Clinical Dietitians

Petra Teufl, NZRD

Who we are and what we do…

Aims

To gain an understanding of the role of Dietitians and the multi-disciplinary team

To increase awareness of how certain conditions impact on nutritional status

To increase awareness of how malnutrition is assessed and treated

To improve understanding of the link between wound healing and nutrition

What do Dietitians do?

Registered health professionals Assess, diagnose and treat diet and nutrition

problems Individuals and groups Public Health, Primary Health, Foodservice,

Food Industry Evidence based practice Translate research into practical guidance Nutrition experts!

Dietitians and NutritionistsWhat’s the difference?

Dietitians NutritionistsScope of practice Medical nutrition

Lifestyle nutrition Practice based on current scientific evidence

Lifestyle nutrition only May or may not be based on current scientific evidence

Government regulation

Yes (Dietitian Act 1950) No

Training required Undergraduate degree in Human Nutrition Post Graduate/Masters in Dietetics

May have a qualification in Human Nutrition

Registration Yes mandatory under the Health Practitioners Competence Assurance (HPCA) Act 2003

No, voluntary

Licensing body NZ Dietitians Board Nutrition Society of NZ

Who do we see?

At risk or Malnourished patients Patients with known disease states

Liver disease, IBS, CRF, COPD, Diabetes, Cancer, Diverticular disease.

Increased nutritional requirements Wound healing

Texture modified diets Micronutrient deficiencies Nutrition education

Hospital Menus

21 different menus, currently 2 week cycle Standard (suitable for Diabetics)

Sufficient to facilitate weight loss for overweight/obese patient if not eating food from home

HEP (High energy and protein menu) Vegan, Dairy free, Renal specific, Low sodium Texture modified

Soft Dysphagic, Minced and moist, Pureed Mildly / Moderately thickened fluids

Malnutrition – a hospital problem

Malnutrition at WDHB 28% admitted at med-high risk Of those, 36% referred to dietitian

Consequences of Malnutrition??↑ length hospital stay↑ risk of infection ↑ depression, apathy, self neglect↓ recovery from illness

↓ wound healing capacity↓ respiratory muscle function↓ muscle strength (poorer performance at physio)↓ function / quality of life

Malnutrition costs more than obesity

Malnutrition screening

Section One

Measure weight and height Actual weight measurement always

preferred Unable to measure height?

Try measuring the ulna length

Unable to do either? Try MUAC

Work out BMI (see chart on the back)

Section Two

Unintentional weight loss in the last 6 months While weighing the patient ask what they usually weigh and if

they think they have lost weight. If a patient doesn’t know their usual weight – ask if jewellery

is looser, clothes baggier etc

Rule of thumb: no weight loss = <5% some weight loss= 5-10% lots of weight loss = >10%

% wt loss chart available to help work it out

Section Three

“There has been or is likely to be little/no nutritional intake for >5 days and acutely unwell”

Looking for patients consistently eating <1/3 meals, or patients been on NBM/Preoperative clear fluids for a long time and not progressing

Patients who aren’t eating because they don’t like the food, or don’t have their dentures are not necessarily going to score a yes on this question – are there things you can do as their nurse to help this out?

Practice: Ulna length to height

Identifying High Risk Patients

Underweight (BMI < 18.5kg/m2)

Unplanned weight loss >10%

NBM / no nutrition > 5 days

i.e. Must score 2 or greater refer to Dietitian

MUST Screen: Refer to Dietitian

ASAP

What can you do?

Ask: patient’s weight/height of usual reported weight

Have they lost weight recently without meaning to?

O/E - Do they look very thin or wasted?

Visible signs of subcutaneous fat and muscle wasting

Weigh your patient regularly, complete MUST screening

Monitor: How long have they been NBM?

If in doubt, discuss with Dietitian

Other scores

Score 0- no intervention. Re-screen weekly

Score 1-place on HEP menu, start food diaries for 3 days and re-screen weekly

Neurology patients

Factors affecting nutritional status

Impact of neurological conditions

Perception Planning &

sequencing Neglect Behaviour Aphasia Apraxia

Memory Appetite control Hemiplegia Ataxia Psychological effects Dysphagia

Screening and assessment

Malnutrition risk screening1, 2

High risk patients referred to dietitian Patients with dysphagia 1,3

Often referred by SLTs Assessment:

Anthropometry Biochemistry Clinical Dietary intake Estimate requirements - predictive equations (Schofield,

Harris Benedict), ESPEN/ASPEN guidelines Monitoring

1NICE Stroke (2008), 2Stroke Foundation Guidelines (2010)

3 New Zealand Guideline for management of stroke

Oral Nutrition Support Patient will not receive supplements unless Dietitian referral

made Ensures patients receive correct supplement for their disease state

(eg. CRF, Liver disease, Diabetes, wound healing, malnutrition – different disease states may require different dose/type/times of administration)

Allows full nutritional assessment to be completed Ensures requirements for special authority applications fulfilled

