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Version 1.0 - 10 November 2017 (Review date 2019)
Hydration
and
Nutrition
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
4
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.
5
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
sweating.
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, achievable, realistic and time-framed (SMART). The care plan should outline the following:
How much fluid you are aiming for e.g. 8 glasses/cups per day
Frequency and quantity of drinks e.g. do they always drink a whole cup or only a half
a cup, are you aiming for 8 whole glasses or 16 half-glasses
How you will monitor what the person is drinking e.g. fluid chart or equivalent
If there are certain times of the day the resident likes to have a drink
What assistance they need to have a drink e.g. a straw, teaspoon, someone to lift the cup/glass
Preferences on how they take drinks e.g. use a specific cup/glass, what drinks they like, what drinks they don’t like
Any variation to normal drinking pattern e.g. does resident need a drink at different times to the norm
If there is any advice from the speech and language therapist (for those with difficulty swallowing)
What can I do if my resident is still not drinking enough?
If you have tried everything and you still don’t think your resident has been drinking enough, it is important to get advice, either from the care home liaison nurse, district nurse (for residential homes only) or GP. They will want to know how much the person is drinking and what strategies you have already tried so be sure to keep a fluid chart and include different fluids offered. See the example fluid chart in Appendix A.
6
2.0 Nutrition
Why is nutrition important?
A healthy balanced diet is essential for everyone. A healthy diet should provide us with the
right amount of energy (calories) to maintain energy balance (where the calories taken in
from the diet are equal to the calories used by the body, therefore weight remains stable)
and the right nutrients to maintain health. Energy is important for all the functions of the
body, including walking and moving about, breathing, thinking, keeping warm and pumping
blood around the body. Vitamins, minerals and other nutrients have various functions to
keep both the mind and body healthy and functioning optimally.
As we get older, the sense of taste and smell can change which may affect appetite and
enjoyment of food. The body’s ability to absorb some nutrients also becomes less efficient
with age so it can be harder to get all the necessary nutrients for good health. Older people
tend to have lower energy requirements due to a decrease in basal metabolic rate (the rate
at which the body uses energy while at rest to maintain vital functions such as breathing and
keeping warm) and often decreased levels of physical activity. It is important for older people
to eat a varied diet to ensure an adequate supply of all the essential vitamins and minerals,
and enough food to cover their energy requirements. Dietary recommendations are the same
for older people as for the rest of the population and similar healthy eating guidelines apply.
A range of factors may influence the nutritional status of older people. This might include
general frailty, ill health and other medical conditions, poor appetite, altered vision, drug-
nutrient interactions, lack of mobility, less independence and dexterity, low mood and poor
oral health (see section 7). Due to these factors, older people, including those living in care
homes are at risk of malnutrition (see section 3).
What is a healthy balanced diet?
No matter what age we are the body needs a diet made up of lots of healthy and nutritious
foods in order to function correctly. The basic components of any diet should include a
combination of the following:
Protein from meat, fish, eggs and pulses.
Five portions of fruit and vegetables per day.
Carbohydrates from brown rice, potatoes, cereals, whole-wheat pasta and couscous.
What we need to avoid also remains the same as we age and it is advisable to limit the
amount of salt, alcohol and sugar we consume.
There are certain vitamins, minerals and food groups which become particularly important as
we get older. These are outlined in Table 1 overleaf.
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Table 1: Important nutrients for older people.
Nutrient Why is it important? What foods is it in?
Calcium Maintaining healthy bones and teeth
as we get older, calcium may begin to be reabsorbed back into the body from the bones (osteoporosis), leading to weak and brittle bones that are more likely to fracture
milk and dairy foods such as yogurt and cheese
leafy green vegetables
Calcium-fortified breakfast cereals.
Fibre Maintaining a healthy gut and digestive system
as we get older, less physically active and drink less fluid, constipation becomes an issue
plenty of fluids also help the gut to function properly
wholegrain cereal and bread
porridge
brown pasta and rice
fresh fruit and vegetables
Beans and pulses.
