NUTRITION AND

STROKE PATIENT

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Page 1

Contents
Introduction.......3
Literature searching process3
Nutrition and Stroke.4-5
Nutritional assessment and screening . 5-6
Nurses education6-8
Swallowing problem/ Dysphagia 8-9
Patients' education and compliance.. 9-10
Conclusion..10
References..11-13

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Nutrition and Stroke Patients

Nutrition is the intake of food in the body used for growth and energy. It is an essential
element for quality care and important to health. Nutrition contributes largely to a patient's
recovery (Royal College of Nursing, 2014); moreover, poor nutrition can lead to reduced immunity
and physical impairment (World Health Organisation (WHO), 2014). The choice of the topic was
influenced by the Francis Report (2013) on how food and drink were out of reach from patients.
Another influence is that 30% of patients admitted to care settings are at risk of malnutrition
(British Association for Parenteral and Enteral Nutrition (BAPEN 2012).

Regarding stroke's

outcome, the National Institute for Health and Clinical Excellence (NICE) (2013) states more
than 900,000 people in the United Kingdom (UK) are disabled because of stroke, which can
affect swallowing, and lead to malnutrition. Malnutrition costs the National Health Service 13
billion per annum (BAPEN, 2009). This essay discusses nutrition, stroke and the interrelation
between the two. It also emphasizes the significance of conducting nutritional assessment and
screening and why nurses must be knowledgeable in detecting the signs of malnutrition. Finally,
the essay focusses on swallowing problems and patients' education.
The search strategy was used via Anglia Ruskin University library, the subject guides were
selected then the 'N ' letter for nursing, from there 'Adult Nursing' was selected. The key
database selected was CINAHL Plus with full text: (EBSCO), because it is an accredited
search engine for nursing and allied health literature. The key word 'Nutrition' was typed in
the search-box and 67,683 publications such as books, academic journals and magazines from
1937-2014 were displayed. To refine this search, Boolean operators were used to join the
keywords Nutrition and stroke patients, displaying 170 articles. To further narrow down the
search, 2009 to 2014 date was selected, generating 59 articles. Then to narrow down more all
adults were selected and 39 articles were displayed and this was brought down to 7 articles
after selecting UK & Ireland. Only research publications written in E n g l i s h were considered
for this essay. Policies were found by going to the organisation websites.
In practice, nurses use of evidence-based research is about the way they respond to the
reality of the patient's situation (Ellis, 2013). This essay discusses four major approaches to
nursing research; they all use different methods in collection and data analysis. These
methodologies are qualitative, quantitative, sampling and data collection (Rebar et al, 2011).

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Dietary requirements are important for cell metabolism. A balanced intake diet embodies the
right amount of macronutrients that are: carbohydrates, proteins and fats as well as micronutrients
such as vitamins and minerals (Clancy, McVicar, 2009). When a person's diet does not meet the
appropriate amount of nutrients, this leads to malnutrition.
Malnutrition is the inadequate intake of certain nutrients in order to meet the bodys requirements.
Malnutrition can either be under-nutrition or over-nutrition with adverse effects on health.
Malnutrition affects more than 113 of adults admitted to hospitals among which 32% are over
65 years old; and the rate of malnutrition on admission to hospitals increased from 2007 to
2010 ( BAPEN,2012). In the nutrition screening survey, quantitative research carried out by
BAPEN in April 2011, this to establish the commonness of malnutrition risk in patients.
Quantitative research collects numerical

information, which is analysed using statistical

procedures (Kozier et al, 2008). The research involved 171 hospitals, 78 care homes and 67
mental health units in the UK and 26 hospitals and six care homes in The Republic of
Ireland. The study centred on two questionnaires, a general questionnaire on the practice of
nutritional

