Palliative Care Course: Nutrition

Transcription

1 Palliative Care Course: Nutrition Anna Chalaczkiewicz Macmillan/Home Enteral Feed Dietitian April 2018 Aims & Objectives Healthy Eating Malnutrition Oral Nutritional Supplements Feeding Tubes Nutritional implications within palliative care My Role 60% MacMillan Share my Role with Rebecca Duckworth, Macmillan Dietitian at Scunthorpe (40%) Part of the Head & Neck Team Attend Upper GI Drop in Sessions 1/month Oncology Clinic on Fridays in Scartho Medical Centre Links with Breast Cancer Nurses (Moving Forward Course) 40% Community Home visits own homes, Care Homes, Day Centres, Hospice 1

2 Healthy Eating What is healthy Eating? 2

3 Fluids Not a nutrient, but essential for life Need to ensure that your body is fully hydrated by drinking enough fluid Some symptoms of dehydration are: Tiredness, headache, thirst, confusion, constipation, darker urine colour, dry skin and dry lips. Aim for approx. 6-8 cups/glasses of fluid per day - Water, tea, coffee, milk, fruit juice, etc. Remember to drink more fluids when it is hot or if you are exercising as more water is lost naturally through sweat. Superfoods & Alternative Diets Malnutrition 3

4 Definition of Malnutrition A state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue/body structure and clinical outcome NICE, Malnutrition At any point in time more than 3 million people in the UK are at risk of malnutrition, around 93% live in the community. Malnourished patients have: 65% more GP visits 82% more hospital admissions 30% longer hospital stays Disease related malnutrition costs in excess of 13 billion per annum. Elia et al. BAPEN, 2005, 2009 Facts 4

5 The Consequences Impaired immune response Reduced muscle strength eg heart, lungs Impaired wound healing Impaired psycho-social function Impaired recovery from illness and surgery Poorer clinical outcomes Stratton et al Food First & Fortified Diet Fortified Diet Fortify/Enrich Foods Increase protein & energy content by adding: creams, cheese, butter, sugar, skimmed milk powder to foods/drinks Nourishing fluids: Encouraging milk, milky drinks, fruit juice 5

6 Milk 1 pint skimmed milk 200kcals, 20g protein, ~700mg Ca 1 pint semi-skimmed milk 269kcals, 20g protein, ~700mg Ca 1 pint full cream milk 386kcals, 20g protein, ~ 700mg Ca 1 pint fortified milk 595kcals, 42g protein, 1468mg Ca (FCM with 4 tablespoons skimmed milk powder) 1 pint fortified milk 643kcals, 34g protein, 1193mg Ca (FCM with small can evaporated milk) 6

7 How many Calories? Food Item Amount Banana 1 medium (100 g) Butter/Marg Cheese (hard) Egg (boiled) Ice Cream (dairy) 1½ Portion Packs 25 g /1 oz 1 Large 1 Scoop (60 g) Calories Jaffa Cakes 2 Biscuits Calories Dried milk powder 29gr = 2 tablespoons Mayonnaise 15gr =1 tablespoon Double Cream 20gr = 1 dessert spoon Jam 38gr= 2 heaped teaspoons Sugar 25gr = 5 teaspoons Honey or Syrup 34gr = 2 heaped teaspoons Chocolate 19gr = 2 small squares Sausage Roll 36gr = one bite size 7

8 Nutritional Values Snacks M.U.S.T 8

9 COMMUNITY Malnutrition Universal Screening Tool (MUST) Nutrition and Dietetic Service Community Team July Low Risk Routine clinical care Repeat screening monthly in care homes or annually in the community, and additionally whenever there is clinical concern 1 Medium Risk Observe Record or review food intake over 3 days Encourage nourishing snacks, drinks and food fortification Provide Food First leaflet Encourage Build-up or Complan, up to 3 times daily Repeat screening in 1 month - if weight stable/increased at review, repeat screening every 2-3 months - if weight has fallen, continue to screen monthly 2 or more High Risk Treat Refer to Dietitian* Follow advice as per Medium Risk * Unless detrimental or no benefit is expected from nutritional support e.g. imminent death. 9

10 MUST Management guidelines STEP 5 Referral to a Dietitian 10

11 How to refer? We accept referrals from GP s, District Nurses, Practice Nurses and other Health Professionals Complete a Community Dietitian Referral form (on intranet) or an Electronic Referral via SystmOne Community Dietitians based at The Diana Princess of Wales Hospital, Grimsby if in doubt, ring us! Oral Nutritional Supplements 11