Vitamin D Helps the body to absorb calcium thus slowing the rate of calcium loss from bones
exposure to sunshine
oily fish e.g. sardines, salmon, tuna
egg yolk and liver
Vitamin D-fortified foods e.g. some breakfast cereals, milk and yoghurts.
Zinc Maintaining a healthy immune system meat and shellfish,
wholemeal bread and pulses
Iron Makes haemoglobin, which helps to store and carry oxygen in the red blood cells from the lungs to the rest of the body.
without iron, the body organs receive less oxygen than they should, leading to tiredness and lethargy
meat,
some vegetables
dried fruit
Vitamin C Helps the body to make collagen, which is needed to make skin, ligaments, blood vessels and tendons, heal wounds and repair bones and teeth
fresh fruit and vegetables
3.0 Malnutrition
What is malnutrition?
According to BAPEN (British Association for Parenteral and Enteral Nutrition);
“Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy,
protein, and other nutrients causes measurable adverse effects on tissue/body form (body
shape, size and composition) and function, and clinical outcome.”
According to NICE (The National Institute for Health and Care Excellence), a person is
malnourished if they have:
A body mass index (BMI) of less than 18.5 kg/m2,
Unintentional weight loss greater than 10% within the last 3-6 months, OR
A BMI of less than 20 kg/m2 AND unintentional weight loss greater than 5% within
the last 3-6 months
Malnutrition is extremely common in older people due to a number of factors discussed
above. It is estimated that about 35% of people living in care homes across the UK are
malnourished (BAPEN 2015), compared to about 10% of people over 65 living in the
8
community who are malnourished or at risk. Malnutrition is both largely preventable and
treatable; it is not a natural consequence of older age and has a wide-ranging impact on
people’s health, wellbeing and quality of life. Sometimes malnutrition can develop as a
result of a medical condition, such as dysphagia (difficulty swallowing). See section 5 for
further information on supporting residents with dysphagia. The signs and causes of
malnutrition are outlined in Tables 2 and 3 below.
Malnutrition increases the risk of:
developing infections
ill-health and hospitalisation,
delayed recovery from illness
developing more health problems
Malnutrition has an impact on:
mood, anxiety and depression
reduced muscle strength and energy levels resulting in fatigue, lethargy and
increased risk of falls
impaired wound healing
constipation
risk of falls
further weight loss
quality of life
Table 2: Signs of malnutrition
D Decreased mobility Dry mouth
H Hair Loss Hollowed temples, cheek bones and clavicle
I Increased Infections and falls
E Emaciated (looking very thin and frail)
E Eyes (sunken) L Loose dentures, clothes and jewellery Low mood (depression, irritability etc.)
T Tiredness P Pale complexion,
Poorly (feeling poorly)
S Sores (and other skin conditions)
Table 3: Causes of Malnutrition W Wounds L Loss of memory, motivation or interest
Loss of ability (to self-feed or to choose foods)
E Emotional changes (low mood, depression, anxiety)
O Oral Factors (dentures, oral thrush, etc.)
I Illness (sickness, urine infections, chest
infections)
S Swallowing (texture modified diets, pain on
swallowing)
G Gastrointestinal problems (diarrhoea, constipation, nausea, vomiting)
S
Sensory (reduced taste, sight, smell or hearing)
H Habits (food preferences, meal timings)
T
Tablet and medication side effects
9
How do I know if my resident is malnourished (or at risk)?
Every resident should have their risk of malnutrition assessed using the MUST tool
(malnutrition universal screening tool). This should be completed on admission to the care
home and then reassessed at least every month. If your resident has been in hospital (or
another care setting), it is good practice to reassess their risk of malnutrition (and other risk
assessments)on their return to the care home in case they have changed whilst in hospital.
