Nutritional Assessment and Management - Essay Example

Nutritional Assessment and Management Introduction: Pancreatitis may be defined as the inflammation of the pancreas followed by an infectious process. It is broadly classified into acute pancreatitis and chronic pancreatitis. The incidence of acute pancreatitis is rapidly increasing with the current hospital admission rate of 9.8 per year per 100,000 populations in the UK (Gurusami, Farouk & Tweedie 2005). The incidence of acute pancreatitis varies between 4.9 and 73.4 cases per 100,000 population worldwide (Tenner et al. 2013). The incidence of chronic pancreatitis is lower when compared to acute pancreatitis. Both these types may lead to the development of pancreatic cancer. Various factors are attributed to the aetiology of acute pancreatitis. The risk of development of pancreatitis differs with age and sex, and it most commonly occurs among the black population than any other race (Yadav & Lowenfels 2012). The most common cause of acute pancreatitis is gall stones and can be eliminated with the help of early cholecystectomy (Yadav & Lowenfels 2012). Alcoholism and smoking lead to be independent factors in the development of pancreatitis. Acute pancreatitis can occur within hours or 2 days following the consumption of alcohol. Other causes of acute pancreatitis include abdominal trauma, infections, medications, tumours, and genetic abnormalities. The symptoms include upper abdominal pain which may be gradual or sudden followed by consumption of food. The pain may be mild initially and may result in severe form later. Symptoms like nausea, vomiting, fever, rapid pulse may be present. Severe acute pancreatitis may be fatal to the patient with failures of the kidney, the lungs and the heart. In the following essay, an attempt is made to critically evaluate the clinical condition of Mrs. Barrowman diagnosed with acute pancreatitis and to identify the factors that may affect her nutritional status, and to assess her nutritional risk status using ‘MUST’ (Malnutrition Universal Screening Tool). BRIEF DESCRIPTION OF PATIENT PROFILE Mrs. Barrowman, 54 years, got admitted in the ITU with the diagnosis of acute pancreatitis. During admission, the patient was presented with symptoms of severe abdominal pain and vomiting, which are one of the main signs of acute pancreatitis. Physically, height of the patient is 1.78 m and weight 58 kg prior to the period of ill health, and might have possibly lost 1-5 kg during her illness. Third day observation charted the following: BP: 105/75 mm Hg, heart rate: 130 bpm and is presented with sinus tachycardia. She has pitting edema all over the body. Other laboratory investigations had been done. FACTORS AFFECTING THE NUTRITIONAL STATE OF THE PATIENT Based on the Atlanta Criteria, about 75% of patients with acute pancreatitis have mortality rate of less than 1%. Most of the patients who have mild pancreatitis may be treated with standard treatment and can resume a normal diet within 3-7 days (Meier et al. 2002). Malnutrition may aggravate the disease process. In order to form an adequate nutritional support, it is necessary to understand and analyze the sequence of pancreatic secretions during acute inflammation of pancreas. Non-specific and specific changes occur during acute pancreatitis. Pain and release of inflammatory mediators triggers the increase in basal metabolic rate and thus results in higher energy consumption. However, these changes may not occur in all patients. Acute pancreatitis associated with sepsis may result in hypermetabolic state (Meier et al. 2002) with increase in resting energy expenditure (REE) (Alexander & Pharm n.d.). Due to increased REE and protein breakdown, these patients have higher nutritional requirement. Clinical outcomes become worse with the presence of negative nitrogen balance. In some patients with acute pancreatitis, the net nitrogen loss is approximately 20-40 g/day. If there are prolonged periods of inadequate oral intake, for more than 10 days approximately, it may result in protein calorie malnutrition in patients with acute pancreatitis. Here, Mrs. Barrowman is nil per oral following admission and hence, protein calorie malnutrition must be anticipated. Certain amino acid deficiency may trigger the inflammatory process. Patients may be presented with “increased endogenous gluconeogensis” (Alexander & Pharm n.d.), which is a symptom of metabolic response in the disease process. As a result, insulin may be required in 81% of the cases (Alexander & Pharm n.d.). Mrs. Barrowman’s blood sugar level is 4.2 mmol/l. If there is an increase in oxygen consumption by “20-30%” (Meier et al. 2002), it indicates increased energy consumption and decreased blood supply to the vital organs due to decreased cardiac performance or hypovolemia. Mrs. Barrowman is ventilated via ETT with a biphasic mode, pressure support 15 cm H2O. ABG results are stable. Hypocalcemia during the initial days of attack may trigger the disease condition and this may be associated with hypoalbuminemia, hypomagnesemia, increased calcitonin release and decreased parathyroid hormone secretion. Mrs. Barrrowman has an albumin range of 12g/dl whereas the normal range of albumin in blood is 3.4 to 5.4 g/dl (Albumin – Blood (Serum) 2014), patient’s blood albumin level is high. The magnesium value of the patient is 1.4 mmol/l whereas