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Nutrition support in adults

About

What is covered

This pathway covers nutrition support in adults who are malnourished or at risk of malnutrition. It includes advice on oral nutrition support, enteral tube feeding and parenteral nutrition.
Malnutrition is a state in which a deficiency of nutrients, such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome. Malnutrition is both a cause and a consequence of ill health. It is common and increases a patient's vulnerability to disease. Methods to improve or maintain nutritional intake are known as nutrition support. These include:
  • oral nutrition support – for example, fortified food, additional snacks and/or sip feeds
  • enteral tube feeding – the delivery of a nutritionally complete feed directly into the gut via a tube
  • parenteral nutrition – the delivery of nutrition intravenously.
These methods can improve outcomes, but decisions on the most effect and safe methods are complex. This pathway aims to help healthcare professionals correctly identify people in hospital and the community who need nutrition support, and enable them to choose and deliver the most appropriate nutrition support at the most appropriate time.

Updates

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on nutrition support in adults.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Updates to this pathway

4 September 2014 Minor maintenance updates.
22 April 2014 Link to pressure ulcers pathway added.
19 February 2014 Minor maintenance updates.
9 December 2013 Minor maintenance updates.
5 July 2013 Minor maintenance updates.
28 February 2013 minor maintenance updates.
25 October 2011 minor maintenance updates.

Short Text

Nutrition support in adults. Oral nutrition support, enteral tube feeding and parenteral nutrition

What is covered

This pathway covers nutrition support in adults who are malnourished or at risk of malnutrition. It includes advice on oral nutrition support, enteral tube feeding and parenteral nutrition.
Malnutrition is a state in which a deficiency of nutrients, such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome. Malnutrition is both a cause and a consequence of ill health. It is common and increases a patient's vulnerability to disease. Methods to improve or maintain nutritional intake are known as nutrition support. These include:
  • oral nutrition support – for example, fortified food, additional snacks and/or sip feeds
  • enteral tube feeding – the delivery of a nutritionally complete feed directly into the gut via a tube
  • parenteral nutrition – the delivery of nutrition intravenously.
These methods can improve outcomes, but decisions on the most effect and safe methods are complex. This pathway aims to help healthcare professionals correctly identify people in hospital and the community who need nutrition support, and enable them to choose and deliver the most appropriate nutrition support at the most appropriate time.

Sources

The NICE guidance that was used to create the pathway.
Nutrition support in adults. NICE clinical guideline 32 (2006)

Quality standards

Nutrition support in adults quality standard

These quality statements are taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statements

Screening for the risk of malnutrition

This quality statement is taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statement

People in care settings are screened for the risk of malnutrition using a validated screening tool.

Rationale (why it is important)

Malnutrition has a wide-ranging impact on people's health and wellbeing. Screening for the risk of malnutrition in care settings is important for enabling early and effective interventions. It is important that tools are validated to ensure that screening is as accurate and reliable as possible.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people in care settings are screened for the risk of malnutrition using a validated screening tool.
b) Evidence of local arrangements to ensure that screening for the risk of malnutrition is carried out by health and social care professionals who have undertaken training to use a validated screening tool.
c) Evidence of local arrangements to ensure that care settings have access to suitably calibrated equipment to enable accurate screening to be conducted.
Process
a) The proportion of people in care settings who are screened for the risk of malnutrition using a validated screening tool.
Numerator – the number of people in the denominator who are screened for the risk of malnutrition using a validated screening tool.
Denominator – the number of people in a care setting.
b) The proportion of people admitted to hospital who are re-screened weekly for the risk of malnutrition.
Numerator – the number of people in the denominator who are re-screened weekly for the risk of malnutrition.
Denominator – the number of people admitted to hospital.
c) The proportion of people in care home settings who are screened monthly for the risk of malnutrition.
Numerator – the number of people in the denominator who are screened monthly for the risk of malnutrition.
Denominator – the number of people in community care settings.
Outcome
a) Incidence of people at risk of malnutrition.
b) Prevalence of risk of malnutrition.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to screen people in the appropriate context (see Definitions below) for the risk of malnutrition using a validated screening tool.
Health and social care professionals ensure they screen people in their care (see Definitions below for settings) for the risk of malnutrition using a validated screening tool.
Commissioners ensure they commission services with local arrangements for screening in the appropriate care settings (see Definitions below) for the risk of malnutrition using a validated screening tool.
People admitted to hospital, attending an outpatient clinic for the first time or having care in a community setting are offered checks for their risk of malnutrition (not getting enough calories and nutrients, such as protein and vitamins, to meet the body's needs) using an accurate and reliable tool.

