R

Dysphagia/aspiration >

Caloric-dense foods Exercise program for appetite stimulation

Between-meal liquid calorically dense supplements

Consider other treatment options, e.g. hospitalize or palliative care

Suggestions for family:

• Discuss alternate food sources

• Review food preferences

• Recommend favorite foods or comfort foods

• Discuss quality of life issues and treatment goals

Checklist for nurse to provide physician/dietitian:

• Temperature

• Constipation

• Fecal impaction

• Mood/behavior

• Food/fluid intake

• Vomiting/nausea

• Indigestion

• Skin condition

• Swallowing problem * Included in MDS

Food considerations:

• Stop therapeutic diet

• Consistency changes based on assessed needs

• Offer meal substitutes

• Medications not given at meal time

• Supplements not given at meal time

• Food served at proper temperature

• Food palatability (consider taste enhancers)

• Encourage family involvement in feeding

Other:

• Taste/sensory changes

• Ill-fitting dentures, missing teeth

• Motor agitation, tremors, wandering

This is a tool to assist in compliance. This is not an endorsement of the HCFA mandated criteria. It should be noted that because malnutrition in long-term care is multifactorial, any treatment that is initiated should be monitored for efficacy, and nursing interventions should proceed simultaneously with medical interventions.

Physician considerations:

• Complete blood count

• Blood urea nitrogen

• Creatinine

• Hemoglobin

• Hematocrit

• Serum transferrin

• Cholesterol

• Consultation by dietitian

• Consult Clinical Guide for Physicians, Pharmacists, and Dietitians

Environmental considerations:

• Surroundings quiet and calm, comfortable

• Positive dining room atmosphere

• Caregivers are friendly and polite

• Residents are happy with the meals and meal service

• Staff directs conversation to resident at meal time

• Dining room service not rushed

• Assistance encouraged

• Prompt service and assistance

• Compatible companions

• Appetite assessment

• Serum transferrin<180*

Meal time assistance, restorative dining program

Swallowing evaluation/food consistency change, thickened liquids, special feeding program, enteral/parenteral feeding

While presented for simplicity as a linear guide in two parts, many of the suggestions can be done simultaneously, and the order in which this approach is taken can be varied dependent on individual resident needs.

Document reason

Table 4. continue

Nursing Nutritional Checklist (for use in Care Planning)

The American Dietetic Association supports the Nursing Nutritional Checklist (for use in Care Planning). Representatives from the American Dietetic Association were instrumental in its development. This Nursing Nutritional Checklist (for use in Care Planning) was developed by the Council for Nutrition.

A special committee of The Gerontological Society of America (GSAj served as critical reviewers and provided input and modification of the final Checklist. While GSA does not endorse specific clinical measures, we support the principles underlying this Checklist and its potential to improve nutrition in the nursing home.

Problem List (check all that apply)

■ 1. Patient has > 5% involuntary weight loss in 30 days?

Patient has >10% involuntary weight loss in 180 days or less. BMI is < 21. (703 x weight in lbs/height in inches2 or weight in kilograms/height in meters2) Resident leaves 25% or more food on tray? (in last 7 days) Quality Indicators — Does patient have:

A. Fecal impaction in last 7 days

B. Infection (UTI, URI, Pneumonia, GI) in last 7 days

C. Tube feeding

D. Functional ADL decline

E. Development of pressure ulcer in low risk patient

Suggested Action Plan (check when completed)

O 1-4 . Monitor weight weekly.

Continue to step #5 on problem list

■ A. Implement bowel program

■ C. Contact dietitian for assessment

■ D. Consider OT/PT assessment

E F. Implement skin program_

O 6. Patient takes in <1500cc fluid/day for the last 7 days? Is patient on fluid restriction?