The risk of malnutrition should also be reassessed when there is a clinical concern or
change in the person’s health, for example in the following situations:
unintentional weight loss, loose-fitting clothes or loose dentures
fragile skin
poor wound healing
apathy or more sleepy
altered bowel habit e.g. constipation or diarrhoea
muscle wasting (decrease in muscle mass)
change to appetite
change to ability to eat/drink, e.g. dysphagia, sore mouth, loss of independence
prolonged or recurrent illness or infection
To complete MUST you will need to weigh your resident and know how tall they are in order
to calculate their BMI. You will also need to know whether they have had any unintentional
weight loss in the last 3-6 months. The MUST tool and guidance for completion can be found
in Appendix C.
Unintentional weight loss is an indication of malnutrition risk and noticing changes to your
resident will help identify this. For example are their clothes becoming looser, do they seem
sleepier or have less energy, do they take longer to eat their meals, is their skin or lips dry
and chapped? Observing that something has changed provides a good opportunity to
reassess the resident’s level of risk.
Interpreting the MUST score- what to do next
The actions required will be different depending on whether your resident has scored 0 (low
risk), 1 (medium risk) or 2 (high risk). BAPEN have made recommendations for the
management of residents at low, medium and high risk of malnutrition and these are detailed
in Table 4 over the page.
10
Table 4: BAPEN guidelines for the management of individuals identified at different levels of risk of malnutrition
LOW RISK, score = 0
Screen monthly
Encourage to maintain a healthy diet
If BMI is greater than 30kg/m2, provide healthier alternatives to promote weight loss
MEDIUM RISK, score = 1
Screen monthly
Monitor nutritional intake carefully and investigate reason for score
Plan care appropriately (see care plan section below)
Document intake for at least 3 days; be specific when notating food quantities eaten (see example food chart in Appendix A)
PROVIDE at least 2 nourishing drinks, snacks OR a fortified diet (fortify ONLY ONE dish per meal). The goal is to increase oral intake by 500 calories and 20g protein per day.
HIGH RISK, score = 2
Screen monthly – adjust care plan if ‘MUST’ score changes
Monitor nutritional intake carefully and investigate reason for score
Plan care appropriately (see care plan section below)
Document intake for at least 3 days; be specific when notating food quantities eaten (see example food chart in Appendix A)
PROVIDE at least 2 nourishing drinks, snacks AND a fortified diet (fortify ONLY ONE dish per meal). The goal is to increase oral intake by 500-1000 calories and 30g protein per day.
Residents whose weight remains stable or increases after one month of following a fortified
diet plan (as outlined on page 12) should be continued on the plan until the ‘MUST’ score is
lowered. Once ‘MUST’ score is back to 0, fortification can be lessened or removed. MUST
screening should continue to be conducted routinely for every resident, ideally on a monthly
basis.
Residents who continue to lose weight after one month on a fortified diet plan must be
referred to a dietician.
How to write a care plan for nutrition
Residents who are at medium or high risk of malnutrition need to have a care plan that
concisely outlines what specific support is required to enable that person to gain weight and
reduce their risk score. Care plans should be written in discussion with the resident and
their family and should be specific, measurable, achievable, realistic and time-framed
(SMART). The care plan should outline the following:
What food intake and frequency you are aiming for e.g. breakfast, lunch and dinner
and 2 snacks at 3.30pm and before bedtime
Any variation to normal food patterns e.g. does resident need meals at different times
to the norm
11
How you will monitor what the person is eating e.g. food chart or equivalent
If they require any assistance to eat e.g. prompting, food cut-up, full feeding
Preferences on how they take meals and food e.g. use a fork or spoon, need
adapted cutlery, use a specific plate (see section on dementia below)
If they require feeding, how much time do they need, how will you know if they are
getting tired or full-up
Do they need a special diet e.g. gluten free, suitable for diabetics
Do they have any dietary allergies/intolerances e.g. nuts
What are their favourite foods or foods they particularly dislike
If there is any advice from the speech and language therapist (for those with difficulty
swallowing) e.g. pureed diet/thickened fluids (need to specify how many scoops of
thickener), feed only when alert and sitting upright
If there is any advice from the dietician e.g. use of nutritious shakes/snacks
If they are on prescribed supplements e.g. calogen, the details should be specific i.e.
the type, frequency, volume, the time to be administered and where to document
when it has been given
How you will monitor whether the care plan interventions are successful e.g. Monthly
weight and MUST reassessment
What to do if interventions are not having the impact expected i.e. when to refer to
dietician (if not already known)
How do I help my residents to eat more?