the normal value of magnesium is 0.75 to 1.2 mmol/l (McAuley & Pharm 1993). The patient’s serum magnesium level is slightly increased. From the above analysis, it is evident that Mrs. Barrowman’s nutritional status may be affected by keeping the patient nil per oral. SCREENING TOOL FOR ASSESSING NUTRITIONAL RISK SIGNIFICANCE OF NUTRITIONAL SUPPORT Today’s health care delivery system focuses on the delivery of quality care to the patients. This mainly focuses on the prevention of malnutrition among hospitalized patients. The prevention of malnutrition among hospitalized patients, will result in providing optimized health with high quality of patient care, improved clinical outcomes, and reduced the costs. Most of the malnutrition in hospitals go unrecognized. Therefore, it is important to identify patients who are malnourished. Kelly et al 2013 has suggested a model to improve the delivery of care in terms of nutrition in hospitals. They have suggested six principles: 1) The hospitals should create a culture where the stake holders value the importance of nutrition. 2) The clinicians should redefine their roles to include nutrition in care. 3) The health care professionals should recognize and diagnose all malnourished patients and those who are at risk. 4) They should implement interventions in terms of comprehensive nutrition and should be continually monitored. 5) The health care professionals should communicate the nutritional care plans. 6) The hospital should develop a discharge nutrition care and education plan. Due to the increased risk of complications, the level of malnutrition should be assessed. First process in assessing malnutrition is screening. All the patients during hospital admission should be assessed for the risk of malnutrition. Screening should be systematically performed by doctors or nurses. If the patient is diagnosed of high risk malnutrition. Then a nutritional support plan should be made, and then the patient’s dietary intake may be monitored by the nurse or other care personnel. The screening tool that is used for assessing the nutritional risk of Mrs. Barrowman is ‘MUST’ (Malnutrition Universal Screening Tool) (Must n.d.). This is a five-step screening tool that is used to assess clients who are at risk of malnutrition, malnourished or undernourished. The Malnutrition Universal Screening Tool is a valid and effective method (3). It combines the percentage of unplanned weight loss, BMI and the acute disease effect. It is easier to use and straight foreword and the structure is easy to maintain by the nursing staff. Step 1: Measure the height and weight using BMI chart. The patient’s height is 1.75 m (5 feet 7 inches) and weight is 58 kg prior to illness. The patient may have lost 1 to 5 kg during illness. Based on the MUST chart, patient’s BMI is 19, with a score 1 (colour yellow). But as the patient might have lost approximately 1-5 kgs, we can assume that the patient’s weight is 53 kg, and so the patient’s BMI according to the MUST chart is 18 with a score 2 and colour red. Step 2: Note the unplanned weight loss. The unplanned weight loss based on the chart may be between 5 - 10% with a score of 1, as the patient might have lost 1-5 kg during the course of the disease. Step 3: Acute disease affects score. If the patient is acutely ill and did not have any nutritional intake for 5 days or more then the score is 2. Mrs. Barrowman has been kept nil per oral for 3 days, so the score may be 1. Step 4: Assess the overall risk of malnutrition by adding step 1, 2, and 3. So the overall score for the patient is 1+1+1 = 3. Based on the chart, the scores are rated accordingly. Score 0 – Low risk, Score 1- Medium Risk, Score 2 or more – High Risk. The patient’s score is 1, and therefore the risk of malnutrition is high. Step 5: Management based on risk scores. Based on the MUST chart, the following guidelines were recommended. The patient should be referred to a dietician or a nutritional support team. The staff should develop a care plan and review it. The underlying condition should be treated, and the food should be prepared based on the likes and dislikes of the patient. MANAGEMENT OF ACUTE PANCREATITIS: The incidence of acute pancreatitis continues to rise in the UK. Therefore, this issue should be addressed seriously. The initial management of acute pancreatitis includes fluid resuscitation (UK Guidelines for the Management of Acute Pancreatitis 2005). This is done to prevent systemic complications. It is said that adequate fluid resuscitation with oxygen supplementation reduces organ failure and, in turn, reduces the mortality. Oxygen saturation should be ensured continuously. Supplemental oxygen may be administered so that the arterial saturation may be kept above 95%. Fluids should be administered intravenously, it may be either colloids or crystalloids, so that a urine output of >0.5 ml/kg (UK Guidelines for the Management of Acute Pancreatitis 2005) can be maintained. Fluid replacement rates should be monitored frequently by assessing the central venous pressure. There is no specific proven drug therapy for the management of acute pancreatitis. The most severe local complication of acute pancreatitis is infective necrosis. This results in high rate of mortality among patients. It is advisable to administer prophylactic antibiotics in order to prevent this complication. Many trials