1. Clinical Dietitians
Who we are and what we do…
Petra Teufl, NZRD

2. Aims
To gain an understanding of the role of Dietitians and the multi-disciplinary team
To increase awareness of how certain conditions impact on nutritional status
To increase awareness of how malnutrition is assessed and treated
To improve understanding of the link between wound healing and nutrition

3. What do Dietitians do? Registered health professionals
Assess, diagnose and treat diet and nutrition problems
Individuals and groups
Public Health, Primary Health, Foodservice, Food Industry
Evidence based practice
Translate research into practical guidance
Nutrition experts!
GPs, hospitals, health trusts, watties, 3

4. Dietitians and Nutritionists What’s the difference?
Scope of practice
Medical nutrition
Lifestyle nutrition
Practice based on current scientific evidence
Lifestyle nutrition only
May or may not be based on current scientific evidence
Government regulation
Yes (Dietitian Act 1950) No
Training required
Undergraduate degree in Human Nutrition
Post Graduate/Masters in Dietetics
May have a qualification in Human Nutrition
Registration
Yes mandatory under the Health Practitioners Competence Assurance (HPCA) Act 2003
No, voluntary
Licensing body
NZ Dietitians Board
Nutrition Society of NZ

5. Who do we see? At risk or Malnourished patients
Patients with known disease states
Liver disease, IBS, CRF, COPD, Diabetes, Cancer, Diverticular disease.
Increased nutritional requirements
Wound healing
Texture modified diets
Micronutrient deficiencies
Nutrition education
At waitemata dhb we have specialist dietitians working in paediatrics, renal, diabetes, surgical as well as general medical. We also have a specialist nutrition support team (TPN) made up of a dietitian, Nutrition nurse specialist, pharmacist and consultant. We cover both inpatient, outpatient and community. Talks-weight, cardaic, pulmonary and bariatric talks
On-call Dietitian

6. Hospital Menus 21 different menus, currently 2 week cycle
Standard (suitable for Diabetics)
Sufficient to facilitate weight loss for overweight/obese patient if not eating food from home
HEP (High energy and protein menu)
Vegan, Dairy free, Renal specific, Low sodium
Texture modified
Soft Dysphagic, Minced and moist, Pureed
Mildly / Moderately thickened fluids

7. Malnutrition – a hospital problem

8. Malnutrition costs more than obesity
Malnutrition at WDHB
28% admitted at med-high risk
Of those, 36% referred to dietitian
Consequences of Malnutrition??
↑ length hospital stay
↑ risk of infection
↑ depression, apathy, self neglect
↓ recovery from illness
↓ wound healing capacity
↓ respiratory muscle function
↓ muscle strength (poorer performance at physio)
↓ function / quality of life
Malnutrition costs more than obesity

9. Malnutrition screening
This form should be in every patient’s medications folder or observations and assessment part of the patient file.
If you cant find it in the ob’s folder, there will be a copy on your ward somewhere.
This actually only takes 5mins to do and can be done in stages at different times or done while you are measuring ob’s or walking them to the shower etc

10. Section One Measure weight and height
Actual weight measurement always preferred
Unable to measure height?
Try measuring the ulna length
Unable to do either?
Try MUAC
Work out BMI (see chart on the back)

11. Section Two Unintentional weight loss in the last 6 months
While weighing the patient ask what they usually weigh and if they think they have lost weight.
If a patient doesn’t know their usual weight – ask if jewellery is looser, clothes baggier etc
Rule of thumb:
no weight loss = <5%
some weight loss= 5-10%
lots of weight loss = >10%
% wt loss chart available to help work it out
We are worried about those who haven’t been trying to lose weight. If your patient tells you they have lost 20kg but that’s because they have been exercising more and eating healthily then that is ok. You may want to write it on the form though if you wish. It is always useful to document.
Make sure you say ‘in the last 6 months’. If they lost weight unintentionally 3 years ago and have been maintaining it since its not an acute problem.

