Identification and treatment of undernutrition in care homes

Transcription

1 Distance learning workbook Identification and treatment of undernutrition in care homes Developed January Focus on Undernutrition is part of the Nutrition and Dietetics Service in County Durham and Darlington

2 Introduction Do you think any of your residents are at risk of undernutrition? Up to 35% of elderly residents are at risk of undernutrition (Elia and Russell, 2008). Every elderly care home is likely to have residents who are undernourished. This is not a reflection of poor working practices, more so that older people are simply at greater risk of undernutrition. What is essential therefore is that care staff can identify those at risk of undernutrition and give them appropriate and timely treatment before they become undernourished. This workbook has been developed as a distance learning workbook to support the Focus on Undernutrition (FoU) training programme within elderly care homes. The training is designed to support your care home identify who is at risk of losing weight and becoming undernourished. The FoU training encompasses both attendance at a FoU workshop and successful completion of this workbook by the agreed submission date. You have been allocated one month to complete the workbook, following which you should return it to your home manager by the submission date on page 2. Failure to complete and return your workbook will result in the home being invoiced. The workbook is divided into modules, of which there are eight. The modules include: the nutritional needs of older people, monitoring food intakes, what is undernutrition, how to identify undernutrition, developing nutritional care plans and treatment for undernutrition, including oral nutritional supplements. Each module contains activities and at the end of the workbook are assessments. The workbook will also act as a useful reference tool after the training. The activity based nature of the workbook will enable it to be used as evidence for your continuing professional development. Informed consent is required to complete the case study in the workbook. Any evidence of plagiarism (copying) will result in an automatic referral (non pass). The university will request staff to resubmit their workbook. The care home will be invoiced for the cost of the second workbook. Further information about obtaining informed consent and plagiarism can be found on the Teesside University CD and on blackboard ( FoU is part of the nutrition and dietetic services in County Durham and Darlington. The FoU service provides training to health and social care professionals on the identification and treatment of undernutrition. The aim of the FoU service is to ensure the timely detection and treatment of undernutrition; and the appropriate use of nutritional supplements This training has been accredited by Teesside University as a 10 credit certificate, level 4 module. To be awarded the accreditation you must attend a FoU workshop and submit and pass the workbook by the submission date. Further reading associated with this module can be found in the Focus on Undernutrition resource file in the care home, or on For further information on FoU contact , info@focusonundernutrition.co.uk or visit 3

3 Contents Module Page Module 1 Factors that influence eating in older people 7 Module 2 The nutritional needs of older people in care homes 13 Module 3 Undernutrition how does it affect older people in care homes? 21 Module 4 The identification and monitoring of undernutrition in care homes 31 Module 5 The prevention and treatment of undernutrition in care homes 49 Module 6 Nutritional supplements 67 Module 7 Referral to the dietitian 75 Module 8 Assessments 77 Appendices References/further reading and assessment feedback 89 5

4 Module 1 Factors that influence eating in older people

5 We all need to eat; some of us live to eat while many of us eat to live Some people just live to eat ; they love talking about food, enjoy preparing food and love to eat lots of different foods and drinks. Are you this type of person? Some older people in care homes find meal times the highlight of their day. Other people just eat to live ; food keeps them alive, but they find little enjoyment in eating meals and may even find it a chore. A good diet is essential to help minimise health problems Residents regard the food they are given as one of the most important factors in determining their quality of life Food and eating bring shape to the day and facilitates interaction as well as providing essential nutrients Good nutrition is necessary for our bodies to function to provide energy for physical activity for tissue repair and renewal What we eat can influence our health regardless of what age we are. However, food and mealtimes also provide social interaction and structure to the day. 8

