Upload
dangnhu
View
215
Download
0
Embed Size (px)
Citation preview
QAH HospitalPortsmouth Hospitals NHS Trust
Objectives• The importance of ‘MUST’ and how often to complete• Understanding the first line action plan (FLAP) for ward
patients at risk of malnutrition• The range of nutritional supplements available and when
each one can be used• To appreciate that if oral intake has not improved after 5-7
days then to discuss a plan with medical staff e.g. NG feeding
• To know when and how to refer to the dietitians• 30 minutes
Page 212/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Why is Preventing Malnutrition Important?
Page 412/20/2016
Pressure ulcers
Increased length of stay
Decreased Immunity
£19.6 Billion
Increased risk of falls and fractures
Increased mortality
QAH HospitalPortsmouth Hospitals NHS Trust Page 512/20/2016
Disease/Nutrition Intake Score
Weight Loss Score
BMI Score
Add Scores together to determine overall risk of malnutrition
Step 5Implement appropriate
management guidelines
BAPEN ‘MUST’ (Malnutrition Universal Screening Tool)
QAH HospitalPortsmouth Hospitals NHS Trust
Nutritional Screening – ‘MUST’ To be completed every 5-7d (VitalPAC will prompt intermediate reviews if indicated)
Score: 0 LOW risk = observe
Score: 1MEDIUM risk = monitor
Use weight chart to monitor weight
Score: 2HIGH risk = TREAT
Initiate FLAP!
Page 612/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Case study patient: Mrs Jones
• 90 years old Admitted with exacerbated COPD Lives with husband at home Normally independent with ADLs Her weight has dropped from 58kg to 52kg (10% weight loss) She does not know her height- estimated 1.52m (5ft) BMI= 22.5kg/m2 Not eaten properly for last 5 days
Page 712/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Mrs Jones
•BMI >20 score = 0•Weight loss 10% score = 1
•Acute disease effect score = 2•Total 3= high risk
……. Plan: Initiate FLAP
Page 812/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
If MUST score >2 initiate FLAP (First Line Action Plan)
•Encourage ‘H’ high calorie options from main menu•High protein diet•Trial with supplement drinks •Monitor intake with food charts, fluid balance charts complete ‘MUST’ score every 5 days
Page 912/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
If patient is referred to the dietitian before FLAP has been initiated:
Page 1012/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Turn FLAP into a Care Plan
• FLAP needs to be personalised for each patient
• Mrs Jones has a sweet tooth and enjoys puddings and milky drinks
• She needs encouragement with eating and drinking
• What would you offer her?
Page 1112/20/2016
From the information, make a nutrition care plan anddocument this in the yellow nursing care plans
QAH HospitalPortsmouth Hospitals NHS Trust
Extras available for patients…
Snack boxes •Can collect from main kitchen on B Level between
06:30 – 19:30
•Sandwich, fruit juice, yoghurt, digestive biscuits, fruit
•Calshake, made with fresh milk on the ward•Ice Cream•Fresubin Powder Extra•Cheese & biscuits•Cake and biscuits from the tea trolley
Page 1212/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Nutritional Supplements
Page 1312/20/2016
*high in protein*
*high in protein*
QAH HospitalPortsmouth Hospitals NHS Trust
• What nutritional supplement would be most appropriate for a
diabetic patient who requires them?
Page 1412/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
• Fresubin Protein Energy
• 24g CHO per 200ml bottle
• Fresubin Jucy • 67g CHO per 200ml
bottle
Page 1512/20/2016
NB Fresubin stage 1 and 2 also have 24g CHO per 200ml bottle
QAH HospitalPortsmouth Hospitals NHS Trust
• Which fat emulsion supplement, provides energy, but does not
provide any protein, vitamins or minerals?
Page 1612/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
• Use under guidance of dietitian
• Should be used in conjunction with a nutritionally complete supplement (e.g. Fresubin 2kcal)
Page 1712/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust Page 1812/20/2016
* NB all Fresenius products (except 5kcal shots) contain fish oils (the carrier for vitamin A is fish gelatine) and milk protein and is therefore not suitable for strict vegetarian/ Vegan diets
Please discuss this with patients before offering the supplements if they are known to be vegetarian/ Vegan.
