Download Eating and Drinking Care Pathway - Leicestershire Partnership NHS

EATING AND DRINKING DIFFICULTIES
IN ADULTS WITH A LEARNING DISABILITY
Introduction
Skills and
Competency
Framework
Referral
Screening Assessment
Specialist Assessment
Referral to
Other
Services
Standards and
Guidance
Management
Review
Discharge
EATING AND DRINKING DIFFICULTIES
IN ADULTS WITH A LEARNING
DISABILITY
Aiming to minimise the risks and maximise
independence and nutrition when eating
and drinking
Information for
Carers
Information for
Professionals
Back to Pathway
Information for Carers
These leaflets may help you to decide whether to refer:
Eating and Drinking information leaflet
Information for Carers (From NPSA 2007)
If you decide you need further help, use the appropriate referral form for
where you live. You can fill it in and send it to the address given or ask
your GP to make the referral.
If the person to be referred is coughing when eating or drinking, it would
be helpful to have a record of coughing incidents to bring with you to the
appointment.
If the person has choked, check with this alert document what to do.
You could complete a choking incident form to bring with you to the
appointment.
If the person is losing weight or refusing food, you could complete a
Food diary chart to bring with you to the appointment. The Food First
leaflet will give you some tips to keep a person’s weight healthy until
your appointment.
You may find the following websites helpful
NPSA npsa.nhs.uk
MENCAP www.mencap.org.uk
Alzheimers society www.alzheimers.org.uk
Caroline Walker trust www.cwt.org.uk
BILD www.bild.org.uk
Rett UK www.rettuk
Further information for carers link A10
Back to Pathway
Initials
d/m/y
Date
No problem
Time
Food
Back to Pathway
Drink
A little cough
Cough and effort
ALERT
Problems with swallowing food and drink
(dysphagia) can be life threatening.
If you are concerned that someone is having difficulty when
eating or drinking, first decide –
Is it an emergency?
Yes
This is life
threatening e.g.
difficulty breathing,
turning blue, choking,
severe distress
whilst eating or
drinking.
What should you
do?
 Use your first aid
procedures.
 Call for an
ambulance.
 Later make a full
report of the
incident and tell your
GP about the
incident.
Back to Pathway
 No - any of these signs whilst eating
may suggest problems with swallowing:
coughing, choking, some distress, face
reddening, eyes watering, nose running,
or breathlessness. In this case refer to
Speech and language therapy (SALT)
(See below).
 Swallowing difficulties are often
associated with other health problems.
If you are concerned about the person’s
general health, contact the GP as soon
as possible.
 Make a referral to Speech and
language therapy through the Learning
Disability Team for an assessment.
(SALT does not respond to emergency
referrals and you may have to wait for
up to a month to see someone)
 If the person has an eating and
drinking plan and you are not sure of the
recommendations or think the plan
needs updating contact the Learning
disability team.
Side 1
Leicestershire Partnership Trust
FOOD CHART
NAME…………………………………………………..
WARD…………………………………………………….
Please Record (a) Type of food e.g. Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements
DATE:
BREAKFAST
Cereal
Toast / bread (no of slices)
Marg ( ) Preserves ( ) tick if yes
Other
0
0
1/4
1/4
1/2
1/2
3/4
3/4
All
All
0
1/4
1/2
3/4
SNACK
0
1/4
1/2
3/4
LUNCH
Main course
Potato / rice
Vegetable
Dessert / fruit
Other
0
0
1/4
1/4
1/2
1/2
3/4
3/4
All
All
All
DATE:
BREAKFAST
Cereal
Toast / bread (no of slices)
Marg ( ) Preserves ( ) tick if yes
Other
0
1/4
1/2
3/4
All
All
SNACK
0
1/4
1/2
3/4
All
teaplate size portion YES / NO
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
LUNCH
Main course
Potato / rice
Vegetable
Dessert / fruit
Other
SNACK
0
EVENING MEAL
Sandwich
Main course
Vegetable
Potato / rice
Dessert / fruit
Other
teaplate size portion YES / NO
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
EVENING MEAL
Sandwich
Main course
Vegetable
Potato / rice
Dessert / fruit
Other
SNACK
0
SNACK
1/4
1/4
1/2
1/2
3/4
3/4
All
All
SNACK
Continued overleaf………
teaplate size portion YES / NO
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
teaplate size portion YES / NO
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
All
All
All
All
All
All
All
All
All
All
All
All
All
FOOD CHART
Side 2
NAME…………………………………………………..
WARD…………………………………………………….
Please Record (a) Type of food e.g. Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements
DATE:
BREAKFAST
Cereal
Toast / bread (no of slices)
Marg ( ) Preserves ( ) tick if yes
Other
0
0
1/4
1/4
1/2
1/2
3/4
3/4
All
All
0
1/4
1/2
3/4
SNACK
0
1/4
1/2
3/4
LUNCH
Main course
Potato / rice
Vegetable
Dessert / fruit
Other
0
0
1/4
1/4
1/2
1/2
3/4
3/4
All
All
All
DATE:
BREAKFAST
Cereal
Toast / bread (no of slices)
Marg ( ) Preserves ( ) tick if yes
Other
0
1/4
1/2
3/4
All
All
SNACK
0
1/4
1/2
3/4
All
teaplate size portion YES / NO
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
LUNCH
Main course
Potato / rice
Vegetable
Dessert / fruit
Other
SNACK
0
EVENING MEAL
Sandwich
Main course
Vegetable
Potato / rice
Dessert / fruit
Other
teaplate size portion YES / NO
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
0
1/4
1/2
3/4
All
EVENING MEAL
Sandwich
Main course
Vegetable
Potato / rice
Dessert / fruit
Other
SNACK
0
SNACK
1/4
1/4
1/2
1/2
3/4
3/4
All
All
SNACK
teaplate size portion YES / NO
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
teaplate size portion YES / NO
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
0
1/4
1/2
3/4
EVALUATION
Action taken following evaluation of 4 days intake :
Qualified nurse signature..................…………………………………...
Eating well and no weight loss – discontinue
Poor intake, refer to screening tool action plan
Continue to monitor
Back to Pathway
All
All
All
All
All
All
All
All
All
All
All
All
All
Information for Professionals
Introduction / Overview
Referral Forms
Eating and Drinking Leaflet
Referrals may come from a GP
GP Referral Protocol (from NPSA 2007)
Role of Primary Care
Or referrals may come from other incidents or indicators
Inpatient or residential homes using the
Malnutrition Universal Screening Tool
MUST
Or people who have had choking incidents
Alert Leaflet
Triaging Referrals
List of Foundation Workers
ICD10 Codes
List of medications that may affect swallowing
Useful Websites
NPSA npsa.nhs.uk
MENCAP www.mencap.org.uk
Alzheimers society www.alzheimers.org.uk
Caroline Walker trust www.cwt.org.uk
BILD www.bild.org.uk
Rett UK www.rettuk
Back to Pathway
Please place client / service user label
here.
NUTRITIONAL SCREENING TOOL (MUST)
COMPLETE ON FIRST SCREEN - DATE :
Current Weight
Height
Body Mass
Index (BMI)
Weight 3-6
months ago
% Weight Loss
Change in weight
_______ kg
______ m
______
_______ kg
YES / NO /
Don’t know
Measured / Recall
Measured / Recall
PLEASE CIRCLE
PLEASE CIRCLE
USE CHART TO
CALCULATE FROM
CURRENT WEIGHT
AND HEIGHT
Measured / Recall
/ Don’t Know
IF YES USE CHART
TO CALCULATE %
USING CURRENT
AND PREVIOUS
WEIGHT
PLEASE CIRCLE
MUST SCORE
DATE
A
B
BMI
% Weight loss More than 10% = 2
NB Oedema may
mask loss of muscle
weight
C
Less than 18.5 = 2
Between 18.5 and 20 = 1
More than 20 = 0
Please
circle
score
Between 5 and 10% or visual
loss of weight if not known = 1
Less than 5 = 0
Starvation
score
NO or likely to be NO Intake for
> 5days:
YES = 2
NO = 0
TOTAL
Add scores to give RISK
If score 1 or more start Nutrition
Treatment plan overleaf. If no
improvement or score > 4 refer
to Dietitian
RISK
LOW = 0
MEDIUM = 1
HIGH = 2
NUTRITIONAL TREATMENT PLAN STARTED?
YES
NO
NOT NEEDED
2
1
0
2
2
1
0
2
2
1
0
2
2
1
0
2
1
0
1
0
1
0
1
0
2
0
2
0
2
0
2
0
Write in
total
score
SIGN
Please circle
WEIGH PATIENT WEEKLY AND DOCUMENT ON WEIGHT CHART
Repeat MUST weekly or if condition changes – Using new weight
Nursing Nutrition Care Plan For Patients At ‘Medium or High Risk’ Of
Malnutrition.
MEDIUM/HIGH RISK