Care and interventions that improve or maintain nutritional intake are known as nutrition
support and there are several ways to provide this. For most people eating meals is a
pleasant and social event therefore it is important that residents are offered food that they
enjoy, food that looks tasty to eat (presentation) and in a pleasant environment conducive to
eating. Involving family and friends at mealtimes enhances the social aspect of eating and
for many residents, will improve the quantity of food they eat. Strategies to optimise nutrition
intake are based on the ‘Food First’ principles’ outlined below:
Increase … the Calories and Protein in food and drink
Increase … the Amount eaten
Increase …the Frequency of intake
Increasing the calories and protein in food and drink
It is quick and easy to increase the amount of protein and number of calories by using food
fortification. Food fortifying is when small quantities of regular foods, such as cream, milk
powder, butter or milk are added to a food dish to increase the energy and nutrient content
without increasing the portion size. This means that every mouthful your resident eats is full
of nourishment. Lots of ideas for how to add extra calories and protein can be found in
Appendix D and E.
12
Increasing the amount eaten and frequency of intake
This can be achieved through the use of snacks and finger foods. Snacking between meals
is very helpful if your resident has a small appetite, is easily distracted during mealtimes or
gets tired trying to eat a whole meal. Snacking helps to increase the overall intake of food
and nutrients and providing several smaller meals is as good as providing 3 larger ones. Get
to know your residents favourite foods and if possible, provide what they enjoy the most. Try
to provide 2-3 snacks between meals in addition to the normal diet, encouraging small
amounts to be eaten regularly- for instance, breakfast, morning tea, lunch, afternoon tea,
dinner and supper. Although residents may enjoy a biscuit with their cup of tea, this is not
enough in terms of calories.
Finger foods include anything that can be eaten with your fingers. Like snacks, finger foods
may be particularly helpful for residents who have a small appetite, are easily distracted or
get tired quickly when eating. Some ideas for finger foods can be found in Appendix F and
ideas for snack foods can be found in Appendix G.
What can I do if my resident is still not eating enough?
If you have tried the ideas above and your resident is still losing weight, or you are still
concerned, it is important to get advice from the dietician. They will want to know what the
person is eating, how much they are eating and what strategies you have already tried. This
information should be documented for 3-4 days prior to the dietician visiting to enable
calculation of calorie and nutritional input and provision of specific advice. An example food
chart can be found in Appendix A.
The dietician will make recommendations based on the amount of calories and types of food
the person is eating, their preferences and choices and any health issues that they may
have. Sutton has adopted the Food First principles in all care homes and the dietician will
first recommend trying homemade nourishing drinks and/or puddings (see Appendix D and E
for recipe ideas). It is important to provide a homemade ‘supplement’ from real food first
before resorting to Oral Nutritional Supplements like Foodlink. Real food ‘supplements’ made
in the kitchen can provide the same number of calories, cost less and are fresh. If, after
trying the Food First approach it is determined that ONS are still needed, the dietician can
provide advice on the best option for your resident. They may make a recommendation to
the residents GP to start ONS for example, complan or fortisip to enhance the amount of
nutrition your resident consumes. Oral nutritional supplements generally should be stopped
when the resident is established on adequate oral intake from normal food.
As discussed in the section above on causes of malnutrition, if your resident develops a new
health related problem, for example, recurrent illness, a wound, difficulty eating/swallowing
or frequent gastrointestinal problems (such as vomiting or diarrhoea) it is important to obtain
advice from the dietician to support your resident to make a fast recovery to wellness.
