Clinical Nutrition Support Nursing

Malnutrition Definition — GLIM Criteria

GLIM Consensus (2019) — Two-Step Process

Step 1: Screen positive using a validated tool (MUST / NRS-2002 / MNA). Step 2: Diagnose malnutrition using ≥1 phenotypic criterion + ≥1 aetiologic criterion.

Phenotypic Criteria

Unintentional weight loss: >5% in 6 months or >10% beyond 6 months
Low BMI: <20 kg/m² if <70 years; <22 kg/m² if ≥70 years
Reduced muscle mass: low MUAC, calf circumference, or DEXA-confirmed low lean mass

Aetiologic Criteria

Reduced food intake/absorption: ≤50% estimated requirement >1 week, or chronic GI impairment
Inflammation/disease burden: acute injury or illness (C-reactive protein elevation), chronic disease (cancer, COPD, renal disease)

Screening Tools

Tool	Setting	Components	Scoring	Action Threshold
MUST Malnutrition Universal Screening Tool	Community / acute	BMI score (0–2) + weight loss score (0–2) + acute illness effect score (0/2)	0 = Low risk 1 = Medium risk ≥2 = High risk	Score ≥2 → dietitian referral + nutrition care plan
NRS-2002	Hospital inpatients	Nutritional status score + disease severity score; add 1 if ≥70 years	≥3 = At nutritional risk	Score ≥3 → initiate nutrition support
MNA Mini Nutritional Assessment	Elderly (≥65 years)	Short-form (6 questions) followed by full 18-item assessment if indicated	<17 = Malnourished 17–23.5 = At risk ≥24 = Normal	At risk → full MNA + dietitian
STRONGkids	Paediatric (1 month–18 years)	Subjective clinical assessment + high-risk disease + intake/losses + weight loss	0 = Low 1–3 = Medium 4–5 = High	High risk → immediate dietitian referral

Anthropometric Assessment

BMI

Formula: weight (kg) ÷ height² (m²)

<18.5 = Underweight
18.5–24.9 = Normal
25–29.9 = Overweight
≥30 = Obese

Limitation: does not differentiate fat vs muscle mass; unreliable in oedema.

MUAC

Mid-Upper Arm Circumference — measured at the midpoint of the left upper arm.

<23.5 cm (females) / <25.5 cm (males) = Malnutrition indicator
Useful when weight/height unavailable
Sensitive for muscle wasting

Other Measures

Triceps skinfold: estimates subcutaneous fat; technique-dependent
Calf circumference: <31 cm suggests sarcopenia in elderly
Waist circumference: cardiovascular risk (>94 cm M / >80 cm F)

Body Composition Assessment

Advanced Techniques

DEXA (Dual-Energy X-ray Absorptiometry): gold standard for body composition; measures fat mass, lean mass, bone mineral density. Not bedside.
Bioimpedance Analysis (BIA): bedside, non-invasive; measures body water compartments and estimates lean/fat mass. Affected by hydration status — unreliable in oedema or dehydration.
CT muscle area: lumbar L3 cross-sectional area. Gold standard for sarcopenia diagnosis in oncology patients; radiation exposure limits routine use.

Functional Assessment

Handgrip Strength (Dynamometer): measured in the dominant hand. Low grip strength is a diagnostic criterion for sarcopenia (EWGSOP2: <27 kg male / <16 kg female). Simple, reproducible bedside test.
6-Minute Walk Test (6MWT): functional capacity; distance <400 m suggests significant physical deconditioning.
Sit-to-stand test: proxy for lower limb muscle function in the elderly.

Biochemical Markers

Key Nursing Principle

Albumin and prealbumin are negative acute-phase reactants — they fall in inflammation/infection regardless of nutritional status. Always interpret alongside CRP. Low albumin ≠ malnutrition in an acutely ill patient.