Food first approach prior to supplementation Ensures prescriptions correctly provided, follow up arranged

Different strengths / formulations 1 kcal/ml : Ensure/ Fortisip Powder, Diasip 1.2kcal/ml : Cubitan 1.5kcal/ml : Fortisip, Ensure plus, concentrated Ensure/Fortisip powder 2 kcal/ml : 2 Cal HN (high nitrogen formula) 4.5kcal/ml : Calogen (fat emulsion)

Please refer to Dietitian if you feel your patient may require supplementation

Oral nutrition support in dysphagia

Identification of all factors contributing to poor nutrition status – MDT approach

Food first – strategies to improve nutritional density of modified texture diets

Fortification strategies Prepared supplementary products e.g. sip feeds

Standards & Definitions for Texture Modified Foods and Fluids (2007) NICE Adult Nutrition Support (2006)

Considering artificial nutrition support?

IS GUT FUNCTIONING?

NORMAL DIET OR SLT RECOMMENDS

TEXTURE MODIFIED DIET& FLUIDS

ENTERALTUBE

FEEDING

TPN OR COMFORT

CARES

DIETITIAN ASSESSMENT &ADVICE TO ACHIEVEADEQUATE INTAKE

IS ORAL INTAKE SUFFICIENT?

PEGFEEDING

NGTUBE

FEEDING

YES NO

YES

NO LONG TERM >6-8 weeksSHORT TERM

YESNO

NO

CAN PATIENTSWALLOW?

Enteral nutrition support in dysphagia

Ethical considerations Consent MDT approach – prognosis? Methods of enteral nutrition support

Nasogastric (NGT) vs Percutaneous endoscopic gastrostomy (PEG)

Timing of initiation of enteral nutrition support Hours of feeding and rehab Withdrawal of enteral nutrition support

Routes of enteral feeding

Wound Healing and Nutrition

Wound healing and nutrition

Malnourished patients are at high risk of developing pressure areas.

Good nutrition has been shown to be effective at facilitating wound healing

October 2011 November 2011 December 2011

                                    

         

The role of Arginine Arginine, the substrate for nitric oxide

synthase, was first noted to enhance wound healing in 1978

Dietary arginine supplementation has been shown to improve collagen deposition and wound strength in human and animal models

Studies have clearly indicated the role of L-Arginine in wound healing. The evidence is strongest in the treatment of Pressure Ulcers.

Practice time

Mrs S

Mrs S has been in hospital for the last three days with pneumonia. She has been managing to eat about ½ her meals. While you are helping her change she comments on her cardigan being too big now. You weigh her later in the day and she is 48kg, but thinks when she was at the doctors in December she was 52kg. Her height is 1.54m.

Mr T

Mr T was admitted with abdominal pain and underwent a cholecystectomy 5 days ago. He had seen a dietitian last year and his weight had decreased from 110kg to 90kg with dietary changes and exercise. He currently is NBM as he has had some complications post surgery. He is 1.8m tall.

Case Study

Case Study

Feb 2011 84yr female, found by family at home on floor after

collapsing approx two days prior Left sided paralysis and slurred speech Admitted to acute stroke ward Malnutrition risk screen = 4+ Weight 36.5kg, BMI 16.2kg/m2 Weight loss of 12% over previous 2 months

SLT NBM

Dietitian Nasogastric feed

Discharge planning started ?PH Transferred to stroke rehab ward mid-March

Initial Dietetic Assessment

How many days NBM so far? Calculate risk, prevent, monitor and treat refeeding syndrome Ability and speed of feeding to meet fluid and nutritional

requirements

Current weight/previous weight/ weight history Biochemistry

Na, PO4, K+, Mg2+, Ca2+, Glucose, Albumin, prealbumin

Hydration – IVF/SCF Pressure areas

prevention and monitoring, provision of nutrients Time, rate, duration of feeding

Case Study

4 weeks post admission Commenced oral trials with SLT, little progress Team wanting to discharge patient Gastrostomy (PEG) – overnight feed

5 weeks post admission -trialled puree diet Titrated feed + fortified puree diet & moderately thickened fluids Food diary – reduced feed accordingly Poor intake of thickened fluids – top up PEG water flushes

7 weeks post admission – Minced and moist diet Fatiguing quickly during meals High calorie yoghurt/snacks, high energy and protein thickened

supplement Bolus PEG feeds

Case Study

Discharged to daughter’s home Sitting in a wheelchair Communicating Dysphagia continuing to improve Able to self feed Minced and moist, thickened fluid education from SLT &

DT PEG Care and instructions Referral to community DT and SLT

PEG was removed 3 months post-discharge Weight 42kg, BMI 18.6kg/m2

Summary

Dietitians assess, diagnose and treat nutrition problems

Neurological conditions increase risk of undernutrition

Undernutrition has a negative effect on outcomes – eg pressure areas, rehab potential

Treatment is individualised Teamwork allows better coordination of care for the

patient

Questions?