Download here - Birmingham Community Healthcare

Adults and Community Division
NUTRITIONAL GUIDELINES
Specific to Community Hospitals
(In-patient services)
Summary of Guidelines
The overall aim of this guideline is to improve the nutritional care of patients by identifying patients
at risk of malnutrition and providing nutritional support
Method of Approval :
Divisional Managers Meeting
Originating Department :
Community Nutrition & Dietetic Department
Date of Issue :
November 2009
Review Date :
November 2011
Impact Assessment Date :
June 2009
Page 1 of 31
Contents
Page
1. Introduction
3
2. Background
3
3. Statement of Purpose
4
4. Nutritional Screening
4
5. Weighing the Patient and obtaining the Patient‟s height:
Calculation of body mass index (BMI)
4
6. Provision of Food and Drink
5
7. Dietitian Support
5
8. Nurses Responsibilities
6
9. Rehabilitation Assistants Responsibilities
6
10. Housekeepers‟ Responsibilities
7
11. Discharge of Patients
7
12. Documentation
7
13. Training
8
14. Monitoring
8
13. References
9
Appendices 1-10
11 - 31
Page 2 of 31
NUTRITIONAL GUIDELINES
1. Introduction
The aim of this guideline is to improve the nutritional care of patients provided within South
Birmingham Community Hospitals. Good nutritional care requires a
multi-disciplinary, evidenced-based approach focusing on assessment and identification of the “at
risk” patient.
2. Background
A number of studies have demonstrated that malnutrition remains an issue and it tends to worsen
during hospitalisation. Malnutrition is under-recognised and under-treated (BAPEN, 2008).
The nutrition screening survey in the UK in 2008 (BAPEN, 2008) showed that malnutrition is
common on admission to community hospitals. McWhirter and Pennington (1994) revealed that
two in five adults admitted to hospital were malnourished. Most of them received no nutritional
support and lost more weight during their stay. Low body weight and poor nutritional status have
been linked to increased complications during illness, delayed postoperative recovery, longer
hospital stays and increased morbidity (Green, 1999 and BAPEN, 2008).
Only 5% of malnourished hospital patients received nutritional support. Of these, most gained
weight, and their nutritional status improved (McWhirter and Pennington, 1994). The evidence
suggests that the solution lies in identifying “at risk” patients.
"Hungry in Hospital?" a report from the Association of Community Health Councils (1997)
highlighted the problem that patients do not receive adequate food or fluids in hospital; their
observations included:
Patients who were incapable of choosing meals left to complete their menu order.
Lack of nursing assistance at mealtimes.
Patients who were not given the appropriate cutlery/utensils to eat with.
The British Association for Parenteral and Enteral Nutrition (BAPEN) has provided the research
and evidence base to demonstrate the link between under-nutrition and ill health. This is provided
in the „MUST‟ report (BAPEN, 2003), the cost of disease-related malnutrition in the UK (Elia, 2006)
and Combating Malnutrition: Recommendations for Action (Elia, 2008).
The Royal College of Nursing (RCN) has signalled its commitment to addressing this issue
through its Nutrition Now Campaign (2008), which aims to help nurses at all levels improve the
nutrition and hydration of patients.
The Hospital Caterers Association (HCA) also highlighted this as an important issue through its
2007 National Service Excellence Day. Staff throughout the country were provided with practice
advice and tips on how to make a difference.
Key documents have been produced within the last 6 years which provide guidance and
recommendations for the implementation of national guidance in food and nutritional care in
hospitals. These documents include:10 Key Characteristics of good nutritional care in hospitals (2003) (appendix 10)
Improving Nutritional Care (Department of Health, 2007)
Essence of Care (Department of Health, 2001)
Page 3 of 31
3. Statement of Purpose
All patients will receive good quality nutritious food taking account of individual needs, cultural and
religious beliefs, served to them by members of staff who understand the important role food plays
in the care, recovery and social wellbeing of adults. In addition, patients who require nutritional
support and/or specialised dietetic intervention will be identified and treated accordingly with
dignity, respect, fairness and sensitivity.
4. Nutritional Screening
All patients on admission will be screened using the „MUST‟ (Malnutrition Universal Screening
Tool) (appendix 1 & 9). This nutritional screening will be repeated weekly for patients identified
as being at risk of malnutrition, (Department of Health, 2003), (NICE 2006), (10 Key
Characteristics of good nutritional care in hospitals, 2003).
