Distance learning workbook
Identification and treatment of undernutrition in care homes
Developed January 2012
www.focusonundernutrition.co.uk
Focus on Undernutrition is part of the Nutrition and Dietetics Service inCounty Durham and Darlington
Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
3Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Introduction
Do you think any of your residents are at risk of undernutrition? Up to 35% of elderly residentsare at risk of undernutrition (Elia and Russell, 2008). Every elderly care home is likely to haveresidents who are undernourished. This is not a reflection of poor working practices, more sothat older people are simply at greater risk of undernutrition. What is essential therefore is thatcare staff can identify those “at risk” of undernutrition and give them appropriate and timelytreatment before they become undernourished.
This workbook has been developed as a distance learning workbook to support the Focus onUndernutrition (FoU) training programme within elderly care homes. The training is designed tosupport 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 completionof this workbook by the agreed submission date. You have been allocated one month tocomplete the workbook, following which you should return it to your home manager by thesubmission date on page 2. Failure to complete and return your workbook will result in thehome being invoiced.
The workbook is divided into modules, of which there are eight. The modules include: thenutritional needs of older people, monitoring food intakes, what is undernutrition, how toidentify undernutrition, developing nutritional care plans and treatment for undernutrition,including oral nutritional supplements. Each module contains activities and at the end of theworkbook are assessments. The workbook will also act as a useful reference tool after thetraining. The activity based nature of the workbook will enable it to be used as evidence foryour continuing professional development.
Informed consent is required to complete the case study in the workbook. Any evidence ofplagiarism (copying) will result in an automatic referral (non pass). The university will requeststaff to resubmit their workbook. The care home will be invoiced for the cost of the secondworkbook. Further information about obtaining informed consent and plagiarism can be foundon the Teesside University CD and on blackboard (http://eat.tees.ac.uk).
FoU is part of the nutrition and dietetic services in County Durham and Darlington. The FoUservice provides training to health and social care professionals on the identification andtreatment of undernutrition. The aim of the FoU service is to ensure the timely detection andtreatment 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 theworkbook by the submission date.
Further reading associated with this module can be found in the Focus on Undernutritionresource file in the care home, www.focusonundernutrition.co.ukor on http://eat.tees.ac.uk
For further information on FoU contact 01388 452330, [email protected] or visit www.focusonundernutrition.co.uk.
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5Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
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
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Factors thatinfluence
eating in olderpeopleM
od
ule
1
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8Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Some people just “live to eat”; they love talking about food, enjoy preparing food and love toeat lots of different foods and drinks. Are you this type of person? Some older people in carehomes find meal times the highlight of their day.
Other people just “eat to live”; food keeps them alive, but they find little enjoyment in eatingmeals and may even find it a chore.
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 andmealtimes also provide social interaction and structure to the day.
We all need to eat;some of us live toeat while manyof us eat to live
Residents regard thefood they are given as
one of the mostimportant factors in
determining theirquality of life
A good diet isessential to helpminimise health
problems
Food and eating bringshape to the day andfacilitates interactionas well as providingessential nutrients
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The nutritionalneeds of olderpeople in care
homesMo
du
le 2
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What isundernutrition -
How does it affectolder people
in care homes
Mo
du
le 3
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29Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Failure of a care home to provide evidence for nutritional screening, care planning, treatment ofundernutrition 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 toidentify service users who are at risk of undernutrition.
■ produce an individualised care plan and risk assessment, which is implemented, reviewed andupdated 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 theimmediate 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.
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The identificationand monitoring of
undernutrition in care homes M
od
ule
4
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The preventionand treatment ofundernutrition in
care homes Mo
du
le 5
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52Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
The prevention and treatment of undernutrition in thecommunity
4.1 Dietary prevention of undernutrition
The prevention and treatment of undernutrition for older people living in care homes should beinitially treated from a food first perspective.
Every mouthful counts when a resident’s appetite is poor. It is therefore very important torecommend food and drinks that are packed full of nourishment. This means that even thoughsomeone may only eat small portion sizes, they may still be able to meet their nutritionalrequirements and prevent weight loss.
It is important that an appropriate diet is given and this can be achieved by providing:
1. Nourishing snacks2. Nourishing drinks3. 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 ofundernutrition, which will be worked out using ‘MUST’. The following dietary interventions arerecommended for the various risk categories.
Refer to the Focus on Undernutrition resource file and information leaflets for further information.
