Nutrition

In this assignment I will be describing an account of the assistance I provided a resident at mealtimes in a care home that I was on placement in. I will be discussing the use of screening tools to assess nutrition in older people and care planning for effective implementation of nutritional needs. I will also consider the importance of support provided for people with dementia at mealtimes and the monitoring and promotion of hydration. I will be looking at best practice guidelines for nutrition and hydration and physiology associated with conditions caused by malnutrition and dehydration. In accordance with the Nursing and Midwifery Council, Code of Conduct (2008), I will not disclose the name of the practice area, or the resident’s personal details and I will also adhere to the practice area’s copyright and confidentiality policy. One of the most important things I noticed when on placement in a care home was the emphasis on staff to promote and encourage residents to eat and drink. Staff were trained to weigh and complete a nutritional assessment on each resident at least monthly, and weekly weights were carried out if a resident was rapidly losing weight. After speaking to the chef I noticed that the home maximised choice in dining location, type of food, portion size and presentation, also taking into account likes and dislikes. They also catered for special diets such as diabetic diets, soft and pureed diets as well as for those who were fed by percutaneous endoscopic gastrostomy or nasogastic tube. I was aware that the staff aimed to maintain independence in eating and drinking, using aids where appropriate. They also referred residents to dietetics, GP and Speech and Language Therapy when needed. I was keen to put into practice some of the knowledge and research I had on nutrition and my mentor had asked if I wanted to assist one of the residents, Mrs Smith, with her lunch. I was encouraged to read her care plan to help me understand her nutritional needs and any underlying medical conditions that may be of specific importance. Mrs Smith suffered with dementia and was experiencing gradual loss of her memory and a decline in her ability to think, reason and make decisions. This meant she had problems with using cutlery independently, recognising food and making menu choices. Being aware of eating habits and capabilities at mealtimes ensures that the experience of eating is less stressful for the person with dementia as well as for staff (Alzheimer’s Society, 2004). As a result of dementia she suffered with dysphagia and after Speech and Language assessment, was put on a pureed diet. As part of the initial assessment of a resident with swallowing difficulties, a Speech and Language Therapist should assess the individuals swallow and identify where the problem is. (Royal Institute of Public Health, 2002) The prevalence of oropharyngeal dysphagia is estimated currently to be 60 per cent in nursing home residents and there is a close link between dysphagia and nutritional compromise (National Institute for Health and Clinical Excellence, 2006). Indications of dysphagia are regurgitation of undigested food, drooling, coughing or choking, difficult or painful chewing and swallowing and unintentional weight loss, for example in people with dementia. (Heath et al, 2009). The home’s policy was that each resident would have their nutritional status assessed on a regular basis using the Malnutrition Universal Screening Tool (MUST) (British Association for Parenteral and Enteral Nutrition, 2003). This screening tool is designed to use national criteria to alert nurses and carers when and underlying physical or psychosocial problem is likely to be present for example, unintentional weight loss. Piper (2006) stated that the health professional often needs to have some idea of an individual’s nutritional status. There are various methods which can be used singly or in combination, according to the particular situation. The five MUST steps are to calculate body mass index (BMI) from weight and height, determine unplanned weight loss, consider the effect of acute disease, add scores from 1, 2 and 3 together to give an overall risk of malnutrition, and initiate appropriate nutritional management. (Webster-Gandy et al, 2006). The effects of malnutrition may be physical or psychosocial. For example it could lead to an impaired immune response increasing the risk of infection, reduced muscle strength and fatigue contributing to inactivity and poor self care, predisposition to falls. Other physiological effects are reduced respiratory muscle strength, inactivity; increasing the risk of pressure sores and thrombosis and delayed wound healing. Psychosocial effects include apathy, depression, self neglect and deterioration in social interaction. (Malnutrition Advisory Group, 2000). After introducing myself to Mrs Smith, ensured she felt comfortable and understood and consented to the assistance I was going to provide, I assessed the environment we were in and found it to be a quiet and calm setting with classical music playing softly in the background. Mrs Smith did not appear stressed or upset and the dining room was well lit and I sat on a chair next to hers so that she was able to see both me and her lunch. Heath et al (2009) stated that care settings should provide a pleasant environment, that is quiet and calm, and offer as many sensory cues as possible, such as cooking smells, to stimulate the appetite. I made sure Mrs Smith was sitting upright and her head and arms were well supported and I then explained that she should try to eat slowly and we both had plenty of time so she should not rush. I also explained to her that I would not encourage her to talk whilst she was eating. The Caroline Walker Trust (2004) and O’Regan (2009), recommend that staff should respect the need for quiet and calm during mealtimes, make sure the person is in an upright position, sit