Actions identified from the nutritional screening tool will be implemented by nursing staff.
This may include:
 Implementation of multidisciplinary action plan for patients with small appetites (appendix
3).
 Referrals to (as appropriate):
o Dietitian
o Speech and Language Therapist
o Dentist
o Occupational Therapist
o Social Worker
5. Weighing the Patient and obtaining the Patient‟s height: Calculation of BMI
All patients should be weighed to monitor body weight changes according to their care plan.
All scales should be calibrated annually (BAPEN, 2008 and Department of Health, 2008).
It is recommended that all patients should be weighed and a height measurement taken (or
estimated) on admission. The patient‟s weight (kg) and height (m) should be recorded on the
record of „MUST‟ Nutritional Screening and Action Taken Sheet (Appendix 2).
See the „MUST‟ Explanatory Booklet if alternative measurements for body mass index (BMI) or
height or alternative considerations are required. It is recommended that ulna length is used if
unable to obtain an accurate height measurement and that mid upper arm circumference
(MUAC) is used to estimate BMI category if unable to obtain an accurate height or weight
measurement.
If the patient cannot or declines to be weighed/measured this should be documented on the
record of „MUST‟ Nutritional Screening and Action Taken sheet (appendix 2). This should be
reattempted as per recommendations on care plan.
Calculation of BMI – refer to BMI calculation table included in the „MUST‟ tool.
If neither BMI or weight loss can be established, a subjective assessment should be made to
assess overall risk of malnutrition and this should be documented on the record of „MUST‟
Nutritional Screening and Action Taken sheet (appendix 2).
The patient‟s weight and BMI should be reviewed on a weekly basis for every patient identified
“at risk” of malnutrition.
Page 4 of 31
6. Provision of Food and Drink
This will be in line with the “Better Hospital Food” requirements (Department of Health, 2000) and
the 10 Key Characteristics of Good Nutritional Care in Hospitals. The patients will receive the care
and assistance they require with eating and drinking, be able to access food and drink at any time
in a conducive environment. Ward based areas will operate a protected mealtimes policy, thus
reducing inappropriate activity at mealtimes. However, relatives are to be encouraged where
assisted feeding is required. Patients should be involved in the planning and monitoring
arrangements for food service provision.
These include provision of24 hour ward kitchen service
Snack boxes (menus available at ward level)
Light bites (menus available at ward level)
NHS menu, including special diets, cultural & wellbeing diets
A minimum of 7 drinks served per day
Drinking water available at the patients bedside (water jugs to be refreshed at least 3
times a day)
RGN‟s will have overall responsibility for the nutrition of their patients
Ward Housekeepers will help patients with their menu‟s and ensuring that individual
preferences and therapeutic needs are met
Red tray system to be used with patients identified as needing assisted feeding
Food textures as recommended by Speech and Language Therapists are provided (see
modified texture chart appendix 8) and must be adhered to.
Nurses will ensure that appropriate nutritional supplements are provided and use the
appropriate drinking vessel as recommended by Speech and Language Therapist (if
required)
A range of equipment is available to meet individual patient needs and promote
independence
Staff are to ensure that food is served at the correct temperature
Food is available and served in a way that meets cultural and religious needs
7. Dietitian Support
A Registered Dietitian will assess the patients who are identified as being at high risk of
malnutrition or those requesting specialised Dietitian intervention.
The Dietitian will determine and document a nutritional care plan. If the Dietitian feels further
review or Dietetic monitoring is necessary they will indicate this on the Dietetic Nutrition Care Plan
(appendix 6). Otherwise Dietetic review will be at the request of the ward staff via re-referral to the
Dietetic Department.
Page 5 of 31
8. Nurses Responsibilities
Oversee Nutritional screening using the „MUST‟ screening tool (appendix 1 & 9) ensuring that it
takes place for all patients on admission and weekly for patients where there is clinical
concern.
Implement appropriate nutrition care plans following screening. This could include
implementing a “red tray” system for identified patients (Hungry to be Heard, Age Concern,
2006).
Oversee the Multidisciplinary Action Plan for Patients with Small Appetites (appendix 3) and
Dietetic Nutrition Care Plan sheet (appendix 6) where appropriate.
