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1、Nutrition support in adultsFebruary 2006Changing clinical practice NICE guidelines are based on the best available evidenceThe Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission MalnutritionMalnutrition is a s
2、tate in which a deficiency of nutrients such as energy, protein, vitamins and minerals causesmeasurable adverse effects on tissue composition, function or clinical outcomePrevalenceEstimates vary depending upon the screening tool used Using body mass index (BMI 20 kg/m ): 10-40% of adults in hospita
3、ls and care homes are underweight 5% underweight in the general population at homeThe need for this guidelineMalnutrition is commonIt increases a patients vulnerability to ill healthNutrition in the home or in hospital may not be adequateDecisions on providing nutrition support are complexThere is a
4、 wide variation in nutritional care standardsNutrition supportMethods to improve or maintain nutritional intake: oral nutrition support e.g. food, fortified food, sip feeds enteral tube feeding delivery of a nutritionally complete feed directly into the gut via a tube parenteral nutrition delivery o
5、f complete nutrition intravenouslyOrganisation of nutrition supportSCREENRECOGNISETREATORALENTERALPARENTERALMONITOR AND DOCUMENTREVIEWWhat needs to happenScreenRecognise who is malnourished and who is at riskTreat: oral, enteral, parenteralMonitor and reviewneeds a multidisciplinary team where do yo
6、u fit in?St. Bartholomews Hospital/Science Photo LibraryThe whole team makes it happenHealthcare professionals involved in patient care should receive education and training on nutrition supportAll people who need nutrition support should receive coordinated care from a multidisciplinary teamAcute t
7、rusts should employ at least one specialist nutrition support nurseHospital trusts should have a nutrition steering committee working within the clinical governance frameworkSuggested actions Identify an implementation groupRaise awareness of the guideline recommendations among all staff directly in
8、volved in patient careInclude nutrition support within induction programmesIdentify staff training needs and provide training using externally commissioned and in-house programmesReview service protocols and care pathwaysScreeningWhereWhenHospital inpatients On admission and repeated weeklyHospital
9、outpatientsFirst clinic appointment and when there is clinical concernCare homesOn admission and when there is clinical concernGeneral practiceInitial registration, when there is clinical concern and opportunistically, e.g. flu jabs, long term condition clinics use a screening tool that includes BMI
10、, percentage unintentional weight loss and consideration of the time over which nutrient intake has been reduced or likelihood of future impaired intake e.g. MUSTSuggested actionsClearly identify who is responsible for screening in all care settings including care homes Ensure staff have access to a
11、nd are using appropriate screening and assessment toolsEnsure staff have access to appropriate equipment in the hospital and community setting, e.g. weighing scales that are regularly servicedRecognise who is malnourishedMalnourished = one or more of the following: BMI of less than 18.5 kg/m uninten
12、tional weight loss greater than 10% within the last 3-6 months BMI of less than 20 kg/m and unintentional weight loss greater than 5% within the last 3-6 monthsRecognise who is at riskAt risk of malnutrition = one or more of the following: eaten little or nothing for more than 5 days and/or likely t
13、o eat little or nothing for the next 5 days or longer poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needsNormal provisionWhen unwell, normal food and drink with physical help to eat if required, will often sufficeIf this fails, is impracti
14、cal or unsafe, measures to provide nutrition support may be indicatedThis nutrition support may be alone or in combination:OralEnteralParenteralWhat to giveThe total nutrient intake of people prescribed nutrition support should account for: energy, protein, fluid, electrolyte, mineral, micronutrient
15、s and fibre needs activity levels and the underlying clinical condition gastrointestinal tolerance, potential metabolic instability and risk of refeeding problems the likely duration of nutrition supportConsider oral nutrition supportandstop when the patient is established on adequateoral intake fro
16、m normal foodsurgical patients may have different needsif patient malnourished/at risk of malnutritioncan swallow safely and gastrointestinal tract is workingIf the person has dysphagiaRecognise co-morbidities that increase the risk of dysphagiaPeople who present with any obvious or less obvious ind
17、icators of dysphagia should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disordersPeople with dysphagia should be given a drug review to ascertain if the current drug formulation, route and timing of administratio
18、n remains appropriate and without contraindicationsHigh risk of refeeding problemsOne or more of the following: BMI less than 16 kg/m unintentional weight loss greater than 15% within the last 3-6 months little or no nutritional intake for more than 10 days low levels of potassium, phosphate or magn
19、esium prior to feedingTwo or more of the following: BMI less than 18.5 kg/m unintentional weight loss greater than 10% within the last 3-6 months little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diureticsHigh risk o
20、f refeeding problemsConsider: starting nutrition support at 10 kcal/kg/day max increasing levels slowly restoring circulatory volume and monitoring fluid balance and clinical status providing thiamin and multivitamin/trace element supplement providing extra potassium, phosphate and magnesiumConsider
21、 enteral tube feedingand use the most appropriate route of access and mode of delivery stop when the patient is established on adequateoral intake from normal foodsurgical patients may have different needshas a functional and accessible gastrointestinal tractif patient malnourished/at risk of malnut
22、ritiondespite the use of oral interventionsConsider parenteral nutritionuse the most appropriate route of access and mode of delivery stop when the patient is established on adequateoral intake from normal food or enteral tube feedingsurgical patients may have different needsand has eitherintroduce
23、progressively and monitor closelyif patient malnourished/at risk of malnutritiona non-functional, inaccessible or perforatedgastrointestinal tractinadequate or unsafe oral or enteral nutritional intakeMonitoringReview indications, route, risks, benefits and goals of nutrition support at regular inte
24、rvals Frequency is dependent upon the patient, mode of feeding, care setting and duration of nutrition supportReview and update monitoring protocols in hospital setting, e.g. nutritional, anthropometric, clinical and laboratorySupport in the communitySupported by a co-ordinated multidisciplinary tea
25、m and receive an individualised care planGiven training and information on:management of delivery systems and the regimen and how to troubleshoot common problemsdelivery of equipment, ancillaries and feedGiven routine and emergency telephone contact numbers for appropriate healthcare professionalsGi
26、ven contact details for relevant support groups, charities and voluntary organisationsEveryone has a part to playThis guideline should:help healthcare professionals recognise malnourished patients and those at riskguide healthcare professionals to chose the best method of nutrition supportreduce the
27、 number of people with malnutritionAccess tools onlineCosting toolscosting reportcosting templateAudit criteriaImplementation adviceAvailable from: www.nice.org.uk/cg032Access the guideline onlineQuick reference guide a summary www.nice.org.uk/CG032quickrefguideNICE guideline all of the recommendations www.nice.org.uk/CG032niceguidelineFull guideline all of the evidence and rationale www.nice.org.uk/CG032fullguidelineInformation for the public a plain English version www.nice.org.uk/CG032publicinfo