Source clinical guideline references

NICE clinical guideline 32 recommendations 1.2.2, 1.2.3 (key priorities for implementation), 1.2.4 and 1.2.5.

Data source

Structure
a), b) and c) Local data collection.
Process
a)
i) Local data collection. Acute hospitals, care homes and mental health trusts can review historical data on screening rates by reviewing the previous findings of the annual national nutrition screening survey conducted by the British Association for Parenteral and Enteral Nutrition (BAPEN).
ii) Department of Health Essence of Care benchmarks for food and drink, best practice indicators for factor 7 (screening and assessment) include measures for screening on admission to hospital, care homes and on registration with GP surgeries.
b) Local data collection
c) Local data collection
Outcome
a) and b) Local data collection

Definitions

Care settings and eligibility
The term 'settings' refers to any care setting where there is a clinical concern about risk of malnutrition. These include the following, as set out in NICE clinical guideline 32.
  • All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and for outpatients if there is clinical concern.
  • Screening should take place on initial registration at general practice surgeries and when there is clinical concern. Screening should also be considered at other opportunities (for example, health checks and flu injections).
  • People in care homes on admission or where there is clinical concern. The topic expert group (TEG) advised that screening should be repeated monthly for people in this setting, or sooner if there is clinical concern.
  • The TEG, based on their expert opinion and professional practice, advised that community settings include domiciliary care and local authority day care services and should have protocols for conducting screening when a person first accesses services.
  • Hospital departments who identify groups of patients with a low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving specialists in nutrition support.
Clinical concern
Screening should be carried out when there is clinical concern, for example, if the person has unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose-fitting clothes or prolonged intercurrent illness.
Validated screening tool
As set out in NICE clinical guideline 32 recommendation 1.2.6: 'Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this'.
A validated tool should be used to conduct the screening to support accuracy and consistency within and between settings. The TEG agreed that a validated tool is a tool for which there is evidence that it has been tested to ensure that:
  • it measures what it is intended to measure
  • its measurements are reproducible.
  • it is user friendly
  • it has been developed by a multidisciplinary group.
The term 'screening' is not used here to refer to a national screening programme such as those recommended by the UK National Screening Committee.

Equality and diversity considerations

Nutritional screening should be available to everyone for whom it is appropriate, including people who are unconscious, sedated, unable to speak or communicate (because of language problems or because of their condition), and those who cannot be weighed or have their height measured. Some screening tools (such as MUST) cater for all of these people.

Treatment

This quality statement is taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statement

People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their complete nutritional requirements.

Rationale (why it is important)