Marker	Normal Range	Half-Life	Clinical Use	Limitations
Albumin	35–50 g/L	~20 days	Chronic nutritional status; predicts complications	Reflects inflammation more than nutrition; long half-life = poor short-term marker; affected by hydration, liver disease, nephrotic syndrome
Prealbumin (Transthyretin)	200–400 mg/L	~2 days	More responsive marker for monitoring nutrition intervention	Still falls in acute inflammation; expensive; affected by renal failure (elevated) and liver disease
CRP (C-Reactive Protein)	<5 mg/L	~19 hours	Inflammation marker; contextualises albumin/prealbumin	Not a nutritional marker — used to interpret other results
Transferrin	2.0–3.6 g/L	~8 days	Nutritional status; intermediate between albumin and prealbumin	Affected by iron stores, inflammation, liver disease
Lymphocyte count	>1.5 × 10⁹/L	—	Immune function marker in malnutrition	Non-specific; affected by many conditions

Dietitian Referral Criteria

Refer Immediately

MUST score ≥2 / NRS-2002 ≥3
Dysphagia or unsafe swallowing identified by SLT
Requirement for enteral or parenteral nutrition
Refeeding syndrome risk identified
BMI <18.5 with clinical deterioration
Post-bariatric surgery patients

Refer Routinely

MUST score = 1 (medium risk) — observe and refer if not improving
Significant unintentional weight loss (>5% in 3 months)
Chronic disease with nutritional implications (IBD, renal failure, cancer, MASLD)
Post-surgical patients with prolonged poor intake
Patients requiring disease-specific oral supplements

GCC Clinical Note — Ramadan Fasting

Ramadan fasting (approximately 29–30 days of dawn-to-dusk fasting) significantly impacts nutritional status in hospitalised and ambulatory patients. Nurses must document fasting intention, reassess nutritional status at initiation and post-Ramadan, counsel on suhoor (pre-dawn meal) composition (complex carbohydrates, adequate protein), and ensure oral nutritional supplements are prescribed for nighttime administration in at-risk patients. Patients receiving enteral nutrition should have feeding schedules adjusted to non-fasting hours with medical team input.

Enteral Nutrition Overview

Guiding Principle

"If the gut works, use it." Enteral nutrition (EN) is always preferred over parenteral nutrition when the GI tract is functional. EN preserves gut mucosal integrity, maintains the gut microbiome, reduces infection risk, and is significantly more cost-effective.

Indications for Enteral Nutrition

Functioning GI tract + inability to maintain adequate oral intake (<60% requirements for >3–5 days)
Dysphagia (neurological: stroke, motor neuron disease; structural: head and neck cancer)
Impaired consciousness / reduced GCS
Hypermetabolic states (burns, major trauma, critical illness) with inadequate oral intake
GI tract disuse prevention (post-surgical anorexia, oncology treatment)
Anorexia nervosa (supplemental feeding)

Access Routes

Short-Term Routes (<4 Weeks)

Nasogastric (NG) Tube

Most common; gastric feeding; tolerates standard polymeric feeds
Insert via nostril → stomach (pH ≤5.5 confirms gastric position)
MUST verify position by pH testing before each use or after vomiting/dislodgement
Never use X-ray as routine check (radiation); use only if pH test inconclusive
Contraindicated: basal skull fracture (use oral tube)

Nasojejunal (NJ) Tube

Tip positioned post-pyloric (duodenum/jejunum)
Indications: gastroparesis, acute pancreatitis, high aspiration risk, gastric outlet obstruction
Requires fluoroscopy or endoscopy for placement confirmation
Must use semi-elemental or elemental feeds — no standard polymeric

Long-Term Routes (>4 Weeks)

Percutaneous Endoscopic Gastrostomy (PEG)

Gold standard for long-term gastric feeding
Placed endoscopically under conscious sedation
Stoma care required; site check daily; rotate feeding tube to prevent buried bumper syndrome
Complications: infection, leakage, tube migration, granulation tissue

Jejunostomy

Surgical placement directly into jejunum
Indications: gastric surgery (gastrectomy), gastroparesis, oesophageal cancer
Continuous infusion only — no bolus (jejunum has no reservoir)
Requires elemental or semi-elemental feeds

