Part

II
Chapter 10 Nutritional assessment and needs 171 171
Links to other chapters in Foundation Studies for Caring
: lnterproresslonallearnlng
, Lvldence-basedpractlceandresearcb
, Communlcatlon
c Culture
) ubllcbealtbandbealtbpromotlon
++ |luldbalancelncblldren
+: |luldbalancelnadults
:s kebabllltatlon
,, Complementaryandalternatlvemedlclnes
Links to other chapters in Foundation Skills for Caring
+o ressureareacare
: Assesslngandmanaglngbydratlon
:c Lnteralreedlng
:) reparatlonorlnrantreeds
Uontrorgettovlsltwww.palgrave.com}glasperroraddltlonal
onllneresourcesrelatlngtotblscbapter.
l
l
w
Chapter

Pam Jackson
Nutritional
assessment and
needs
172 Part II Insights into essential care issues
Introduction
Nutrltlon ls or rundamental lmportance to llre. lls cbapter explores a number or aspects
or nutrltlon. lt conslders tbe current guldellnes ror bealtby eatlng and bow to lmplement
tbem.ltlooksattberactorstbatlnuenceroodcbolceandroodconsumptlon,andprovldes
guldellnesonbowtoundertakeanutrltlonalassessment,andpollclestoldentlryandprevent
malnutrltlonlnbospltals.ltalsolooksattbelmportanceorgoodnutrltlonlntbepreventlon
andmanagementorotberbealtbproblems,sucbasconstlpatlonandpressureulcers.|lnally,lt
dlscussesmetbodsornutrltlonalsupport.
Learning outcomes
llscbapterwlllenableyouto.
dlscusstbebaslcnutrltlonalprlnclplesornutrlentsand
energy
exploreanddescrlbetbecomponentsorabealtby,
balanceddlet
outllnetberactorswblcbmaylnuenceroodcbolcesln
tbeelderly,lnbotbbospltalandcommunltysettlngs
recognlsetbeneedrorassessmentornutrltlonal
status,andknowbowtocarryoutaslmplenutrltlonal
screenlngtest
outllneslxstrateglesrorpromotlngappetlteandsuggest
waysoroptlmlslngoralnutrltlonallntake
dlscusstbeconsequencesormalnutrltlon
llsttenractorstbatcancontrlbutetoconstlpatlon,and
dlscussltsmanagement
suggestvestrateglestbatcouldbeusedtolmprove
nutrltlonlnbospltals
llsttbreemetbodsorprovldlngenteralnutrltlonand
dlscusstbelruse.
Concepts
Nutrltlon
Screenlng
8alanceddlet
Assessment
Malnutrltlon
lealtbeducatlon
Uebydratlon
lealtbyeatlng
Constlpatlon
|oodcbolces
Agelng
Nutrltlonlndlerentetbnlcgroups
8ereavement
Adjustment
Lonellness
Communltysupport
ressureulcers
Motlvatlon
Nutrltlonalsupport
Lnteralnutrltlon
Scenario: Introducing Jack
acklsan8z-year-oldman,llvlngalonelnabouselntbeoldpartortown.ledoesnot
eatwellandbasrecentlylostwelgbt.ackswlrelettydledslxmontbsago,lesstbana
yearartertbecouplebadcelebratedtbelrdlamondweddlngannlversary.
Learning activity
Consldertberactorstbataectyourroodcbolceandroodconsumptlon.lentblnk
abouttboseractorstbatmlgbtaectwbatackeats.
lnyourpractlceplacement,ndoutwbatractorslnterrerewltbnormaleatlngand
drlnklng.Conslderbowackmlgbtbereellngarterblswlresdeatb.lowmlgbttblsaect
blsbealtb:
s
a
Chapter 10 Nutritional assessment and needs 173
Factors that affect food choices
Wesballconsldertbesewltbspeclcrelatlontoack.
Physiological changes.ackls8zyearsold.lerelspbyslologlcaldeterloratlonlnmost
bodysystemswltblncreaslngage,andslowerstructuralrepalr.lntbegastrolntestlnal
systemtberearereductlonslnsecretlon,absorptlonandmotlllty,andlmpalredablllty
tometabollseandsyntbeslse.Otbersystemsbaveslmllardeterloratlon,sucbasreduced
senses,muscleweakness,reexesandsoon.ackslossorappetltemlgbtpartlybearesult
ortbeseeectsoragelng.(|oramoredetalleddlscusslonortbeeectsoragelng,see
Cbapterzonolderpeople.)
Psychological factors.acklsreellngverylowrollowlngtbedeatborblswlre.llscanaect
appetlteandleadtoanorexla.(|oramoredetalleddlscusslonortbeeectsorbereavement
anddepresslon,seeCbapterz9onloss,grler,bereavementandpalllatlvecare.)
Socioeconomic factors.ackreelslonelyandlsolated.lebasnoonetoeatmealswltb.le
onlybasblspenslontollveon.
Cultural factors.llswlrebasalwaysdonetbesbopplngandcooklng.acklsusedtovery
tradltlonalLngllsbcooklng.
Cognitive factors.ackdoesnotknowwbatconstltutesabealtby,balanceddletandbas
llttleawarenessortbellnksbetweennutrltlonandlllness.
Psychomotor ability.acklspbyslcallyabletocarerorblmselr,butlacksexperlenceorsucb
tblngsassbopplngandcooklng,andblsmotlvatlonlslow.lendscarrylngsbopplngany
dlstanceaproblem.
Resources available.ackbasakltcbenwltbabob,anovenandarrldge,butbasdlculty
gettlngtoasupermarketandtbelocalsbopsdonotsellmucbrresbproduce.
Health and disease.ackbasenjoyedqultegoodbealtb,butbassueredrromlndlgestlon
rorseveralmontbsandbasrecurrentbackpaln.lelscurrentlysuerlngrromconstlpatlon
andasoremoutb.
Convenience.acklsllkelytocbooseroodstbatrequlrellttlepreparatlonorcooklng.
Drugnutrient interactions.Somedrugs,lncludlngalcobol,lnterrerewltbnormal
dlgestlon.acktakesregularantacldsrorblslndlgestlonandlbuprorenrorblsbackpaln.le
drlnksalcobolmostdays.
lnbospltaltberemaybeotberractors.
environmental factors sucbasunramlllarrood,strangesurroundlngsandsmells,and
reducedaccesstoroodanddrlnks
loss of independence,wltbreducedcbolceovertypesormealandtlmlng
eects of treatment wblcbcanreduceappetlte
institutional factorssucbascbangelnroutlneandmealtlmes
increased nutritional requirementsasaresultorlllness,surgeryortrauma.
Scenario continued
ackbecameapubllcanartertbeSecondWorldWar,and
onlyretlredtenyearsago.lettybadalwayslookedarter
blm,dolngalltbesbopplngandcooklng,asbewasso
busyrunnlngtbepub.ackstlllenjoysadrlnk,andsmokes
z0clgarettesaday.lebasonesonwbollvesabroad.