It is important that nutrition support goes beyond just providing sufficient calories and looks to provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide this and identifies condition specific circumstances and associated needs linked to nutrition support requirements.
A nutritionally complete diet can improve speed of recovery and contribute to reducing admissions to hospital and length of hospital stays.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people who are malnourished or at risk of malnutrition are offered a management care plan that aims to meet their complete nutritional requirements including underlying conditions, specific circumstances and associated needs.
b) Evidence of a local written protocol that all management care plans aim to provide complete nutritional requirements.
c) Evidence of local arrangements to ensure that care settings are able to provide appropriate nutrition support including artificial feeding when needed.
Process
The proportion of people who are malnourished or at risk of malnutrition who receive a management care plan that aims to meet their complete nutritional requirements.
Numerator – the number of people in the denominator who receive a management care plan that aims to meet their complete nutritional requirements.
Denominator – the number of people who are malnourished or at risk of malnutrition.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for all people who are malnourished or at risk of malnutrition to have a management care plan that aims meet their complete nutritional requirements.
Health and social care professionals give all people who are malnourished or at risk of malnutrition a management care plan that aims to meet their complete nutritional requirements.
Commissioners ensure they commission services that give people who are malnourished or at risk of malnutrition a management care plan that aims to meet their complete nutritional requirements.
People who have malnutrition (not getting enough calories and nutrients, such as protein and vitamins, to meet the body's needs) or who are at risk of malnutrition receive a management care plan that, in combination with any food they are able to eat, aims to provide all the nutrients their body needs.

Source clinical guideline references

NICE clinical guideline 32 recommendations 1.3.3 (key priority for implementation), 1.3.4 and 1.6.7).

Data sources

Structure
a) and b) Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Management care plan
This refers to the nutrition support provided alongside other dietary intake that aims to provide a person's complete nutritional requirements. The plan also takes into account any underlying conditions and the individual’s specific circumstances and associated needs.
Complete nutritional requirements
This includes providing adequate energy, proteins, fluids, electrolytes, minerals, micronutrients and fibre, taking into account personal factors including physical activity levels.

Equality and diversity considerations

People's special dietary requirements, including those that are consistent with religious and cultural beliefs, should be taken into account irrespective of the underlying reason for these requirements.

Documentation and communication of results and nutrition support goals

This quality statement is taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statement

All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable), documented and communicated in writing within and between settings.

Rationale (why it is important)

Documentation and written communication of a person's nutrition screening results and any nutrition support goals is important for ensuring continuity of care both within settings and after transfer between settings. This also helps to manage significant patient safety issues, such as nutrition support not continuing when it is required or people being given inappropriate food for their circumstances.

Quality measure

Structure
a) Evidence of local arrangements to ensure that a person's screening results and nutrition support goals (if applicable) are documented and communicated in writing when a person transfers within and between settings.
Process
a) The proportion of people screened for the risk of malnutrition whose screening results and nutritional support goals (if applicable) are documented in their care plan.
Numerator – the number of people in the denominator whose screening results and nutritional support goals (if applicable) are documented in their care plan.
Denominator – the number of people in a care setting who meet the criteria for screening (see statement 1).
b) The proportion of people screened for the risk of malnutrition whose screening results and nutritional support goals (if applicable) are communicated in writing within and between settings.
Numerator – the number of people in the denominator whose screening results and nutritional support goals (if applicable) are communicated in writing.
Denominator – the number of people transferred within or between settings and who have been screened for the risk of malnutrition.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals, when a person transfers within and between settings.
Health and social care professionals document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals when the person transfers within and between settings.
Commissioners should ensure they commission services with systems in place to document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals when a person transfers within and between settings.
People who are screened for the risk of malnutrition (not getting enough calories and nutrients, such as protein and vitamins, to meet the body's needs) have the results of their screening and the goals of any nutrition support (such as special nutrient-rich foods, nutritional supplements and fortified foods, or liquid food given through a tube) they are having recorded and communicated in writing when they transfer within and between settings.

Source clinical guideline references

NICE clinical guideline 32 recommendations 1.9.1, 1.9.2 and 1.9.5.

Data source

Structure
a) Local data collection.
Process
a) and b) Local data collection. Acute hospitals, care homes and mental health trusts can review historical data on screening rates by reviewing the previous findings of the annual national nutrition screening survey conducted by the British Association for Parenteral and Enteral Nutrition (BAPEN).
Outcome
Local data collection.