Ensure patients have access to diet and fluids and assist and encourage patients with diet and
fluids, including the provision of adaptive aids wherever possible.
Work with voluntary sector organisations and community care services to consider how
provision for additional assistance with eating can be given to those who need it, for instance
by using trained volunteers to help at mealtimes.
Oversee the provision of nutritional supplements to patients as directed by the Dietitian and
ensure they are evenly spaced between meals.
Seek and act on feedback from service users on nutritional issues and their experiences of
mealtimes.
Prioritise training for staff in nutritional care and assistance with eating and set aside training
time for staff to complete the NHS core learning module on nutritional care and assistance with
eating and attend training sessions when required.
Review discharge procedures to ensure that whatever accommodation an older person is
returning to (e.g. own home or sheltered housing) appropriate arrangements are in place to
ensure continuity of nutritional care.
Communicate discharge plans with Dietitians in a timely way and ensure (where directed by
the Dietitian) discharged patients have one week‟s supply of nutritional supplements upon
discharge and a nutrition support information discharge pack.
9. Rehabilitation Assistants Responsibilities
Liaise with Dietitian/Nursing Staff/Housekeepers and report on the progress of individual
nutritional care plans.
Implement appropriate nutrition care plans following screening. This could include
implementing a “red tray” system for identified patients (Hungry to be Heard, Age Concern,
2006).
Oversee the Multidisciplinary Action Plan for Patients with Small Appetites (appendix 3) and
Dietetic Nutrition Care Plan sheet (appendix 6) where appropriate.
Ensure patients have access to diet and fluids and assist and encourage patients with diet and
fluids, including the provision of (and assistance with) adaptive aids wherever possible.
Monitor patient‟s nutritional intake and complete food record charts where appropriate
(appendix 5).
Liaise with housekeepers and nursing staff in order to identify suitable patients for adaptive
cutlery and drinking aids and ensure texture and consistency recommendations provided by
Speech and Language Therapists are adhered too.
Provision of nutritional supplements to patients as directed by the Dietitian and ensuring they
are evenly spaced between meals. Documented on the supplement record (appendix 4).
Weigh patients weekly and record this on the record of „MUST‟ nutritional screening and action
taken sheet (appendix 2). Report any concerns to nursing staff.
Seek and act on feedback from service users on nutritional issues and their experiences of
mealtimes.
Page 6 of 31
Ward Rehabilitation Assistants who have undertaken appropriate training will assist to monitor
patients who are at nutritional risk including patients who are referred to the Dietitian using the
report on progress/individualised care plan (appendix 6).
10. Housekeepers Responsibilities
Responsible for serving drinks and snacks to patients at regular intervals (minimum of 7 per
day), providing and encouraging patients with nutritional supplements (as recommended on an
individual patient basis if required).
Refreshing drinking water jugs (at least three times a day) and highlighting any areas of
concern regarding patients‟ fluid intake to nursing staff.
Implementing advice from the nutrition care plans (appendix 3 and 6), following the “red tray”
system for identified patients and ordering meals for patients (encouraging suitable menu
choices).
Preparing the environment for mealtimes, food service and portion size control.
Liaise with rehabilitation assistants and nursing staff in order to identify suitable patients for
adaptive cutlery and drinking aids and ensure texture and consistency recommendations
provided by Speech and Language Therapists are adhered too.
Seek and act on feedback from service users regarding nutrition issues and the mealtime
experience.
11. Discharge of Patients
Continuity of nutritional care should be routinely followed through into discharge planning with
nutritional information included in the discharge communications for those patients identified as
„malnourished‟ (BAPEN, 2008).
A Dietitian will input into a discharge plan and arrange appropriate follow-up when informed of
discharge arrangements (see appendix 7 – Guidelines for Dietetic follow-up of patients discharged
from a Community Hospital).
12. Documentation
All wards will have an up to date copy of the Nutrition Manual provided by the
Dietetic department. It is the ward‟s responsibility to ensure this is accessible and utilised
within the ward.
Nutritional scores, patients‟ height and weights will be recorded on the Record of „MUST‟
Nutritional Screening and Action Taken sheet, including date and signature and repeated
weekly (appendix 2).
Nutritional supplements given will be recorded, timed, dated and signed off on the supplement
intake chart (appendix 4). Quantity drunk will also be documented on this chart.