Feed Types

Category	Examples	Indication	Key Features
Standard Polymeric	Jevity, Ensure, Osmolite	Normal GI function; first-line EN	1 kcal/mL; intact protein, carbohydrate, fat; osmolality ~300 mOsm/kg
Renal (Disease-Specific)	Nepro, Suplena	Chronic kidney disease (CKD); haemodialysis	Low K⁺, low PO₄, low fluid volume; 1.8–2 kcal/mL; high protein (HD patients)
Diabetic	Glucerna	Diabetes mellitus; hyperglycaemia on EN	Low glycaemic index carbohydrates; higher fat content; slower glucose rise
Pulmonary	Pulmocare	Respiratory failure; ventilator-dependent (CO₂ retention)	High fat (~55%), low carbohydrate (~28%); reduces CO₂ production (RQ)
Hepatic	Heparu, NutriHep	Hepatic encephalopathy	Enriched in BCAA (leucine, isoleucine, valine); restricted aromatic amino acids; low electrolyte
Elemental / Semi-Elemental	Modulen, Peptamen, Vivonex	Malabsorption, IBD (Crohn's), pancreatitis, short bowel syndrome	Pre-digested protein (peptides/amino acids); easily absorbed; low residue; higher osmolality → start slowly
Fibre-Containing	Jevity 1.2, Fresubin Fibre	Long-term EN; constipation prevention; gut microbiome support	Soluble + insoluble fibre; promotes bowel regularity; avoid if bowel obstruction suspected
Concentrated (1.5–2 kcal/mL)	Ensure Plus HN, Jevity 1.5	Fluid restriction (cardiac/renal failure)	Higher osmolality; tolerate smaller volumes; monitor GI tolerance

Feeding Regimens

Continuous (24-hour)

Constant infusion via pump at a fixed rate (e.g., 50–100 mL/hr). Preferred in:

ICU / critical illness
Jejunal feeding (mandatory)
Poor GI tolerance to bolus
Tight glycaemic control required

Intermittent / Bolus

4–6 feeds per day (e.g., 200–400 mL over 20–30 min per feed). Advantages:

Mimics normal eating pattern
Allows patient mobility between feeds
Suitable for PEG / NG (gastric)
Preferred for community/home EN

Overnight Feeding

Feeding over 10–12 hours during sleep. Used for:

Supplemental EN alongside oral intake
Patients active during day
Ramadan fasting (feed during non-fasting hours)
Paediatric oral supplement patients

Nursing Monitoring — Enteral Nutrition

Aspiration Risk — Key Nursing Actions

Elevate head of bed 30–45° during feeding and for 1 hour post-bolus. Check gastric residual volume (GRV) per local protocol (typically hold if >250–500 mL × 2). Do not routinely check GRV in all patients — clinical assessment (abdominal distension, vomiting) is equally important.

Parameter	Frequency	Normal Target / Action
Daily weight	Daily	Trend over 3–5 days; acute changes reflect fluid shifts not true nutritional response
Fluid balance	Every shift (8-hourly)	EN volume + IV fluids + oral = total input; ensure feed volume counted in fluid balance
Blood glucose	Every 4–6 hours initially	Target 6–10 mmol/L in hospital; more frequent if insulin prescribed
Electrolytes (Na, K, Mg, PO₄)	Daily initially → 3×/week when stable	Correct any deficiencies; refeeding risk — see Tab 4
Urea & creatinine	2–3×/week	Monitor renal function; adjust feed if deteriorating
Tube position	Before each use; after vomiting/coughing; after procedure	pH ≤5.5 confirms gastric position; if pH 5–6, recheck in 30 min
Bowel output	Daily documentation	Bristol stool chart; diarrhoea (>3 loose stools/day) → review feed type, fibre, medications, C. difficile
Tolerance assessment	Each shift	Nausea, vomiting, abdominal distension, high GRV — reduce rate or change regimen

Parenteral Nutrition (PN)

Reserve for Non-Functioning GI Tract

PN carries significant risks: catheter-related bloodstream infection (CRBSI), hepatic steatosis, metabolic complications, and high cost. It should only be used when the enteral route is not feasible or insufficient.

Indications for PN

Intestinal failure: short bowel syndrome (SBS), enterocutaneous fistula (>500 mL/day output)
Paralytic ileus not resolving within 5–7 days
Bowel obstruction (mechanical — surgical management pending)
Severe mucositis (post-chemotherapy / haematopoietic stem cell transplant)
Severe acute pancreatitis when NJ tube not feasible
Supplemental PN when EN provides <60% of requirements beyond 7 days

PN Formulation Components

Amino acids: nitrogen source; 0.8–2.5 g protein/kg/day depending on clinical state
Glucose (dextrose): primary energy source; maximum oxidation rate 4–5 mg/kg/min; excess → fatty liver
Lipid emulsion: essential fatty acids + energy density; maximum 1 g/kg/day in critical illness
Electrolytes: Na, K, Ca, Mg, PO₄, Cl — individualised daily
Vitamins: water-soluble (B-complex, C) + fat-soluble (A, D, E, K) — added daily
Trace elements: zinc, copper, selenium, manganese, chromium, iron
Water: 30–35 mL/kg/day standard; adjust for fluid status

PN Formulations

Commercial All-in-One Bags

Pre-mixed sterile bags (e.g., Kabiven, SmofKabiven, Clinimix). Available in standard formulations. Advantages:

Ready to use — reduced compounding errors
Stable, longer shelf life
Cost-effective for standard patients

Disadvantage: cannot individualise electrolytes within the bag.

