Distance learning workbook Identification and treatment · PDF fileDistance learning workbook...

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.

LP42335 FoU Distance Learning Workbook (CDDFT)_Layout 1 02/02/2012 09:25 Page 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


Factors thatinfluence

eating in olderpeopleM

od

ule

1



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


The nutritionalneeds of olderpeople in care

homesMo

du

le 2


What isundernutrition -

How does it affectolder people

in care homes

Mo

du

le 3



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.


The identificationand monitoring of

undernutrition in care homes M

od

ule

4


The preventionand treatment ofundernutrition in

care homes Mo

du

le 5



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


Nutritionalsupplements

Mo

du

le 6



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?


Referral to adietitian

Mo

du

le 7


Assessment

Mo

du

le 8



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.



■ 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


References,further reading

and Assessmentfeedback A

pp

end

ices



Assessment Feedback

To be completed by the Focus on Undernutrition assessor

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

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



Assessment 1: Case study

Assessment 2: Reflection in implementation

Assessment 3: Personal development plan

9

10

11

17

23

24

26

39

40

41

41

42

43

43

44

46

50

54

58

61

65

68

73

74

74

80-82

83-85

4,86,87

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Fail pass

Activitynumber Activity Page Marking

options



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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