Nutrition after Stroke. Nina Belk, Dietitian Helen Mann CNS

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1 Nutrition after Stroke Nina Belk, Dietitian Helen Mann CNS

2 Nutrition after Stroke Evidence & Guidelines Dysphagia & Malnutrition Managing mealtimes Tube care

3 Why is nutrition important? Poor nutritional status is linked with poor outcome in acute stroke patients If a patient is malnourished they are: Increased risk of infection Easily fatigued At risk of dysphagia Increased risk of chest infection Increased risk of low mood Decreased muscle mass Likely to have increased length of stay

4 Evidence NICE clinical guidelines 68 Stroke: Diagnosis and initial management of acute stroke and transient ischemic attack (TIA) Management of Patients with Stroke: Identification and Management of Dysphagia, SIGN Guideline No 119 ISBN , June 2010 UK Nutrition screening survey (BAPEN 2008) 09.pdf A review of the relationship between dysphagia and malnutrition following stroke (2009) Foley, Norine C et al, Journal of Rehabilitation Medicine, Volume 41, Number 9, pp

5 Nutritional status of stroke patients is influenced by: Dehydration Early satiety Busy ward environment Low mood Difficulty in expressing likes and dislikes Embarrassment and anxiety at meal times Impaired initiation of eating and drinking Premorbid nutritional status Positioning Dysphagia

6 Stroke patients are at high risk of dehydration and malnutrition. Those with dysphagia are at further risk... swallow Impaired physical & psychological recovery length of stay Lethargy and confusion infection risk Weight loss Low mood Dysphagia can cause Malnutrition: which will cause Dehydration Low mood Weight loss Fatigue infection risk Poor mouth state Intake

7 Oral health is important (RCP Guidelines 2008) Causes: cognitive impairment, visuospatial neglect, upper limb weakness, medication Consequences: risk of poor nutrition self-esteem Patients with poor oral hygiene, decayed teeth and feeding dependency are significantly more likely to develop chest infection (RCP 2008)

8 But it s s only a meal. Choice & alternatives Timing Unthinking preparation for eating (toilet, handwashing,, comfortable in chair, table position) Social rituals and interaction Empathic observation & awareness Apraxia,, functional eating difficulties Motivation & self esteem

9 Managing mealtimes Complexity of issues Time management, mealtime preparation Supervisory & feeding skills training Priorities, protected mealtimes Training & Awareness trained & untrained staff, volunteers, kitchen & catering staff

10

11 Volunteer mealtime assistants Theoretical 3hr training How stroke affects swallowing How stroke affects communication Visual defects hemianopia Distractibility, concentration, fatigue

12 Volunteer mealtime assistants research, Robinson et al hr training, MDT teaching 2 month trial: Volunteers fed 34 pts Nurses fed 34 different patients Volunteers: mean pt intake 58.88% Nurses: mean pt intake 32.45%

13 Skills training for mealtimes

14 The role of the MDT and nutrition Positioning of patients for meals and drinks Carry over of rehabilitation into meal times: e.g. sitting out for a meal Behaviour management influences on intake Provision of the correct modified texture foods and fluids Regular review of a patients malnutrition risk Monitoring biochemistry of those patients who are risk of dehydration

15

16 Nasogastric tubes Confirm NGT position: 1. Acidic ph ( ) 2. No aspirate, ph over 5.5 Monitor skin for redness & breakdown Use specifically designed plaster Secure away from mouth & line of sight Position at 30-45

17 Restraint

18 PEG tube and site care: PEG feeding and site care is a clean procedure. Therefore hand washing should be carried out before and after the care. Clean the site using warm soapy water daily and dry with clean towel Clean the external fixator daily (method will differ with each tube type)

19 PEG tube and site care ctn Ensure the tube is rotated and gently pushed in by about 1 inch weekly (refer to local guidelines on when to start this process) Patients can have a bath or shower two weeks after insertion Remove site dressing after 24hours unless directed otherwise. Avoid using a site dressing as this can increase the risk site infection

20 Balloon Gastrostomy care Balloon gastrostomy tubes are used for Radiologically placed gastrostomies (RIGs) Stoma care and tube rotation are the same as PEGs Additional considerations needed for RIGS are: Stitches to be removed at day 14 Balloon volume to be checked weekly once the tube has been in situ for 14 days

21 Summary The nutritional needs of a stroke patient are complex and dynamic Successful outcomes need multidisciplinary team work

22 References and websites Donaldson, E., Early, T., Sheilds, P (2007) The Nasal Bridle It s place within an integrated nutrition service: a prospective audit of one year s data. Gut (56) Suppl 56 A137 Metheny NA (2004) Preventing Aspiration in older adults with Dysphagia. Try This: Best Practices in Nursing Care to Older Adults, vol./is. /20(0-1) Sandman,L et al (2008) Ethical considerations of refusing nutrition after stroke Nursing Ethics 15 (2) Robinson, S, Clump, D, Weitzel, T, (2002) The Memorial Meal Mates: a program to improve nutrition in hospitalized older adults Geriatric Nursing, 23:6(332-5), Westergren, A, (2006) Detection of eating difficulties after stroke: a systematic review. International Nursing Review 53,

23 References and websites Dennis, M. Lewis, S. Warlow, C (2005) Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 365(9461): McLaren, S, Dickerson,J (2000) Measurement of eating disability in an acute stroke population Clinical Effectiveness in Nursing 4: Holmes S (2008) Nutrition and eating difficulties in hospitalised older adults Nursing Standard 22, 26, Faulkner M, (2001) The onset and alleviation of learned helplessness in older hospitalized people Ageing & Mental Health 5 (4),

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