6 Module 2 The nutritional needs of older people in care homes

7 Module 3 What is undernutrition - How does it affect older people in care homes

8 Failure of a care home to provide evidence for nutritional screening, care planning, treatment of undernutrition and staff training records may influence the funding the home receives The quality standard and resident agreement states the provider shall: ensure that all service users are nutritionally screened on admission and on a basis of need to identify service users who are at risk of undernutrition. produce an individualised care plan and risk assessment, which is implemented, reviewed and updated on a monthly basis (as minimum). undertake monthly reviews of nutritional status and weight. use documentation to record and report intake. ensure that all care and catering staff are made aware of service users nutritional needs. have in place a policy and procedure in relation to unexplained weight loss, to include the immediate involvement of other health care professionals. use real food to treat under nutrition following advice from the dietitian. ensure that catering staff are trained in nutritional needs. ensure that care staff are trained in nutritional screening and monitoring. 29

9 Module 4 The identification and monitoring of undernutrition in care homes

10 Module 5 The prevention and treatment of undernutrition in care homes

11 The prevention and treatment of undernutrition in the community 4.1 Dietary prevention of undernutrition The prevention and treatment of undernutrition for older people living in care homes should be initially treated from a food first perspective. Every mouthful counts when a resident s appetite is poor. It is therefore very important to recommend food and drinks that are packed full of nourishment. This means that even though someone may only eat small portion sizes, they may still be able to meet their nutritional requirements and prevent weight loss. It is important that an appropriate diet is given and this can be achieved by providing: 1. Nourishing snacks 2. Nourishing drinks 3. High protein high calorie diet (fortified diet) 4. Homemade fortified drinks Dietary interventions for undernutrition The interventions required will differ slightly depending upon the resident s risk of undernutrition, which will be worked out using MUST. The following dietary interventions are recommended for the various risk categories. Risk category High Moderate Low Criteria 2 or more 1 0 ACTION POINTS to include in a nutrition care plan 1. Provide 2 homemade fortified drinks/day 2. Provide a fortified diet 3. Provide 2 nourishing snacks a day in-between meals 4. Provide a general multivitamin and mineral tablet daily 5. Complete food charts for four days, then review 6. Weigh weekly. Re-screen monthly After one month if still high risk and losing weight, refer the resident to the GP for an assessment of Complan Shake 1. Provide a fortified diet 2. Provide 2 nourishing snacks a day in-between meals 3. Provide nourishing drinks during the day 4. Provide a general multivitamin and mineral tablet daily 5. Complete food charts for four days, then review 6. Weigh weekly. Re-screen monthly No action necessary. Re-screen monthly. Refer to the Focus on Undernutrition resource file and information leaflets for further information. 52

12 Module 6 Nutritional supplements

13 Nutritional supplements The role of nutritional supplements Sometimes despite best efforts, some residents will not be able to meet their nutritional requirements from food alone and nutritional supplements may need to be considered. Prescribed nutritional supplements have a valuable role in the management of undernutrition when used properly. However, before any prescription is offered an assessment should be made to determine their level of risk of undernutrition using MUST. Nutritional supplements should only be considered for residents who are still high risk after one month and lost weight. Residents taking nutritional supplements should be monitored monthly. This should include weight, risk of undernutrition, if they are taking them and dietary intake. To ensure a consistent approach to the use of nutritional supplements in the community a care pathway has been developed. This care pathway can be found on the next page. When do you think it might be necessary to suggest nutritional supplements? 68