have been conducted to identify the most appropriate antibiotic, but none has been identified. The American College of Gerontology proposes the following guidelines. When a patient is presented with organ failure or systemic inflammatory response syndrome (SIRS), the patient should be admitted to intensive care unit. The patient should be provided with aggressive hydration (Tenner et al. 2013) that is about 250 - 500 ml per hour of isotonic crystalloid solution (Tenner et al. 2013) unless there are any cardiovascular or renal complications. Lactated Ringer’s Solution is the fluid of choice for hydration. During the first 12-24 hours, aggressive intravenous hydration is most beneficial. Fluid requirements should be frequently assessed within the first 6 hour of admission and the next 24 - 48 hours (2013). Within the 24 hour admission, these patients should undergo endoscopic retrograde cholangiopancreatography (ERCP). In patients with infected necrosis, administration of prophylactic antibiotics is highly recommended, as it helps to delay the progress of the disease and decreases the mortality rate. If the patient has mild acute pancreatitis without nausea and vomiting, oral feedings may be started. Enteral nutrition is recommended in severe acute pancreatitis, so as to prevent infectious complications. NUTRITIONAL SUPPORT: Previously patients were kept nil per oral to rest the pancreas. This has proven to be imperative. Based on the guidelines, enteral nutrition is recommended in acute pancreatitis. Oral feedings may be started immediately in the absence of nausea and vomiting in mild acute pancreatitis. Low fat solid diet may be administered in mild cases of acute pancreatitis. Enteral nutrition is recommended in severe acute pancreatitis to prevent infectious complications. Parental nutrition is not recommended in the case of severe acute pancreatitis. If enteral route is not available or not tolerated or is not able to meet the caloric requirements, parenteral nutrition may be administered. It is strongly recommended that enteral feeding through nasogastric or nasojejunal route be administered. Studies conducted by Spanier et al 2010 on enteral feeding have recommended the following: Enteral nutrition (EN) should be initiated in patients who cannot consume normal food after 5-7 days. If the patients cannot tolerate oral intake even after 7 days, EN is recommended in severe acute pancreatitis. The assessment can be made initially during the time of admission within the first 3- 4 days. EN can be supplemented with parenteral nutrition if possible. Tube feeding can be initiated in patients with complications like pancreatic fistulas, ascites and pseudocysts. If the patient cannot tolerate gastric feeding then jejuna feeding should be administered. Continuous feeding may be administered instead of bolus feeding. If there is gastric outlet obstruction, feeding may be administered beyond the tip of obstruction. Unless this is possible, parenteral nutrition should be administered. If the patient had undergone surgery for complications associated with acute pancreatitis, then intra operative jejunostomy may be ensured for post operative feedings. The researchers have also suggested the use of peptid-based semielemental formulas, if they are tolerated by the patient. In an article by Shishir K et al on the best approach in nutrition in acute pancreatitis suggested that the role of nutrition in this acute disease continues to evolve. It is still a debate among researchers on resting the pancreas by keeping the patient nil per oral. The authors suggest that this is not a right approach as the systemic inflammatory response in the acute phase of illness may lead the patient to a catabolic state. Supplementation of adequate amount of nutrition helps the patients for a faster recovery. The authors do not recommend the use of total parentral nutrition as it increases the chance of mortality among the patients. Total parentral nutrition has led to increased infectious complications. Most of the patients with acute pancreatitis do not require nutritional support. Patient is kept on intravenous hydration until there is no more complaints of abdominal pain, tenderness, nausea, or vomiting , after that oral feedings can be initiated. It is only recommended for patients who cannot tolerate oral intake within 5-7 days or if they cannot tolerate oral feeds for prolonged period of time. In a research study, when patients were fed 25 kcal /day, 21% developed pain and this led to longer hospital stay (33 vs 18 days). It was seen that patients with lower lipase level did not develop pain on re feeding. When nutritional support is indicated, enteral nutrition is preferred instead of total parenteral nutrition, as it reduces the complications and mortality rate when compared to total parenteral nutrition in acute pancreatitis. Total parenteral nutrition is only recommended in patients who cannot tolerate enteral nutrition. EN should be initiated as early as possible, approximately within 48 hours of admission, as it is highly beneficial. Some researchers suggest that total parentral nutrition is better for prolonged periods than enteral feeding. As the access to tubes are poorly tolerated for longer periods of time in some cases. Therefore, they suggest that total parental nutrition may increase the quality of life for these patients, despite