Food intake will be documented on a food diary where indicated (appendix 5).
Nursing updates regarding food intake will be recorded in the patient records (appendix 6).
Enteral feeds will be documented on the fluid balance chart.
Nutrition action/comments will be recorded on the Report on progress/Individualised care plan
(appendix 6).
Page 7 of 31
13. Training
All staff to have access to NHS Core Learning unit – Food, Nutrition and Hydration in Health and
Social Care E-Learning Training Programme. Nursing staff, rehabilitation assistants and
housekeepers to demonstrate completion of the programme through their professional
development review (overseen by the line manager).
All staff to have access to training on use of the „MUST‟ nutritional screening tool and nursing staff,
rehabilitation assistants and housekeepers to demonstrate completion of annual update on using
the tool through their professional development review. This training is to be provided by Nutricia
personnel and is in association with the Birmingham Community Nutrition and Dietetic Service and
forms part of the contractual agreement for the enteral feeding provision.
Specific nutritional training will be provided by the Birmingham Community Nutrition and Dietetic
Service and via a service level agreement.
Nutritional training at the appropriate level will be undertaken during the Rehabilitation Assistant
course and be part of Housekeeper training. Two Rehabilitation Assistants per ward will undergo
training with the Community Dietetic service and assume the responsibilities of the role of
Rehabilitation Assistant (Nutrition).
All food handlers will undertake statutory training and updates as required by the relevant
legislation (overseen by the line manager).
Management level trained to Advanced Food Hygiene
Supervisory & Chefs trained to Intermediate Level 3
Production Catering Staff trained to Level 1
14. Monitoring
RGN‟s will have overall responsibility for the monitoring of their patients‟
Rehabilitation Assistants will assist nurses to monitor and review patients referred to the
Dietitian and re-refer for review when appropriate (see Dietetic nutrition care plan, appendix
6).
Rehabilitation Assistants will also monitor all ward patients for nutritional problems and
highlight these to nursing staff when they arise.
Monitoring and audit will be via the Divisional Nutritional Steering Group.
Page 8 of 31
15. References
Age Concern (2006). Hungry to be Heard: The Scandal of Malnourished Older People in Hospital.
London. www.ageconcern.org.uk/ageConcern/hungry2bheard.asp
Association of Community Health Councils (1997). „Hungry in Hospital?‟
London: Association of Community Health Councils for England and Wales
British Association for Parenteral and Enteral Nutrition (BAPEN) (2008). Nutrition
Screening Survey in the UK in 2008 – Hospitals, Care Homes and Mental Health Units.
www.bapen.org.uk
Council of Europe Resolution Food and Nutritional Care in Hospitals (2003). 10 Key
Characteristics of Good Nutritional Care in Hospitals. www.npsa.nhs.uk
Department of Health (2008). Estates and Facilities Alert: Patient Weigh Scales.
www.dh.gov.uk
Department of Health (2000). The NHS Plan: A Plan for Investment, a Plan for Reform. London.
www.dh.gov.uk
Department of Health (2001). Better Hospital Food Campaign
Department of Health (2001). Essence of Care –„Patient-focused benchmarks for clinical
governance‟ London, pp 1-12. www.dh.gov.uk
Department of Health (2007). Improving Nutritional Care, London, www.dh.gov.uk
Elia M, et al (2006). On behalf of The British Association for Parenteral and Enteral Nutrition
(BAPEN), „The Cost of Disease-Related Malnutrition in the UK and Economic Considerations
for the Use of Oral Nutritional Supplements (ONS) in Adults‟.
Elia M, et al (2008). On behalf of the Malnutrition Advisory Group (MAG) of The British
Association for Parenteral and Enteral Nutrition (BAPEN) (2008). Combating Malnutrition:
Recommendations for Action. www.bapen.org.uk
Green C J (1999). On behalf of the council of the British Association of Parenteral and Enteral
Nutrition (BAPEN) „Existence, causes and consequences of disease related malnutrition in the
hospital and the community and clinical and financial benefits of nutritional intervention‟
Malnutrition Advisory Group (MAG) of The British Association for Parenteral and
Enteral Nutrition (BAPEN) (2003). The Malnutrition Universal Screening Tool („MUST‟).