Pharmacy-Compounded (Bespoke)

Prepared by hospital pharmacy under aseptic conditions. Required for:

Electrolyte abnormalities requiring non-standard concentrations
Paediatric patients (weight-based precise calculations)
Patients with specific metabolic requirements
Home PN patients on long-term individualised regimens

PN Administration — Nursing Safety Requirements

CRITICAL: Central Venous Access ONLY

Full PN must be administered via a central venous catheter (CVC, PICC, or surgically tunnelled line). Peripheral administration causes chemical phlebitis due to high osmolality (>800 mOsm/L). Peripheral PN (PPN) may be used short-term with lower concentration solutions only.

Access Requirements

Dedicated lumen: PN must have its own lumen — no medications, blood products, or IV fluids via the same lumen
Line types: CVC (internal jugular / subclavian), PICC (peripherally inserted central catheter), tunnelled Hickman or Groshong (home PN)
PICC preferred when PN expected <3–4 weeks; tunnelled line for >3 months
Confirm tip position (SVC junction) on X-ray before first use

Aseptic Connection Protocol

Full aseptic non-touch technique (ANTT) at all connections
Disinfect hub with 70% isopropyl alcohol + 2% chlorhexidine for 15–30 seconds; allow to dry
Change PN giving set every 24 hours (lipid-containing bag) or with each new bag
In-line filter: 1.2 micron for lipid-containing; 0.2 micron for lipid-free
Inspect bag for precipitation, turbidity, or layer separation before administration

PN Rate Escalation

Start Low, Go Slow

Begin at 50% of calculated target rate on Day 1. Increase to 100% on Day 2–3 if metabolically stable. Abrupt initiation risks hyperglycaemia and metabolic overload.

Monitoring — Parenteral Nutrition

Parameter	Frequency	Target / Action
Blood glucose	Every 6 hours	Target 6–10 mmol/L; insulin infusion sliding scale if needed; hypoglycaemia risk on abrupt PN cessation — taper before stopping
Electrolytes (Na, K, Mg, PO₄)	Daily initially → alternate days when stable	Monitor for refeeding syndrome (see Tab 4); replace proactively
Liver function tests (LFTs)	Twice weekly	PN-associated liver disease (PNALD): hepatic steatosis with long-term PN; elevated ALT/ALP common. Reduce glucose load, cycle PN (12 hours off), add ursodeoxycholic acid
Triglycerides (TG)	Twice weekly	Check lipid tolerance; hold lipid emulsion if TG >4.5 mmol/L
Full blood count (FBC)	Twice weekly	Anaemia, leucopenia (trace element deficiency); thrombocytopenia
Renal function	Daily	Adjust fluid, electrolyte, and nitrogen content accordingly
Daily weight	Daily	Fluid shift interpretation; aim for slow weight gain in malnourished (<0.5 kg/week)
Central line site	Each shift	Inspect for redness, swelling, discharge; clean per dressing protocol; fever >38°C on PN = line sepsis until proven otherwise

Catheter-Related Bloodstream Infection (CRBSI)

Fever (>38°C), rigors, or haemodynamic instability in a patient on PN must raise immediate suspicion for CRBSI. Take paired blood cultures (central + peripheral), notify medical team, do not remove line without medical review. PN cessation may be required pending infection resolution. CRBSI prevention requires strict ANTT, daily inspection, and regular hub decontamination.

Refeeding Syndrome

Life-Threatening Complication — Nurse-Led Recognition is Critical

Refeeding syndrome (RFS) can be fatal. Nurses are often the first to identify at-risk patients and escalate to the nutrition support team. A high index of suspicion is essential in all patients restarting nutrition after prolonged starvation or severe restriction.

Definition

A potentially fatal metabolic syndrome occurring on reintroduction of nutrition (oral, enteral, or parenteral) after a period of prolonged starvation (>5–7 days) or severe nutritional restriction. Characterised by severe electrolyte disturbances, fluid shifts, and metabolic derangements triggered by glucose loading.