12. Section Three
“There has been or is likely to be little/no nutritional intake for >5 days and acutely unwell”
Looking for patients consistently eating <1/3 meals, or patients been on NBM/Preoperative clear fluids for a long time and not progressing
Patients who aren’t eating because they don’t like the food, or don’t have their dentures are not necessarily going to score a yes on this question – are there things you can do as their nurse to help this out?
This can be quite a tricky question to answer as we don’t have a crystal ball and everyone has different view of what is a ‘little oral intake’
What factors are impacting on their ability to improve intake? –constipated-talked to med team about laxatives. Nausea-talk to med team about anitmetics

13. Practice: Ulna length to height

14. Identifying High Risk Patients
Underweight (BMI < 18.5kg/m2)
Unplanned weight loss >10%
NBM / no nutrition > 5 days
i.e. Must score 2 or greater refer to Dietitian
MUST Screen: Refer to Dietitian ASAP

15. What can you do? Ask: patient’s weight/height of usual reported weight
Have they lost weight recently without meaning to?
O/E - Do they look very thin or wasted?
Visible signs of subcutaneous fat and muscle wasting
Weigh your patient regularly, complete MUST screening
Monitor: How long have they been NBM?
If in doubt, discuss with Dietitian

16. Other scores Score 0- no intervention. Re-screen weekly
Score 1-place on HEP menu, start food diaries for 3 days and re-screen weekly

17. Factors affecting nutritional status
Neurology patients
Factors affecting nutritional status

18. Impact of neurological conditions
Memory
Appetite control
Hemiplegia
Ataxia
Psychological effects
Dysphagia
Perception
Planning & sequencing
Neglect
Behaviour
Aphasia
Apraxia
Aphasia – impairment in language ability
Apraxia – loss of ability to perform tasks
Ataxia – Lack of co-ordination of muscle movements
Hemiplegia – Paralysis of arm, leg and trunk of same side 18

19. Screening and assessment
Malnutrition risk screening1, 2
High risk patients referred to dietitian
Patients with dysphagia 1,3
Often referred by SLTs
Assessment:
Anthropometry
Biochemistry
Clinical
Dietary intake
Estimate requirements - predictive equations (Schofield, Harris Benedict), ESPEN/ASPEN guidelines
Monitoring
The European Society for Clinical Nutrition and Metabolism
1NICE Stroke (2008), 2Stroke Foundation Guidelines (2010)
3 New Zealand Guideline for management of stroke 19

20. Oral Nutrition Support
Patient will not receive supplements unless Dietitian referral made
Ensures patients receive correct supplement for their disease state (eg. CRF, Liver disease, Diabetes, wound healing, malnutrition – different disease states may require different dose/type/times of administration)
Allows full nutritional assessment to be completed
Ensures requirements for special authority applications fulfilled
Food first approach prior to supplementation
Ensures prescriptions correctly provided, follow up arranged
Different strengths / formulations
1 kcal/ml : Ensure/ Fortisip Powder, Diasip
1.2kcal/ml : Cubitan
1.5kcal/ml : Fortisip, Ensure plus, concentrated Ensure/Fortisip powder
2 kcal/ml : 2 Cal HN (high nitrogen formula)
4.5kcal/ml : Calogen (fat emulsion)
Please refer to Dietitian if you feel your patient may require supplementation

21. Oral nutrition support in dysphagia
Identification of all factors contributing to poor nutrition status – MDT approach
Food first – strategies to improve nutritional density of modified texture diets
Fortification strategies
Prepared supplementary products e.g. sip feeds
Standards & Definitions for Texture Modified Foods and Fluids (2007) NICE Adult Nutrition Support (2006) 21

22. Considering artificial nutrition support?
CAN PATIENT
SWALLOW?
YES NO
NORMAL DIET OR
SLT RECOMMENDS
TEXTURE MODIFIED DIET
& FLUIDS
IS GUT
FUNCTIONING?
YES NO
YES
IS ORAL INTAKE
SUFFICIENT?
TPN OR
COMFORT
CARES
ENTERAL
TUBE
FEEDING NO NO
LONG TERM >6-8 weeks
SHORT TERM
DIETITIAN ASSESSMENT &
ADVICE TO ACHIEVE
ADEQUATE INTAKE NG
TUBE
FEEDING
PEG
FEEDING