13
4.0 Supporting nutrition and hydration in residents with dementia
Dementia affects individuals in different ways but it will have an impact on your resident’s
ability to drink enough to remain hydrated and eat enough to maintain good nutrition.
Dementia can affect nutrition and hydration in the following ways:
The sense of being thirsty is reduced- prompting may be needed
The sense of taste alters, many people prefer sweeter options or those with a strong
flavour
Reduced appetite or interest in food
Not recognising different foods, or plates, cups, cutlery
Reduced concentration span and attention affects the ability to finish a whole meal
Disorientation to time may mean they don’t realise it is time for a meal
Some residents may be very fidgety or move around a lot- they may be using up
more calories that they are taking in
Swallowing difficulties resulting in eating/drinking less
Tips on how to help the resident with dementia get enough to eat and drink
(from the Alzheimer’s Society)
To encourage appetite:
Give the person foods that they like. Get to know their preferences and make a record of them.
Allow dessert even if the person has not eaten their savoury meal.
Food that has cooled will lose its appeal. Make sure food stays warm by using a plate warmer or a microwave to reheat food.
Try different types of foods/drinks if the regular meal does not seem to be what they want. Sometimes milkshakes and smoothies are very appealing!
Experiment with herbs and spices. Sometimes with dementia a person’s food tastes will change, so trying stronger or sweeter flavours may help.
Provide gentle reminders to eat, and of what the food is (they may not recognize it).
Try to provide a stress-free atmosphere that is friendly and relaxed. Sometimes soft music may help.
If the person refuses to eat, stay calm and try again a little later.
It is very important not to assume that the person doesn’t want to eat.
When there are problems with physical co-ordination:
If a person is having difficulty managing a fork and knife, cut up the food so that it’s small enough to eat with a spoon.
Try finger foods. These may be easier to manage when co-ordination becomes a problem.
Let the person eat where they are most comfortable.
Arrange for some non-spill cups or specially adapted forks, knives and spoons, if needed.
To encourage hydration:
Whenever the person is eating, have something to drink available as well.
14
Use a clear glass so that what’s inside can be seen or use a brightly coloured cup to draw attention to the drink.
Remind the person what type of drink is in the cup.
Offer a variety of drinks – both hot and cold – throughout the day.
Don’t forget that foods that are high in fluid like gravy, jelly, ice cream, etc. can count toward a person’s overall fluid intake.
When eating habits have changed:
Always try to do what is in the person’s best interest. If a person is suddenly eating unusual food combinations, let them. Strange combinations of food are unlikely to cause harm and at least the person is eating!
Provide naturally sweet foods like fruit, carrots, sweet potato if a person in indicating they prefer sweet things.
Add small amounts of honey or sugar to savoury foods.
Serve sweet sauces or chutney with a meal to add sweetness and interesting flavour.
If you notice the person trying to eat an item that is not food (like a bar of soap or a tissue, for instance), try offering food instead. They may not recognize the item that they are trying to eat and they may be hungry!
Issues with Overeating:
Split the original portion in two and offer the second half later on if the person asks for more.
Make sure that most of the plate is comprised of salad and/or vegetables. Reduce the portion sizes of meats and starches.
Provide bite-sized healthy snacks like grapes, chopped apple slices, chopped banana slices, cherry tomatoes, etc. for snacking.
Try offering a milkshake or other tasty beverage instead of more food.
The eating environment:
Keep clutter off of the eating surface.
Keep noise to a minimum. A noisy room can be very distracting.
Sometimes calm music can help a person relax.
Ensure the room is well-lit as the person may not be able to see very well. Describe the food to them if necessary.
If possible use plates and tableware (like tablecloths or placemats) that are plain and that contrast with each other; for instance, a green tablecloth and a red plate. Avoid patterned plates.
If a mess is made, so what? Remember that the goal is for the person to eat rather than be neat.
Provide plenty of time for the person to eat their meal.
Consider having a ‘slow-eaters’ table for those who need a bit more time.