Complete detailed Nutrition Checklist Tool

Order a special diet if appropriate e.g. Gluten free, diabetic.

Refer onto Eating and Drinking pathway (LD clients) or write appropriate treatment plan

Assist with ordering suitable meal choices (Suggest High Energy (  ) main courses and
puddings and ‘Chefs Specials’ - see ward menus for details).
Or fortify foods prepared according to instructions provided (see home hand book).

Offer the patient additional items for snacks between meals.

Encourage milk and milky drinks.

Offer 1 Build up drink per day (savoury or sweet) Unless contraindicated e.g. renal
disease, lactose intolerant, milk allergy or patients following low residue diets. Contact
ward Dietitian for advice.

Offer assistance with eating and drinking, when required or follow eating and drinking
plan or treatment plan

Treat underlying conditions such as nausea, vomiting, diarrhoea, constipation.

Commence food and drink record charts for all meals and snacks. REVIEW INTAKE
AFTER FOUR DAYS, if intake remains minimal, and a referral has not already been
made, refer to your ward or community dietitian.

Refer to your ward Dietitian if:
DATE made and SIGN here.
o MUST score is greater than 4
o Tube feeding needs considering
o Nil By Mouth > 5 days
o MUST score increases or there is no improvement on medium/high risk nutrition
care plan
o Specialist advice is required following diagnosis, or a full nutritional assessment is
required in response to clinical judgment.

