What is a Nutritional Assessment?
Before the dietitian can recommend a nutritional plan for you, he/she will complete a full nutritional assessment of your nutritional status. Below are the following steps that will be followed to complete a nutritional assessment:
1. Anthropometry – this is the measurement of the human body and will include checking some or all of the following:
a. Height
b. Weight - you should be weighed on admission to hospital and then daily if there are any concerns, otherwise weekly during your admission
c. Determine if there have been any recent weight changes – either weight loss or weight gain
d. Determine if you are carrying extra fluid
e. Body mass index – how healthy your weight is for your height
f. Waist circumference
g. Other measures such as grip strength to assess your body composition
2. Biochemistry and haematology – to check blood results for your kidney and liver function, bone health, signs of infection and for any nutritional deficiencies or dehydration
3. Clinical assessment – you may be asked about your bowel function, presence of nausea, vomiting, loss of appetite, swallowing difficulties or physical disability, temperature
4. Dietary assessment – this will include obtaining information about the quality and quantity of your usual and current dietary intake and also the reasons for any changes in dietary habits. Some nutrients may be looked at in greater detail e.g. iron, calcium depending on the underlying illness.
5. Extra factors that can have a significant impact on nutritional status such as financial difficulties, difficulties preparing food, social isolation, lack of knowledge, alcoholism or drug abuse, bereavement, age, medications
6. Calculate your nutritional requirements for energy, protein, fluid and vitamins and minerals based on the above information and also your activity levels. This will reduce the risks associated with over or underfeeding.
Malnutrition
Are you “frail”?
Have you lost weight unintentionally – do your clothes feel looser?
Have you had a loss of appetite or reduced your intake of food?
Do you have difficulties with feeding, eating, drinking or swallowing?
Have you been skipping or missing meals?
Do you have symptoms such as pain, nausea, constipation, diarrhoea or anxiety or depression that affect how much you eat?
Any of the above, can put you at risk of malnutrition.
Did you know that….
- One in three patients admitted to Irish hospitals are at risk of malnutrition, with 75% of these considered to be at high risk
- A quarter to a third of residents in Irish nursing homes are considered to be at risk of malnutrition
- The highest risk of disease-related malnutrition was associated with gastrointestinal conditions (45% and 48% respectively), with significant risk being associated with respiratory disease (30% and 33% respectively).
In Ireland, it is considered that at any one time there are 140,000 adults at high to medium risk of disease-related malnutrition, of which over 50% are aged 65 or over. People aged 65 and over are five times more likely to be malnourished, compared to younger adults.
The annual cost of disease-related malnutrition to Ireland is estimated to be 1.4 billion euro per year, representing over 10% of the total annual health and social care budget.
What are the consequences of unrecognised or untreated malnutrition?
- Depletion of body protein, energy stores, vitamins and minerals
- Increased hospital length of stay
- Increased hospital mortality
- Increased complications: increased infections, delayed wound healing, increased surgical complications
- Delayed rehabilitation and convalescence
- Reduced quality of life
- Increased GP visits
- Increased readmissions to hospital
- High social cost
- Higher healthcare costs.
If you are experiencing any of the signs of malnutrition tell your doctor who will refer you to a Dietitian.
How a dietitian can help:
A dietitian will complete a full nutritional assessment - see section on ‘What is a Nutritional Assessment’ and will provide you with a nutritional care plan to either meet your needs orally, enterally or parenterally - see section on ‘Nutrition Support’. The dietitian will continue to monitor your nutritional status during your hospital stay and make changes to your plan as required.
When you go home
The dietitian will advise you on a suitable nutritional plan for home. You will be provided with additional resources, prescriptions or equipment as required.
Neurology
A neurological condition can affect your diet and nutritional status in a number of ways: appetite may change, certain medications may cause stomach upset, bowel patterns may change, you may find it difficult to prepare or eat meals, or you may find you have swallowing difficulties. If you have a neurological condition you may be referred to the Dietitian as part of your care. It is likely you will first meet the Dietitian during your hospital stay, but sometimes you may be referred through another outpatient clinic.
- How the Dietitian can help
The Dietitian will help by assessing your nutritional status – see section ‘What is a nutritional assessment’ and recommending a therapeutic diet to ensure you meet your nutritional needs, manage your symptoms and improve your quality of life.
