Bing ads help34 comments
Express options logistics
Education and training should cover:. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support. Screening should also be considered at other opportunities for example, health checks, flu injections.
Potential swallowing problems should be taken into account. Decisions on withholding or withdrawing of nutrition support require a consideration of both ethical and legal principles both at common law and statute including the Human Rights Act When such decisions are being made guidance issued by the General Medical Council [ 5 ] and the Department of Health [ 6 ] should be followed.
They should also have access to appropriate information and be given the opportunity to discuss diagnosis and treatment options.
It should be built up to meet full needs over the first 24—48 hours according to metabolic and gastrointestinal tolerance. Full requirements of fluid, electrolytes, vitamins and minerals should be provided from the outset of feeding. Box 1 Criteria for determining people at high risk of developing refeeding problems.
Pre-feeding correction of low plasma levels is unnecessary. The time between reviews depends on the patient, care setting and duration of nutrition support. Intervals may increase as the patient is stabilised on nutrition support.
Table 2 is particularly relevant to parenteral nutrition. It could also be selectively applied when enteral or oral nutrition support is used, particularly for people who are metabolically unstable or at risk of refeeding syndrome. The frequency and extent of the observations given may need to be adapted in acutely ill or metabolically unstable people.
In addition, they should be reviewed at a specialist hospital clinic every 3—6 months. Monitoring should be more frequent during the early months of home parenteral nutrition, or if there is a change in clinical condition, when the full range of tests in Tables 1 and 2 should be performed.
Some of the clinical observations may be checked by patients or carers. This group of people should be monitored every 3—6 months or more frequently if there is any change in their clinical condition. A limited number of observations and tests from Table 1 should be performed. If clinical progress is satisfactory, laboratory tests are rarely needed.
Table 1 Protocol for nutritional, anthropometric and clinical monitoring of nutrition support. Nutrient intake from oral, enteral or parenteral nutrition including any change in conditions that are affecting food intake.
To ensure that patient is receiving nutrients to meet requirements and that current method of feeding is still the most appropriate. To allow alteration of intake as indicated. To assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle.
Gastric tube position pH less than or equal to 5. Appropriate preparation of drug to reduce incidence of tube blockage. Daily initially, reducing to twice weekly and then progressively to 3—6 monthly, unless clinical condition changes. Table 2 Protocol for laboratory monitoring of nutrition support. Box 3 Factors to be considered before modification of nutrition support and hydration in people with dysphagia.
The patient should be monitored carefully for any signs of nausea or vomiting. In this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed as specified in section 1. Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should assess the prognosis and options for future nutrition support.
If insulin administration is needed it is safe and more practical to administer feeding continuously over 24 hours. Local protocols should address the clinical criteria that permit enteral tube feeding. These criteria include how to proceed when the ability to make repeat checks of the tube position is limited by the inability to aspirate the tube, or the checking of pH is invalid because of gastric acid suppression.
Agreed protocols setting out the necessary clinical checks need to be in place before this procedure is carried out. Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. Withdrawal should be planned and stepwise with a daily review of the patient's progress. Before using most parenteral nutrition products, micronutrients and trace elements should be added and additional electrolytes and other nutrients may also be needed.
Additions should be made under appropriate pharmaceutically controlled environmental conditions before administration. There is no minimum length of time for the duration of parenteral nutrition. A free dedicated lumen in a multi-lumen centrally placed catheter may also be used. Care should be taken in catheter choice, and in attention to pH, tonicity and long-term compatibility of the parenteral nutrition formulations in order to avoid administration or stability problems.
Consideration should be given to cognition, gender, physical needs, culture and stage of life of the individual. Close liaison between the multidisciplinary team and patients and carers regarding diagnoses, prescription, arrangements and potential problems is essential. You can also see this guideline in the NICE pathways on nutrition support in adults and stroke. To find out what NICE has said on topics related to this guideline, see our web page on endocrinal, nutritional and metabolic conditions: See also the guideline committee's discussion and the evidence reviews in the full guideline , and information about how the guideline was developed , including details of the committee.
Introduction Developing this guideline Patient-centred care Key priorities for implementation 1 Guidance 2 Research recommendations Update information.
Next 1 Guidance 1. Education and training should cover: Patient has one or more of the following: BMI less than Table 1 Protocol for nutritional, anthropometric and clinical monitoring of nutrition support Parameter Frequency Rationale Nutritional Nutrient intake from oral, enteral or parenteral nutrition including any change in conditions that are affecting food intake Daily initially, reducing to twice weekly when stable To ensure that patient is receiving nutrients to meet requirements and that current method of feeding is still the most appropriate.