Repeat weight and MUST weekly – if weight drops >1kg/week refer to your ward Dietitian
If Dietetic referral is required please document
Ensure that prior to discharge the patient is reviewed by the ward Dietitian. This will ensure the
patient receives appropriate advice for home, and the need for any supplements can be
assessed.
Nutrition Checklist
ABILITY TO EAT
Able to eat independently
Poor dentition/chewing problems
/ /
Suggested action
Consider referral to community dentist
Ill fitting dentures
Poor oral hygiene
Requires help with feeding
Swallowing problems
Consider referral to community dentist
Consider referral to community dentist
Develop treatment plan for behaviours
Refer to Speech and Language Therapist
Choke risk
Refer to Speech and Language Therapist
SYMPTOMS/SIDE EFFECTS OF DRUGS
Nausea
Vomiting
Constipation
Diarrhoea
PSYCHOLOGICAL STATE
Does not enjoy mealtimes
Mental state not affecting food intake
Loss of interest in food
Disruptive behaviour at meal times
Easily distracted by noise /other clients
Regurgitates/ self induces
History of erratic or chaotic eating
Severe depression
Mild anxiety/confusion relating to food
Paranoia relating to food
Extreme anxiety/agitation
APPETITE AND DIETARY INTAKE
Normal appetite, all meals eaten
On special diet, eg. supplements, liquidized
Reduced appetite, ½ - ¾ of meals eaten
Poor appetite, less than ½ of meals eaten
Can manage finger foods
Has particular cultural dietary requirements
Seems to have foods they do not like
Needs specially adapted cutlery
SKIN TYPE
Healthy
Oedematous
Poor wound healing/
Grade 4 pressure ulcers
Dry and flaky
OTHER ISSUES
Difficulties with posture when eating
Back to Pathway
Request review of meds
Request review of meds
Request review of meds
Request review of meds
Offer support during meal times
Develop treatment plan for behaviours
Develop treatment plan for behaviours
Develop treatment plan for behaviours
Offer support during meal times
Offer support during meal times
Follow nutrition care plan
Follow nutrition care plan
Follow nutrition care plan
Contact catering
Contact catering
Discuss with relations/carers
Refer to OT for assessment
Refer to tissue viability nurse
Refer to Physiotherapy department
Referrals to Eating and Drinking Care Pathway
Trigger Guidelines
If any of these phrases or terms are used in a referral contact a Foundation
Worker before the next locality MDT meeting:
 Aspiration
 Recurrent chest infections
 Difficulty swallowing
 Choking
 Coughing around mealtimes
 Dysphagia
If the Referral from another Speech and Language Therapist you should contact
your link Speech and Language Therapist as soon as possible with the referral
details. You should try and contact the therapist in your area but if you are
unsuccessful or if there is currently no therapist in your area you should try and
contact another therapist on the list below.
You should also send the details to the admin staff for registering and it should be
brought to the next MD Team Meeting.
If the referral is an emergency, advise the referrer to contact emergency services
and to inform the GP, see the ALERT leaflet for more details.
Jan 2012
Back to Pathway
ICD10 Codes
There may be many contributory diagnoses for a person with
learning disability.
The most frequently used ICD10 codes are:
R13
Back to Pathway
Dysphagia
MEDICATIONS AND DYSPHAGIA/ SWALLOWING RISKS
[Some of the medications that can impact swallowing and why this happens]
Dysphagia as a side effect of medication
• Medications that affect the smooth and striated muscles of the esophagus that are involved in
swallowing may cause dysphagia.
Medications with anticholinergic or antimuscarinic effects
Benztropine mesylate (Cogentin) given for movement related effects caused by some
psychotropic meds
Oxybutynin (Ditropan)
improves bladder capacity
Propantheline (Pro-Banthine)
inhibits the release of stomach acid
Tolterodine (Detrol)
affects bladder capacity
 Medications that cause dry mouth (xerostomia) may interfere with swallowing by impairing the person’s
ability to move food
Medications that cause Dry mouth (xerostomia)
ACE Inhibitors- used for high blood pressure
Antiarrythmics- cardiac preparations
Antiemetics- used for nausea
Antihistamines and decongestants- used for
cold symptoms
Calcium channel blockers- used for chronic
chest pain due to angina
Diuretics- given to get rid of excess fluid in
body
SSRIs (Selective serotonin reuptake inhibitors)antidepressant medications
Captopril (Capoten)
Lisinopril (Prinivil, Zestril)
Disopyramide (Norpace)
Mexiletine (Mexitil)
Procainamide (Procan)
Meclizine (Antivert)
Metoclopramide (Reglan)
Prochlorperazine (Compazine)
Chlorpheniramine (Chlor-Trimeton)
Diphenhydramine (Benadryl)
Pseudoephedrine (Sudafed)
Amlodipine (Norvasc)
Ethacrynic adic (Edecrin)
Citalopram (Celexa)
Fluoxetine (Prozac)
Nefazodone (Serzone)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor)
* see also Antipsychotic/ Neuroleptic medication list below

Local anaesthetics such as Novocain which is often used for dental work may temporarily cause a loss
of sensation that may affect swallowing before it wears off.
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Antipsychotic/ Neuroleptic medications
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Fluphenazine (Prolixin)
Risperidone (Risperdal)
Haloperidol (Haldol)
Thioridazine (Mellaril)
Lithium (Eskalith, Lithobid)
Thiothizene (Navane
Loxapine (Loxitane)
Trifluoperazine (Stelazine)
 Antipsychotic/ Neuroleptic medications given for treatment of psychiatric disorders may affect
swallowing as many of them produce dry mouth and some of them can cause movement
disorders that impact the muscles of the face and tongue which are involved in swallowing.
Dysphagia as a complication of the therapeutic action of the medication
• Medications that depress the Central Nervous System (CNS) can decrease awareness and
voluntary muscle control that may affect swallowing.
Medications that depress the CNS
Antiepileptic drugs- for seizures
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Phenobarbital
Phenytoin (Dilantin)
Valproic acid (Depakote)
Benzodiazepines- antianxiety drugs
Narcotics- for pain relief
Skeletal muscle relaxants- relieves
muscle spasms and relaxes muscles
Alprazolam (Xanax)
Clonazepam (Klonopin)
Clorazepate (Tranxene)
Diazepam (Valium)
Lorazepam (Ativan)
Codeine (Tylenol #3)
Fentanyl (Duragesic)
Propozyphene (Darvon, Darvocet)
Baclofen (Lioresal)
Cyclobenzaprine (Flexeril)
Tizanidine (Zanaflex)
Medications that can cause esophageal injury and increase risk
•
Some medications can cause dysphagia because of injury to the esophagus caused by local
irritation. This can happen because the person is in a reclining position shortly after taking the
medication or because an inadequate amount of fluid is taken with the medication. In both
instances, the medications remain in the esophagus too long, potentially causing damage and
affecting swallowing.
Drugs that may cause esophageal injury
Acid- containing products
Clindamycin (Cleocin)
Doxycycline (Vibramycin)
Erythromycin (Ery-tabs, E-mycin)
Tetracycline (Sumycin)
Aspirin
Bisphosphonates- given for osteoporosis
Iron containing products
Methylxanthines- bronchodilators
Nonsteroidal anti-inflammatory drugs- relieves
pain
Potassium chloride supplements
Vitamin C (ascorbic acid) supplements