www.bapen.org.uk
Malnutrition Advisory Group (MAG) of The British Association for Parenteral and
Enteral Nutrition (BAPEN) (2003). The „MUST‟ Explanatory Booklet: A Guide to the
“Malnutrition Universal Screening Tool („MUST‟)” for Adults. www.bapen.org.uk
McWhirter J P, Pennington C R (1994). „Incidence and recognition of malnutrition in hospital „
BMJ 308:945-948
Page 9 of 31
National Institute for Health and Clinical Excellence (NICE) (2006). Nutrition Support in Adults
– Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition, Clinical Guidance 32.
www.nice.org.uk
Royal College of Nursing (2008). Nutrition Now Campaign, London.
www.rcn.org.uk/nutritionnow
The British Association for Parenteral and Enteral Nutrition (BAPEN) (2003). The „MUST‟
Report: Nutritional Screening of Adults – A Multidisciplinary Responsibility. www.bapen.org.uk
The Hospital Caterers Association (HCA) (2007). National Service Excellence Day: Serving
Excellence, Enhancing Patient Mealtimes. www.hospitalcaterers.org
Water UK (2005). Wise Up On Water!: Hydration and Healthy Ageing. London. www.water.org.uk
Page 10 of 31
Appendix 1
Surname:
Ward:
First Name:
Consultant:
Registration No.:
Date of Birth:
NUTRITION
SCREENING
TOOL and CARE PLAN
Instructions for use:
Every patient should have their weight, height and nutritional risk score measured on
admission. Follow the 5 „MUST‟ steps and refer to the „MUST‟ Explanatory Booklet if
alternative measurements or considerations are required.
Repeat the screening weekly in order to identify any changes.
Record the total score with the date and patient weight on the Record of „MUST‟ Screening and
Action Sheet.
Document the action you have taken or “none” if no action indicated, on the Record of „MUST‟
screening and Action Sheet.
Follow “Multidisciplinary Action Plan for Patients with Small Appetites” and/or “Dietetic Nutrition
Care Plan” after screening, should action need to be taken i.e. a ‟MUST‟ of 1 or more.
„MUST‟ scoring and Weight should be taken weekly and recorded in the table. Variations in
weight should be highlighted to nursing staff and acted on as appropriate.
To refer a patient to the Dietitian:
A referral form should be completed and faxed to the Nutrition and Dietetic Dept,
Springfields Centre 0121 627 8834.
After faxing, the form should be filed in the medical notes for completion by the Dietitian.
Do not send any referrals in the post to Springfields.
The „Malnutrition Universal Screening Tool‟ („MUST‟) is reproduced here with the kind
permission of BAPEN (British Association for Parenteral and Enteral Nutrition).
For further information on „MUST‟ see www.bapen.org.uk
Page 11 of 31
Appendix 2
RECORD OF „MUST‟ NUTRITIONAL SCREENING AND ACTION
TAKEN
Record date, score, weight and what action you have taken (see Action Plan at foot of page 2) in
the table below. Weight change can be plotted on the graph below.
Please use clinical judgement when weighing and nutritionally screening patients and comment in
the section in the below table e.g. fluid disturbances, amputations, plaster casts and action taken.
Patient height ……..m Date…...... Measured/Recalled/Calculated/Other(state method) ……….
DATE:
WEIGHT (kg):
BMI (kg/m2):
Step 1 Score:
Step 2 Score:
Step 3 Score:
Overall
„MUST‟ Score:
ACTION
TAKEN:
Comments:
SIGNATURE:
D Weight increase
a (kg)
t
e
Start Weight
………Kg
Weight decrease
(kg)
kg
+9
+8
+7
+6
+5
+4
+3
+2
+1
-1
-2
-3
-4
-5
-6
-7
-8
-9
Page 12 of 31
DATE:
WEIGHT (kg):
BMI (kg/m2):
Step 1 Score:
Step 2 Score:
Step 3 Score:
Overall
„MUST‟ Score:
ACTION
TAKEN:
Comments:
SIGNATURE:
D Weight increase
a (kg)
t
e
Start Weight
………Kg
Weight decrease
(kg)
Action Plan:
SCORE
0
No Risk
Identified
1
Medium Risk
2 OR MORE
High Risk
kg
+9
+8
+7
+6
+5
+4
+3
+2
+1
-1
-2
-3
-4
-5
-6
-7
-8
-9
ACTION
No action necessary
Repeat screening weekly
Routine clinical care
Observations needed.