high risk of infection. A study conducted by Li et al 2013, reveals that initiation of EN within 48 hours improves the clinical outcomes in patients with acute pancreatitis and reduces the complications. It also reduces the chance of developing infections, hyperglycemia and death. They also suggested the use of EN instead of total parenteral nutrition. Enteral feeding is recommended in patients with severe acute pancreatitis. The systemic inflammatory response may lead to multi-organ failure or multi-organ dysfunction syndrome (MODS). If the patients do develop early MODS, it may lead to the development of late MODS and ultimately lead to death. Many studies have found that enteral feeding in such cases reduces the chance of septic morbidity. When the enteral feedings are started early that is within 72 hours, it has been found that about 50% to 60% of the calories are delivered. It has also proven to be cost effective(1). Enteral nutrition provides nutrition and alters the bacterial flora, therefore, chances of developing infection decreases. Use of nasogastric feeding is recommended, as it helps the pancreas to rest. Dietary recommendations for patients with acute pancreatitis: it is important to maintain a healthy body weight. Clients should be administered with diet which is low in fat and high in fibre, as it helps in preventing gallstones, which is the primary course for acute pancreatitis. The triglyceride levels should be controlled; so as to control this, a fat restricted diet is recommended. Patients are advised to chose carbohydrate diet that do not raise the triglyceride level which has low glycemic index and are high in fibre. Avoidance of alcohol is strictly recommended as it induces or triggers the disease process. CONCLUSION: Acute pancreatitis is a rising concern in the UK and other countries. The management differs for each patient based on severity. It is evident that for mild cases of acute pancreatitis oral feeding may be initiated. Nutrional supplementation is emphasized, as the patients tend to be malnourished. There is also a need to discuss the nutritional intake of the patient with the doctor and the dietitian Mrs. Barrowman has high risk of malnutrition and therefore, it is important to initiate enteral feeding as soon as possible. The fluid intake should be monitored frequently and the necessary antibiotics must be administered. The nurse must also educate the patient and family members regarding the importance of nutrition and dietary recommendations. Acute pancreatitis is disease condition that may occur as a result of the presence of gall stones or heavy alcohol consumption. It is evident that nutritional support is the most important factor in the treatment in this disease condition. Therefore, the health care professionals should be aware of the type of feed the patient should receive. Nurses should ensure to keep a chart on the intake and output of patients. It is imperative that keeping the pancreas at rest by placing the patient nil per oral is no longer recommended, as these results in malnourishment of patients. References Alexander, E. & Pharm, D. (n.d.). ‘Nutritional Management in Acute and Chronic Pancreatitis.’ Nutritional Management in Acute and Chronic Pancreatitis. [Online] Available at [23 April 2014] ‘Albumin – Blood (Serum).’ (2014). Medline Plus. [Online] Available at [23 April 2014] Balthazar, E.J. (2001). ‘Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation.’ Radiology. [Online] Available at [23 April 2014] Duggan, S. (2013). ‘Evidence-Based Solutions to Clinical Problems: Nutritional Management of Chronic Pancreatitis.’ IRSPEN. [Online] Available at [23 April 2014] Duggan, S. (2013). ‘A Practical Guide to the Nutritional Management of Chronic Pancreatitis.’ Nutrition Issues on Gastroenterology. [Online] Available at [23 April 2014] Gurusami, K.S., Farouk, M. & Tweedie, J.H. (2005). ‘UK Guidelines for Management of Acute Pancreatitis: Is It Time To Change?.’ Gut. [Online] Available at [23 April 2014] McAuley, D. & Pharm, D. (1993). ‘Common Laboratory (LAB) Values [M-N-O].’ GLOBALRPh. [Online] Available at [23 April 2014] Meier et al. (2002). ‘Consensus Statement: ESPEN Guidelines on Nutrition in Acute Pancreatitis.’ Clinical Nutrition: Elsevier Science Ltd. [Online] Available at [23 April 2014] ‘Must.’ (n.d.). BAPEN. [Online] Available at [23 April 2014] ‘Nutrition Guidelines for Chronic Pancreatitis Patient Education.’ Digestive Health Center Nutrition Services. Stanford Hospital & Clinics. [Online] Available at [23 April 2014] ‘Pancreatitis.’ (2008). NIH Publication. [Online] Available at [23 April 2014] ‘Pancreatitis: Nutritional Considerations.’ (n.d.). Nutrition MD. [Online] Available at [23 April 2014] Spanier, B.W.M., Bruno, M.J. & Mathus-Vliegen, E.M.H. (2010). ‘Enteral Nutrition and Acute Pancreatitis: A Review.’ Gastroenterology Research and Practice. [Online] Available at [23 April 2014] Tenner et al. (2013). ‘American College of Gastroenterology Guideline: Management of Acute Pancreatitis.’ Nature Publishing Group. [Online] Available at [23 April 2014] ‘UK Guidelines for the Management of Acute Pancreatitis.’ (2005). Gut. [Online] Available at [23 April 2014] Yadav, D. & Lowenfels, A.B. (2012). ‘The Epidemiology of Pancreatitis and Pancreatic Cancer.’ Official Journal of the AGA Institute. [Online] Available at [23 April 2014] Read More