Altbougbbebasenjoyedreasonablygoodbealtb,
besuersrromlndlgestlon,rorwblcbbetakesregular
antaclds,andbackstraln,wblcbbeputsdowntobandllng
beavybarrelsorbeerovertbeyears.Slnceblswlredled,be
bastendedtoneglectblsbealtb,andbasbeensuerlng
rromconstlpatlonrortbepastrewmontbs.
Learning activity
Wbymlgbtackbesuerlngrromconstlpatlon:llnkabouttblsberoremovlngonto
tbenextsectlon.
s
a
Part
II
174 Part II Insights into essential care issues
Causes of constipation
Normalderecatloncanbedenedastberegularandeasypassageorasort,well-rormedand
complete stool. lere ls a wlde range or normal rrequency, rrom tbree tlmes a day to tbree
tlmesaweek(8rockleburst,!990).lrapersonbasdlcultywltbevacuatlonorraeces,tbeyare
saldtobesuerlngrromconstlpatlon.
Constlpatloncanbecausedbyawlderangeorractors.ltcanbe.
self-induced,byrorexampleadlettbatlspoorlnbre,eatlngtoollttle,notdrlnklng
enougb,lackorexerclse}lmmoblllty,lgnorlngtbecalltoderecate,or
unnecessaryuseorlaxatlves
environmentally induced,bylssuessucbaspoortolletracllltles,travel
oradmlsslontobospltal
drug-induced.manyanalgeslcs,antlcbollnerglcs,alumlnlum-based
antacldsandantldepressantsbavetblsslde-eect
disease-related,tberesultorrorexampleneurologlcaldlsorders,
musculardeclencles,obstructlon,endocrlneormetabollcdlsordersor
psycblatrlcproblems
psychological,causedbyadlsordersucbasdepresslon
relatedto local tissue factors sucbasbaemorrbolds,orweakpelvlc
oormuscles.
SeeWlnney(!998)rorrurtberlnrormatlon.
Management of constipation
Suerersrromconstlpatloncouldbeadvlsedto,
Increase their bre intake.llscouldcomerromcereals,especlallyporrldgeandbran
types,gralnsandwbolemealbread,rrultandvegetables,pulsesandbeans.Stoolstbat
areblgblnbrearebulklerandbaveablgberwatercontent,andaretbereroresorterln
conslstency,andeaslertoexpel.lebrealsoprovldesamoreacldlcenvlronmentwblcbls
conduclvetonormalgutoraactlvlty.
lt ls orten dlcult to eect a cbange or dlet, as many people are reslstant to cbanglng
llretlmebablts.lowever,tblscanbedonebysuggestlngtbegraduallntroductlonorblgb-bre
cereals,encouraglngbrown}granary}wbolemealbreadlnsteadorwblte,andtrylngtolncrease
tbenumberorservlngsorrrultandvegetables.
Increase their uid intake.leysbouldalmroramlnlmumlntakeor!!.lltresaday.
lnadequateuldlntakereducestbestlmulusrorlntestlnalactlvltyandtrlggersagreater
absorptlveresponselntbecolon,leavlngtbestoolbardanddry.Someuldsstlmulate
bowelactlvlty,rorlnstancerrultjulces,realaleandtea.(Asackenjoysadrlnk,tbementlon
orrealalemlgbtencourageblm.)
Learning
activity
llnkaboutpeoplewbo
wereconstlpatedtbat
youbavemetlnyour
practlceplacements.Wbat
speclcractorsmlgbt
bavecontrlbutedtotbelr
constlpatlon:
a
Scenario continued
ackwenttotbecbemlsttobuy
alaxatlve,totrytoallevlatebls
constlpatlon.lepbarmaclst
overbeardblmasklngroralaxatlve.
leadvlsedsenna,!ztablets,but
alsosuggestedtbatackmlgbtnd
ltbelprultoseetbepractlcenurse
atblslocalsurgery.
s
Learning activity
lowdolaxatlveswork:
Wbatlstberoleortbepbarmaclstata
cbemlstssbop:
lowmlgbttbepractlcenursebelp
ackmanageblsconstlpatlon:You
mlgbtwlsbtorevlewyouranswerto
tblsquestlononceyoubavereadtbe
rollowlngparagrapbs.
a
Chapter 10 Nutritional assessment and needs 175
Increase their activity level. Lxerclseandgeneralmobllltybelppreventconstlpatlon,by
stlmulatlngsmootbmuscleactlvltylntbegut,andaldlngtbeprocessorderecatlon.
Re-establish regular bowel emptying.lgnorlngtbecalltostoolleadstolncreasedwater
absorptlonrromtbestoolasaresultortbeprolongedtranslttlme,andreducedresponse
togutactlvlty.
Avoid unnecessary use of laxatives.Stlmulantlaxatlvessucbasblsocodylsbouldonlybe
usedsbort-term,astbelargebowelbecomeslnsensltlvetotbelractlon,andtbenstronger
laxatlveswlllbeneededtoeecttbesameresult.ldeally,supposltorlesormlcro-enemas
sbouldbeusedlnprererencetolaxatlves,astbeywlllonlybavealocalactlonorlrrltatlng
tbemucosaandlubrlcatlngtbepassage.
|orrurtberreadlngontbeeectlvenessorlaxatlveslntbeelderly,seeCentrerorkesearcband
Ulssemlnatlon(z00!).
A healthy, balanced diet
le rollowlng recommendatlons ror bealtby eatlng are based onTe Balance of Good Health
(8N|,z00),wblcblsconslstentwltbtbegovernmentselgbttlpsroreatlngwell.
Base your meals on starchy foods.Aboutatblrdoryourroodlntakesbouldconslstor
complexcarbobydrates,astbeyarerlcblnbre,vltamlnsandmlnerals,andagoodenergy
source.leselncludepasta,rlce,potatoesandbread,especlallywbolemealvarletles.
Eat lots of vegetables and fruit.lesetoosbouldmakeupaboutatblrdoryourrood
lntake.Almtoeatatleastveservlngsorvegetablesandrrultaday,astbeyarerlcblnbre
andvltamlns,especlallydarkgreenandorangerrultandvegetables.(Uldyouknowtbere
lsaUlveadaywebslte(Ul,z00!),wltbdetallsorresearcbrelatedtorrultandvegetable
lntake:)
Eat more sh.Latsbatleasttwlceaweek,especlallyollysb,sucbassalmon,tuna,
mackerelandsardlnes,astbesearerlcblnOmega-!rattyaclds,wblcbbelpreducetberlsk
orbeartdlsease.
Cut down on saturated fat and sugar.Latlnsmallamountsandnottooorten.|atlsa
goodsourceorenergyandrat-solublevltamlns.Sugarcanlncreasetberlskordentalcarles.