■ 6. Develop systematic plan to ensure adequate fluid intake (e.q., 300 mL with meals and 240 mL between meals)

■ 7. Available labwork completed in the last 30 days:

Hgb _ Albumin_

Hct_

■ 7. Notify physician of values

Serum WBC

Sodium _

Potassium __

Glucose_

Creatinine __

Cholesterol _

Urine WBC_

Spec. Gravity _ Leuk. Esterase Other_

8. Nursing assessment of physical/psychological problems

A. Skin (pressure ulcers and skin tears)

A. Implement skin program

B. Presence of fever (2° above baseline)

B. Implement facility protocol

C. Presence of diarrhea

C. Implement facility protocol

D. Presence of constipation

D. Implement facility protocol

E. Takes drugs other than multivitamins/minerals

E. Contact pharmacy consultant for drug review

F. Symptoms of depression/anxiety

F1. Evaluate for depression/anxiety (short geriatric mini depression scale)

G. Loss of usual appetite

G. Implement care plan to increase appetite

H. Presence of nausea/vomiting

H. Implement facility protocol

I. Presence of dysphagia/choking

I. Contact dietitian for evaluation

J. Ill-fitting dentures, missing teeth, periodontal disease

B

J. Contact dentist or dental technician

9. Not satisfied with food currently offered

n

9. Stop therapeutic diets and provide preferred

(for example, ethnic preferences)

foods/food substitutions

10. Patient needs meal time assistance

10. Provide timely, polite assistance during dining

Provide tray set up

Provide partial assistance/supervision (evaluate resident/staff

ratio and supervision by licensed professional staff)

Provide total assistance (consider resident/staff

ratio and supervision by licensed professional staff)

■ 11. Patient has motor agitation, tremors, or wanders

^ Consider training staff to provide meal time assistance

■ 11. Consider OT evaluation

■ Provide meal time assistance

O Provide self-help feeding devices

■ Offer finger foods

■ 11. Patient has motor agitation, tremors, or wanders

^ Consider training staff to provide meal time assistance

■ 11. Consider OT evaluation

■ Provide meal time assistance

O Provide self-help feeding devices

■ Offer finger foods

■ 12. Presence of environmental distractions or meal time environment concerns

^O 12. Minimize environmental distractions ^O Provide compatible companions

■ 13. Inadequate lighting in the dining room

^O 13. Evaluate location in dining room

B 14. Patient needs 30-60 minutes to eat

^O 14. Implement dining program, e.g. special area to eat for impaired residents or two meal time sessions

■ 15. Patient is unable to tolerate current food consistency

^O 15. Contact dietitian for texture screen

■ 16. Supplements are given at meal time

■H 16. Give liquid supplements in a pattern that optimizes nutrient intake

H 17. Medications are given at meal time

^O 17. Contact pharmacist for appropriate administration time

■ 18. Impaired visual acuity

^O 18. Assure resident is wearing clean glasses at meal time BB Provide meal time assistance (see #10)

■ 19. Impaired hearing

^O 19. Ensure that hearing aid is in place and working at meal time

■ 20. Patient has a decline in taste and smell

^O 20. Season foods

^O Serve food at proper temperature

■ When problem list is completed, contact physician, dietitian and pharmacist as appropriate with suggested action plan.

Completed by: ______________________________________________________________ Date: __________________________________

■ When problem list is completed, contact physician, dietitian and pharmacist as appropriate with suggested action plan.

Completed by: ______________________________________________________________ Date: __________________________________

Table 5. Clinical guide to prevent and manage malnutrition in long-term care. The information in this table is aimed at physicians, pharmacists, and dietitians, and follows the strategy evaluate, document, and treat

Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care

For Physicians, Pharmacists, and Dietitians (Evaluate, Document and Treat)

The American Dietetic Association supports the Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care. Representatives from the American Dietetic Association were instrumental in its development. These Guidelines were developed by the Council for Nutrition.

A special committee of The Gerontological Society of America (GSA) served as critical reviewers and provided input and modification of the final Guidelines. While GSA does not endorse specific clinical measures, we support the principles underlying these Guidelines and their potential to improve nutrition in the nursing home.

The American Dietetic Association supports the Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care. Representatives from the American Dietetic Association were instrumental in its development. These Guidelines were developed by the Council for Nutrition.

A special committee of The Gerontological Society of America (GSA) served as critical reviewers and provided input and modification of the final Guidelines. While GSA does not endorse specific clinical measures, we support the principles underlying these Guidelines and their potential to improve nutrition in the nursing home.

Treat cause

If acute decrease in food intake, consider delirium, acute illness and/or pain

Treat cause

Geriatric Depression Scale (see Appendixes A and B)

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