Parameter Frequency Rationale Interpretation Sodium, potassium, urea, creatinine Baseline Daily until stable Then 1 or 2 times a week Assessment of renal function, fluid status, and Na and K status Interpret with knowledge of fluid balance and medication Urinary sodium may be helpful in complex cases with gastrointestinal fluid loss Glucose Baseline 1 or 2 times a day or more if needed until stable Then weekly Glucose intolerance is common Good glycaemic control is necessary Magnesium, phosphate Baseline Daily if risk of refeeding syndrome Three times a week until stable Then weekly Depletion is common and under recognised Low concentrations indicate poor status Liver function tests including International Normalised Ratio INR Baseline Twice weekly until stable Then weekly Abnormalities common during parenteral nutrition Complex.
May be due to sepsis, other disease or nutritional intake Calcium, albumin Baseline Then weekly Hypocalcaemia or hypercalcaemia may occur Correct measured serum calcium concentration for albumin Hypocalcaemia may be secondary to Mg deficiency Low albumin reflects disease not protein status C-reactive protein Baseline Then 2 or 3 times a week until stable Assists interpretation of protein, trace element and vitamin results To assess the presence of an acute phase reaction APR.
Box 2 Indicators of dysphagia Obvious indicators of dysphagia Less obvious indicators of dysphagia Difficult, painful chewing or swallowing Regurgitation of undigested food Difficulty controlling food or liquid in the mouth Drooling Hoarse voice Coughing or choking before, during or after swallowing Globus sensation Nasal regurgitation Feeling of obstruction Unintentional weight loss — for example, in people with dementia Change in respiration pattern Unexplained temperature spikes Wet voice quality Tongue fasciculation may be indicative of motor neurone disease Xerostomia Heartburn Change in eating habits — for example, eating slowly or avoiding social occasions Frequent throat clearing Recurrent chest infections Atypical chest pain.
Recurrent chest infections Mobility Dependency on others for assistance to eat Perceived palatability and appearance of food or drink Level of alertness Compromised physiology Poor oral hygiene Compromised medical status Metabolic and nutritional requirements Vulnerability for example, immunocompromised Comorbidities. Route of access 1. People with dysphagia 1. Mode of delivery 1. Management of tubes 1. Management of catheters 1. Consideration should be given to cognition, gender, physical needs, culture and stage of life of the individual have the opportunity to discuss diagnosis, treatment options and relevant physical, psychological and social issues are given contact details for relevant support groups, charities and voluntary organisations.
Enteral tube feeding 1. More information You can also see this guideline in the NICE pathways on nutrition support in adults and stroke. Or patient has two or more of the following: Daily initially, reducing to twice weekly when stable. To ensure that patient is receiving correct volume of feed. Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly. Monthly, if weight cannot be obtained or is difficult to interpret. To rule out any other causes of diarrhoea and then assess tolerance of feeds.
To rule out other causes of constipation and then assess tolerance of feeds. Enteral tube — nasally inserted. Tube insertion and rotation gastrostomy without jejunal extension only.
Balloon water volume balloon retained gastrostomies only. Jejunostomy tube position by noting position of external markers. To ensure that patient is tolerating feed and that feeding and route continue to be appropriate. Daily initially, reducing to monthly when stable.
To ensure that feeding is appropriate to overall care of patient. Baseline Daily until stable Then 1 or 2 times a week. Assessment of renal function, fluid status, and Na and K status. Interpret with knowledge of fluid balance and medication Urinary sodium may be helpful in complex cases with gastrointestinal fluid loss. Baseline 1 or 2 times a day or more if needed until stable Then weekly.
Baseline Daily if risk of refeeding syndrome Three times a week until stable Then weekly. Baseline Twice weekly until stable Then weekly. Abnormalities common during parenteral nutrition. May be due to sepsis, other disease or nutritional intake. Correct measured serum calcium concentration for albumin Hypocalcaemia may be secondary to Mg deficiency Low albumin reflects disease not protein status.
Baseline Then 2 or 3 times a week until stable. Assists interpretation of protein, trace element and vitamin results. To assess the presence of an acute phase reaction APR. The trend of results is important. Baseline Then every 2—4 weeks, depending on results. Deficiency common, especially when increased losses.