Try to eat less salt. Almtoconsumenomoretban6 gaday.Avoldaddlngsaltattbetable
andreducesaltlncooklng(mlcrowavecooklngavoldstbeneedrorsalt),assaltlncreases
tberlskorbypertenslon.
Get active and try to be a healthy weight. Actlvltycantakeavarletyorrormssucbas
regularexerclsetbrougbsportorwork,andeverydayactlvltles.
Learning
activity
Conslderwbateectbls
bereavementmlgbtbave
badonacksappetlteand
nutrltlonalstatus,berore
revlewlngtbenextrew
paragrapbs.
Uoyouknowwbat
constltutesabealtby,
balanceddlet:Youmlgbtalso
llketotblnkaboutwbatyou
knowberorereadlngon.
a
Scenario continued
ackstlllmlssesblswlreandndsltbardtocopewltboutber.
leneverdldvlslttbepractlcenurse,butbecausebelsreellnglonely,be
decldestowrltetoblsson.artorblsletterreads.
lstlllmlssyourmotberverymucbandsometlmeslndtbesllencealmost
unbearable. l can plcture ber ln tbe kltcben wltb ber apron on, busy
baklng an apple ple ror dlnner. l can smell lt even now! l dont seem to
bavemucboranappetltetbesedaysandtberedoesntseemmucbpolnt
lngettlngamealwbentberesjustme.Anyway,yourmotberneverletme
lntbekltcben,solwouldntknowbowtocookdlnner.lgetbymalnlyon
soupandsandwlcbes.lstlllgodowntbeklngsleadmostevenlngsrora
coupleorplntsandmypackorclgarettes.lrldontgotbere,lcangoror
dayswltboutseelnganyone.
s
Part
II
176 Part II Insights into essential care issues
Drink plenty of water. Coodbydratloncanbelppreventpressureulcers,urlnarytract
lnrectlons,cardlovasculardlsease,conruslon,rallsandmanyotberbealtbproblems.
Dont skip breakfast.Abealtbymealattbestartortbedaycanreducereellngsorbunger
andmalntalnenergylevels.
lnaddltlon,eatmoderateamountsor meat, sh and alternatives,astbeyareagoodsource
orproteln,vltamlnsandmlnerals.Cbooseleanmeats.llsgrouplncludeseggs,pulses,soya
andnuts.Alsoeatmoderateamountsormllkanddalryroods,astbeyareallgoodsources
orprotelnandcalclum.Cbooselow-ratalternatlveslrposslble,exceptrorcblldrenunder
yearsorage.
Figure . leeatwellplate
Learning activity
WbatlstbecurrentlevelorobesltylntbeUnlted
klngdom:|lndouttbe Health of the Nation targets(Ul,
!99z)llnkedtonutrltlon.Wbatractorsbavecontrlbuted
totbelargelncreaselnobesltyovertbepast!0!years:
Wbataretbekeyrlsksassoclatedwltbobeslty:Lookat
tbeWorldlealtbOrganlzatlon(WlO)websltereport
onDiet, Nutrition and the Prevention of Chronic Diseases
(z00!).
Workoutabalancedbealtbymenurorackovertwoor
tbreedays,taklnglntoaccountblsageandllrestyle.
|lndoutwbatracllltlesrelatedtonutrltlonareavallable
rortbeelderlylnyourcommunlty.rorexampleMealson
Wbeels,luncbeonclubsorbelpwltbsbopplng(seealso
Cbapterzonolderpeople).
Scenario continued
acklacksanyappetlteandndsltbardtomotlvateblmselrtoeat.
Learning activity
Wbylsroodlmportant:Conslderyourresponseberoremovlngon.
a
s
a
CCrowncopyrlgbtmaterlallsreproducedwltbtbepermlsslon
ortbecontrollerorlMSOandQueensrlnterrorScotland.
Chapter 10 Nutritional assessment and needs 177
Why is food important? Nutrition science
|ood ls absolutely essentlal ror llre. luman metabollsm ls a complex process wblcb ls
constantly actlve, and wblcb relles on a supply or speclc cbemlcals, or nutrlents. lese
provlde energy, and malntaln structure and runctlon. Many or tbese cbemlcals can be
syntbeslsed by tbe body, but some cannot. lese are called essential nutrients, and we bave
to lngest tbem as we cannot syntbeslse tbem. 8roadly, tbere are tbree categorles or essentlal
nutrlents.
Minerals. leseareusuallyonlyrequlredlnsmallamounts(rorexample,lronandcalclum)
orverysmallamounts(traceelementssucbaslodlne).
Organic compounds.lesearesyntbeslsedlntberoodcbaln,butnotbybumans.ley
lncludeessentlalrattyaclds,vltamlnsandessentlalamlnoaclds.
Organic precursors.lesearenecessaryastbesubstratesrorsyntbeslsororganlc
compoundsneededbybumans.lrtbedletdoesnotprovldesuclentprecursors,tbebody
lsunabletosyntbeslsetbecompoundsneededrormalntalnlngstructureandrunctlon.
lecbemlcalcompoundspresentlnroodtlntooneormoreortberollowlngcategorles.
nutrients.carbobydrates,rats,protelns,vltamlns,mlneralsandwater
energy sources.carbobydrates,rats,protelnsandalcobol
other compounds.addltlvesandtoxlnsrorexample.
Ascanbeseen,severalroodgroupsappearlnmoretbanonecategory.leycanbeusedror
a varlety or purposes, dependlng on tbe lndlvldual requlrements. Malntenance or a stable
metabollcstaterequlressuclentenergyandnutrlentstosatlsrymetabollcdemand.lrrood
lntakelsrestrlcted,tbebodysenergyrequlrementstomalntalnmetabollsmwllltakeprlorlty
overotberactlvltlessucbasmalntalnlngstructureandrunctlon.
|or more detalled explanatlons and rurtber readlng about major rood groups and
metabollsm,seeeltber8arasl(z00!)orCarrow,amesandkalpb(z000).
Body mass index
8Mlmeasuresbelgbtandwelgbt,andlsusedasanestlmateorratness.ltlscalculatedbytbe
equatlon.
8Ml=
Welgbt(kg)
lelgbt
z
(m)
8Ml ls a better lndlcator or ratness tban welgbt alone, and ls commonly used ln nutrltlonal
assessment tools. lt ls consldered to be a stable, easlly perrormed and sensltlve measure or
Scenario continued
ackslackormotlvatlonandpoor
appetltearecontrlbutedtobybls
reellngconstlpated,suerlngrrom
lndlgestlon,andbyasoremoutb,
causedpartlybyblsdenturesno
longerttlngproperly,andposslble
vltamln8declency,asaresultor
anlnadequateroodlntake.
ackbaslost!z kglnwelgbt
slnceblswlredled.Slxmontbsago
bewelgbed7! kg.lels!.7 mtall.
s
Learning activity
Wbateectcanasoremoutbbave:
(Seelolmes,!996,rorlnrormatlonon
oralcarelnolderpatlents.)
lowwouldyoudescrlbeacks
currentwelgbt:
Wbatlsbodymasslndex(8Ml):
Calculateacks8Ml.lsltlntbe
normalrange:(See1able!0.!roran
explanatlon.)