Bayer aspirin and generic brands
Alendronate (Fosamax)
FeoSol, Feratab, Slow-FE, Fer-Iron etc.
Theophylline (Theo-Dur, Unidur, Slo-Bid)
Ibuprofen (Advil, Motrin)
Naproxen (Aleve, Naprosyn)
K-Dur, K-tabs, Klor-Con, Slow K, etc.
Allbee with C
Vitamin C tabs, etc.
Other medications such as high dose steroids and chemotherapeutic (anti-cancer) preparations
may cause muscle wasting or damage to the esophagus and may suppress the immune system
making the person susceptible to infection.
Reference: Balzer, KM, PharmD, “Drug-Induced Dysphagia”, International Journal of MS Care,
page 6, Volume 2 Issue 1, March 2000. (http://www.mscare.com/a003/page_06.htm)
DMR Health Standard 07-1 Guidelines for Identification and Management of Dysphagia and
Swallowing Risks Attachment A
Screening Assessment
When an individual is referred to the Eating and Drinking Care
Pathway, a trained Foundation Worker will contact the person
or carers to arrange to carry out a Screening Assessment.
The Foundation Worker will leave Initial Assessment
recommendations at the first visit and then report back findings
from the assessment to the Locality LD team for further in depth
discussion
Screening Assessment Outcomes
If there are no further actions
needed after the screening
assessment, a discharge letter
is sent from the Locality LD
team
Back to Pathway
Further action needed after
screening will result in referral
on to the appropriate
professional member of the
Locality LD team for specialist
assessment
Skills and Competency
Framework
Interdisciplinary Dysphagia Competence Framework
(2009) Embed J2 here prob as externl link
Training for competencies
Awareness (Under development)
Carers
Foundation Worker
Specialist
Consultant
The consultant is required to carry out complex case work and
advanced assessments. If FEES and Videofluoroscopy are available
the consultant should be able to implement an assessment if
appropriate ( see competences from RCSLT).
The consultant also progresses work at a strategic level and work with
other services.
Currently there are no clear courses, although Manchester Metropolitan
University does offer an Advanced Dypshagia practitioner level course.
Back to Pathway
Foundation Worker Training
Foundation Workers are trained according to the
Interdisciplinary
Dysphagia Competencies
Foundation workers receive an initial days training
This training takes one day. In the morning, presentations
are received from each of the different members of the
ALD team on their role in the E&D care pathway
FW’s receive annual updates which focus upon
 Refreshing of process and theory
 Updating on new process and new theory
 Peer support and feeding back into the pathway
 New issue information
 2011 Focus on supplements in diets
 2012 Focus on role of FW and choke reporting
Back to Pathway
Specialist Dysphagia Workers
Each professional is specialist in their own field
This is the point where each professional is specialist in their own field. For
instance the OT would not be expected to do a specialist dysphagia (swallowing)
assessment but would be the appropriate specialist professional for
recommending the independence support for safe eating and drinking.
Only the SLT would have specialist swallowing assessment skills. Each other
professional has their specialist skill (see ‘Roles’ in the SEAD Pathway)
Specialist swallowing skills are acquired locally by a qualified speech and
language therapist who has attended and passed a Post graduate training course,
having had some years experience. DMU provide a week-long course which
includes a six-month period of mentoring and is fully assessed by the university
through assignments.
Back to Pathway
Screening Assessment Tools may
Include
Capacity Assessment
Consent form (from NPSA 2007)
Best Interest Documents
Morgan Risk Assessment
Case History
Mealtime Observation
Protocol Guidelines
MUST Screening Tool
Food Diary
Cough Recording Chart
Choke Recording Forms
List of medications that
may affect swallowing
DIS DAT
Back to Pathway
Other Useful Leaflets
Client Name:
DOB:
NHS Number:
Please place client / service user label
here
Community Team for People with Learning Disabilities
Mansion House, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF
Tel: 0116 225 5200 Fax: 0116 225 5202
Eating and Drinking Case History
Name:
D.O.B.
Preferred Name:
NHS Number:
Refer to core information: Health and social needs section and the HONOS section.
Clients concerns about their eating and drinking
Carers main concerns around eating and drinking
Name of carer:
Consent:
Consent gained:
Yes
No
(how was consent gained? If not, why?)
Refer to Core Information: Social Circumstances section for Weekly schedule and names of specific support workers
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
Client Name:
DOB:
NHS Number:
Weight and appetite
1 Current weight without shoes:
2 BMI if known (Body Mass Index):
3 Has the MUST screening tool been completed with the client?
Yes/No/Don’t Know.
4 Has there been any unplanned weight loss in the last 6 months?
Yes/No/Don’t Know.
If yes, how much?
Action: Refer to Dietician if unplanned weight loss of more than 5%
5 Has the person gained weight?
Yes/No/Don’t know.
If yes…
Is the person’s weight gain affecting physical or mental health?
Yes/No/Don’t Know.
Please give details: -
Are there any known causes for weight gain?
Yes/No/Don’t know.
Please give details:-
Action: Refer to Community Nurse/ and/or Dietician if there are concerns
6. Have there been any changes to the person’s appetite, level of alertness
Yes/No/Don’t Know.
or stamina during eating/drinking?
Please give details: -
Action: If yes, go to GP for blood tests and/or ask for a medication review
Client Name:
DOB:
NHS Number:
Dentition and general health
7. Does the person have rotten teeth, sensitive teeth or ill fitting dentures?
Yes/No/Don’t know
8. Does the person have dentures?
Yes/No/Don’t know
Do they fit well?
Yes/No/Don’t know
If yes, do they consistently wear them for eating and drinking?
Action: Any problems, make an appointment with your Dentist
9. Does the person have ulcers, sore mouth, discoloured tongue and bad
Yes/No/Don’t know
breath?
Action: If yes, check mouth care, check for constipation, dentist appointment.
10. Does the person have any problems taking medication?
Yes/No/Don’t know
Please give details: -
Action: ask GP/pharmacist for alternative forms; refer to SALT
11. Has the person had any recent hospital admissions or diagnostic
Yes/No/Don’t know
procedure?
Please give details: -
12. Current Medication: [Listed in core information]