Commence “Multidisciplinary Action Plan For Patients With Small Appetites”
Repeat screening and weigh weekly
Refer to Dietitian if patient has complications.
Treatment needed.
Refer to Dietitian
Commence „‟Dietetic Nutrition Care Plan‟‟ with the aim to improve and
increase overall nutritional intake.
Repeat screening and weigh weekly
Page 13 of 31
Appendix 3
MULTIDISCIPLINANRY ACTION PLAN FOR PATIENTS
WITH SMALL APPETITES
INITIAL ACTIONS FOR PATIENTS SCORING 1 ON „MUST‟
1. Always ask your patient why they are not eating well, you may be able to find other ways
of helping e.g., getting appropriate texture menu, cutlery, helping to cut food, getting
dentures reviewed, reassuring patients with memory problems that they do not need to pay
money etc.
If your patient is not eating full meals
regularly and has no other complications*
1. Commence food diary (stop after 3 days
if patient eating well)
2. Order high energy meals – inform
housekeeper
3. Encourage: with meals
milk to drink
small snacks between meals
4. Give Build-Up between meals – write
out supplement chart for housekeeper
5. Weigh weekly
6. Review in one week - see below
*Complications: e.g., dysphagia, pressure sores, uncontrolled diabetes, renal failure,
coeliac disease.
If your patient has a small appetite and
complications*
1. Commence above action (points 1-6)
2. Refer to Dietitian
3. Commence Dietetic Nutrition Care
Plan.
4. Refer to Speech Therapist if swallowing
difficulties identified
5. Consider medical review.
6. Consider pharmacology review
AFTER ONE WEEK
Review food chart, weight and re-screen patient using „MUST‟ assessment.
If no improvement in intake and/or patient at
high risk („MUST‟) score
If intake improving and patient at
low/medium risk („MUST‟) score
1. Continue above action
2. Refer to the Dietitian
3. Commence Dietetic Nutrition Care Plan.
1. Continue above until appetite fully
returned
Page 14 of 31
SUPPLEMENT CHART
NAME OF PATIENT:
DATE
SUPPLEMENT TYPE
WARD:
RECOMMENDED DAILY
AMOUNT/TIMES
Appendix 4
DATE SUPPLEMENT COMMENCED:
ALL
QUANTITY CONSUMED
>1/2 <1/2
NONE (give reason)
Review Supplement Use Weekly/Before Starting Continuation Sheet:
SIGNATURE
Document on “Report on Progress” Sheet.
Page 15 of 31
NOTES ON USING FOOD RECORD CHART
Appendix 5
Food diaries help Dietitians to calculate a patient‟s nutrient intake and establish what level of
dietetic intervention they require. They are also helpful for all staff involved with a patient to obtain
a clear picture of a patient‟s actual food intake where there are concerns.
When completing the diary please ensure the following is done:
Complete dietary intake as accurately as possible for 3 days.
Complete fluid intake as accurately as possible for 3 days using a fluid balance chart.
Indicate the level of assistance required for feeding the patient, e.g. Full assistance/Cutting
up food/Prompting and encouragement/Independent.
State the required texture of diet as indicated by Speech and Language Therapist, e.g.
texture A-E.
Where nutritional supplements have been prescribed, please state what has been
prescribed and what has been consumed.
Complete the food diary by entering the relevant code to indicate how much of a meal has
been eaten and mark with the appropriate colour code.
Add any item of food consumed which is not on the list to the „other‟ section including as
much detail as possible.
File charts in the patient‟s medical notes once completed.
Refer to Multidisciplinary Action Plan For Patients With Small Appetites for more
information
For each meal recorded, the member of staff who has recorded the food taken should sign
in the appropriate box
Please use food record continuation sheets if further records needed.
Please record food intake using the relevant codes and highlight/mark with colour coding as
shown.
Community Dietitian…………………………………………………………………...
Tel: 0121 627 1627 Ext 51484
Fax: 0121 627 8834 (Internal 53443)
Page 16 of 31
FOOD RECORD CHART
Name ……………………………………..
Ward ………………………………………
Diet texture ……………………………...
Level of assistance ……………………...