Workoutackspercentagewelgbt
loss.lstblsslgnlcant:lrso,lnwbat
way:(See8ond,!997,cbs!and4.)
a
Part
II
Table . Classlcatlonor8Ml
19 or less underweight
20-25 normal weight
26-30 overweight
31-40 obese
40 + severely obese
178 Part II Insights into essential care issues
malnutrltlon, lncludlng ror tbe bospltallsed and rrall elderly. lowever, tbe gures sbould be
lnterpretedwltbcautlonlntblsagegroup,astbepubllsbednormsarebasedonyoungadults.
ln tbe elderly, tbere ls orten reduced muscle mass as well as rat, and tbererore ranges are
sllgbtlyblgbertbanpubllsbednorms.
lesuggestedclasslcatlonor8MllntbeUnltedklngdomlssbown
ln1able!0.!.
kesearcbsbowstbattberelsarelatlonsblpbetween8Mlandbealtb
outcome,wltbtbegreatestrlsksorlll-bealtbassoclatedwltbtbeblgber
andlowest8Ml(8ray,z00!).
ln cases wbere belgbt ls dlcult to measure, tbere are otber
parameterstbatcanbeusedlnstead,sucbastbedemlspan(see8ond,
!997. 68, ror detalls). lr botb belgbt and welgbt are dlcult to obtaln,
tbe mld-upper arm clrcumrerence (MUAC) can be used (see tbe MUS1 tool on tbe 8ALN
webslte.www.bapen.org.uk).
Learning activity
Wberedoestberesponslbllltylletosurveybealtbneedsortbeelderly:Wblcbbealtb
proresslonalsmlgbtbelnvolved:ANatlonalUletandNutrltlonSurveylsconductedln
tbeUnltedklngdomatregularlntervals.lelatestonerorpeopleaged6yearsand
olderwasln!998(|lncbetal,!998).|lndoutwbetbertbelrdletwasadequate,and
wbetberltwasdeclentlnanynutrlents.
Scenario continued
ackwalksdowntoblslocalpubmostevenlngs,rora
coupleorplntsandapackorclgarettes.llslsblsonly
regularsoclalcontact.
lepubllcanbecameconcernedrorackswelrarearter
bebadnotbeenlnrorarewdays.lecontactedsoclal
servlces,andacallerroundackatbome,dlsorlentedand
lylngontbeoor.lerewasveryllttleroodlntbebouse,
andabalr-emptycartonorstalemllksatontbekltcben
table.
ackwasadmlttedtotbeLlderlyCareUnltortbelocal
communltybospltalrorlnvestlgatlons.leparamedlcs
assessmentnotesstatetbatackappearedmalnourlsbed,
debydratedandconrused,andwascomplalnlngor
sorenessoverblsblp.lewasroundontbeoor,wberebe
badremalnedlmmobllerorseveralbours.
Learning activity
Wbataretbeslgnsordebydratlon:(SeeCbapters!!and!zon|luldbalance,and8ond,
!997,sectlon6.9).
Asacksnamednurse,youwouldundertakeanlnltlalnutrltlonalscreenlngonbls
admlsslontobospltal.Wbatwouldyouneedtondoutandwby:(Seebelowrormore
lnrormatlon.)
Nutritional screening and assessment
Nutrltlonalscreenlngsbouldbecarrledoutwltballpatlentscomlnglntobospltal,toldentlry
tbosewltb,oratrlskor,malnutrltlon.|actorslncludedlnascreenlngtoolmaylncludewelgbt
and belgbt (8Ml), unlntentlonal welgbt loss, recent cbanges to appetlte and dlet, ablllty to
eat, drlnk and swallow, gastrolntestlnal runctlon (sucb as constlpatlon or dlarrboea), mental
condltlonandmedlcalproblems.
w
a
s
a
Chapter 10 Nutritional assessment and needs 179
Learning activity
|lndoutwbetberanutrltlonalassessmenttoollsused
lnyourpractlcearea,andcarryoutanassessment,uslng
tbattool.keectonboweasyltwastocarryoutandbow
valldandrellabletbetoolmlgbtbe.
|lndoutwbatpercentageorpatlentsareatrlsk
ormalnutrltlon(seewww.ageconcern.org.uk).Wbat
strateglesarelnplacelnyourpractlceareatodealwltb
malnutrltlon(rorexample,dletlclanrererral,accessto
nutrltlonalsupplements,protectedmealtlmes):Lookat
tbe8ALNwebslte(www.bapen.org.uk)tonddetallsor
tbeCouncllorLuropeUkAlllance!0keycbaracterlstlcs
orgoodnutrltlonalcarelnbospltalswblcbprovldesa
cbeckllstrorbospltalsandbospltalstatoensuretbat
eectlvenutrltlonalcarelsprovlded..
leNatlonalatlentSaretyAgencycarrledouta
revlewlnz007ortbeprotectedmealtlmeslnltlatlve
(NSA,z007).keectontbebenetsandllmltatlonsor
restrlctlngvlsltorsandwardactlvltlesdurlngmealtlmes.
le Uepartment or lealtb publlsbed patlent-rocused bencbmarklng
ror bealtbcare proresslonals ln z00!, and rood and nutrltlon are one or
tbeelgbtldentledareas(Ul,z00!).llsdocument, Te Essence of Care,
encouragestruststobeactlvelnlmprovlngandralslngtbeproleornutrl-
tlonalscreenlngandassessment,asameansorreduclngmalnutrltlon.ltls
avaluableresource,wblcbcanbeusedtobelplmprovequalltyorcareas
ltrocusesonrundamentalelementsorcaretbatmattermosttopatlents.
A number or nutrltlonal screenlng or assessment tools bave been
developed to try to ldentlry patlents at rlsk or malnutrltlon, but very
rew bave been evaluated (Creen and Watson, z00). One tbat bas been
valldatedlstbeMalnutrltlonUnlversalScreenlng1ool(MUS1)developed
byLlla(z00!)roruselnadults.See|lgure!0.z.
Learning activity
Workoutacksnutrltlonscore,uslngtbenutrltlonalrlskassessmenttoolstepsglven.
Wbataretbelmpllcatlonsoruslngunvalldatedtools:(Seeattlsonetal,!99.4.)
MUST: a nutritional risk assessment tool
MUS1(seealso|lgure!0.z)comprlsesvesteps.
Step!. Measuretbesubjectsbelgbtandwelgbttogeta8Mlscore.
Stepz. Notetbepercentageorunplannedwelgbtloss,andscoreltuslngtbetables
provlded.