screening

in hospital

using criteria based

on the 'Malnutrition Universal

Screening Tool' (MUST) and a patient data collection sheet. Data were collected (Data
Collection is a method used to collect information; it can be a questionnaire or an inte1view
(Ellis, 2013)) on patients within 72 hours of admission to hospitals, acute mental health units
and care homes. The outcomes assert that 'malnutrition' is common on admission to all types
of care settings. The results show that malnutrition risk in 20ll was 25% lower than the 34% in
2010 (BAPEN, 2012). There is validity and reliability in the outcomes because of the number of
care settings involved. Nutrition is important for the body and if the diet is dominated by saturated
fat, fatty plaques will obstruct the coronary artery and therefore provoke a stroke.
Stroke or cerebral vascular accident is a sudden death of brain cells due to the disruption of
blood flow to the brain. The disruption is either a blockage of an artery or a rupture of an artery
to the brain. Brain cells die because oxygen and nutrients cannot be delivered to the brain. Over
150,000 people a year have a stroke in England and it is the largest cause of adult disability in
the UK (National Health Service, 2014).
Nutrition is important in the prevention of stroke. As the body needs a healthy and balanced
diet in order to gain all the necessary energy it is important that people are aware of what kind
of food they must consume in order to stay healthy. If patients are unaware of what to

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eat, they can speak to a nurse who will advise and educate them on the necessity of a healthy
diet and

how to spot the first signs of malnutrition. Nurses themselves must show an

understanding of the importance of good nutrition and they must be competent in conducting
nutritional assessment and screening. According to NICE (2006) the screening for malnutrition
and the risk of malnutrition should be carried out on patients by competent and skilled healthcare
staff N I CE (2006) also emphasizes that nutritional support should be considered in people
at risk of malnutrition or who are malnourished. Guidance from the Royal College of
Physicians (RCP) (2004), the Scottish Intercollegiate Guidelines Network (SIGN) (2004) and
the Department of Health (DoH) (200la) highlight that nurses must carry out a nutritional
assessment within 48hours of a patient's admission to hospital. The assessment must be
conducted using MUST, this is in order to identify patients at risk of malnutrition (NICE, 2006).
Being overweight, a culture of poor diet, as well as having diabetes are some of the causes
of stroke, which is a cause of morbidity (Stroke, 2014). A swallowing problem and the loss of
muscle tone in the arm c a n occur as a result of stroke and these difficulties will affect nutrition
in stroke patients (NICE, 2008).

Nutritional assessment and screening:

There are guidelines on nutrition that recommend nutritional screening on inpatients in all care
settings (NICE, 2006). BAPEN (2012) has produced a tool kit to ensure that best nutritional care
is entrenched in all UK healthcare settings. According to Stroud (2011) after malnutrition has
been identified through screening and assessment, people who are malnourished and those at
risk of malnutrition must have suitable care pathways. This is supported by the BAPEN toolkit
number Three, which highlights a need for a development of nutritional screening, assessment and
care pathways that meet agreed standards. It includes a seven step approach to ensuring that these
key decision points are based on best available evidence.
NICE (2006) has stated all inpatients should be screened on admission but in 2011 only 31%
of patients were screened on admission raising concerns on the remaining 69% that were left
unscreened (The Patients Association, 2011). The National Patient Safety Agency (NPSA)
conducted an investigation with nurses and dieticians from 10 acute NHS Trusts and held two

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patients meetings. They found there are some barriers to compliance, which are: a lack of
awareness of standards relating to weighing scales in all settings, lack of equipment, lack of
leadership, lack of education and training for nursing staff and dependency of patients. This
was supported by Omidvani et al (2013), through a study that reported that the weight and
height of patients were not documented, making it difficult to estimate body mass index,
modification in weight and risk of under-nutrition. They also state as the NPSA (2007) that
nutritional screening is prompt and simple but there are still gaps in practice, and patients are
put at risk of malnourishment. Also nurses are not complying with the Nursing and
Midwifery Council Code (2008) that states nurses must promote the health and wellbeing of
those in their care. The findings of this research are transferable to most trusts in a way that
the majority of nurses work with a limited time; there is also some credibility because the
research answers to the prevalence of patients being screened on admission. By reducing
those barriers, this will increase patient chances of being screened and assessed on admission
therefore detecting the risks of malnutrition.
A Scottish study carried out quantitative research, they examined clinical data from stroke patients
in two hospital registers with routine blood urea and creatinine results to determine the level of
dehydration (Thomason, 2012). 19,503 ratio blood tests were measured on 18,812 days in 2,591
patients. Blood tests showed that within one day of admission, 927 (36%) patients were
dehydrated and 1,606 (62%) were dehydrated at any stage during their hospital stay. On
discharge, 2,549 patients discharge information was available. Of these, 687 of the
1,580 with dehydration at some point during their hospital stays died in hospital or were
discharged to institutional care compared to 177 of 969 who were hydrated. Researchers
concluded that dehydration is common in patients admitted to hospital following a stroke. They
suggest that reducing dehydration can improve patients outcomes after stroke (Thomason, 2012).
The findings can be representative to all stroke patients admitted to hospital.