Add additional information re dose, form of medication and date last reviewed

Add a * to any medication that has changed in the last 6 months.
Client Name:
DOB:
NHS Number:
13. Medical condition: conditions that may contribute to or be affected by the ability to eat and drink

Does the person have any of the following? [Refer to HONOS section of the core information]
Respiratory
Details including Treatment
Actions if unresolved issue
Asthma
Go to GP or Respiratory Nurse if
involved.
Shortness of Breath
Go to GP/Sprint team
Respiratory tract/chest infections
How many in the last 6 months: How many in the last 12 months: -
Go to GP
Pneumonia
Go to GP
Bronchitis
Go to GP
COPD
Go to GP
Difficulties coughing out phlegm / Secretions in
upper airway.
Referral for chest physiotherapy
Pooling of saliva/excessive dribbling
Referral for chest physiotherapy
Other

Digestion
Vomiting and regurgitation
Details including Treatment
Actions if unresolved issue
Go to GP
Client Name:
DOB:
NHS Number:
Hernia
Go to GP
Urinary infections
Go to GP
Constipation or Diarrhoea
Go to GP
Acid reflux
Go to GP
Indigestion
Go to GP
Other gastro-intestinal problems
Go to GP/specialist consultant
Physical
Poor alignment and symmetry of body segments
Refer to Physiotherapy
Altered movements due to muscle tone or
reflexes?

Physical continued
Difficulties controlling head position and seating
balance.
Any paralysis
Refer to Physiotherapy
Details including Treatment
Actions if unresolved issue
Refer to Physiotherapy
GP or refer to Physiotherapy
Client Name:
DOB:
NHS Number:
Cleft palate
Refer to SALT
Oedematous or poor wound healing
GP/district nursing/dietician
Diabetes
GP
Dehydration – dry skin, lips or mouth; less alert,
constipation etc
Increase fluids if possible
Refer to Dietician
Neurological
Dementia
Check if on the Dementia Pathway.
GP, CLDN or psychiatry
Parkinson’s
GP, CLDN or psychiatry
Epilepsy: increased signs of seizures/jerks

Other
Behavioural issues e.g. Pica, taking food not
prepared for them, rushing, distracted
disorientated etc.
Mental illness e.g. increasingly anxious and
mealtimes, depression etc
Other conditions known to affect eating &
drinking, such as Rett, cerebral palsy, anxiety,
depression
Details including Treatment
Check if on Epilepsy Pathway and
refer to person who is managing
Epilepsy.
GP, CLDN or psychiatry
Actions if unresolved issue
Refer to Community Team
GP, CLDN or psychiatry
Refer to Psychiatrist.
Go to GP
Refer to Dietician
Client Name:
DOB:
NHS Number:
Information about meal/drink times
14. How do you and the person communicate at meal times e.g. choice, knowing what will happen and when etc?
Please give details: -
15. Does the person have an Eating and Drinking Plan?
Yes/No/Don’t Know
Please attach copy.
16. Please describe the person’s table, seating and positioning at meal times. Are there any problems in relation to this? Please give
details: -
16. How long does the person take to eat a usual meal?
What is the speed of eating? Are there rests or pauses?
Does this vary throughout the day/week?
17. What kind of food and drink does the person have?
(Include preferences; soft or pureed food; thickened drinks; dietary or cultural requirements; allergies or intolerances.)
18. Are you aware of any other preferences the person has around meal times, e.g. tastes, textures, environment or who they sit with
etc?
Please give details: -
Client Name:
DOB:
NHS Number:
19. Is the person able to get their food to their mouth?
What equipment is your client currently using? (e.g. plates, cutlery, cups, mats, individualised furniture etc)
Do they overfill their mouth?
Have there been any changes in skill level in relation to this?
22. Who regularly supports the person and manager details, if relevant?
What is the usual staff:client ratio at a meal and time allowed for meal?
23. Where does the person currently go to have their meals? – note on timetable in core information if relevant.
24. Do you regularly see any of the following …

 food or drink comes out of his/her nose or mouth during eating and drinking

 food or tablets become stuck on the roof of their mouth, teeth or gums after or during eating? If so,
 please describe where the food sticks and how you and/or the person frees up the food

 the person has difficulty chewing?