Definitions

Results
Identification of a person's malnutrition risk category that is recognised across care settings, including 'no risk' (this should also be communicated within and between settings).
Goals
The aims of any nutrition support that is documented in the management care plan, agreed following review of the person's risk of malnutrition.
Documented
The results from the screening should be documented in the person's care records and linked to a care plan. People who are identified as well-nourished will usually continue with routine care. For people identified as malnourished, the specific care plan and nutrition support goals should be clearly documented.
If applicable
For people screened who are not malnourished or at risk of malnutrition, the results should be recorded in their care plan but they do not need specific nutrition support goals.

Self-management of artificial nutrition support

This quality statement is taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statement

People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their wellbeing.

Rationale (why it is important)

People and/or their carers managing their artificial nutrition support need to be able to prevent and quickly recognise any adverse changes in their wellbeing that could be linked to their nutrition support. This includes their nutrition delivery system and storage of feed before administration. Early recognition of adverse changes enables people to obtain advice and urgent support to prevent problems arising or worsening.

Quality measure

Structure
a) Evidence of local arrangements to ensure that systems are in place for people managing their own artificial nutrition support and/or their carers to be trained to manage their nutrition delivery system and monitor their wellbeing.
b) Evidence of local arrangements to ensure that systems are in place for people managing their own artificial nutrition support and/or their carers to be able to contact a specialist urgently for advice if they identify any adverse changes in their wellbeing and in the management of their nutrition delivery system.
Process
a) The proportion of people managing their own artificial nutrition support and/or their carers who are trained to manage their nutrition delivery system and monitor their wellbeing.
Numerator – the number of people in the denominator who have received training to manage their nutrition delivery system and monitor their wellbeing.
Denominator – the number of people or the carers of people managing their own artificial nutrition support.
b) The proportion of people managing their own artificial nutrition support, and/or their carers, who are provided with contact details of a specialist in nutrition support who can provide urgent advice.
Numerator – the number of people in the denominator who are provided with contact details of a specialist in nutrition support who can provide urgent advice.
Denominator – the number of people and or the carers of people managing their own artificial nutrition support.
Outcome
a) People's confidence and competence to manage their own or others’ artificial nutrition support.
b) Rates of adverse events and complications in people managing their own or others’ artificial nutrition support.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for people managing their own artificial nutrition support and/or their carers to be trained to manage their nutrition delivery system and monitor their wellbeing and told how to contact a specialist to provide urgent advice and support when needed.
Health and social care professionals provide people managing their own artificial nutrition support and/or their carers with training in how to manage their nutrition delivery system and monitor their wellbeing and give them contact details of a specialist who can provide urgent advice and support if needed.
Commissioners ensure they commission services that have systems in place for people managing their own artificial nutrition support and/or their carers to be provided with training in how to manage their nutrition delivery system and monitor their wellbeing, and that provide contact details of a specialist who can provide urgent advice and support if needed.
People who are managing their own artificial nutrition support (feeding through a tube) and/or their carers are taught how to prevent, recognise and respond to any problems with their wellbeing or their artificial nutrition support system and given contact details of a specialist who can provide urgent advice and help if needed.

Source clinical guideline references

NICE clinical guideline 32 recommendation 1.5.7.

Data source

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.
Outcome
a) and b) Local data collection.

Definitions

Training
The training should ensure that a patient or carer is competent to prevent, recognise and respond to changes in their wellbeing, particularly those related to their nutritional support. They should also be competent in managing their own nutrition delivery system, including the equipment used to deliver the feed, and storing the feed in an appropriate environment.
Management
The daily self-management of a person's artificial nutritional support. Management should also include a system through which people are able to obtain urgent help from a specialist in nutritional support when needed. Self-management and/or management of artificial nutritional support by carers is not a replacement for monitoring and follow-up by care professionals. Management should be regarded as a partnership between the person and/or their carer and the care professional.
Artificial nutrition support
Enteral tube feeding and/or parenteral nutritional support.
Urgently
Urgent access to specialist advice should be available 24 hours a day, every day of the week (NICE clinical guideline 32).