Pathophysiology

Core Mechanism

Starvation → depletion of intracellular electrolytes (total body deficits despite normal serum levels) → glucose reintroduction → insulin surge → massive intracellular shift of phosphate, potassium, and magnesium → acute extracellular depletion → organ dysfunction.

Hypophosphataemia

Most dangerous feature. Phosphate is required for ATP synthesis. Effects:

Cardiac arrhythmias, heart failure
Respiratory muscle failure (cannot wean ventilator)
Neuromuscular weakness, seizures
Haemolytic anaemia
Rhabdomyolysis

Hypokalaemia & Hypomagnesaemia

Potassium deficiency effects:

Ventricular arrhythmias (QT prolongation)
Paralytic ileus
Muscle weakness

Magnesium deficiency effects:

Exacerbates hypokalaemia (Mg required for K⁺ retention)
Neuromuscular excitability, tetany
Cardiac arrhythmias

Thiamine Deficiency

Glucose metabolism requires thiamine (vitamin B1). Refeeding without thiamine causes:

Wernicke's encephalopathy: confusion, ophthalmoplegia, ataxia
Korsakoff's syndrome (irreversible memory impairment)
Wet beriberi: high-output cardiac failure
Lactic acidosis

High-Risk Criteria (NICE 2006)

One or More Severe Criteria = HIGH RISK

The following criteria are used to identify patients at high risk of refeeding syndrome. Any ONE severe criterion is sufficient to classify as high risk. Two or more moderate criteria also confer high risk.

Severe Criteria (Any ONE = High Risk)

BMI <16 kg/m²
Unintentional weight loss >15% in the past 3–6 months
Little or no nutritional intake for >10 days
Low levels of serum potassium, phosphate, or magnesium before feeding

Moderate Criteria (TWO or more = High Risk)

BMI <18.5 kg/m²
Unintentional weight loss >10% in the past 3–6 months
Little or no nutritional intake for >5 days
History of alcohol misuse or drugs including insulin, chemotherapy, antacids, or diuretics

Management Protocol

Step	Action	Detail
1	Correct electrolytes BEFORE starting nutrition	Phosphate >0.6 mmol/L, K⁺ >3.0 mmol/L, Mg²⁺ >0.5 mmol/L. Replace IV if severe. Do not delay >24 hours — this is a medical emergency if profoundly low.
2	IV Thiamine (Pabrinex) before glucose	Pabrinex 1 pair (vials I + II) IV over 30 minutes, three times daily for 3–5 days, then once daily for days 5–10. Give BEFORE any glucose or feed is started.
3	Restrict starting energy	Maximum 10 kcal/kg/day (or 5 kcal/kg/day in extreme cases: BMI <14 / refeeding following >15 days starvation). Increase gradually over 4–7 days to full requirements (25–30 kcal/kg/day).
4	Proactive electrolyte replacement	Replace K⁺, Mg²⁺, PO₄ regardless of serum levels (total body deficit). Typical regimens: Potassium chloride 40 mmol/day oral/IV; Magnesium sulphate 0.2–0.4 mmol/kg/day IV; Phosphate 0.3–0.6 mmol/kg/day IV.
5	Daily electrolyte monitoring	Check Na, K, Mg, PO₄, Ca, glucose daily for minimum 10 days. Cardiac monitoring if severely low electrolytes.
6	Gradual escalation	Increase nutrition by ~200–300 kcal increments every 1–2 days if electrolytes remain stable. Full requirements typically achieved by Day 5–7.
7	Nutrition support team referral	All high-risk patients should be reviewed by a dietitian and the nutrition support team within 24 hours of identification.

Electrolyte Targets Before Escalating Nutrition

Phosphate

Target: >0.6 mmol/L before increasing feed rate

Normal: 0.8–1.5 mmol/L

Severe: <0.3 mmol/L → IV replacement; cardiac monitoring

Potassium

Target: >3.0 mmol/L before increasing feed rate

Normal: 3.5–5.0 mmol/L

Severe: <2.5 mmol/L → IV KCl infusion; cardiac monitoring

Magnesium

Target: >0.5 mmol/L before increasing feed rate

Normal: 0.7–1.0 mmol/L

Severe: <0.3 mmol/L → IV MgSO₄; monitor deep tendon reflexes

Refeeding Syndrome Risk Calculator

Based on NICE CG32 (2006) criteria. Answer each question, then press Calculate to receive risk classification, management recommendations, and escalation thresholds.