All are Halal / kosher Certified
QAH HospitalPortsmouth Hospitals NHS Trust
True or False1.Mrs Jones needs to have supplements prescribed in order to trial them2.Mrs Jones needs to be seen by a dietitian in order to have nutritional supplements3.Mrs Jones has a score of 0 for her BMI on the ‘MUST’, therefore she shouldn’t trial supplements4.All the Fresenius nutritional supplements are gluten free and lactose free
Page 1912/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
True or False
1. Mrs Jones needs to have supplements prescribed in order to trial them …FALSE
2. Mrs Jones needs to be seen by a dietitian in order to have nutritional supplements …FALSE
3. Mrs Jones has a score of 0 for her BMI on the ‘MUST’, therefore she shouldn’t trial supplements …FALSE
4. All the Fresenius nutritional supplements are gluten free and lactose free …TRUE
Page 2012/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
If Mrs Jones does not like the milky nutritional supplements, what
alternatives could you offer her?
Page 2112/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Possible Answers:
• Meritene Soup – 50g sachet made with 150ml hot water
• Fortified soup from menu
• Fresubin Jucy
• Fresubin 2kcal Crème and YoCrème
Page 2212/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Mrs Jones: 3 days into admission
You notice Mrs Jones is having problems with swallowing her food, resulting in coughing and reduced
intake. The Speech and Language Therapist recommends thickened fluids
What supplements are suitable for dysphagic patients requiring thickened fluids?
Page 2312/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
•Fresubin stage 1 and 2• Fresubin 2kcal crème• Fresubin Yocrème
Page 2412/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Mrs Jones: 5 days into admission:
•Lost further 2kg: wt now 50kg (13.7% loss)•Eaten minimal amounts for last 5 days•‘MUST’ score increases from 3 to 4
(BMI=0 + wt loss=2 + acute disease =2)
•Implemented FLAP with no improvement•Medical condition starts to deteriorate•Doctors decide to NG feed.
Its 8pm on Friday, what do you do next?....
Page 2512/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
NG Feeding
When to choose the Refeeding Starter Regime?•Consider at risk if:
•BMI <18.5• a poor nutritional intake for >5 days
•unintentional weight loss >10% within 3-6months•Discuss with the patient’s doctor if unsure which regimen to use
•Do not start NG feeding until Thiamine has been prescribed•Refeeding syndrome policy
Page 2612/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust Page 2712/20/2016
Out of hours starter regimes for when NGT first inserted;
•Standard starter regime- for patients 40kg and over
•Refeeding Starter Regime-for those who are at risk of Refeeding Syndrome(or <40Kg)
QAH HospitalPortsmouth Hospitals NHS Trust Page 2812/20/2016
When to choose the Refeeding Starter Regime?
•Consider at risk if:•BMI <18.5• a poor nutritional intake for >5 days•unintentional weight loss >10% within 3-6months
Discuss with the patient’s doctor if unsure which regimen to use
Do not start NG feeding until Thiamine has been prescribed
Refeeding syndrome policy
QAH HospitalPortsmouth Hospitals NHS Trust
Food SafetyAll clinical staff have to be mindful of food safety:
•Hands must be washed before food service•All patients should be encouraged/ helped to use the ‘wet wipe’ PRIOR to eating their meal•Blue plastic aprons must be worn and hair tied back•Cutlery used for main course should not be re-used for dessert
Refrigerators in the beverage bay/ ward kitchen are the ward/ department’s responsibility:•Food stored in ward fridges should be labelled with the patients name and used within 24 hours if they are not sealed•The temperature of the fridge should be recorded to ensure it is under 40C
Page 2912/20/2016
QAH HospitalPortsmouth Hospitals NHS Trust
Referring Patients to the Dietitian
As of 13th June 2016 please refer via ICE
(We are no longer accepting verbal/telephone referrals)
•If it’s a swallow problem contact SLT for swallow ax•If it’s a tube problem i.e. tube insertion, poor compliance, blocked tubes contact Nutrition Nurses (x5918)
Page 3012/20/2016