Equality and diversity considerations

Training and education should be accessible to people who have difficulties reading or speaking English and those who need information in non-written form.

Review

This quality statement is taken from the nutrition support in adults quality standard. The quality standard defines clinical best practice in nutrition support in adults and should be read in full.

Quality statement

People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.

Rationale (why it is important)

People's nutritional status is affected by a number of different factors and can therefore change rapidly. Regular review of the nutrition support care plan by a care professional enables the plan to be adapted to best meet the current needs of the person.

Quality measure

Structure
Evidence of local arrangements to ensure that people receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.
Process
a) The proportion of people receiving nutrition support who have the indications, route, risks, benefits and goals of their nutrition support reviewed at planned intervals.
Numerator – the number of people in the denominator whose most recent review (subject to decision) is no later than planned after their last review.
Denominator – the number of people receiving nutrition support.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people receiving nutrition support to be offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.
Health and social are professionals review the indications, route, risks, benefits and goals of nutritional support in people who are receiving nutrition support at planned intervals.
Commissioners ensure that they commission services that have systems in place for people receiving nutrition support to have the indications, route, risks, benefits and goals of their nutrition support reviewed at planned intervals.
People receiving nutrition support have their need for nutrition support, their method of nutrition support and the risks, benefits and goals of their nutrition support reviewed at planned times.

Source clinical guideline references

NICE clinical guideline 32 recommendations 1.1.3, 1.5.1, 1.6.9 and 1.7.3.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Nutrition support
This refers to recommendation 1.6.7 in NICE clinical guideline 32 on the overall nutrient intake needed in any nutrition support treatment, and recommendation 1.3.3 on the appropriate method of providing nutritional support (oral, dietary advice, enteral or parenteral nutrition support, alone or in combination).
Planned intervals
The intervals between reviews will depend on the clinical needs of the person and the complexity of the nutrition support needed. Table 1 of NICE clinical guideline 31 provides a guide for intervals between reviews for people with more complex needs.
Clinical concern
A review should be carried out if there is clinical concern that includes, for example, unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose-fitting clothes or prolonged intercurrent illness.

Equality and diversity considerations

The review should take into account the person's dietary requirements, including those that vary according to religious and cultural beliefs.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on nutrition support in adults.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Updates to this pathway

4 September 2014 Minor maintenance updates.
22 April 2014 Link to pressure ulcers pathway added.
19 February 2014 Minor maintenance updates.
9 December 2013 Minor maintenance updates.
5 July 2013 Minor maintenance updates.
28 February 2013 minor maintenance updates.
25 October 2011 minor maintenance updates.