Step!. Lstabllsbtbeacutedlseaseeectandscorelt.
Step4. Addtbescoresrromsteps!,zand!toobtalntbeoverallrlskormalnutrltlon.
Step. Usemanagementguldellnesand}orlocalpollcytodevelopaplanorcare.
Scenario continued
UslngMUS1,ackscored!outoraposslble6onadmlsslon.llsplacedblmlntbeat-rlsk
category,andbewasrererredtotbedletlclan.
a
w
a
s
Learning
activity
vlslttbeUlwebpagesat
bttp.}}www.dob.gov.uk}
essenceorcare}lntro.btm
andseewbetberanyor
tbeotbersevenldentled
areasarepertlnenttotbls
scenarlo.
a
w
Part
II
Figure . leMalnutrltlonUnlversalScreenlng1ool(MUS1)
keproducedberewltbtbeklndpermlsslonor8ALN(8rltlsbAssoclatlonrorarenteraland
LnteralNutrltlon).|orrurtberlnrormatlononMUS1seewww.bapen.org.uk.
180 Part II Insights into essential care issues
Chapter 10 Nutritional assessment and needs 181
Professional conversation
ane,abospltaldletlclan,comments,Nursesanddletlclansdonotbavetbesamerolelntbe
management or patlent nutrltlon, but bave complementary skllls tbat can be used togetber
lnauserulpartnersblp.Manypeopletblnkdletlclansareonlylnterestedlnpatlentswboneed
speclal dlets, sucb as patlents wltb llver or renal dlsease, but dletlclans want to be lnvolved
ln tbe management or any patlent wbo ls at blgb rlsk or malnutrltlon, so tbat we can make
a rull nutrltlonal assessment. We can tben try to calculate tbe exact nutrltlonal needs or an
lndlvldual.Weworkcloselywltboccupatlonaltberaplstsandspeecbandlanguagetberaplsts,
especlallylntbemanagementorpatlentswltbswallowlngorotbereatlngdlcultles,toensure
tbat tbe patlent recelves tbe optlmum nutrltlon. lere ls also a dletlclan ln tbe nutrltlon
supportteam,wbereberrolelspartlcularlywltbpatlentsrequlrlngenteralreedlng.
We spend a lot or tlme talklng to patlents about tbelr dlet and glvlng lnrormatlon and
advlce,especlallylrtbenutrltlonproblemsaremultlpleorcomplex.llscouldbeteacblnga
groupornewlydlagnoseddlabetlcpatlentstbelmportanceorbealtbyeatlng,orbelplngtbe
parentsorcblldrenwltbcoellacdlseasetoexploretbeworldorgluten-rreedlets,orglvlngone-
to-oneadvlcetoapatlentwltbdlabetesmellltuswbobasjustbeendlagnosedwltbcoronary
beartdlsease.Weseealotorourpatlentslnoutpatlentcllnlcsaswellasontbewards.Wealso
consldertbatteacblngnursesandotberbealtbproresslonalslslmportant,sotbatconslstent
messagesareglventopatlents.ltlslmportanttbattbeyunderstandourrole,sotbattbeycan
makeapproprlaterererralstous.
Werelyonnursestoldentlrytbepatlentsatrlskanddealwltbstralgbtrorwardnutrltlon-
relatedproblems,relnrorclngtbenutrltlonaladvlceglvenbyadletlclan.lereareonlyarew
dletlclansworklnglneacbtrust,soltsvltaltbatourexpertlselsusedaseectlvelyasposslble.
ldeally, we sbould be lnvolved ln all cases wbere tbe dlagnosls or tbe nutrltlonal advlce ls
compllcated,andwberenutrltlonalsupportlsrequlred.Wearealsobappytoseeanyonewbo
doesnotseemtobemaklngprogress.
ln acks case, we were asked to advlse arter be bad been ln bospltal ror a rew days. le
nursesbadcarrledoutanlnltlalnutrltlonalscreenlngandldentledblmasatrlsk.Wecarrled
outamoredetalledassessmentandweretbenabletoglvetbemadvlceaboutlncreaslngtbe
calorles or acks rood, and belp to work out wbat nutrltlonal advlce be needed berore golng
bome.ltslmportanttbatdletaryadvlcelsglvenaspractlcalguldanceandnotjusttbeoretlcal
prlnclples,wltbtbepatlentlnvolvedlntbedeclslonsaboutblseatlngpatternsandbablts.
Learning activity
Wbatstrateglescanbeusedtolncreaseacksnutrlentlntakeandreduceblslevelorrlsk:
Ulscussyourldeaswltbyourmentororotberstudents,tbenreadtbesectlonbelow.
Nutritional support
Scenario continued
acksroodanduldlntakewasmonltoredrorseveral
daysuslngaroodcbarttorecordlt,andblsnutrltlon
scorewasreassesseduslngMUS1arteroneweek.ackls
underwelgbtandmalnourlsbed.lelstbererorelnneedor
bulldlngup,andtblslstbeprlorltyratbertbantrylngto
makeblmadberetobealtbyeatlngprlnclples.lowever,be
lselderlyandbasasmallappetlte.ledoesnotbaveany
problemsassoclatedwltbswallowlngandtbereroreoral
nutrltlonlsapproprlate.
c
a
s
Part
II
182 Part II Insights into essential care issues
Lookrorwaysorrortlrylngtberoodapatlentllkeackeats,and
maklngeverymoutbrulcount.|orexample.
encouragetbepersontodrlnkuldswltbcalorlesratbertban
justwater,teaorsquasb.rorexamplemllkydrlnkswltbadded
mllkpowder,slpreeds,blgb-calorledrlnksandtblckenedsoups
addprotelnorratsucbasgratedcbeeseoverpotatoes}soup,
extramargarlneonvegetables,cream}lce-creamwltbpuddlngs
addsugar,rorexamplejamorboneylnpuddlngs,sugarln
drlnks
useneutralorvanlllaavourslpreedslnplaceormllkon
cereals.
Consequences of malnutrition
lere are a wlde varlety or compllcatlons assoclated wltb tbe development or malnutrltlon,
wblcbmayleadtolncreasedmortallty.
reducedmoblllty,leadlngtolncreasedrlskordeepvelntbromboslsandpressureulcers(see
Cbapterz8onrebabllltatlonrormoredlscusslon)
proteln,vltamlnandmlneraldeclency,leadlngtolncreasedrlskordelayedwoundbeallng
reducedlmmunocompetence,leadlngtolncreasedrlskorlnrectlon
muscleatropbyandweakness,causlngreducedresplratoryrunctlon,reducedcardlac
runctlonandratlgue,wblcbcanleadtoacbestlnrectlonorbeartrallure,andcanrurtber
reduceactlvltyandmoblllty
atropbyortbelntestlnalmucosa,leadlngtoreducedabsorptlonornutrlentsandrurtber
welgbtloss
apatby,letbargyanddepresslon
lncreasedsensltlvltytodrugsasaresultordrugtoxlclty.
