation…

Malnourished adults account for approximately

 30% of hospital admissions  15% of outpatient clinic attendance

 35% care home admissions  10% of those visiting their GP

Risk Factors of Malnutrition

 Degenerative disease (e.g., MND, Parkinson’s, Duntington’s Dementia

 Poor appetite
 Constipation, diarrhea, nausea or vomiting
 Poor posture
 Ill-fitting dentures or sore mouth
 Swallowing difficulties
 Anxiety or depression

Consequences of Malnutrition

 Infection  Depression
 Muscle weakness  Falls
 Poor wound healing  Fatigue
 Pressure wound healing  Apathy
 Pressure ulcers  Inactivity
 Self-neglect

Can result in increased

 Dependency  Length of hospital stay

 Medical intervention  Number of deaths
 Medication  Micronutrient deficiencies

MILD

 Dark urine  UTI

 Headache  Constipation
 Dizziness  Poor concentration
 Tiredness  Passing urine less often

SEVERE

 Sunken eyes  Rapid weak pulse

 Confusion  Cold hands and feet
 Irritability

5 Steps of MUST

1. Body Mass Index (BMI) scire

2. Weight loss score
3. Acute disease effect sore
4. Overall risk of malnutrition
5. Management guidelines
STEP 1

Calculating Body Mass Index (BMI)

BMI is a measure of body fat (based on height and weight)

weight (kg)
BMI = 2
height (m )

Ex. John weights 74.6kg and is 1.78m tall

74.6 2
BMI = =23.6 kg /m
(1.78 x 1.78)
BAPEN has useful tools to help workout BMI

If unable to obtain a height or weight, use alternative measurements and use subjective criteria

A guide for assessing weight

What if there’s fluid retention?

Subtract the following weight (kg) from the person’s actual weight (kg)

Ascites Peripheral Edema

Minimal: 2.2kg Minimal: 1.0kg (ankles)
Moderate: 6.0kg Moderate: 5.0kg (up to knees)
Severe: 14.0kg Severe: 10.0kg (full leg)
Ex. A man has edema up to his knees, he weighs 72kg. To estimate his dry weight, 5kg should be subtracted from his
actual weight due to moderate peripheral edema. His estimated dry weight would therefore be 67kg. This weight should
be then used for MUST calculations.
What if there’s an amputation

Add the following % (kg) to the person’s actual weight (kg)

Full leg: 15.6% Full arm: 4.9%

Above knee: 9.7% Upper arm: 2.7%
Below knee: 4.5% Forearm: 1.6kg
Foot: 1.4% Hand: 0.6%
Ex. A woman has had her full arm amputated. She weighs 54kg. To correct the weight, 4.9% of the actual weight should
then be added.

4.9
x 54=2.6
100
This equates to 2.6kg, therefore the corrected weight is 56.6kg. This weight should then be used for MUST calculations.

STEP 2

Calculating % weight loss

Different in weight = heaviest weight – current weight

difference(kg)
% weight loss = x 100
heaviest weight (kg)

Ex. John currently weighs 74.6kg. John weighed 86.9kg 6 months ago.

12.3( kg)
% weight loss= x 100=14.2 %]
86.9 ( kg )

STEP 3

Calculating disease effect score

This would apply only to people who are critically ill, in a catabolic state, who have not eaten or not expected to eat for 5
days or more (unlikely to happen outside of hospital)

Ex. Include: dysphagia, intestinal obstruction, unconsciousness, a head or critical injury

Please note:
  Would not apply in end-of-life care
 Remember to treat underlying issues e.g., nausea, vomiting and pain

STEP 4

Add step 1, 2 and 3 together to take the overall risk of malnutrition score

Score 0 = low risk

Score 1 = medium risk
Score 2 or more = high risk

STEP 5

0 1 2 or more
Low Risk Medium Risk High Risk
Routine Clinical Care Observe Treat
 Repeat screening  Document dietary intake for 3  Refer to dietitian, nutritionist,
 Hospital = weekly days support team or implement local
 Care homes = monthly  If adequate – little concern and policy
 Community = annually for repeat screening  Set goals, improve and increase
special groups (e.g., those  Hospital – weekly overall nutritional intake
>75 yo)  Care home – monthly  Monitor and review care plan
 Community – at least every  Hospital – weekly
2-3months  Care home – monthly
 If inadequate – clinical concern –  Community – monthly
follow local policy, set goals,  Unless detrimental or no benefit
improve and increase overall is exported from nutritional
nutritional intake, monitor and support (e.g., imminent death)
review care plan regularly

All risk categories

 Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary
 Record malnutrition risk category
 Record need for special diets and follow local policy

Obesity

 Record presence of obesity; for those with underlying conditions, these are generally controlled before the
treatment of obesity
 SUBJECTIVE GLOBAL ASSESSMENT

Subjective Global Assessment (SGA)

 The gold standard for diagnosing malnutrition

 A simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition
care
 Assessment includes taking a history of recent intake, weight change, gastrointestinal symptoms, and a clinical
evaluation
 This is validated in a variety of patient populations
 Known to be reliable and valid tool that predicts morbidity and mortality associated with malnutrition

Objectives of SGA

 To identify patients likely to benefit from nutrition intervention and therefore identify persons in whom
inadequate nutrition intake or absorption explain features of malnutrition including body wasting

2 Conditions that is important to know in SGA are

1. Cachexia – weakness of body due to severe chronic illness

 Fat and muscle wasting due to disease and inflammation
2. Sarcopenia – age-related, involuntary loss of skeletal muscle mass and strength
 Reduce muscle mass and strength
 NURSING DIAGNOSIS RELATED TO NUTRITION

Pattern

Problem R/T Etiology AEB signs/symptoms

NANDA

 Imbalanced nutrition: less than body requirements

 Imbalanced nutrition: more than body requirements
 Risk for overweight
 Obesity
 Impaired swallowing
 Readiness for enhanced nutrition
 Risk/Fluid volume deficit: Electrolyte imbalance
 Risk/Excessive fluid volume

Etiology: Causes/reason

Signs and symptoms: RELATED to the problem

 History
 Physical assessment
 Laboratory or diagnostic findings

PLANNING: SMART

 Weight loss/gain: 2lbs/week – healthy achievable realistic

 Morbidly obese: increases morbidity and mortality  surgery: stomach clip
 Malnourish: low