Hydration - Sutton CCG 5.0 Supporting nutrition and hydration in residents with dysphagia 14 6.0...

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  • Version 1.0 - 10 November 2017 (Review date 2019)




    Information and Guidance for Nursing and Residential Care Homes

    Incorporating National Evidence-Based Guidelines

  • 2

    Introduction to using this resource folder

    This folder contains comprehensive information about the assessment, monitoring and

    maintenance of nutrition and hydration for care home residents. For many residents,

    maintaining adequate levels of nutrition and hydration can be a challenge, however both are

    essential for health and wellbeing. This folder contains information, advice and plenty of ‘top

    tips’ to ensure your residents remain well-nourished and well hydrated. You may want to

    print some of the appendices to make them easily available to all staff.

    This resource folder has been developed by the Sutton Homes of Care Vanguard in

    partnership with The Royal Marsden Hospital Community Services and Sutton Clinical

    Commissioning Group. The contents of this folder represent best practice in this area of

    care; however, the safe and effective management of residents’ needs remains the legal

    responsibility of the care home.

    Contents Page 1.0 Hydration

     Why is it important to stay hydrated?

     How much fluid is recommended?

     How do I know if my residents drink enough?

     What may happen if my resident doesn’t drink enough?

     How do I help my residents to drink more?

     What can I do if my resident is still not drinking enough?

    3 3 3 4 5 5

    2.0 Nutrition

     Why is nutrition important?

     What is a healthy balanced diet?

    6 6

    3.0 Malnutrition

     What is malnutrition?

     How do I know if my resident is malnourished (or at risk)?

     Interpreting the MUST score- what to do next

     How to write a care plan for nutrition

     How do I help my residents to eat more?

     What can I do if my resident is still not eating enough?

    7 9 9 10 11 12

    4.0 Supporting nutrition and hydration in residents with dementia 13 5.0 Supporting nutrition and hydration in residents with dysphagia 14 6.0 Supporting nutrition and hydration in residents approaching end of life 16 7.0 Oral and dental health 17 8.0 Residents transferring between care settings 18 9.0 How to utilise the NICE quality standards for nutrition 18 References 20 Acknowledgements 20

    Appendices Page A Example food and drink record charts (5 pages) 21 B Reference card- Preventing and Managing UTIs 26 C MUST tool (6 pages) 27 D Basic food fortification 33 E Replacing oral nutritional supplements with nourishing drinks 35 F Using finger foods 38 G Using snacks 39 H Dysphagia diet food texture descriptors (6 pages) 40 I Audit tool using NICE quality standards 46

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    1.0 Hydration

    Why is it important to stay hydrated?

    Water is necessary for life. As adults over half of our body is water!

    Water has lots of different functions in the body. It is an essential component of blood and so

    helps to transport nutrients around the body, it forms urine and so help to remove waste

    products and it also acts as a lubricant and helps to absorb shocks in joints.

    Older people can often be at risk of poor fluid intake and dehydration. This could be due to

    limited mobility so they do not have access to drinks, or it could be due to cognitive decline

    whereby they forget to drink. Thirst is an indication of dehydration, however older people

    may also have reduced thirst sensation (feeling a need to drink) and it is important to

    regularly remind, prompt and encourage residents’ to drink, providing assistance where

    needed. Fluid intake does not necessarily mean just water and can also include hot drinks

    such as tea and coffee, fruit juice or squash

    If a person is unwell, has diarrhoea and/or vomiting, they will be losing fluid from the body

    and therefore will need to drink more to replace what has been lost.

    When the weather is hot (or the central heating is on high), the body sweats more and

    similarly, fluid is lost from the body and needs to be replaced.

    Dehydration can result in drowsiness and confusion, in addition to having an impact on risk

    of falls, constipation and skin integrity so it is important to keep hydrated throughout the day.

    How much fluid is recommended?

    It is recommended for adults to have around 1.6l (for women) and around 2l (for men) daily.

    This is equivalent to around 3-4 pints or 8 -10 cups or glasses. This does not have to be

    pure water; tea, coffee, milk and fruit juices all count as well. Fluid is also available in foods

    such as soup or ice cream and fruits like melon.

    For some residents with specific health conditions such as kidney failure or heart failure,

    their doctor may have recommended a fluid restriction. This will be the maximum amount of

    fluid the person should consume in 24 hours. Any resident who is on a fluid restriction must

    have their intake monitored using a fluid chart and the GP must be consulted if you have any

    concerns regarding their hydration.

    How do I know if my residents drink enough?

    Monitor their fluid intake

    It is important to monitor how much your residents’ are drinking and encourage them to

    reach the targets above. For some residents, particularly those who cannot tell you how

    much they have drunk, it may be an idea to complete a fluid chart to monitor their intake and

    an example fluid chart can be found in Appendix A. It is important to know how much fluid

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    the cup, glass or beaker contains so you can estimate the quantity taken more accurately.

    Please be aware that for some residents such as those with urinary catheters or kidney

    failure, it may be necessary to record how much urine they are passing (urine output). In this

    situation you will need a different fluid chart that records how much the person is drinking, in

    addition to how much urine they are passing.

    Monitor the colour of urine

    If your resident is well hydrated, urine should be a pale yellow colour. If it is dark yellow or

    brown, the resident is not drinking enough. Use the colour chart below as a guide (see

    Appendix B) and remember, “Healthy pee is 1-3, 4-8 you must hydrate!”

    Observe for other signs

    There are physical signs that indicate a person is dehydrated, these include wrinkled or

    cracked lips, dry skin, dry mucous membranes like the tongue and lining of the mouth, new

    or increased confusion, tiredness, loss of balance and falls. The person will also have low

    blood pressure and a faster heart rate.

    What may happen if my resident doesn’t drink enough?

    Dry mouth is one of the first things to happen. This can cause mouth sores and infections

    like thrush which may in turn negatively impact on eating and drinking, causing weight loss

    and continued dehydration.

    Tiredness and headaches are also common if not enough fluid is consumed. These

    symptoms can be accompanied by confusion, dizziness and irritability which can in turn

    cause imbalance leading to falls, slips and trips.

    Constipation is often associated with a poor fluid intake and can also lead to confusion,

    discomfort and rectal bleeding.

    In the long term, poor fluid intake can cause kidney damage and repeated urinary infections,

    which may also then lead to confusion and falls.

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    How do I help my residents to drink more?

    It is important to always have fresh water/drinks available at all times. A ‘hydration station’ is

    an area where fresh drinks are easily available to residents, however some residents will still

    need prompting or support to get drinks from the hydration station.

    Many residents need reminding to drink, encouraging to finish their drinks or be supported to

    drink. If the resident has any swallowing difficulties (see section 5, page 15), ensure you

    follow the recommendations from the speech and language therapist, which might include

    using a teaspoon or straw or adding a thickener to drinks.

    Around 20% of our daily intake of fluid is contained within our food, so encourage your

    residents to eat foods high in moisture such as fruits and vegetables which are up to 90%

    water. When the weather is hot, ice lollies, jelly, ice cream and chilled fruit such as melon or

    pineapple are good ways to increase fluid intake to replace what has been lost through


    For residents with dementia, either use a clear glass/cup so that they can see what’s inside or use a brightly coloured glass/cup to draw attention to the drink. Some residents will have a specific cup/glass they like to use. The person may need reminding what type of drink is in the glass/cup. Find out what your resident’s favourite drinks are as this will encourage the person to drink.

    Residents who always have difficulty getting enough to drink should have a hydration care plan. Care plans should be written in discussion with the resident and their family and should be specific, measurable,