Malnutrition in Hospital

It has been known since 1936 (Studley) that patients who had lost 20% of their body weight were at a higher risk of post operative complications and death than those with normal body weight. Hill (1977), working with surgical patients found that 60% were malnourished after one week in hospital. Dickerson (1985) found that after surgery, the amount of food eaten provided only half of the nutrients recommended by the DHSS. Indeed surgery seems to increase the requirement of vitamin C and thiamine, so exacerbating these deficiencies. Clearly these groups of patients were not ingesting enough for their nutritional requirements.

In malignant disease it has been strongly suggested that well nourished patients resist the side effects of radio and chemotherapy better than those who are malnourished, (Schwartz et al 1971). Food choice is important in malignant disease as patients sometimes develop dislikes due to changes in the senses of taste and smell.

It should be considered serious if any patient has lost 10% of their normal healthy body weight, (Dickerson, 1995). Any patient considered at risk of Protein Energy Malnutrition (PEM) must be assessed, weighed and actively managed. Dietetic advice should always be taken, but it is primarily a nursing responsibility to ensure prescribed protocols are adhered to.

In a recent study in Dundee McWhirter, (1994) found that 200 out of 500 people were undernourished on admission. On discharge 112 of these, when reassessed, were found to have lost 5.4% of their body weight. Of the 200 undernourished on admission only 96 had any nutritional data recorded in their notes.

Perhaps one of the main causes of severe malnutrition in hospital is delay in starting off nasogastric or intravenous feeding, (TPN). Patients have often already deteriorated before they are fed in these ways.

There are many consequences of undernourishment, eg. poor wound healing, precipitation of pressure sores, increased susceptibility to infection, muscle atrophy, weight loss and increased toxicity of drugs.

Never forget that water is a component of the diet, and maintenance of hydration is vital.

Clearly some patients admitted may already be malnourished and we should be on the look out for this as part of our initial assessment.

Question 1. What factors would you tend to associate with an increased risk of undernourishment on admission?

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One group you may have identified above is the elderly, from your knowledge of the components of the diet and the life styles of some elderly people have a go at the following question

Question 2. What types of nutritional deficiency, in terms of components of the diet, are the elderly particularly at risk from?

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Question 3. List some possible causes of dysphagia?

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Question 4. What other psychomotor disorders may effect the physical ability of an individual to eat?

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Question 5. What eating aids are available to help the types of patients mentioned in question 4?

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Question 6. A common problem in dysphagic or anorexic patients is lack of food intake, how do you assess what you patients actual intake is as opposed to what you put in front of them?

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Question 7. Patients who are under increased stress will have an increased metabolic rate, and therefore have increased dietetic requirements. Give some examples of patients who may be under increased stress.

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Question 8. Some disease states increase the metabolic rate of the whole body or certain tissues. Give some examples of diseases which increase metabolic activity.

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Question 9. Conversely to the conditions mentioned in the answer to question 8, some conditions cause reduced metabolic activity either directly or because they reduce mobility. Give some examples of such conditions.

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Question 10. List some possible causes of anorexia.

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Question 11. Clearly nausea and vomiting may lead to reduced food intake. List some causes.

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Question 12. Patients on prescribed diets may be at risk from losing out on some dietary components. What types of prescribed diets have you come across?

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Question 13. How would you feed an unconscious patient?

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It is interesting to note that in a study by Jones (1977) into the feeding of unconscious patients he found the following;

* all the diets provided less than the recommended energy requirements

* 37 out of 39 of the diets provided insufficient fluids

* When asked to state the energy requirements for unconscious patients 80% of nurse gave inaccurate answers

* 64% of nurses gave fluid requirements which would lead to dehydration

Question 14. How would you ensure a patient on nasogastric feeds was receiving adequate nutrition?

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Question 15. Do you thing a persons psychological state will have much influence of their utilisation of ingested nutrients, comment briefly

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As usual Florence had a comment on the topic "If the nurse is an intelligent being and not a mere carrier of diets to and from the patient, let her exercise her intelligence in these things"

Answers

Question 1.

Anyone with chronic GI disease, eg. oesophageal or gastric cancers, any condition causing dysphagia. Anorexia nervosa, alcoholism or drug abuse, mental illness, poor social circumstances.

Some older people, especially the recently bereaved and socially isolated, widowers, mentally impaired and the very old.

Question 2. Often the missing dietary components are those we obtain from fresh fruit and vegetables eg. vitamin D, B group vitamins, particularly thiamine, vitamin C and folic acid.

Question 3. Neurological deficit for whatever reason, facial trauma, food passage stricture for whatever reason, lack of teeth or dental caries, any condition causing a painful mouth will render people unwilling to eat, eg Monilial infection

Question 4. Mental disorders and neuromotor/articular deficits eg. CVA, rheumatoid arthritis

Question 5. non-slip pads, knives and forks with oversized handles, (ask the OTs)

Question 6. Observation of what is given and what is left. Use of food charts.

Question 7. Any one in hospital, in your answer you should have included, physical, psychological, social and spiritual dimensions

Question 8. Hyperthyroidism, any form of malignancy, Addisons disease, mania, hypomania, anxiety states, hyperkinesis

Question 9. Any musculoskeletal/neurological condition which reduces mobility, Cushings syndrome, patients on steroids, hypothyroidism

Question 10. Viral infections, bacterial infections, anxiety, any nausea inducing disorder

Question 11. Drugs, infections, gastroenteritis for whatever cause

Question 12. Obesity, diabetic, renal, high calorie

Question 13. Nasogastric drip or TPN, (Total Parental Nutrition)

Question 14. Weigh what is made up or record the intake in the case of ready made up feeds, calculate the intake every 24 hours in terms of fluids and the other nutrients.

Question 15. In a study of undernourished orphans, (Widdowson, 1952) it was found that disturbed children receiving the same diet as happy children did not gain weight, whereas the happy ones did. Evans (1984) found that the more time nurses spent with patients undergoing radiotherapy the better their appetite. It would therefore seem reasonable to argue psychological state effects appetite and utilization of ingested food.

Remember anorexia nervosa is a psychogenic disorder, but results in significant mortality.

References

Dickerson JWT. et al (1985) Postoperative food intake, in Chandra RK (Ed.) Nutrition, Immunity and Illness in the Elderly, Pergamon Press, Oxford.

Dickerson J. (1995) The problem of hospital-induced malnutrition, Nursing Times, 91 (4) 44-45

Evens M (1984) An assessment of dietary change that occur in patients receiving radiotherapy, BSc thesis, University of Surrey

Hill et al (1977) Malnutrition in Surgical patients, Lancet 2 303

Jones DC (1977) Food for Thought,(an RCN research report), RCN publishing

McWhirter JP, (1994) Incidence and recognising of malnutrition in Hospital, British medical journal, 308: 945-948

Studley (1936), quoted in Dickerson JWT. (1986) Hospital induced malnutrition, Professional Nurse, 1 (11) 293-296

Widdowson, (1952), cited in Dickerson JWT, (1986) Hospital Induced Malnutrition, Professional Nurse, 1 (11) 293-296