Supplements prescribed ..…………………………
Date:
Date:
A
¾
½
¼
M
R
All of standard portion
¾ of standard portion
½ of standard portion
¼ of standard portion
Eaten minimal amount
Refused
Date:
BREAKFAST
Cereal/porridge
Cooked breakfast
Toast and butter
Other (please
specify)
Sign:
MID-MORNING
Snack (please
specify)
Supplement
Sign:
LUNCH
Main course
Sandwich
Soup
Pudding
Custard
Ice cream/mousse
Other( please
specify)
Sign:
MID-AFTERNOON
Snack (please
specify)
Supplement
Sign:
EVENING MEAL
Main course
Sandwich
Soup
Pudding
Custard
Ice cream/mousse
Sign:
Other(please
specify)
Page 17 of 31
Appendix 6
DIETETIC NUTRITION CARE PLAN
Action for patients scoring 2 or above on „MUST‟
Name: _________________________________________
Date
DATE: ______________
Implement Small Appetite Action:
1. Order and encourage high energy meal options
2. Encourage: - Milk to drink if liked
- Small snacks between meals
- Supper snack
Record on food record chart where needed
3. Give Build Up between meals or supplements if specified by Dietitian in
plan below.
Record on supplement chart
4. Weigh patient weekly
Record on „MUST‟ Nutritional Screening and Action Taken Sheet
5. Commence food diary / continue if directed by Dietitian
Problems
Date of dietetic assessment……………
1. Dysphagia
5. Pressure sores
2. Poor appetite
6. Wound healing (please specify)
3. Weight loss
7. Other (please specify)……………………….…..
4. Special diet (please specify)
Aim of Dietetic Intervention
1. Increase Weight
2a. Prevent Weight Loss
2b. Prevent Significant Weight
Loss
3. Reduce Weight
4. Improve Nutritional Intake
5. Facilitate Provision of
……………………………….………………. Diet
6 Educate Patient / Carer re:
…………………………………………………Diet
7 Provide Suitable Tube Feeding Regime
to…………………….. ……………….…
8 Other………………………………………….…..
Action Plan to Fulfill Aims
1.
4.
2.
5.
3.
6.
Review by Dietitian
at request of ward
Report on progress over page
other………………………………..
Community Dietitian _______________________________________Tel: 0121 627 1627 Ext. 51484
Page 18 of 31
REPORT ON PROGRESS/ INDIVIDUALISED CARE PLAN
To be completed by members of the multidisciplinary team as part of the monitoring process.
Date
Review of Action Points (document action)
Name/signature
Criteria for requesting review by Dietitian:
Weight change in opposite direction to aim of treatment
Refusal/dislike of prescribed supplements
Change in dietary intake
Significant change in clinical condition
Discharge date arranged
Prior to Discharge:
Review supplement use and current appetite
Review MUST score
Give patient a “nutrition support discharge pack” if „MUST‟ score is 1 or above
Request a review by the Dietitian and inform Dietitian of discharge plans if patient is likely to
need Dietetic support in the community.
If patient has been discharged by the Dietitian during admission but is likely to need support in
the community, please re-refer patient to the Dietitian prior to discharge.
Page 19 of 31
Appendix 7
Guidelines for the Dietetic Follow-Up of patients
Discharged from a Community Hospital
Patients who are identified as at risk of malnutrition („MUST‟ score of one or
above) will be given a nutrition support information discharge pack by ward staff
on discharge from the Community Hospital, this will include healthy eating and
food fortification dietary advice leaflets.
Dietetic follow-up of patients requiring dietetic treatment on discharge from a
community hospital may be achieved in various ways.
By means of:
1.
Phone call to patient/carer/nursing home/health professional
2.
Follow up appointment at ATS clinic
3.
Domiciliary visit
The above methods will be used in conjunction with a clinical letter or standard
information letter to the patient‟s GP and/or other relevant health professionals.
For the majority of patients requiring follow -up this will involve 1 contact per
discharge. However, some patients will require further follow-up until their
nutritional condition is stable. Patients falling into this latter category will include
patients being enterally fed in their own homes, patients who were admitted in a
severely malnourished state, have pressure sores, or wounds requiring
continued and changing nutritional support.
Patients Who Will NOT Receive Dietetic Follow-Up
Patients requiring special diets admitted to community hospitals for other medical
reasons unaffecting their usual dietetic management.