- During your hospital stay
If you are worried about a poor appetite or weight loss, the Dietitian can tailor your diet to help you maintain or gain weight, and optimise protein intake to help maintain muscle mass. This may be done through food alone, or the Dietitian may recommend supplement drinks for extra nourishment or you may need additional support with nutrition through a feeding tube - see section ‘Nutrition Support’. You will need to be assessed by a Speech and Language Therapist if you have swallowing difficulties – see section ‘Swallowing Difficulties’.
Special Diets: If you go home on a special diet or taking supplement drinks, the Dietitian may wish to follow-up with you in clinic, in which case you will receive an appointment by post. If you are taking supplement drinks you will be given a prescription when leaving the hospital.
Tube Feeding: If you are going home with a feeding tube, the Dietitian will create a plan specific to your nutritional needs and answer any of your questions around tube-feeding. She will help you to learn about your tube and about feeding so that you are confident going home.
Healthy Eating: Some neurological conditions are affected by carrying excess weight, in which case the Dietitian may advise you around healthy lifestyle and diet for weight loss – see section ‘Healthy Eating for Adults’. This is usually done as an outpatient. The Dietitian will send you an appointment by post, or you may be referred to a Dietitian in the community if appropriate.
Irish Motor Neuron Disease Association: Eating and Drinking
(http://imnda.ie/wp-content/uploads/2014/03/Eating+and+Drinking.pdf)
Irish Nutrition and Dietetic Institute: Eating Well with Parkinson’s Disease (https://www.indi.ie/resources/fact-sheets/515-eating-well-with-parkinson-s-disease.html)
MS Ireland: Swallowing and Nutrition (http://www.ms-society.ie/pages/living-with-ms/carers-/providing-care/swallowing-and-nutrition?size=smaller)
Stroke
The role of diet and nutrition in stroke can be divided into three areas (see below).
How a Dietitian Can Help
1. Preventing Stroke
Some conditions, such as high blood pressure, high blood cholesterol and being overweight, can increase the risk of developing stroke. As these are diet related, the dietitian will advise you to modify your diet to manage these conditions. You will also be given practical tips on how to maintain a healthy lifestyle.
2. Immediate period After stroke
A dietitian will help by assessing your nutritional status – see section ‘What is a nutritional assessment’ and recommend a therapeutic diet to ensure you meet your nutritional needs.
Weight change is common after a stroke, so your weight will be monitored regularly. Some people lose a lot of weight because of poor appetite, taste changes or low mood. The dietitian will advise you on how to make sure you have enough calories and protein in your diet to help you regain any weight lost - see section ‘Nutrition support’.
Swallowing problems are very common after a stroke and you may have to modify the texture of your diet – see section ‘Swallowing Difficulties’. Sometimes you may not be able to swallow safely. You may need to receive some or all of your nutrition through a feeding tube. Most people only need a feeding tube for a short time - see section ‘Nutrition Support’.
3. Rehab Post Stoke
A healthy balanced diet will help to prevent you from having another stroke.
It is essential to:
- Be a healthy weight and avoid excess weight gain
- Eat a balanced diet with a variety of foods.
- Avoid fried foods and choose lean cuts of meat. Use low-fat dairy products and spreads.
- Increase your fruit and vegetable intake aiming for five portions per day.
- Increase your intake of oily fish to two portions per week. Examples include salmon, sardines, mackerel, trout, kippers, pilchards and fresh tuna.
- Drinking enough is important, aim for eight glasses of fluid per day (water, milk, juice, sugar free squash).
- Avoid adding salt to your food and keep salt to a minimum in cooking.
- Avoid excess alcohol.
- Take regular exercise.
If you need more advice on your diet, ask your GP or hospital consultant to refer you to a Dietitian.
Links / Useful resources
www.irishheart.ie
Swallowing Difficulties
If you have swallowing difficulties you may have been advised by the Speech & Language Therapist to change the texture of the foods you eat e.g. soft diet, minced moist diet, smooth puree or liquidised diet. You may also have been advised to have your drinks thickened. A change in texture means a restriction in the range and type of food you can eat. This can lead to undesired weight loss.
How a dietitian can help:
A dietitian will help by assessing your nutritional status – see section ‘What is a nutritional assessment’ and recommending a therapeutic diet to ensure you meet your nutritional needs, manage your symptoms and improve your quality of life.