Scenario continued
Onadmlsslon,ackwasalsoroundtobavedevelopedaCradezpressureulceroverbls
lerttrocanter.
le pressure ulcer ack bad developed, togetber wltb tbe lmpact or malnutrltlon, ls llkely
to result ln delayed recovery and a prolonged bospltal stay. All tbese ractors bave cost
lmpllcatlons,rorbotbtbelndlvldualandtbebealtbservlce.
Learning activity
Wbataretberactorstbatwouldbaveledtoackdeveloplngapressureulcer:
le ractors tbat put people partlcularly at rlsk or developlng pressure ulcers are
malnutrltlon, debydratlon, loss or body welgbt, age and lmmoblllty. See below ror ractors
aectlngtbedevelopmentorpressureulcers.|oramoredetalleddlscusslonortbelmportance
ornutrltlonlnwoundbeallng,seeeltberCreenandMcLaren(!998)orkussell(z00!).
s
a
Learning activity
|ormoreldeas,readsectlon6.!,
Smalllsbeautlrul,lnEating Matters
(8ond,!997).
lowwouldyoumonltorackto
ensuretbatbelsgalnlngwelgbt:
Wbataretbepotentlal
consequencesormalnutrltlonror
ack:
a
Chapter 10 Nutritional assessment and needs 183
Evidence-based practice
Assessment and management of pressure ulcers
lecrltlcaldetermlnantsorpressureulcersarebelleved
tobetbelntensltyandduratlonorapplledpressure
(CullumandClark,!99z).lereareanumberorextrlnslc
andlntrlnslcractorstbatlnuencetlssuetolerance.le
lntrlnslcractorslncludeage,nutrltlonalstatus,lncrease
ordecreaselnbodywelgbt,lmmoblllty,lncontlnence,
neurologlcalractors,vascularractors,andconcurrent
dlseaseorlnrectlon.Lxtrlnslcractorslncludelnadequate
supportsurraces,poorbyglene,poorposltlonlng,poor
movlngandbandllngtecbnlqueorcarers,orprolonged
slttlngwltboutadequatesupport.
Apressureulcercanbedenedasanareaorlocallsed
damagetotbesklnandunderlylngtlssuecausedby
pressure,sbear,rrlctlonandoracomblnatlonortbese
(LUAwebslte).ressureulcersareunllkelytobeal
unlesstbepressurelsremoved,andasmanyasposslble
ortbepredlsposlngractorsareallevlated.Nutrltlonls
oneortbemostlmportantractorstoaddress(Creenand
McLaren,!998),andspeclcnutrltlonalguldellnesrortbe
preventlonandmanagementorpressureulcersbavebeen
developed.
Scenario continued
ackwasassesseduslngtbeWaterlowpressureulcerrlskassessmentscaleandscored!!,
wblcbputblmatmoderaterlskordeveloplnganotberpressureulcer.lnaddltlontotbe
exlstlngCradezpressureulceronblstrocanter.
Learning activity
SeeWaterlow(z00)rormoredetallsabouttblspartlcularrlskassessmentscale.Wbat
strategleswouldyou,astbenamednurse,usetoreducetberlskorackdeveloplng
rurtberpressureulcers:
lere are lnternatlonally agreed guldellnes ror tbe preventlon and treatment or pressure
ulcers,basedontbebestavallableevldence(LUA,!998).
Learning activity
LookattbeLUArecommendatlonsandcomparetbemwltbtbestrateglesyoubad
consldered.
e
s
a
a
Learning activity
LookattbeLuropeanressureUlcerAdvlsoryanel
webslte(www.epuap.org)andndtbenutrltlonal
guldellnesdevelopedlnz00!.Alternatlvely,readClark
andcolleagues(z004).
atlentsllkeacksbouldbeassessedonadmlsslon
rorrlskordeveloplngrurtberpressureulcers.A
valldatedrlsk-assessmenttoolcouldbeusedaspartor
tbatassessment.
a
w
Learning activity
Astbenamednurseresponslblerorackscare,bow
wouldyouselectanassessmenttooltbatldentles
patlentsatrlskordeveloplngpressureulcers:Wbat
ractorsareconsldered:|lndoutwbetberapressure
ulcerrlskassessmentscalelsusedlntbepractlcearea
wbereyouareworklng.Areallpatlentsassessed:lrso,
bowortenaretbeyreassessed:|lndoutwbetbertbere
lsaprotocoltorollowrorpatlentsldentledatrlsk.
lowsultablewouldltberorassesslngackslevelor
rlsk:lowvalldandrellablelslt:(Seekatclle,!998.)
a
Part
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184 Part II Insights into essential care issues
A blgb-proteln and blgb-energy dlet was ordered ror ack. lls lncluded lncreaslng tbe
calorlc content or bls rood, and nutrltlonal supplements. le majorlty or patlents recelve
tbelr nutrltlon rrom tbe caterlng department. lt ls lmportant tbat all tbe dlerent agencles
tbatbaveanyresponslbllltyrorpatlentnutrltlonworktogetbertoensureoptlmumnutrltlonal
care.
Learning activity
Studysomebospltalmenucardsandndoutbowtbe
needsordlerentpatlentsarecateredror.Conslderbow
exlbleyoucouldbeoverdletarycbolcelrackwasbelng
caredrorlnapractlceareawbereyoubaverecentlybad
experlence.
|lndoutwbetbertbereareanyrormalorlnrormalllnks
betweentbeareawbereyouareworklngandtbecaterlng
department.
Wouldltbeposslbleroracktorecelvevesmall
meals}snacksaday,wltbaddedbutter}cbeeseto
vegetablesandaddedlcecreamtopuddlngs:lrnot,
tbenbowelsecouldblsdletaryneedsbemet:(Seetbe
Organisation of Food and Nutrition Support in Hospitals
report,8ALN,z007,orMlllar,!998.)
lnwbatotberwayscouldacksappetltebepromoted
durlngblsstaylnbospltal:
Promoting appetite in the elderly
lerearesomesuggestlonsrorencouraglngpatlents,partlcularlytbeelderly,toeatsuclently.
Presentation of food.lstbeportlonslzeapproprlate:Uoestberoodlookattractlve:lslt
servedattbecorrecttemperature:Aremealtlmesapproprlate:
Variety and choice of food.Areramlllarroodsserved:Aretbeyanapproprlatetype}
conslstency:lavelndlvldualroodprererencesandtbeneedsoretbnlcmlnorltygroups
beenacknowledged:
Frequency.Aresmallerormoreregularmeals}snacksavallable:
Duration.Aremealsrusbed:
Assistance.lsbelpwltbeatlngavallable,lrneeded:Aretberereedlng
aldstopromotelndependence:
Oral hygiene.lsmoutbcareoeredartermeals:Aredentureswell
ttlng:lstbemoutbclean,rresbandwltboutlnrectlon:
Positioning.Arelndlvldualsposltlonedcomrortably,andsupported
lrnecessary,toallowtbemtomanagetbelrmealaslndependentlyas
posslble:
Exercise.lowactlveandmobllearelndlvlduals:Lxerclsecanlmprove
appetltebecauseltcreatesanlncreaseddemandrorenergy.