Patients receiving nutritional support while on a ward but by the time of discharge
have improved sufficiently not to require prescribed nutritional support on
discharge.
Patients Who May Need to Receive Dietetic Follow-Up After Hospital
Discharge
1.
2.
3.
4.
Patients with newly diagnosed conditions requiring dietetic treatment, e.g.
newly diagnosed diabetes mellitus.
Patients requiring prescribed nutritional support to continue after hospital
discharge.
Patients discharged on diets where food needs to be of an altered
consistency.
Patients requiring to be fed via a nasogastric or PEG tube.
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Appendix 8
Texture Modification – Fluid
Texture
Description of Fluid
Texture
Appendix 9
Fluid Example
Thin Fluid
Still Water
Water, tea, coffee without milk, diluted
squash, spirits, wine.
Naturally Thick
Fluid
Product leaves a
coating on an empty
glass.
Full cream milk, cream liqueurs,
Complan, Build Up (made to
instructions), Nutriment, commercial
sip feeds.
Thickened Fluid
Fluid to which a commercial thickener has been added to
thicken consistency.
Stage 1 =
(Single cream
consistency)
• Can be drunk
through a straw.
• Can be drunk from
a cup if advised or
preferred.
• Leaves a thin coat
on the back of a
spoon.
Stage 2 =
(Double cream
consistency)
• Cannot be drunk
through a straw.
• Can be drunk from
a cup.
• Leaves a thick coat
on the back of a
spoon.
Stage 3 =
(Very thick
custard
consistency)
• Cannot be drunk
through a straw.
• Cannot be drunk
from a cup.
• Needs to be taken
with a spoon.
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Texture Modification – Food
TEXTURES C – E used in community hospitals
Texture
Description of Food Texture
Food Examples
A
• A smooth, pouring, uniform consistency.
• A food that has been pureed and sieved to
remove particles.
• A thickener may be added to maintain stability.
• Cannot be eaten with a fork.
• Tinned tomato
soup
• Thin custard
• A smooth, uniform consistency.
• A food that has been pureed and sieved to
remove particles.
• A thickener may be added to maintain stability.
• Cannot be eaten with a fork.
• Drops rather than pours from a spoon but cannot
be piped and layered.
• Thicker than A.
• Soft whipped
cream
• Thick custard
• A thick, smooth, uniform consistency.
• A food that has been pureed and sieved to
remove particles.
• A thickener may be added to maintain stability.
• Mousse
• Smooth fromage
frais
B
C
• Can be eaten with a fork or spoon.
• Will hold its own shape on a plate, and can be
moulded, layered and piped.
• No chewing required.
D
• Food that is moist, with some variation in texture.
• Has not been pureed or Sieved.
• These foods may be served or coated with a
thick gravy or sauce.
• Foods easily mashed with a fork.
• Meat should be prepared as C.
• Requires very little chewing.
• Flaked fish in
thick sauce
• Stewed apple and
thick custard
E
• Dishes consisting of soft, moist food.
• Foods can be broken into pieces with a fork.
• Dishes can be made up of solids and
thick sauces or gravies.
• Avoid foods which cause a choking hazard (see list
of High Risk Foods).
• Tender meat
casseroles
(approx 1.5cm
diced pieces)
• Sponge and
custard
Any foods.
Include all foods
from “High Risk
Foods” list.
Normal
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High Risk Foods
Stringy, fibrous texture e.g. pineapple, runner beans, celery, lettuce.
Vegetable and fruit skins including beans e.g. broad, baked, soya, black eye peas,
grapes.
Mixed consistency foods e.g. cereals which do not blend with milk, e.g.
muesli, mince with thin gravy, soup with lumps.
Crunchy foods e.g. toast, flaky pastry, dry biscuits, crisps.
Crumbly items, e.g. bread crusts, pie crusts, crumble, dry biscuits.
Hard foods, e.g. boiled and chewy sweets and toffees, nuts and seeds.
Husks, e.g. sweetcorn and granary bread.
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Appendix 9
The „Malnutrition Universal Screening Tool‟ („MUST‟) is reproduced here with the kind permission of
BAPEN (British Association for Parenteral and Enteral Nutrition).
For further information on „MUST‟ see www.bapen.org.uk
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Appendix 10
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