23. Enteral nutrition support in dysphagia
Ethical considerations
Consent
MDT approach – prognosis?
Methods of enteral nutrition support
Nasogastric (NGT) vs Percutaneous endoscopic gastrostomy (PEG)
Timing of initiation of enteral nutrition support
Hours of feeding and rehab
Withdrawal of enteral nutrition support 23

24. Routes of enteral feeding

25. Wound Healing and Nutrition

26. Wound healing and nutrition
Malnourished patients are at high risk of developing pressure areas.
Good nutrition has been shown to be effective at facilitating wound healing
October 2011
November December 2011
                                             

27. The role of Arginine
Arginine, the substrate for nitric oxide synthase, was first noted to enhance wound healing in 1978
Dietary arginine supplementation has been shown to improve collagen deposition and wound strength in human and animal models
Studies have clearly indicated the role of L-Arginine in wound healing. The evidence is strongest in the treatment of Pressure Ulcers.

28. Practice time
If you can try and work individually through the practice case and then we will go through it all together at the end.
I will give you a few minutes to do it.

29. Mrs S
Mrs S has been in hospital for the last three days with pneumonia. She has been managing to eat about ½ her meals. While you are helping her change she comments on her cardigan being too big now. You weigh her later in the day and she is 48kg, but thinks when she was at the doctors in December she was 52kg. Her height is 1.54m.
BMI = 20.3 (Must score 0 )
Weight loss Percentage = 7.7% (MUST score = 1)
Eating adequately (MUST score 0)
Score 1 - HEP menu/Food Diaries/Re-screen in 1 week
Ask around the room people to tell you what they got for each section. Ask if anyone got anything different and why they put what they put.
Once determined what the score is then ask them what they would do from there.

30. Mr T
Mr T was admitted with abdominal pain and underwent a cholecystectomy 5 days ago. He had seen a dietitian last year and his weight had decreased from 110kg to 90kg with dietary changes and exercise. He currently is NBM as he has had some complications post surgery. He is 1.8m tall.
Question 1– Score 0
Question 2 – Score 0
Question 3 – Score 2
Needs a referral to the dietitian.

31. Case Study

32. Case Study Feb 2011 SLT Dietitian Discharge planning started ?PH
84yr female, found by family at home on floor after collapsing approx two days prior
Left sided paralysis and slurred speech
Admitted to acute stroke ward
Malnutrition risk screen = 4+
Weight 36.5kg, BMI 16.2kg/m2
Weight loss of 12% over previous 2 months
SLT
NBM
Dietitian
Nasogastric feed
Discharge planning started ?PH
Transferred to stroke rehab ward mid-March 32 32

33. Initial Dietetic Assessment
How many days NBM so far?
Calculate risk, prevent, monitor and treat refeeding syndrome
Ability and speed of feeding to meet fluid and nutritional requirements
Current weight/previous weight/ weight history
Biochemistry
Na, PO4, K+, Mg2+, Ca2+, Glucose, Albumin, prealbumin
Hydration – IVF/SCF
Pressure areas
prevention and monitoring, provision of nutrients
Time, rate, duration of feeding

34. Case Study 4 weeks post admission
Commenced oral trials with SLT, little progress
Team wanting to discharge patient
Gastrostomy (PEG) – overnight feed
5 weeks post admission -trialled puree diet
Titrated feed + fortified puree diet & moderately thickened fluids
Food diary – reduced feed accordingly
Poor intake of thickened fluids – top up PEG water flushes
7 weeks post admission – Minced and moist diet
Fatiguing quickly during meals
High calorie yoghurt/snacks, high energy and protein thickened supplement
Bolus PEG feeds 34 34

35. Case Study Discharged to daughter’s home
Sitting in a wheelchair
Communicating
Dysphagia continuing to improve
Able to self feed
Minced and moist, thickened fluid education from SLT & DT
PEG Care and instructions
Referral to community DT and SLT
PEG was removed 3 months post-discharge
Weight 42kg, BMI 18.6kg/m2

36. Summary Dietitians assess, diagnose and treat nutrition problems
Neurological conditions increase risk of undernutrition
Undernutrition has a negative effect on outcomes – eg pressure areas, rehab potential
Treatment is individualised
Teamwork allows better coordination of care for the patient 36

37. Questions?