Social events.Uolndlvldualseataloneordotbeybavecompany
durlngmealtlmes:
Distractions.Aretbereotberactlvltlestaklngplaceatmealtlmes:Are
tbereanyunwantedsmells}sounds}slgbtstbatmlgbtbeo-puttlng:
Professional conversation
Anne, slster on an elderly care unlt, says, ack ls strong enougb to reed blmselr wblle ln
bospltal, but a number or our patlents are not. varlous ldeas bave been promoted ln tbe
Eating Matters pack (8ond, !997), sucb as lnvltlng vlsltors and rrlends ln at mealtlmes to
belp,oruslngvolunteers.Severaltrustsbaverevertedtoabulkrooddellverysystem,sotbat
patlentscancboose,attbetlmeoreacbmeal,wbatroodtbeywantandbowmucbtbeywlsb
to eat. Otbers bave employed a unlt cook ror long-stay wards, so tbat patlents lndlvldual
needs and prererences can be met more easlly. Anotber ldea ls to use red trays to ldentlry
patlents wbo need belp wltb eatlng or wbose rood lntake ls belng monltored (8radley and
a
c
Learning
activity
keectonposslblewaysln
wblcbmealtlmeslnyour
practlceareacouldbebetter
managedtoglveablgber
prlorltytopatlentnutrltlon.
Seealsotbelastparagrapb
ortbeproresslonal
conversatlonbelow.
a
Chapter 10 Nutritional assessment and needs 185
kees, z00!). ln tbls unlt, we llalse wltb tbe caterlng department to try to ensure patlents get
tbe correct dlet. We bave a responslblllty to ensure tbat our patlents recelve tbe rood tbey
need,andtomonltortbelrlntake(kCN,!996).ltblnknutrltlonsbouldbeasmucbaprlorlty
asdrugsprescrlbedtoourpatlents.Arterall,patlentswboaremalnourlsbedwllltakelonger
torecover,andaremorellkelytodevelopcompllcatlonsandbavetbelrstayextended.
Nutrltlon needs to be glven tbe prlorlty lt deserves, and tbe ward organlsatlon needs to
reecttbls.Nurslngstaneedtobeavallabletobelpwltbmealtlmesratbertbancompletlng
admlnlstratlon, taklng our own luncb-break or bandlng over to nurses on tbe next sblrt.
atlents need to be on tbe ward at mealtlmes, and lnvestlgatlons, pbyslotberapy and otber
essentlalactlvltlessbouldbeplannedaroundmealtlmeswbeneverposslble.|orpatlentswbo
arenotontbewardwbenmealsareserved,tberesbouldbeprovlslontoensuretbattbeydo
notmlsstbelrmeal.Slmllarly, tbereneedsto be aprocedureror newly admlttedpatlents,or
rorpatlentswbosesurgerybasbeenpostponed,torecelveameal.llslsespeclallylmportant
now tbat rood can no longer be prepared on tbe unlt, because or tbe bealtb and sarety
regulatlons.
Mealtlmesarenotjusttbemalnsourceornutrltlon,tbeyarealsoasoclaleventrormost
people. We must try to ensure tbat patlents bave tbe opportunlty to soclallse over meals lr
tbelr condltlon allows. Many wards were not deslgned wltb communal meals ln mlnd, and
nurses need to be lmaglnatlve to try to create an atmospbere conduclve to eatlng. lls ls
especlallytrueonlong-staywardsandelderlycareunltssucbastblsone.
Learning activity
lryouweretbenurseglvlngcare,wbatwouldbeyourresponsetoMrWbltebead:You
maywlsbtodlscusstblswltbyourpeersandwltbpractltlonersandteacbers,lnrelatlon
toetblcalconslderatlons.keadCllbbens(!996.z9!0).
Oral nutrltlonal supplements can be
oered to patlents wbose nutrlent lntake
ls lnsuclent. lere are several dlerent
typesorsupplementsavallable,sometbat
canbeglventoreplaceamealandotbers
tbat supplement a normal dlet. ley can
be glven ln a varlety or dlerent rorms,
sucb as rreezlng to create an lce cream or
mousse conslstency, or warmlng and eat-
lngasasoup.
a
Learning activity
|lndoutwbatnutrltlonalsupplementsareavallablelnyour
cllnlcalarea,anddlscusstbepurposeoreacbortbemwltb
yourmentororwarddletlclan.
|lndtbeNlCLrererenceguldetonutrltlonsupportln
adults(z006)anddlscusstbecarepatbwayoutllnedlnlt
wltbyourmentororwarddletlclan.Comparetblswltbtbe
caredellveredlnyourpractlceplacement.|oradetalled
dlscusslonorenteralnutrltlonandtbecareorpatlents
recelvlnglt,readCreenandackson(z00).
a
Learning activity
LookatChoosing a Better Diet (z00b)ontbe
Uepartmentorlealtbwebslte.(www.db.gov.uk.)
andndtbeFood and Health Action Plan(Ul,z007).
Wbatactlonsdoesltsuggesttbatyoucouldconslder
lmplementlng:
a
w
Scenario
ackwasadmlttedtoarour-beddedbay.lntbebed
nexttoblmwasaratberconrusedelderlyman,
MrWbltebead,wborrequentlyrerusedtoeat.le
wasalreadymalnourlsbed,andatrlskorbecomlng
debydrated.Nursestrledtopersuadeblmtoeatand
drlnk,butortentonoavall.
s
Part
II
186 Part II Insights into essential care issues
Enteral nutritionlstbedellveryornutrlentsdlrectlylntotbestomacborsmalllntestlnesvla
an enteral tube or percutaneous endoscoplc gastrostomy (LC) reed, and ls anotber optlon
tbatcanbeconslderedlntbeseclrcumstances
Scenario continued
lemanlntbebedopposltewasrrlendlyandalwayskeen
tocomeoverandtalktoack.leregaledackwltbstorles
orblsyoutblntbeunjabreglonorlndla.lewasallndu
andavegetarlan,andberoundbospltalroodgenerally
tastelessandunappetlslng.
lerourtbbedlnacksareawasoccupledbyarecently
retlredmanwbobadsueredastroke(seeCbapterz)
andwasatrlskorbecomlngmalnourlsbedasberoundlt
verydlculttoswallow.llsmanbadtobaveblsdrlnks
tblckenedtoenableblmtoswallowtbem.
Learning activity
|lndoutabouttbenutrltlonprovlslonroretbnlcmlnorlty
groupslntbebospltalorlnstltutlonwbereyouare
worklng.