Nurses' education and knowledge:

In 2006, NICE stated that all health professionals directly involved in caring for patients in both
acute and primary care must be educated, trained and knowledgeable on the necessity of
providing satisfactory nutrition. Best (2011) Nurses are usually responsible for completing a
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nutritional screening tool in hospital because screening is often part of the admission assessment.
According to the Francis report (2013), nutrition and hydration are essential to a patient's
recovery.
When screening for malnutrition and the risks of malnutrition, nurses must know that swallowing
difficulties and the inability to self-feed will affect nutrition in stroke patients (NICE, 2008).
According to SIGN (2010), there is a need for patients to have a regular review and those with
swallowing problems must be reviewed frequently. Healthcare staff must imperatively spot
patients with feeding and swallowing difficulties so that malnutrition and aspiration can be
avoided (Tanton, 2010).
BAPEN (2007) emphasizes that nurses are responsible for the assessment of nutritional risk
and the ability of the patient to eat: they must help with feeding as appropriate; they must
monitor and keep records of food intake as well as enteral and parenteral nutrition and must
be alert to unsafe feeding. In contrast, the RCN (2007) states that every member of the
nursing team is accountable for assessing, implementing the nutritional and hydration needs of
patients as well as monitoring their nutrition. Adopting this attitude will allow nurses to detect
patients at risk of malnutrition so that those who need intervention will have a care plan
implemented and, if needed, the dietician's involvement. Patients who are unable to take oral
hydration should be hydrated via another route (Rowat, 2011). Elia & Russell (2008) reported
that under-nutrition is frequently unrecognised due to lack of nutrition training and subsequent
awareness of frontline nursing staff.
In a quantitative study conducted by O'Mahony et al ( 2011) a sample of nurse were
requested to complete a pre-training questionnaire as well as a post training questionnaire on
their nutrition knowledge and practice. Ellis (2013) defines a sample as a group of people
who have gone through the same process; this research used a convenience sample because
they attended the same hospital. On the three questions, two relevant were chosen. The first
was: are patients weighed on admission? 74% of nurses answered yes pre-training and 94% post
training. The second was: is malnutrition a significant problem for NHS today? 39% of nurses
answered yes pre-training and 82% post training. A significant improvement is noticed post training,
from 74% to 94% and from 39% to 82%. The research found that a Positive Nutrition

Education

Programme could improve nutritional knowledge and awareness, and result in improved nutritional
practices. Elia & Russell (2008) wrote nursing staff with nutritional training and skills are needed
in order to better nutritional screening and

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nutritional practices on acute hospital wards. Because of the sample size, the sample is not
representative of nurses and therefore results are not generalisable.

Swallowing problem/ Dysphagia:

Why is it important to manage nutrition in patients who have had a stroke? One fifth of
patients with acute stroke are malnourished on admission to hospital; factors include feeding
difficulties and poor nutrition intake due to unsafe swallowing. The RCP (2012) and NICE
(2008) recommends that stroke patients should be assessed within 48 hours of admission for
ability to swallow using the swallow screening test, nutritional status using the MUST tool
and hydration. If the person presents swallowing problems, he/she should have a specialist
assessment within 24 hours of admission (RCP, 2012). SIGN (2010b) states regular weight and
height as well as food and drink intake should be recorded but according to the Food Trial
Collaboration, this cannot be done because of mobility problems. Malnutrition after a stroke
is a common problem encountered by patients who have had a stroke (Rowat, 2011). So by
following the guidance from NICE (2008), the RCP (2012), the SIGN (2010) and the NPSA
(2012), healthcare professionals are more than able to contend with malnutrition in stroke
patients, and improve stroke patients' care.
Dysphagia is when food or fluid enters the airway instead of entering the oesophagus. There is
a link between dysphagia and malnutrition. Dysphagia after stroke is commonly quoted at an
incidence of 40% (NICE, 2008); this figure is supported by Crary et al (2012) whose study revealed
37% prevalence. Signs of dysphagia include coughing or choking when eating or drinking.
Dysphagia can either be: oropharyngeal, which are swallowing difficulties at the level of the
throat, or oesophageal, which is a swallowing problem with the oesophagus. People with
dysphagia can become undernourished and dehydrated (Nazarko, 2009).
In qualitative research led by Sarah Michelle Hughes (2011); qualitative research asks questions
about people's attitudes, experiences and feelings. It focuses on the collection of information as
it is expressed by people within the normal context of their lives (Rebar et al, 2011). The author
illustrates the problem of dysphagia through a case study based on a 72 year old retired baker
who has had a stroke. As a consequence of his stroke, he has dysphagia, and requires assistance
with eating and drinking. His swallowing problem was assessed and he was on soft diet, his drink
was thickened. After starting pocketing his food,

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his texture dietary was reassessed and his nutrition was reviewed using the MUST tool. Although
he

lost

weight during admission, his weight stabilised.

With the weekly involvement of the

Multidisciplinary team (such as nurses, dieticians and speech and language

therapists), his

dysphagia was managed successfully and his nutritional status improved as well as his weight. This
study demonstrates the importance of maintaining nutrition and hydration status in order to
prevent the patient from being malnourished. Also there is some credibility in the research
findings.

Patients' education and concordance.

A better way to educate patients about a healthy diet is a visual representation of the eatwell
plate, which is the government's recommendation for a healthy balanced diet. The plate is split
into five food groups. Food high in fat and sugar represents 8% as they are not essential to a
healthy diet (Public Health England, 2013). Healthy eating is about consuming the right amount
of food for energy needs.
According to BAPEN (2007), patients must be able to know their weight and height when
going to the hospital, they should be aware that someone has to weight them and measure
them when admitted. They must communicate their dietary needs and know that illness
changes appetite

and taste. But mobility and communication problems can be barriers to

concordance. Patients should also be able to recognise signs of malnutrition such as tiredness,
loose clothes and rings. I t is important to educate patients who are over 65 years old because
1.3 million of them are affected with malnutrition (BAPEN, 2014).
In quantitative research undertaken by the Patient Association (2011), 5,018 people including
1,136 aged over 65 years were surveyed on their understanding of malnutrition. The research
found that while 60% of the elderly identify good nutrition as eating a balanced diet, only 8%
associate it with maintaining a regular weight. There is a warning that a majority of older
people do not think observing their weight is a tool of checking if they are properly nourished;
16% of older people were unaware of dietary advice and changing

meal structures;

31% recalled being asked questions about their diet and weight. Of those who were in hospital
for more than one night, 26 % were asked screening questions.
These results reveal the theory and practice gap because only 26% were asked screening questions.
Nutritional assessment is a clinical issue that must be implemented in everyday

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practice (The patient Association, 2011). If nurses fail to adopt theory into practice, this will
lead to poor outcomes for patients.

Nutrition is an important factor for patients' recovery. Guidelines from NICE (2006), SIGN
(2004) and BAPEN (2012) require nurses to assess patients on admission. Unfortunately, this is
not always the case and this gap between theory and practice puts patients at risk.
Malnutrition causes disease such as stroke, and patients with stroke can suffer further
complications linked to their swallowing and become undernourished. As a consequence of this
topic, nurses and patients must be educated on the importance of nutritional assessment and the
necessity of breaking barriers to compliance. For best practice, nurses are accountable and
responsible for assessing patients on admission in any healthcare settings.

Words count: 3000

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