Supporting information

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. To allow alteration of intake as indicated
Actual volume of feed delivered*
Daily initially, reducing to twice weekly when stable
To ensure that patient is receiving correct volume of feed. To allow troubleshooting
Fluid balance charts (enteral and parenteral)
Daily initially, reducing to twice weekly when stable
To ensure patient is not becoming over/under hydrated
Anthropometric
Weight*
Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly
To assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle
BMI*
Start of feeding and then monthly
Mid-arm circumference*
Monthly, if weight cannot be obtained or is difficult to interpret
Triceps skinfold thickness
Monthly, if weight cannot be obtained or is difficult to interpret
GI function
Nausea/vomiting*
Daily initially, reducing to twice weekly
To ensure tolerance of feed
Diarrhoea*
Daily initially, reducing to twice weekly
To rule out any other causes of diarrhoea and then assess tolerance of feeds
Constipation*
Daily initially, reducing to twice weekly
To rule out other causes of constipation and then assess tolerance of feeds
Abdominal distension
As necessary
To assess tolerance of feed
Enteral tube – nasally inserted
Gastric tube position (pH less than or equal to 5.5 using pH paper – or noting position of markers on tube once initial position has been confirmed)
Before each feed begins
To ensure tube in correct position
Nasal erosion
Daily
To ensure tolerance of tube
Fixation (is it secure?)
Daily
To help prevent tube becoming dislodged
Is tube in working order (all pieces intact, tube not blocked/kinked)?
Daily
To ensure tube is in working order
Gastrostomy or jejunostomy
Stoma site
Daily
To ensure site not infected/red, no signs of gastric leakage
Tube position (length at external fixation)
Daily
To ensure tube has not migrated from/into stomach and external overgranulation
Tube insertion and rotation (gastrostomy without jejunal extension only)
Weekly
To prevent internal overgranulation/prevention of buried bumper syndrome
Balloon water volume (balloon retained gastrostomies only)
Weekly
To prevent tube falling out
Jejunostomy tube position by noting position of external markers
Daily
To confirm position
Parenteral nutrition
Catheter entry site*
Daily
To check for signs of infection/inflammation
Skin over position of catheter tip (peripherally fed people)*
Daily
To check for signs of thrombophlebitis
Clinical condition
General condition*
Daily
To ensure that patient is tolerating feed and that feeding and route continue to be appropriate
Temperature/blood pressure
Daily initially, then as needed
To check for sign of infection and monitor fluid balance
Drug therapy*
Daily initially, reducing to monthly when stable
To ensure appropriate preparation of drug (to reduce incidence of tube blockage). To prevent/reduce drug nutrient interactions
Long-/short-term goals
Are goals being met?*
Daily initially, reducing to twice weekly and then progressively to 3–6 monthly, unless clinical condition change
To ensure that feeding is appropriate to overall care of patient
Are goals still appropriate?*
People at home having parenteral nutrition should be monitored using observations marked *.

Protocol for laboratory monitoring of nutrition support

The information in this table 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.
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. Urine 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, 3 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). The trend of results is important
Zinc, copper
Baseline, then every 2–4 weeks, depending on results
Deficiency common, especially when increased losses
People most at risk when anabolic. APR causes Zn ↓ and Cu ↑
Seleniuma
Baseline if risk of depletion, further testing dependent on baseline
Se deficiency likely in severe illness and sepsis, or long-term nutrition support
APR causes Se ↓. Long-term status better assessed by glutathione peroxidase
Full blood count and MCV
Baseline, 1 or 2 times a week until stable, then weekly
Anaemia due to iron or folate deficiency is common
Effects of sepsis may be important
Iron, ferritin
Baseline, then every 3–6 months
Iron deficiency common in long-term parenteral nutrition
Iron status difficult if APR (Fe ↓, ferritin ↑)
Folate, B12
Baseline, then every 2–4 weeks
Iron deficiency is common
Serum folate/B12 sufficient, with full blood count
Manganeseb
Every 3–6 months if on home parenteral nutrition
Excess provision to be avoided, more likely if liver disease
Red blood cell or whole blood better measure of excess than plasma
25-OH Vit Db
6-monthly if on long-term support
Low if housebound
Requires normal kidney function for effect
Bone densitometryb
On starting home parenteral nutrition, then every 2 years
Metabolic bone disease diagnosis
Together with lab tests for metabolic bone disease
a This test is needed primarily for people having parenteral nutrition in the community.
b These tests are rarely needed in people having enteral tube feeding (in hospital or in the community), unless there is cause for concern.

Glossary

Delivery of a nutritionally complete feed via a tube into the stomach, duodenum or jejunum.
All essential vitamins and trace elements.
Any of the following methods to improve nutritional intake:
  • fortified food with protein, carbohydrate and/or fat plus minerals and vitamins
  • snacks
  • oral nutritional supplements
  • altered meal patterns
  • the provision of dietary advice.
Intake from any food, oral fluid, oral nutritional supplements, enteral and/or parenteral nutrition support and intravenous fluid.

Paths in this pathway

Pathway created: November 2012 Last updated: January 2016

© NICE 2016

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