- During your hospital stay
While you are in hospital the dietitian will ensure that you get the correct texture food and that you are meeting your nutritional needs. You may need additional nutrition support if you are not meeting your nutritional needs through food alone – see section ‘Nutrition Support’. The dietitian will also monitor your hydration status if you are on thickened fluids because you may struggle to drink enough thickened fluids to keep you hydrated.
The dietitian will advise you on a suitable diet for home, appropriate to the recommendations of the Speech and Language Therapist. You will be provided with food lists and recipes and will also be advised how to fortify your food with extra calories and protein if required. If you require nutritional supplements on discharge you will be provided with a prescription.
If you are discharged home on a modified texture diet it would be recommended that you are reviewed by a dietitian to ensure you continue to meet your nutritional needs at home.
Links/ Useful resources
See Tallaght Speech and Language Therapy webpage….
http://swallowingdisorderfoundation.com/ - An American national, independent, not for profit organisation
Gastroenterology/Hepatology
If you have a condition that affects your gut, such as Inflammatory Bowel Disease (IBD), coeliac disease, liver disease or Irritable Bowel Syndrome (IBS) you could be at risk of malnutrition - see section ‘Malnutrition’. These conditions cause symptoms such as nausea, abdominal pain, bloating, diarrhoea, or constipation which reduces your ability to eat. Your metabolism may also be affected so you need additional calories and protein to maintain wellbeing.
How a dietitian can help:
A dietitian will help by assessing your nutritional status – see section ‘What is a nutritional assessment’ and recommending a therapeutic diet to ensure you meet your nutritional needs, manage your symptoms and improve your quality of life.
- During your hospital stay
The dietitian will discuss your individual symptoms and provide a nutritional care plan to suit your needs. You may not be able to eat enough to meet your nutritional requirements for energy, protein and vitamins/minerals and will be advised on ways to improve your intake – see section ‘Nutrition Support’. Throughout your hospital stay the Dietitian will monitor your nutritional status and ensure that you are receiving adequate and appropriate nutrition.
The Dietitian will provide you and your family or carers with education on any specialised diet that you may require prior to going home.
Links/ Useful resources
www.coeliac.ie
www.iscc.ie
www.ibsnetwork.org
www.INDI.ie
Surgery
Anyone undergoing surgery or recovering from surgery is at risk of malnutrition due to a number of reasons, including fasting for surgeries / procedures, the underlying disease/problem and associated symptoms, such as nausea, abdominal pain / discomfort, constipation or diarrhoea – see section ‘Malnutrition’. The type of surgery you have may also impact on your ability to eat and / or ability to digest and absorb nutrients properly. These all lead to poor appetite, weight loss and nutritional deficiencies.
How a Dietitian can help
A dietitian will help by assessing your nutritional status – see section ‘What is a nutritional assessment’ and recommend a therapeutic diet to ensure you meet your nutritional needs, manage your symptoms and improve your quality of life.
- During your hospital stay
A Dietitian will assess your overall nutritional status including any symptoms you have that are impacting on your ability to eat. They will assess your dietary intake (focussing on your protein, energy, vitamin, mineral and fluid intake) to ensure that it is adequate and will provide you with a nutrition care plan to help you meet your goals. Throughout your hospital stay the Dietitian will monitor your nutritional status and ensure that you are receiving adequate and appropriate nutrition.
For a period of time before or after surgery, some patients may require nutrition support in the form of enteral tube feeding or parenteral nutrition (intravenous feeding) – see section ‘Nutrition Support’. The Dietitian will devise a suitable feeding regimen, which will be based on an assessment of your nutritional needs.
When you go home
The Dietitian will provide you and your family/carers with detailed information on any special diet that you may require at home to support your recovery.
Certain patients may need to continue with tube feeding at home. If so, the Dietitian will organise the support and equipment required at home.
Links / Useful resources
http://www.stmarkshospital.nhs.uk/patients-visitors/patient-information-leaflets/
Nutrition Support
Nutrition support is defined as the provision of nutrients orally, enterally (via a tube inserted into your gut) or parenterally (directly into your veins) for the purpose of improving or maintaining a patient’s nutritional status.
