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1、,Nutrition support in adults,February 2006,Changing 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,Malnutrition,Malnutrition is
2、 a state in which a deficiency of nutrients such as energy,protein,vitamins and minerals causesmeasurable adverse effects on tissue composition,function or clinical outcome,Prevalence,Estimates vary depending upon the screening tool used Using body mass index(BMI 20 kg/m):10-40%of adults in hospital
3、s and care homes are underweight 5%underweight in the general population at home,The need for this guideline,Malnutrition 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 standards,Nutrition support,Methods 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 of
5、complete nutrition intravenously,Organisation of nutrition support,SCREEN,RECOGNISE,TREAT,ORAL,ENTERAL,PARENTERAL,MONITOR AND DOCUMENT,REVIEW,What needs to happen,ScreenRecognise who is malnourished and who is at riskTreat:oral,enteral,parenteralMonitor and reviewneeds a multidisciplinary team where
6、 do you fit in?,St.Bartholomews Hospital/Science Photo Library,The whole team makes it happen,Healthcare 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 tea
7、mAcute trusts should employ at least one specialist nutrition support nurseHospital trusts should have a nutrition steering committee working within the clinical governance framework,Suggested actions,Identify an implementation groupRaise awareness of the guideline recommendations among all staff di
8、rectly involved 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 pathways,Screening,use a screening tool that includes BMI,percentage unintenti
9、onal weight loss and consideration of the time over which nutrient intake has been reduced or likelihood of future impaired intake e.g.MUST,Suggested actions,Clearly identify who is responsible for screening in all care settings including care homes Ensure staff have access to and are using appropri
10、ate screening and assessment toolsEnsure staff have access to appropriate equipment in the hospital and community setting,e.g.weighing scales that are regularly serviced,Recognise who is malnourished,Malnourished=one or more of the following:BMI of less than 18.5 kg/m unintentional weight loss great
11、er 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 months,Recognise who is at risk,At risk of malnutrition=one or more of the following:eaten little or nothing for more than 5 days and/or likely to eat little or nothing for
12、 the next 5 days or longer poor absorptive capacity,are catabolic and/or have high nutrient losses and/or have increased nutritional needs,Normal provision,When unwell,normal food and drink with physical help to eat if required,will often sufficeIf this fails,is impractical or unsafe,measures to pro
13、vide nutrition support may be indicatedThis nutrition support may be alone or in combination:OralEnteralParenteral,What to give,The total nutrient intake of people prescribed nutrition support should account for:energy,protein,fluid,electrolyte,mineral,micronutrients and fibre needs activity levels
14、and the underlying clinical condition gastrointestinal tolerance,potential metabolic instability and risk of refeeding problems the likely duration of nutrition support,Consider oral nutrition support,and,stop when the patient is established on adequateoral intake from normal food,surgical patients
15、may have different needs,if patient malnourished/at risk of malnutrition,can swallow safely and gastrointestinal tract is working,If the person has dysphagia,Recognise co-morbidities that increase the risk of dysphagiaPeople who present with any obvious or less obvious indicators of dysphagia should
16、 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 administration remains appropriate and wit
17、hout contraindications,High risk of refeeding problems,One 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 magnesium prior to feeding,Two or
18、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 diuretics,High risk of refeeding problems,Consider:st
19、arting 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 magnesium,Consider enteral tube feeding,and,use th
20、e most appropriate route of access and mode of delivery,stop when the patient is established on adequateoral intake from normal food,surgical patients may have different needs,has a functional and accessible gastrointestinal tract,if patient malnourished/at risk of malnutritiondespite the use of ora
21、l interventions,Consider parenteral nutrition,use 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 feeding,surgical patients may have different needs,and has either,introduce progressively and monit
22、or closely,if patient malnourished/at risk of malnutrition,a non-functional,inaccessible or perforatedgastrointestinal tract,inadequate or unsafe oral or enteral nutritional intake,Monitoring,Review indications,route,risks,benefits and goals of nutrition support at regular intervals Frequency is dep
23、endent 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 laboratory,Support in the community,Supported by a co-ordinated multidisciplinary team and receive an individua
24、lised 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 professionalsGiven contact details for rel
25、evant support groups,charities and voluntary organisations,Everyone has a part to play,This guideline should:help healthcare professionals recognise malnourished patients and those at riskguide healthcare professionals to chose the best method of nutrition supportreduce the number of people with mal
26、nutrition,Access tools online,Costing toolscosting reportcosting templateAudit criteriaImplementation adviceAvailable from:www.nice.org.uk/cg032,Access the guideline online,Quick 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,