 the person has tears, effort to swallow, reddening face, wheezy/gurgling sound or coughing shortly after eating food or
drinking?
25. Has the person choked recently (e.g. within the last month). If yes please give details.
(Has a choking incident form been completed? Do you need to complete an e-irf?)
Client Name:
DOB:
NHS Number:
Does the individual show any worries or fears or become distressed at mealtimes? Yes / No
If yes, please state frequency – occasionally / sometimes / always.
Is there any other information you think may be relevant to this assessment, e.g. person awaiting treatment/intervention?
Signed:
……………………………
Dated:
………………………………
Profession:
signed by (print name): ……………………
………………………………
Name of person information collected from: …………………………………Relationship to Client: …………………………..
Place information collected from:
Actions
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…………………………………………………..
By Whom
Target Date
Date
Completed
Signature
Name:
DOB:
NHS Number:
Please place client / service user label
here
Eating and Drinking
Initial Observation
Name:
D.O.B.:
NHS Number:
Date:
Place of Observation:
Consent:
Activity
Type of Food/Meal
Type of Drink
Amount of food/drink eaten:
Environment
Equipment used
Mobility/Seating and Positioning
Ability/Skill level to feed self, including speed
of eating
Consent gained: Yes
No
(if not, why, how was consent gained)
Comments
Level of Staff support/type of support
Behaviour e.g. Distractions, concentration,
refusal, distress
Emotional Response
Risks when eating and drinking
(Refer to questions 4, 9, 10, 11, 12 of Eating
and Drinking Assessment)
How did Carers respond to any incidents
observed?
Actions
Action
By Whom
Signed:
……………………………
……………………………………..
Dated:
…………………………..
……………………………………..
Target
Date
Name in Capitals:
Profession:
Date
Completed
Signature
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Learning Disability Team
Mansion House
Leicester Frith Hospital
Groby Road
Leicester
LE3 9QF
Tel: 0116-225-5200
Fax: 0116-225-5202
Eating and Drinking
Initial Observation Guidelines
Activity
Examples
Suggested Activity
Type of Food/Meal
Food eaten. Cultural requirements.
Is it pureed/mashed, diabetic?
Allergies, gluten free. Amount given. Did the client
choose?
Hot/Cold; Thickened; Amount given
Refer to Salt and/ or dietician
Is this documented for the person?, is this usual for the
person. Is the person over/under weight.
Where did the person sit?, consider time, noise, lighting,
colour . Who did they sit with / people in the room.
Background influences, eg. TV, radio, door bell, other
people in the room causing a distraction.
Plate, cup, cutlery, mat, apron, chair/table, any individual
furniture?
Posture, head position, gross motor skills. Position and
impact on persons eating/drinking ability. Best position
for the client.
Speed of eating, ability to initiate task, sequence, problem
solve, continue with task to completion. Hand grip, fine
motor skills,
ability to load cutlery, ability to put cutlery in mouth, over
fill mouth?
Number of Staff. Were staff consistent or did they leave
the room or divide their attention between different
clients. Full physical assistance, hand over hand support,
verbal prompts, supervision. Staff position when
assisting the person
Ability to sit and remain seated at the table. Awareness
of the task. Distracted away from the task. Ability to
attend to the task?. Social skills/interaction, did the
person refuse food and or drink. Taking food from others.
Did the person become distressed by food drink, activity,
staff, other people etc.
Signs of tears in eyes, effort to swallow, reddening face,
wheezy/gurgling sound, coughing during/shortly after
eating/drinking. Ability to chew/swallow. Emotional
behaviour.
Refer to MDT
Type of Drink
Amount of food/drink eaten
Environment
Equipment Used
Mobility/Seating and
Positioning
Ability/ Skill level to feed self,
including speed of Eating
Level of Staff support/type of
support.
Behaviour e.g. Distractions,
concentration.
Refusing foods
Emotional response.
Risks when eating & drinking
(Refer to questions 4, 9, 10, 11,
12 of Eating & Drinking
Assessment)
How did carers respond to any
incidents observed?. eg,
choking aspiration
(behavioural)
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Refer to Salt and or dietician
Refer to OT
Refer to OT
Refer to Physiotherapy
Refer to OT
Refer to OT and or Salt
Refer to relevant professional
provide advice
Refer to relevant professional
stated above/discuss with MDT
Refer to Salt and/ or
Physiotherapy
Refer to relevant professional
stated above/discuss with MDT
Leicestershire Partnership NHS Trust
Patients Name
Consultant
DOB
Named Nurse
Fluid Intake Target (mls)
Supplements (see Dietary
Prescription Chart)
Dislikes
Comments
Fluid Chart
Date:
Time
Date:
Type of Fluid Offered
(Record if Refused)
Fluid
Intake
Urinary
Output
Time
01.00
01.00
02.00
02.00
03.00
03.00
04.00
04.00
05.00
05.00
06.00
06.00
07.00
07.00
08.00
08.00
09.00
09.00
10.00
10.00
11.00
11.00
12.00
12.00
13.00
13.00
14.00
14.00
15.00
15.00
16.00
16.00
17.00
17.00
18.00
18.00
19.00
19.00
20.00
20.00
21.00
21.00
22.00
22.00
23.00
23.00
24.00
24.00
Type of Fluid Offered
(Record if Refused)
Fluid
Intake
Urinary
Output
Totals
Totals
Side 1
Patients Name
Consultant
DOB
Named Nurse
Leicestershire Partnership NHS Trust
Fluid Chart
Fluid Intake Target (mls)
Supplements (see Dietary
Prescription Chart)
Dislikes
Comments
Date:
Time
Type of Fluid Offered
(Record if Refused)
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
Fluid
Intake
Urinary
Output
Date:
Time
Type of Fluid Offered
(Record if Refused)
Fluid
Intake
Urinary
Output
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
Totals
Totals
Evaluation – Fluid Chart to be evaluated at least every fourth day
Date of Evaluation:
Action required ( please tick )
Yes - see care plan
Signature of Qualified Nurse:
Evaluated By:
No – discontinue
Continue to monitor
Side 2
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Thank you for taking the time to fill in this form. We will direct this form to a
professional who can look at the details with you and decide on an
appropriate response.
The professional will ring you in the next week. If you have not heard from
us, please call Sue Challis on 0116 225 5812