Risk category
Criteria ACTION POINTS to include in a nutrition care plan
1. Provide 2 homemade fortified drinks/day 2. Provide a fortified diet3. Provide 2 nourishing snacks a day in-between meals 4. Provide a general multivitamin and mineral tablet daily5. Complete food charts for four days, then review6. Weigh weekly. Re-screen monthly
After one month if still high risk and losing weight, refer theresident to the GP for an assessment of Complan Shake
1. Provide a fortified diet 2. Provide 2 nourishing snacks a day in-between meals3. Provide nourishing drinks during the day4. Provide a general multivitamin and mineral tablet daily5. Complete food charts for four days, then review6. Weigh weekly. Re-screen monthly
No action necessary. Re-screen monthly.
High
Moderate
Low
2 ormore
1
0
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Nutritionalsupplements
Mo
du
le 6
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68Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Nutritional supplements
The role of nutritional supplements
Sometimes despite best efforts, some residents will not be able to meet their nutritionalrequirements from food alone and nutritional supplements may need to be considered.
Prescribed nutritional supplements have a valuable role in the management of undernutritionwhen used properly. However, before any prescription is offered an assessment should be madeto determine their level of risk of undernutrition using ‘MUST’.
Nutritional supplements should only be considered for residents who are still high risk afterone month and lost weight. Residents taking nutritional supplements should be monitoredmonthly. This should include weight, risk of undernutrition, if they are taking them and dietaryintake.
To ensure a consistent approach to the use of nutritional supplements in the community a carepathway 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?
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Referral to adietitian
Mo
du
le 7
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Assessment
Mo
du
le 8
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78Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Obtaining informed consent
Rationale
As part of the assessment process students are sometimes required to illustrate the relationshipbetween theory and practice by using information relating to specific clients, e.g. care studies,care plans, assessments, projects and reflective pieces. In these circumstances obtaininginformed consent is essential. In order to demonstrate compliance with statutory/professionalcodes of conduct the obtaining informed consent declaration form (page 79) must be completedand submitted with the work. Failure to obtain consent and complete the declaration form willresult in automatic referral/ failure and could lead to disciplinary action.
A slide show relating to confidentiality and informed consent can be accessed via Blackboard(http://eat.tees.ac.uk/) or the Teesside University CD.
The Focus on Undernutrition lecturer supervising a piece of work for which consent isrequired is responsible for:
■ directing the student to the Blackboard site where they can access a copy of the obtaininginformed 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 thatinformation given by the patient and/or the results of examinations/investigations will notbe disclosed.
– section 5.1 which states that the information obtained from the patients’ health recordsmust not be used in a way as to cause the patient serious physical or mental harm, or thatthe 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 consentdeclaration form.
– reminding the student that the completed declaration form must accompany theassignment when submitted.
The student is responsible for:
■ informing the practice mentor/supervisor of the nature of the assignment and therequirement to complete an obtaining informed consent declaration form.
■ seeking informed consent from the patient/client and/or patient/client representative and/orcarers, 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 theinformed consent and declaration form.
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79Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
■ ensuring that any documentation submitted as part of the assessment will be rewritten andnot 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 informedconsent 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 criteriahave 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 theData 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 anymaterial 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 individualnames.
– information which may identify the patient/client/relatives/carer and colleagues/staff will beomitted 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, otherstudents, 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
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References,further reading
and Assessmentfeedback A
pp
end
ices
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92Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Assessment Feedback
To be completed by the Focus on Undernutrition assessor
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Recording dietary intake
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
9
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58
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68
73
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80-82
83-85
4,86,87
Fail pass
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Fail pass
Fail pass
Fail pass
Activitynumber Activity Page Marking
options
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93Copyright © 2011 Darlington Primary Care Trust. Developed by Rachael Masters of Darlington Primary Care Trust
Details of assessor
Name
Job Role
Signed
Date
Overall marking
Mark
Awarded accreditation
Refer
Fail
Comments
After the university assessment board, you will be informed via e-vision of your ratified results.(E-Vision: http://e-vision.tees.ac.uk). You will receive a certificate from Teesside Universityonce 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 apassword, which will be provided to you by the university following your university registration.
Your unratified feedback can be accessed on the student intranet athttp://healthbase.tees.ac.uk/studnet/login. You will receive your unratified feedbackapproximately six weeks after you have submitted your workbook.
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