1. BMI <16 kg/m²

2. BMI 16–18.5 kg/m² with significantly reduced intake over the past 5+ days

3. Unintentional weight loss >15% in the past 3–6 months

4. Little or no nutritional intake for >10 days

5. Low electrolytes (K⁺, PO₄, or Mg²⁺) before commencing feeding

6. History of alcohol misuse or significant alcohol intake

7. Use of insulin, diuretics, antacids, or chemotherapy agents

Qualifying Criteria

Max Starting Energy

Thiamine (Pabrinex)

Electrolyte Monitoring

Escalation Criteria

Recommendation

Immunonutrition

Agent	Mechanism	Evidence / Indications	Cautions
Glutamine	Primary fuel for enterocytes and immune cells; maintains gut mucosal barrier integrity; reduces bacterial translocation	Burns patients (>20% TBSA); ICU (ESPEN recommends for burns/trauma — not routine critical illness); haematopoietic stem cell transplant (reduces mucositis)	Avoid in severe hepatic or renal failure (ammonia accumulation); high-dose IV glutamine increased mortality in some ICU trials (REDOX, METAPLUS) — use with caution
Arginine	Substrate for nitric oxide (vasodilation, immune modulation); enhances wound healing; stimulates T-lymphocyte function	Elective surgery (ERAS-plus protocols); wound healing; head and neck cancer post-surgical EN	Contraindicated in sepsis/septic shock — excess NO production worsens vasodilation and haemodynamic instability
Omega-3 Fatty Acids (EPA/DHA)	Anti-inflammatory prostaglandin and leukotriene precursors; modulate cytokine production; reduce IL-6, TNF-α	ARDS (fish oil enriched EN — OMEGA trial); oncology; post-surgical inflammation; cardiac cachexia	Antiplatelet effect — caution with anticoagulants; monitor TG levels; avoid high-dose in bleeding disorders
Antioxidants (Selenium, Vit C, Vit E, Zinc)	Neutralise reactive oxygen species; reduce oxidative stress in critical illness and burns	ICU (selenium supplementation in sepsis); burns; major surgery; SICU patients	Selenium toxicity with excessive dosing; copper deficiency with high-dose zinc supplementation

ESPEN ICU Nutrition Guidelines (2023)

Early Enteral Nutrition

Start EN within 24–48 hours of ICU admission when haemodynamically stable
Even trophic feeding (10–20 mL/hr) preserves gut integrity
Avoid EN if: shock requiring escalating vasopressors, uncontrolled GI bleed, bowel obstruction, ischaemic bowel
Post-pyloric (NJ) preferred in high aspiration risk or gastric intolerance

Permissive Underfeeding

Target 70–80% of energy requirements in the first week of critical illness (acute phase)
Overfeeding in acute phase increases CO₂ production, hyperglycaemia, hepatic complications, and mortality
Protein: 1.2–2.0 g/kg/day in ICU; higher in burns (2.0–2.5 g/kg/day)
Reassess energy requirements weekly; indirect calorimetry gold standard

Surgery & Perioperative Nutrition

Prehabilitation

Preoperative nutrition optimisation: identify and treat malnutrition 4–8 weeks before elective surgery
Protein-enriched oral supplements + exercise programme
Reduces post-operative complications and length of stay
Particularly important for: colorectal surgery, oesophagogastric surgery, cardiac surgery

ERAS Protocol (Enhanced Recovery)

Carbohydrate loading: complex carbohydrate drink 6 hours pre-operatively (not just clear fluids); reduces insulin resistance, catabolism, anxiety
Fasting period minimised: clear fluids up to 2 hours pre-op
Early post-operative feeding: Day 0–1 post-surgery for most procedures
Nutritional supplements prescribed from Day 1 post-operatively

Burns Nutrition

Curreri Formula — Burns Energy Requirement

Adults: (25 kcal × body weight kg) + (40 kcal × % TBSA burned)
Burns patients are severely hypermetabolic; protein requirements 2.0–2.5 g/kg/day; glutamine supplementation recommended (>20% TBSA); continuous EN preferred; early EN within 6 hours of burn injury.