Action
Choke report received on
Choke report logged and copy to SEAD
Action: sent to which SLT
Name of SLT
SLT’s action
Response sent to
(Home/ other/reporter)
Letter or other. Saved where?
Was a referral needed? (details)
Date and sign
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Other Useful Leaflets
 Alert
 Foods which give a high risk of choking
 Supporting people who eat and drink too
fast
 What is Dysphagia?
 Supporting people with Dementia to eat
and drink
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Initial Assessment recommendations for:
_____________________________________
NHS Number _________________ DOB __________
was visited today
by
to assess their eating and drinking.
The following recommendations have been made.
A full report and eating and drinking care plan will be produced shortly/This will be the final version
Drinks
Current:
Current:
Actions / recommendations:
Current:
Actions / recommendations:
Position
Equipment
Assistance required
Actions / recommendations:
Things to look out for
Current:
Current:
Actions / recommendations:
Current:
Actions / recommendations:
Actions / recommendations:
Any problems please contact:
………………………………………………...
Telephone number:………………………….
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Discharge
Discharge is considered when
 The individual is stable
 Carers are confident and competent to carry out the Eating
and Drinking Plan
 Carers know how to review the Eating and Drinking Plan and
know how and when to re-refer
When all these criteria are met, the individual is discharged and
the information is relayed back to the GP and the Locality LD
team
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Specialist Assessment
Who may be involved in Specialist
Assessment?
What may be included in Specialist
Assessment?
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Who may be involved in assessment?
Psychiatrist
Mental Health assessment if there are valid
concerns about conditions such as depression,
mania, psychosis, or and eating disorder that may
be impacting nutritional intake
Speech and Language Therapist
Assesses communication and
swallowing
Occupational Therapist
Assess functional skill level and
functional positioning in order to
maximise independence and
enable the individual’s skill level
within eating and drinking
Dietician
Assesses nutritional needs
Physiotherapist
Assesses positioning, posture and
management of secretions
Individual
Knowledge of own likes, dislikes,
preferences, aspirations
(Person Centred Plan and
Health Action Plan)
Acute Liaison Nurse
Outreach Team
Assess significant behaviour
issues
Community LD Nurse
WAITING FOR INFO
Health Facilitator
D19
Psychologist
LEADS TO BLANK
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Carer
Knowledge of the person and their likes
and dislikes, trialling treatment providing
direct support
What may be included in
Specialist Assessment?
The assessment will be person-centred
and tailored to individual needs and may include:
Direct Observation
Capacity
Sensory
Mental Health
Cognitive
Nutritional
Communication
Risk
Environmental
Case History
Psychological
Positioning
Physiological
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Occupational Therapists Role in
Eating and Drinking
The Occupational Therapist considers the impact of physical, cognitive,
perceptual, sensory and behavioural factors in the assessment and
management of individuals with eating and drinking difficulties. This also
reflects the environmental and social factors which affect the individual’s
skills.
This may involve:
 Liaison with other professionals in the assessment of an individual’s
positioning needs. This includes the use of appropriate seating and
other physical supports to facilitate safe and effective eating and
drinking.
 Facilitation of independence through the use of adaptive equipment
and education of individuals and their carer’s in appropriate feeding
techniques, and the method and level of support required.
 Assessment of individual’s cognitive and perceptual skills in relation to
the task, such as understanding of sequence, orientation, problem
solving and spatial awareness.
 Assessing the impact of the individual’s behaviour, psychological and
other social factors in order to promote safe and effective eating and
drinking.
 Assessment of individual’s sensory skills and needs.
The above are considered within the context of an individual’s
environment with regards to the influences this has upon their skills and
ability to function as independently as possible. Occupational Therapists
will monitor and review recommendations made in line with the MDT
Care Pathway.
Some OTs are trained to have the required competency level for a
Foundation Dysphagia Practitioner as part of the eating and drinking care
pathway.
Eating and drinking OT assessment
Eating and drinking OT assessment
Sensory OT assessment 5c
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Occupational Therapist Assessment
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Name:
NHS Number:
Occupational Therapy
Eating and Drinking Assessment
NAME:
ADDRESS:
D.O.B:
NHS NO:
THERAPIST:
Other professionals agencies involved:
Is there a past meal time plan? If yes date of plan:
KEY:
√ √
√ X V
√ X P
X X
Independent
Minimum assistance, verbal
Minimum assistance, physical
Maximum assistance
TASK
KEY
MOTOR SKILLS
Stamina/Tolerance
Strength
Fine Motor Skills
 Movement
 Grip
Gross Motor Skills
 Movement
 Position/Balance
Sensory Skills
Visual
Tactile
COMMENTS
Olfactory
Auditory
Gustatory
Proprioception
(vestibular)
TASK
COGNITIVE SKILLS
Attention/Awareness
Initiation
Continues with task
and continues to the
end.
Comprehension
Memory
Sequencing
Decision Making
Problem Solving
Orientation
PERCEPTUAL SKILLS
Visual e.g. Colour, depth,
figure ground, and form size
and consistency.
Spatial e.g. scanning and
tracking, body position.
KEY
COMMENTS
ADDITIONAL INFORMATION
General Behaviour e.g. risks to
COMMENTS
health or chocking, mood, engagement,
mental health, emotional state.
Social Skills
Environmental Factors e.g.
physical, distractions, other people in
the environment.
Dietary Considerations
TASK
KEY
COMMENTS including type and level of support by carers, carer
positioning etc.
TASK ANALYSIS
Component