at eye level to the person who needs help and use verbal prompts and talk about the food you are offering. I arranged the food into small mouthfuls and loaded it onto a small spoon to ensure that she was not trying to swallow too much at a time. I allowed her plenty of time to taste the food in her mouth, swallow and clear her mouth before I offered her more food. I encouraged and prompted her by giving her gently verbal reminders and letting her know how much food there was left, also making sure that she still wanted more food each mouthful. I offered Mrs Smith a beaker of juice and lifted it up to her mouth after thickening it to the correct consistency, letting her have a small amount of fluid and allowing her time to swallow it before offering her more. It can be a challenge to ensure that people with dementia drink enough. They often forget to drink or do not recognise the sensation of thirst. As a guide people should drink at least eight to ten cups of fluid each day or one and a half to two litres per day for those over sixty five (Alexander et al, 2000). It is also important to assess hydration, for example checking to see if the resident has lost weight rapidly, reduced skin tone, dry mucous membranes, constipation and urinary tract infections, dizziness, confusion and dark urine. (Weinberg et al, 1995). The body’s natural response to dehydration has been shown to be impaired in older people (Bevan 2005). Although fluid balance can be maintained under normal circumstances, dehydration can occur as a result of changes in cognitive functioning or physical functional ability. People who have had a stroke or have Alzheimer’s disease can be particularly insensitive to thirst. (Water UK 2006). After she had finished her meal I offered her oral care and suggested that I help her rinse her mouth out. I also cleaned the skin around her mouth and made sure it was dry and clear of any food. There is a correlation between nutritional status and problems with oral health, such as ill-fitting dentures or dry mouth; older people might have problems in accessing advice on oral care for practical or economic reasons. (Heath et al, 2009). I recorded the assistance I had given Mrs Smith in her daily care plan, her fluid intake on a fluid balance chart and the amounts of what she had eaten on her nutrition chart. ‘You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been.’ (Nursing and Midwifery Council 2008). I have talked about best practice in relation to nutrition and dietetics including the use of care planning, assessment and screening tools and the medical conditions that can arise if a patient is not assessed properly. The knowledge I gained during this practice experience is invaluable and I feel that it has given me an insight into the importance of good nutrition and hydration. It has also shown me how effective communication with patients and colleagues and using the resources and assessments available can not only help a patient recover from a condition relating to malnutrition but can actually prevent illness from occurring. By showing patience and understanding and taking a patient-centred approach to care, all of which are essential nursing skills, can make a big difference to how a patient feels which can directly relate to their recovery. Research into the conditions which can contribute to malnutrition has enabled me to understand how essential it is that in nursing we should be making every effort to adapt services and care to the needs of the patients as they are less likely to adapt to the needs of the service. I have learnt that successful management of nutrition and hydration can be achieved through assessment of risk, fluid balance and effective care planning providing it is evaluated on an ongoing basis and care should always emphasise the importance of maintaining maximum independence in eating and drinking aiming to promote it as a social activity and an enjoyable experience. References Alexander M. F. et al (2000) Nursing Practice: Hospital and Home. The Adult. Edinburgh, Churchill Livingstone, London. Alzheimer’s Society. (2004) Food for Thought – Care Centre Practice Guide. Alzheimer’s Society, London. Bevan M. (2005) Renal Function. In Health H. &Watson R. (Eds) Older People: Assessment for Health and Social Care. Age Concern England, London. British Association for Parenteral and Enteral Nutrition. (2003) The ‘MUST’ Explanatory Booklet. (online) BAPEN, Redditch. www.bapen.org.uk (Accessed 09 July 2009) Caroline Walker Trust. (2004) Eating well for older people: Nutritional and Practical Guidelines. Caroline Walker Trust, Abbots Langley. Heath H. & Sturdy D. (2009) Nutrition and older people. Nursing Standard & Nursing Older People. RCN Publishing, London. Malnutrition Advisory Group. (2000) Guidelines for Detecting and Management of Malnutrition. British Association for Parenteral and Enteral Nutrition, London. National Institute for Health and Clinical Excellence. (2006) CG32 Nutrition Support in Adults: Information for the public. NICE, London. Nursing and Midwifery Council. (2005) Guidelines for Records and Record Keeping. NMC, London. Nursing and Midwifery Council. (2008) Code of Conduct. NMC, London. O’Regan P. (2009) Nutrition for patients in hospital. Nursing Standard. 23 (23), pp. 35-41. Piper B. (1996) Diet and Nutrition: A guide for students and practitioners. Chapman & Hall, Oxford. Royal Institute of Public Health. (2002) Eating for Health in Care centres. RIPH, London. Water UK. (2006) Hydration Toolkit for Hospitals and Healthcare. (online) www.water.org.uk/home/water-for-health/healthcare-toolkit/did-you-know (Accessed 09 July 2009) Webster-Gandy J., Madden A. & Holdsworth M. (2006) Oxford Handbook of Nutrition and Dietetics. Oxford University Press, Oxford. Weinberg A. D. & Minajer K. L. (1995) Dehydration: Evaluation and Management in Older Adults. Journal of the American Medical Association, 274 (19), pp. 1552-1556