Organ-Specific Nutrition

Organ / Condition	Energy	Protein	Key Modifications	Feed Choice
Liver Failure / Cirrhosis	35–40 kcal/kg/day	1.2–1.5 g/kg/day (do NOT restrict unless overt encephalopathy)	BCAA enriched (leucine, isoleucine, valine); small frequent meals; late evening snack to reduce overnight fasting; sodium restriction if ascites	Heparu; NutriHep; standard polymeric usually tolerated
Renal Failure (CKD pre-dialysis)	25–35 kcal/kg/day	0.6–0.8 g/kg/day	Low K⁺, low PO₄, low sodium, fluid restriction; protein restriction to slow progression	Nepro; Suplena; Renilon
Renal Failure (Haemodialysis)	30–35 kcal/kg/day	1.2–1.5 g/kg/day (dialysis removes amino acids)	Liberalised protein; K⁺/PO₄ still restricted; fluid restriction between sessions	Nepro (high protein version)
Respiratory Failure (COPD/ARDS)	25–30 kcal/kg/day	1.0–1.5 g/kg/day	High fat, low carbohydrate diet reduces respiratory quotient (RQ) and CO₂ production — critical in ventilator weaning; avoid overfeeding	Pulmocare; Oxepa
Acute Pancreatitis	25–35 kcal/kg/day	1.2–1.5 g/kg/day	NJ post-pyloric EN preferred over PN (reduces infection, shorter hospital stay); avoid parenteral nutrition if jejunal EN feasible; early EN within 24–48h	Semi-elemental via NJ (Peptamen); avoid fat-rich feeds

GCC Clinical Context — MASLD & Ramadan

Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD/NASH) is highly prevalent in the GCC due to high rates of type 2 diabetes, obesity, and sedentary lifestyle. Nutritional management evidence supports a Mediterranean diet pattern (olive oil, legumes, vegetables, fish, whole grains), low fructose intake (especially sugar-sweetened beverages), low saturated fat, and caloric restriction for 7–10% weight loss as the primary therapeutic goal. Omega-3 fatty acids and vitamin E have emerging evidence. Nurses should screen for MASLD in all obese T2DM patients and refer to dietitian for structured dietary counselling.

During Ramadan, the pattern of prolonged fasting followed by large evening meals mimics intermittent fasting with metabolic effects including improved insulin sensitivity, lipid profiles, and weight loss in some patients. However, dehydration, post-iftar glycaemic spikes, medication timing disruption, and reduced physical activity can negatively impact metabolic conditions. Nurses should assess Ramadan fasting intentions at every admission, adjust meal timing for oral nutritional supplements, and coordinate with pharmacists regarding medication administration timing.

GCC Healthcare System — Nutrition Support Context

Malnutrition in GCC Hospitals

Despite the GCC region's economic affluence, hospital malnutrition prevalence is estimated at 30–50% of inpatients. This reflects disease-related malnutrition (cancer, surgery, critical illness, chronic disease) rather than poverty-driven malnutrition. Factors contributing to high rates include:

Prolonged NPO periods pre/post-procedure
Inadequate routine nutritional screening on admission
Hospitalised patients from expatriate backgrounds with language barriers limiting dietary history
High T2DM and obesity rates leading to paradoxical concurrent micronutrient deficiencies
Cultural food preferences and hospital meal acceptance challenges

Nutrition Support Teams in GCC

King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh: multidisciplinary nutrition support team; formal PN compounding pharmacy; ESPEN-aligned protocols
Cleveland Clinic Abu Dhabi: integrated dietitian-led nutrition service; JCI-accredited nutrition screening protocols
Hamad Medical Corporation (Qatar): dedicated clinical nutrition department; national nutritional guidelines aligned with international evidence
Ministry of Health hospitals (Saudi, UAE, Kuwait, Bahrain): varying nutrition service maturity; nurse-led screening increasingly implemented post-CBAHI accreditation requirements

Regulatory & Licensing Authorities

DHA (Dubai Health Authority) and DOH (Department of Health Abu Dhabi) licencing exams for UAE nurses include clinical nutrition questions within critical care and general nursing competencies. The SCFHS (Saudi Commission for Health Specialties) nursing licensing and specialty board exams include nutrition support nursing as a testable domain, particularly within critical care, oncology, and surgical nursing specialties. Questions commonly test: refeeding syndrome recognition, PN line safety, enteral tube position verification, and MUST scoring.