Equipment
currently in use

Pick up cutlery

Preparation of food

Load Cutlery

Cutlery to mouth

Eating

Food spillage

Speed of eating

Cutlery to plate

Drinking
Considerations
Equipment Considerations
Materials:
Angles:
Size:
Shape:
Colour:
Weight:
Positioning Considerations
Environmental Considerations
Additional Considerations
E.g. task breakdown, intervention plan, staff training and support.
Therapist signature
…………………………………………
Date
…………………………………………
This is an in-house, non-standardised, assessment and observations sheet to inform
Occupational Therapists clinical reasoning for intervention and recommendations
The Role of the Dietitian
Role Definition
Assess individual to ensure that their diet is providing everything
that they need to remain healthy. They advise on ways to make
changes to improve the overall balance of the diet.
The Role of the Dietitian
Dietitians interpret the science of nutrition into practical
advice and guidance to enable people to make appropriate
lifestyle and food choices whilst taking into account the
individual’s circumstances and preferences.
This may involve:
 Meeting with the individual to discuss diet and any
alterations that may be required
 Discussions with carers or other professionals to help
facilitate changes
 Advice around menu planning
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The Speech and Language Therapist
Works with:
Communication Difficulties
Swallowing Difficulties
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Communication Difficulties
The pathway is person-centred, so this means that throughout the whole
pathway, the person should be included, informed and involved in decision
making at every level.
Communication is very important at mealtimes and when drinking.
 It is important to gives choices about the meal, and help people to
know when the meal is anticipated.
 It is important to know the person’s likes and dislikes- this should be
available in the person’s Person-Centred Plan
 It is important to know when the person may be distressed- a DisDAt
tool may be useful here. (please embed link to DISDAT tool which
has been included elsewhere in pathway)
 It is important to know when the person is trying to communicate such
as ‘stop’, ‘wait I am not ready’, ‘more please’, ‘I don’t want that!’ This
should be included in the person’s communication passport if they
have one. (please link to page for communication passport)
What Specialist assessment and intervention may the SLT do?
If the person’s communication requires specialist involvement, the Speech
Therapist may do a specialist communication assessment of understanding
and use of language.
The therapist may work with the support team to write a communication
passport for the individual and may also write a detailed report. ( link to
communication passport page)
The SLT will work with professionals and carers to help them understand
the best ways to involve you and communicate with you.
The SLT may recommend that a person needs supporting methods of
communication alongside speech such as using symbols, photos, pictures,
signing or other ways.
The SLT would support you and the carer to use these.
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Swallowing Difficulties
How will the Speech therapist(SLT) assess swallowing?
Speech therapy assessment may include
 Taking a detailed case history
 Observing the person eating various textures and or drinking fluid
textures.
 Observing the person eat a meal in their usual environments.
 Detailed communication assessment of the carer and persons
interactions
 Using Cervical Auscultation to listen to the sounds of breathing and
swallowing in the person’s throat. This means placing a stethoscope
on the person’s neck whilst swallowing whilst the therapist listens
carefully.
 The speech therapist may also use a Pulse Oximeter to observe any
effect of eating and drinking on respiration and blood oxygen levels.
This entails clipping a monitor on to the person’s finger or ear or toe.
 The speech therapist may suggest more detailed videofluoroscopic
assessment.
 Cough and choke charts
 Develop sensitive idea of food s managed or not
What will the Speech therapist do to help?
A Speech therapist assesses risks of swallowing: swallowing disability may
contribute to getting infections of the chest (chest infections) or lung
(pneumonia). Speech therapists work with the person, their carers and the
wider team to lessen risks of aspiration, choking or getting chest infections
and promote dignity, independence and enjoyment of the meal. The
speech therapist will try to accommodate the person’s wishes and cultural
needs.
The SLT may suggest ways to make swallowing safer and better for you:
 Modifying the texture of food or drink by using thickeners
 Changing the speed of putting food/drink into the mouth
 Changing the environment
 Trying different ways to get food/fluid into the mouth
What if a person is at very high risk of aspiration and all other
adaptions have been tried and the difficulty persists? The speech
therapist may recommend that non-oral feeding is considered ( please put
link to Enteral feeding pathway /document here).
If enteral feeding goes ahead, the speech therapist could support the
person through this process, and would work out safe oral intake after the
PEG has been inserted.
The Speech therapist may also recommend referral on to other specialist
services or further tests from the GP. The Speech therapist would ask the
person’s permission and would liaise with the GP.
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Videofluroscopy
Accessible Information
Videfluoroscopy is radiographic imaging of the person’s swallow.
The person is required to attend an acute hospital in Leicester with a carer.
The person needs to give their consent to the procedure on the day.(unless it has been
decided the assessment is in the best interest of the person)
The staff team are fully trained: a combination of Speech therapist or Radiologist and
radiographer carry out the examination.
In advance, the SLT would work with carers to choose the best textures to trial and the
best ways in which to do this.
The person brings food and drink of a pre-arranged texture for the person to eat or drink.
The food or drink is mixed with a radiographic substance, depending on the risks
identified.
The person is seated between the camera and a monitor. As the person swallows, the
clinicians can observe and interpret the recording.
The SLT or Radiologist writes the report, sending a copy to the person and their GP.
Link to VF competences
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The Learning Disability Acute Liaison Nurse (ALN’S) Team
The team consists of three nurses with a learning disability background.
The team members are: Katrina Dickens – Lead Nurse, Louise Hammond, and Lindsey
Heald.
The ALN’s are employed by the University Hospitals of Leicester Trust to help support
patients with a learning disability who access the acute hospitals.
This may be related to emergency admissions or via the planned care route.
The role of the ALN’s means that they will need to interact with acute nursing staff,
residential carers/supported living staff; families or carers; community learning disability
teams and social workers.
Once a patient has been identified to the ALN’s they will undertake a “meet and greet”
visit. The ALN’s will follow the patients’ progress from admission to discharge.
The ALN’s will also undertake the Learning disability Screening Tool if there are patients
considered to have a learning disability but there may be some uncertainty.
The work of the ALN’s focuses around the recommendations that were established
under the Six Lives Report:
 Accessible information within hospitals.
 Complaints and experiences relating to people with learning disabilities and their
carers.
 Consent and capacity.
 Reasonable adjustments.
 the reasons for admission in relation to geographic areas on a yearly basis
 To submit a yearly report to the Commissioners.
 Learning Disability Awareness Training to the UHL staff.
The Learning Disability Acute Liaison Nurses can be contacted on:
0116 258 4382.
If they are not available, please leave a message on the answer machine
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Health Action Plan Profile
“ADD NAME”
“Add date plan started”
My health need:
INSERT PICTURE
Identified problem:
The things I do well
The things that are important to/for me
.
The things I want to try/ need to do
Who was involved in writing this plan:
Date
Date
What’s working
How best to support me
Who can see this plan:.
What’s Not working
Key Action’s from Health Appointment
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