Manual of Dietetic Practice Resources

Key points

• Malnutrition adversely affects physical and psychological health, and impairs recovery from disease, increasing mortality, complications, hospital stay and use of other healthcare resources.
• Malnutrition is common and costly, but is often unrecognised and untreated.
• Routine and regular screening – using a quick, simple‐to‐use, valid, evidence‐based tool with a care plan – is recommended to improve the detection and treatment of malnutrition.
• Treatment should be undertaken promptly with appropriate nutritional support; energy, protein and other nutrients, including micronutrients, should be considered.

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Key points

• The role of the dietitian is to provide evidence‐based advice on the most appropriate oral nutritional support for patients, and tailor dietary advice to their needs.
• Oral nutritional support aims to improve the nutritional intake of macronutrients and micronutrients; approaches include fortified foods, snacks, nourishing drinks and oral nutritional supplements (ONS).
• Dietary strategies improve intake, weight and body composition, and can have some benefits on functional outcomes, but clinical efficacy has not been fully assessed.
• ONS has been shown to improve intake, weight, and body composition, with other clinical and economic benefits, e.g. improved function, reduced complications and readmissions to hospital.
• All patients receiving oral nutritional support should be monitored regularly against the goals of the intervention.

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Key points

• The decision to start feeding should consider the ethics of individual patient circumstances, the requirement to do no harm and the potential improvement in quality of life.
• The route of feeding and feeding regimen, including timing and type of feed, should be decided on an individual basis, taking into account clinical indications, treatment plan and nutritional status.
• Effective monitoring will help to ensure that nutritional support is provided safely, complications are detected early and treated effectively, and nutritional objectives are met and/or reviewed.
• Patients going home on enteral feeding should have an individual discharge plan.

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Key points

• Parenteral nutrition (PN) should only be used when the enteral route is inaccessible or inadequate.
• PN can be given peripherally or centrally, depending on the predicted duration, availability of venous access and nutritional requirements.
• Electrolytes and micronutrients must be included to meet individual nutritional requirements.
• Detailed pre‐feeding assessment and close monitoring for metabolic, infectious or mechanical complications is essential.
• Nutrition teams have an important role in ensuring quality control around the initiation, supply, monitoring and auditing of PN practice and outcomes.

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Key points

• Water is essential for survival and has many functions in the body.
• Regulation of body fluid is under tight homeostatic control; maintenance of fluid balance is an important aspect of dietetic management.
• Disorders of electrolyte and water balance are common in clinical practice, particularly as a result of surgery, trauma, disease and drug therapy.
• Managing fluids and electrolytes is complex and can be challenging; it requires extensive knowledge and experience, usually from a lead clinician.

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Key points

• Malnutrition is common in patients with chronic obstructive pulmonary disease (COPD) and tuberculosis (TB).
•  Routine nutritional screening using a validated screening tool should be carried out in all patients to identify those at risk and to initiate treatment.
• Nutritional requirements in COPD and TB have yet to be fully established.
• Nutritional support is an effective treatment in the management of malnutrition in COPD, but its role in the management of TB has yet to be determined.

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Key points

• Up to 75% of patients survive an intensive care unit (ICU) admission; however, many are left with severe weakness and delayed recovery.
• The critical illness, ICU procedures, equipment and medications all influence nutritional provision and need to be accounted for.
• Enteral feeding is the route of choice, and feeding should commence within 48 hours of admission; the accurate assessment of energy and protein requirements remains controversial.
• An individualised approach to nutrition support is advocated that adjusts to the different phases of critical illness.

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Appendix 6 Nutritional supplements and enteral feeds