Cbeckoutwblcbnutrlentsaremostllkelytobe
declentlnpeoplewboarevegetarlanorvegan.(Seetbe
8rltlsbNutrltlon|oundatlonbrlengpaper.vegetarlan
nutrltlononbttp.}}www.nutrltlon.org.ukorreadCbappltl,
ean-MarleandCban,z000.)
Wbolntbelnterproresslonalteamlsllkelytobe
lnvolvedlntbeassessmentandcareortbemanwbo
sueredastroke:Wbatrolecantbesetberaplstsand
otbersplaylnnutrltlon:(SeeCbapterz8onrebabllltatlon
andCbapterzonolderpeoplerormore
extenslvedlscusslonsortberolesordlerentmembers
ortbelnterproresslonalteam,seealsotbeproresslonal
conversatlonwltbadletlclanabove.)Canyoutblnkorany
llnksbetweennutrltlonandtberlskorbavlngastroke:
Lookattbe8andollerwebslterorarevleworresearcb
ondletandrlskorstroke.Youcouldalsoexplore8arkers
researcbonlntrauterlnegrowtbretardatlonandtbe
developmentorblgbbloodpressure,strokeanddlabetes
lnmlddleage(Codrreyand8arker,z000).
|lndoutwbytblckenlnguldsaldsswallowlng,and
practlsemaklnguptblckenedreedslnyoursklllslabor
practlcearea.
Nutritional assessment
Nutrltlonalassessmentlsamoreln-deptblnvestlgatlonto
ldentlry tbe extent and nature or malnutrltlon. lls may
lnclude antbropometrlc measurements, sucb as skln-rold
tblckness and mld-arm clrcumrerence, wblcb assess tbe
amount or subcutaneous rat, blocbemlcal measures, sucb
as plasma albumln and plasma transrerrln, to measure
tbe level or proteln, pbyslcal examlnatlon, dletary blstory,
and recorded lntake or rood. A member or tbe nutrltlon
support team, sucb as tbe dletlclan or nutrltlon nurse
speclallst, normally carrles tbls out. (See 8ond, !997, cbs!
and4rorrurtberdetallsornutrltlonalassessment.)
Problems on admission to hospital
acksproblemsonadmlsslontobospltal,wblcbarecommontomanyelderlypatlents,were.
debydratlon,leadlngtouldandelectrolytelmbalance
malnutrltlon,leadlngtolncreasedrlskormorbldlty(cbeckouttbesectlonontbe
consequencesormalnutrltlonabove)
lmmoblllty,leadlngtopressureulcerdevelopment(baveyoureadtbesectlonon
developmentorpressureulcersabove:)
posslbletrauma,rromblsrall
s
a
w
Learning activity
|lndoutwbetbertberelsanutrltlon
supportteam,oranutrltlonnurse
speclallst,lntbetrustwbereyouare
worklng.Wbataretbelrkeyresponslbllltles:
lowarepatlentsrererredtoamemberor
tblsteam:
lnsummary,wbatwereacksproblems
onadmlsslontobospltal:Conslderyour
responseberorereadlngon.
a
Chapter 10 Nutritional assessment and needs 187
rearorralllngagaln(seeNlCL,z004andUl,z00!).
mlldconruslon,posslblycausedbydebydratlonorvltamlndeclency.
Learning activity
Wbatnutrltlon-relatedactlonswouldyouconsldertobeapproprlateonacksadmlsslon
tobospltal:
Appropriate nutrition-related actions
Actlonstbatcouldbetakenlntbeseclrcumstancesare.
Nutritional support.llsreducesmalnutrltlonandlncreasestbeappetlte.Asacklsable
toswallowandbasnoknowndlgestlve}absorptlondlcultles,tbenoralnutrltlonsbould
besuclent.(kevlewtbesectlonsaboveonnutrltlonalsupportandpromotlngappetlteln
tbeelderly.)
Maintenance of uid and electrolyte balance.llslnvolvesmonltorlnglntakeandoutput,
oral}lntravenousulds(lrglven),andcbecklngtbebloodlevelsorelectrolytesregularly.
Pressure ulcer prevention and management. llslnvolvespressurerellerandregular
turnlng,moblllsatlon,adequatenutrltlonandulds,andwoundcare.(kevlslttbesectlon
aboveonpreventlonandmanagementorpressureulcers,andCbapterz8.)
Mobilisation.1oreducemuscleatropby,lncreaseclrculatlon,lncreaseappetlteandenergy
requlrements,andlncreasecondenceandlndependence.
Scenario continued
acklskeentoreturnbomeassoonasposslble.
Learning activity
Wbatwouldyoulncludelnyourdlscbargeplannlngrorack:
Discharge planning
lnplannlngtbedlscbargeorapatlentllkeack,yousbouldconslder,
health educationonmealplannlngandbealtbyeatlng(revlewtbesectlonaboveonwbat
constltutesabealtby,balanceddlet)
community support.communltynutrltlon,sucbasMealsonWbeelsorluncbeonclubs,
bomebelpandbereavementcounselllng
investigation of alternative living arrangements,sucbasaresldentlalbomeorwarden-
asslstedats,orenabllngacktollvemoresarelylnblsownbome,rorexamplebylnstalllng
apersonalalarmortelepbone.
Learning activity
Wbowlllberesponslblerorackscarewbenbereturnstotbecommunlty:
|lndouttbelndlvlduallnvolvedlntbecommunltywbereyouareplaced.Wbatrole
wouldtbeyplaylnmalntalnlngacksbealtb:
a
s
a
a
Part
II
188 Part II Insights into essential care issues
Conclusion
ln tbls cbapter you bave consldered wbat constltutes a bealtby, balanced dlet and tbe
ractors tbat mlgbt aect lt. lere bave been opportunltles to become ramlllar wltb a
nutrltlonscreenlngtool,toldentlrytbeneedrornutrltlonalassessment,andtoconslderbow
nutrltlonal needs can be met ln botb bospltal and communlty settlngs. Some or tbe bealtb
lssues related to poor nutrltlon, sucb as constlpatlon and development or pressure ulcers,
bave been explored and you bave examlned sultable lnterventlons to prevent and manage
tbese problems. You bave also explored otber nutrltlon-related cballenges, sucb as dlculty
ln swallowlng, rerusal to eat, alternatlve dlets sucb as vegetarlan and enteral nutrltlon. You
sbould now be equlpped to go out and contrlbute to meetlng your own and your cllents
nutrltlonalneeds.
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goodpractlceandadvlce,aswellaslncludlngdetalledlnrormatlon
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expertslntbeeldorpubllcbealtbnutrltlonandbavewrltten
tbetextlnaquestlonandanswerrormattbatracllltateseaseor
accessandrespondstomanyortbequestlonscommonlyaskedby
patlents.ltaddressestbelssuesornutrltlonlnbealtbandlllness,
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Further reading
Part
II