We now know that the appropriate use of nutrition support: oral nutritional support, enteral tube feeding and parenteral nutrition can improve patient outcomes and reduce costs of malnutrition.
Nutrition support should be seen as an integral part of the optimal management of malnourished patients.
Read the information below about the three types of nutrition support that may be recommended for you if you are malnourished or at risk of malnutrition.
1. Oral nutritional support
This is used when the patient can swallow safely and the gut is functional. This can take the form of:
- Assistance with eating
- Dietary advise on appropriate food, fluids and snack choices
- Food fortification to increase calories or protein in foods
- Oral nutritional supplement (ONS) use.
A Simple Guide to the Use of Oral Nutritional Supplements
You may be advised by your dietitian to take an oral nutritional supplement if you have lost weight, have a poor appetite or are not able to eat enough food to keep you healthy.Oral nutritional supplements help you get more energy, protein, vitamins and minerals. There are many types and flavours of oral nutritional supplements available including:Milkshake or yoghurt-type supplements, Pudding or dessert type, Juice-based, Savoury flavoured supplements that can be heated gently to make a nourishing soup (do not boil) Powders and liquids can be added to foods or drinks to make them more nourishing
These products are designed to complement your diet, not replace your meals and snacks (with the exception of where you may have been told to have a special liquid diet only). You should continue to keep eating as much of your regular meals as possible. You might find it best to take your oral nutritional supplements between mealtimes so that it does not affect your appetite for meals. Oral nutritional supplements should be stored in a cool dry place before opening. Most taste better chilled so it is useful to keep small amounts in the fridge. Some supplements can be warmed gently, particularly in the winter months. Some can be added to foods or frozen, and served as a dessert. Ask your dietitian for more information or recipe ideas. Check the ‘best before’ dates before opening. Once opened, they must be kept in the fridge and thrown away if not used within 24 hours. Your dietitian will decide how long you should take oral nutritional supplements for. In most cases you only need them while you are having difficulties with eating a normal diet or until you have reached a healthy weight.If you are not able to take your oral nutritional supplements for any reason, contact your dietitian as soon as possible. Oral nutrition support is discontinued when the person can demonstrate an adequate intake persistently from diet.
2. Enteral Tube feeding
Enteral tube feeding is defined as the administration of nutrients via a tube directly in the gut. In the hospital setting enteral feeding can be used to treat or prevent malnutrition. Enteral tube feeding is used for malnourished patients or those at risk, who have a functioning gut, but who cannot meet their needs with oral nutrition support alone, or where oral diet is considered unsafe.
You may be fed through a tube placed in your mouth (oro-gastric), nose (NG or NJ) or directly into your stomach (PEG or RIG) or small bowel (PEJ or RIJ).
Enteral tube feeding may be needed in the short-term as an inpatient or in the longer term at home and this will be fully discussed with you by your dietitian and team.
3. Parenteral Feeding / Intravenous Feeding
Parenteral or intravenous nutrition is reserved for those who have an inadequate or non-functioning gut, where the gut is inaccessible, or when tube feeding is unsafe or unlikely to be effective.
Increasing numbers of patients need to continue these therapies at home - see section ‘Home Parenteral Nutrition’
Home Parenteral Nutrition
When your gut is not working effectively, you may not absorb nutrition from the food you eat. In this situation, intravenous or parenteral nutrition (PN) may be required to provide your full nutritional requirements. This form of nutritional therapy can be continued in your own home once you are medically fit for discharge.
How a dietitian can help:
A dietitian will assess your nutritional status - see section ‘What is a Nutritional Assessment’ and recommend the most appropriate route of nutrition given your medical condition and surgical history.
- During your hospital stay
While you are in hospital the dietitian will explain what is involved in PN. If you are happy to proceed, he/she will liaise with your medical team regarding IV access. The dietitian will then prescribe the right amount of PN to meet your macro and micronutrient requirements. This will be monitored daily and adjusted as needed. When you are stable on PN, the dietitian will arrange for the PN provider to train you on self-administering PN. The dietitian will also apply to the HSE for funding to facilitate the continuation of PN at home.
The dietitian will review your progress on a regular basis in outpatient clinic and/or by phone as needed. He/she will monitor your nutritional status for the duration of the PN, and alter your PN prescription as required.
Links/ Useful resources
www.pinnt.com