12 Supplements Common problems with sip feeds: Over-reliance Taste fatigue Medical Products May not be suitable for all Nutricia Products 12

13 Time to Taste!! Samples Calogen Extra Forticreme Fortisip Compact Fortijuce Fortisip Yoghurt Style Fortisip Compact Protien Nutilis Complete Stage 1 Name Of Supplement kcal Protein (g) Volume (ml) Nutricia Oral Nutritional Supplements Fortisip Compact 300kcal 12g 125ml Fortisip Compact Protein 300kcal 18g 125ml Fortisip Compact Fibre has 4.5g fibre 300kcal 12g 125ml Fortijuce 300kcal 8g 200ml Fortisip Yogurt Style 300kcal 11.8g 200ml Calogen Extra (3 x 40ml shots) 480kcal 6g 120ml Calogen (3 x 30ml) 405kcal 0g 90ml Nutilis Complete (Stage 1 syrup thick) 300kcal 12g 125ml Forticreme 200kcal 11.9g 125g pot Scandishake Mix (powder mixed with 240ml whole milk) Complan shake (powder mixed with 200ml whole milk) 587kcal 12.1g 240ml 380kcal 15.5g 237ml 13

14 Tube feeding Feeding Tubes Least Common in the Community: Naso-gastric Tubes Naso-jejunal Tubes Jejunostomy Tubes PEG-J tubes Feeding tubes Most Common in the Community: PEG Tubes: Freka 15 french Scunthorpe Hospital 14

15 Feeding Tubes. PEG Tubes: Corflo 16 french Grimsby Hospital Feeding Tubes RIG Tubes -15 french Entuit balloon Gastrostomies placed in DPoW -Vygon Balloon Gastrostomies placed in HRI -Corflo Balloon Gastrostomies placed in CHH Feeding Tubes. Low Profile Devices 15

16 Care of Feeding Tubes Rotating - daily Advancing weekly Changing water in a balloon gastrostomy/button weekly Stoma Site complications check daily Enteral Tube Feeding Bolus Feeding: All liquid oral nutritional supplements can be administered by boluses. Continuous Pump Feeding: Common Nutricia Tube Feeds Name of Feed Kcal / 100ml Protein (g) / 100ml Fibre (g) / 100ml Nutrison 100kcal 4.0g 0g Nutrison Energy 150kcal 6.0g 0g Nutrison Energy Multi Fibre Nutrison 1200 Complete Multi Fibre Nutrison 1000 Complete Multi Fibre Nutrison 800 Complete Multi Fibre Nutrison Soya (Multi Fibre) 150kcal 5.5g 1.5g 120kcal 5.5g 2.0g 100kcal 5.5g 2.0g 80kcal 7.5g 1.5g 100kcal 4.0g (1.5g) Nutrison Concentrated 200kcal 7.5g 0g Nutrison Peptisorb 100kcal 4.0g 0g 16

17 Monitoring of Tube Fed Patients Bowels Diarrhoea Constipation Bloating Vomiting Positioning Weight Lifestyle around Tube Feeding Deliveries from Nutricia Able to rotate and advance Tube (where applicable) Any problems contact Dietitian Nutricia Homeward Pump Training before leaving hospital and at home Bolus Training before leaving hospital and at home Care of Tube Education at home Stoma Site Complications at home Visit Patients regularly at home Contact numbers: Nutricia Homeward Nurse Chrissie Nutricia Out of Hours ENFit Connectors 17

18 Palliative Care & Nutrition Palliative care & Nutrition Physically able Emotional/ social Cachexia Aggressive feeding Aiming for maintenance (Weight + Nutritional status) Dependant on stage Non Oral Feeding & End of Life Pros - Nutrition - Preventing Starvation/ Malnutrition - Comfort Cons - Prolongs life(?) - Painful - Invasive procedure - Emotionally stressful - Unnecessary 18

19 MDT Approach.. Doctor Specialist Nurse Carer Social Worker SLT Physio Dietitian Patient+ Family OT Nutrition The goal of nutrition therapy should NOT be weight gain or reversal of malnutrition, but if should be about quality of life, including comfort, symptom relief and enjoyment of food. Aggressive feeding is NOT appropriate, especially if eating and drinking cause discomfort and/ or anxiety to the patient. MacMillan Cancer Support 2007 Any Questions? 19

20 Thank you for listening! 20