14 Module 7 Referral to a dietitian

15 Module 8 Assessment

16 Obtaining informed consent Rationale As part of the assessment process students are sometimes required to illustrate the relationship between theory and practice by using information relating to specific clients, e.g. care studies, care plans, assessments, projects and reflective pieces. In these circumstances obtaining informed consent is essential. In order to demonstrate compliance with statutory/professional codes of conduct the obtaining informed consent declaration form (page 79) must be completed and submitted with the work. Failure to obtain consent and complete the declaration form will result in automatic referral/ failure and could lead to disciplinary action. A slide show relating to confidentiality and informed consent can be accessed via Blackboard ( or the Teesside University CD. The Focus on Undernutrition lecturer supervising a piece of work for which consent is required is responsible for: directing the student to the Blackboard site where they can access a copy of the obtaining informed consent declaration form and guidance notes prior to the assessment. drawing the student s attention to the Access to Health Records Act (1990), in particular: section 5.3, which states that third parties may only access patients, records provided that information given by the patient and/or the results of examinations/investigations will not be disclosed. section 5.1 which states that the information obtained from the patients health records must not be used in a way as to cause the patient serious physical or mental harm, or that the patient may be identified. drawing the student s attention to the Data Protection Act (1998) in particular: reviewing the rationale and each point set out in the obtaining informed consent declaration form. reminding the student that the completed declaration form must accompany the assignment when submitted. The student is responsible for: informing the practice mentor/supervisor of the nature of the assignment and the requirement to complete an obtaining informed consent declaration form. seeking informed consent from the patient/client and/or patient/client representative and/or carers, and/or colleagues/staff in accordance with the declaration form. completing and signing the declaration form with the practice mentor/supervisor. ensuring the completed declaration form is submitted with the assignment by the required date. ensuring that a pseudonym is used for client/patients, relatives, carers and staff the use of the pseudonym should be documented within the assignment and clearly identified on the informed consent and declaration form. 78

17 ensuring that any documentation submitted as part of the assessment will be rewritten and not photocopied e.g. care plans, assessment forms. The practice mentor/supervisor (such as home manager) is responsible for: providing the student with appropriate support and guidance whilst obtaining informed consent from the patient/client and/or patient/client representative and/or colleagues/staff. signing the obtained informed consent declaration form, if s/he is confident that the criteria have been met. Obtaining Informed Consent Declaration Form Declaration by student In order to comply with the requirements of the Access to Health Records Act (1990) and the Data Protection Act (1998), I confirm I have discussed the following with the patient/client* and/or the patient s/client s* representative, e.g. parent/guardian, next of kin, carers, colleagues/staff and have obtained permission to use personal relevant data; The nature of the assessment. The reason I wish to use data relating to the patient/client. That client/patient, carers, colleagues/staff anonymity and confidentiality in relation to any material gathered or produced in the course of this work will be maintained: for all persons mentioned pseudonyms and/or general titles will be used, not individual names. information which may identify the patient/client/relatives/carer and colleagues/staff will be omitted from documentation e.g. care plans, pathways of care, risk assessments etc. Those who will have access to the work in addition to myself e.g. typist, teaching staff, other students, Board of Examiners. Failure to complete all sections of the table will result in automatic referral Resident Resident A (do not write the resident s name) Module title FoU lecturer name Practice mentor name Practice mentor signature Student signature Date 79

18 Appendices References, further reading and Assessment feedback

19 Assessment Feedback To be completed by the Focus on Undernutrition assessor Activity number Activity Page Marking options 1. Recording dietary intake 9 2. Factors influencing food choices Consequences of a poor appetite Balanced menu planning Causes of undernutrition Problems of undernutrition Medical conditions and impact on dietary intake Case study: Mrs Smith part 1 MUST Case study: Mr Singh MUST Weight monitoring Height measuring Ulna height conversions Measuring ulna Reflection on ulna MUAC and BMI Case study on MUAC and MUST Factors influencing dietary intake Reflection on portion sizes Menu planning and food enrichment Special diets and food enrichment Case study: Mrs Smith part 2 care planning Clients suitable for nutritional supplements Taste comparison of a fortified drink and an oral nutritional supplement Case study: Mrs Smith part 3 care planning Case study: Mrs Smith part 4 care planning Assessment 1: Case study Assessment 2: Reflection in implementation Assessment 3: Personal development plan 4,86,87 92

20 Overall marking Mark Awarded accreditation Refer Fail Comments Your unratified feedback can be accessed on the student intranet at You will receive your unratified feedback approximately six weeks after you have submitted your workbook. Details of assessor Name Job Role Signed Date After the university assessment board, you will be informed via e-vision of your ratified results. (E-Vision: You will receive a certificate from Teesside University once your result has been ratified by the University assessment board. To access both the student intranet and e-vision you will require a student user name and a password, which will be provided to you by the university following your university registration. 93