Key Exam Topics Summary

Topic	What Exams Test	Key Points to Remember
MUST Screening	Score calculation; action for each score	BMI + weight loss + acute illness. Score 0=low, 1=medium, ≥2=high risk. Observe/treat/refer accordingly.
Refeeding Syndrome	Recognition of at-risk patients; first nursing action; electrolyte to monitor	Thiamine FIRST before glucose. Hypophosphataemia is the hallmark. Start 10 kcal/kg/day. NICE criteria.
NG Tube Position	Safe confirmation method; acceptable pH range	pH ≤5.5 confirms gastric position. Never aspirate just on colour. X-ray only if pH inconclusive. NEVER use auscultation ("whoosh test") alone.
PN Administration	Line type; lumen use; complication monitoring	Central line only. Dedicated lumen. ANTT for all connections. Fever = CRBSI until proven otherwise.
Albumin Interpretation	Marker of nutrition vs inflammation	Albumin reflects inflammation NOT short-term nutrition. Interpret with CRP. Low albumin ≠ malnutrition in acute illness.
Feed Selection	Match disease-specific feed to condition	Renal=Nepro (low K/PO₄); Pulmonary=Pulmocare (high fat/low carb); Hepatic=BCAA enriched; Diabetic=Glucerna (low GI).

Practice MCQs — Clinical Nutrition Support

1. A patient has a BMI of 17 kg/m², has lost 12% body weight over the past 2 months, and has been eating <30% of their usual intake for 6 days. What is their MUST score and risk category?

A. Score 2 — Medium risk B. Score 3 — High risk C. Score 4 — High risk D. Score 1 — Medium risk

2. Before starting parenteral nutrition via a newly inserted PICC line, what is the PRIORITY nursing action?

A. Obtain baseline blood glucose level B. Confirm central tip position via chest X-ray C. Flush the line with 0.9% saline to check patency D. Begin infusion at 50% of the prescribed rate

3. A patient on parenteral nutrition develops a temperature of 38.6°C and rigors. What is the MOST important immediate nursing action?

A. Increase IV fluid rate and administer paracetamol B. Stop the PN infusion and remove the central line immediately C. Take paired blood cultures (central and peripheral) and notify the medical team D. Change the PN giving set and continue the infusion

4. A malnourished patient (BMI 15.8 kg/m², no food intake for 12 days) is prescribed nasogastric feeding. Which electrolyte must be corrected AND what medication must be given BEFORE starting the feed?

A. Sodium; administer normal saline B. Phosphate/potassium/magnesium; administer IV thiamine (Pabrinex) C. Calcium; administer vitamin D D. Phosphate only; administer folic acid

5. Which enteral feed would be MOST appropriate for a ventilated ICU patient with COPD and CO₂ retention, requiring fluid restriction?

A. Jevity 1.0 (standard polymeric) B. Glucerna (diabetic formula) C. Pulmocare (high fat, low carbohydrate, concentrated) D. Nepro (renal formula)

6. What is the CORRECT method to confirm nasogastric tube position before commencing a feed?

A. Auscultate over the epigastrium while injecting air ("whoosh test") B. Aspirate gastric contents and test pH; pH ≤5.5 confirms gastric placement C. Observe for coughing or respiratory distress D. Request chest X-ray for every feed confirmation

7. A patient's albumin is 22 g/L. The nurse correctly interprets this as:

A. Severe malnutrition requiring immediate parenteral nutrition B. A marker that must be interpreted alongside CRP, as low albumin primarily reflects inflammation rather than nutritional status in acute illness C. Normal for a hospitalised patient — no action required D. A reliable indicator of protein deficiency over the past 2 days

8. A patient develops severe hypophosphataemia (0.2 mmol/L) on day 2 of refeeding via nasogastric tube. What is the CORRECT immediate management?

A. Increase the feed rate to improve phosphate intake B. Stop or reduce the feed, replace phosphate IV/orally, and cardiac monitoring C. Administer oral phosphate supplements and recheck in 24 hours D. Continue current feed rate and replace phosphate orally

9. Which nutritional supplement is CONTRAINDICATED in a septic patient and should NOT be included in their enteral feed?

A. Glutamine B. Omega-3 fatty acids C. Arginine D. Selenium

10. According to ESPEN ICU guidelines, when should enteral nutrition ideally be initiated in a haemodynamically stable critically ill patient?

A. Only after bowel sounds are confirmed B. Within 24–48 hours of ICU admission C. After 7 days, once acute phase has passed D. When the patient's albumin returns to normal range