5.0 Supporting nutrition and hydration in residents with
dysphagia
Dysphagia is a swallowing difficulty which can affect the ability to swallow food, drink and
saliva. It is one of the more common medically-related causes of malnourishment: some
15
48% of people with dysphagia are also malnourished. Signs of dysphagia are outlined in
Table 5 below.
When a person finds it difficult to swallow, they will naturally eat less. Mealtimes can become
a struggle, as eating can become both a slow and scary process. Residents with dysphagia
can have a higher risk of choking or aspirating (when food/fluid particles go into the lungs
rather than the stomach), which can lead to frequent chest infections and in some cases
pneumonia.
Residents with dysphagia would benefit from a review by a speech and language therapist
who will assess their swallowing and if needed, make recommendations regarding the types
and consistency of food/drink they should be eating/drinking in order to reduce their
swallowing difficulties.
Often the speech and language therapist will recommend thickened fluids if the resident is
having difficulty swallowing liquids. The thickened fluids may be recommended in different
consistencies – each consistency requires different amounts of thickener powder to be used.
It is important to follow the recommendations from the speech and language therapist, which
will also be on the back of the thickener powder tin in order for the drinks to be the
appropriate consistency for the resident. It is also important to note that when making drinks,
some thickener powder is added in before the fluid and some are added in after (please
follow instructions on the tin).
The speech and language therapist may also recommend a texture-modified diet, such as
fork-mashable or puree consistency. Unfortunately pureed food can be visually unappealing,
which can fail to trigger salivation, making swallowing even more difficult. For someone with
dysphagia, larger portions may appear more intimidating and may be unlikely to be finished.
If a resident is on a pureed diet, it may be more palatable to offer smaller, more manageable
portions of puréed meals. It is recommended to puree all foods individually and place on the
plate, rather than mixing all of the foods together and if possible, shape the foods to look like
a meal. A resident with dysphagia will need food/drinks that are not only the right texture, but
also visually appealing to help maintain interest in eating and drinking.
To reduce the risk of malnutrition in residents with dysphagia, food fortification can be used
(see Appendix D) and there are many snacks that are a soft or puree consistency (see
Appendix G).
Whenever dysphagia is identified, a detailed medication review needs to take place to determine how the resident’s medicines should now be administered in light of their swallowing difficulties. A pharmacist must be involved to ensure an appropriate formulation is prescribed and adequate directions are given (bearing in mind drug stability, compatibility with certain foods and drinks, palatability and licencing). This is also the case for residents who have been prescribed thickener and are taking medications in liquid forms, including those which are mixed with water prior to administration. Further information regarding the descriptions for fork-mashable and puree diets can be found in Appendix H. These will be very useful to help staff in the kitchen when preparing residents’ meals.
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Table 5: Signs that your resident may have dysphagia
Obvious indicators of dysphagia
Less obvious indicators of dysphagia
Difficult, painful chewing or swallowing Regurgitation of undigested food Difficulty controlling food or liquid in the mouth Change in drooling (increase) Gurgly/Wet voice quality Hoarse voice Coughing or choking before, during or after swallowing either foods, drinks or both Globus sensation (feeling of a lump in the throat) Nasal regurgitation (food coming out of the nose) Feeling of throat obstruction Unintentional weight loss
Xerostomia (dry mouth) Change in eating habits – for example, eating slowly or avoiding social occasions Frequent throat clearing Recurrent chest infections Atypical chest pain/ heartburn
Change in respiration pattern Unexplained temperature spikes Hoarse voice
Residents exhibiting any of the above signs may benefit from referral to a speech and language therapist for a full assessment.
6.0 Supporting nutrition and hydration in residents approaching
end of life (from the National Council for Palliative Care)
As residents approach the end of their life, the body starts to slowly shut down and there are
certain bodily changes that signify a person is likely to be close to death. It is normal for
these signs to come and go over a period of days.
The person’s appetite is likely to be reduced. They may no longer wish to eat or drink
anything. This could be because they find the effort of eating or drinking to be too much. But
it may also be because they have little or no need or desire for food or drink. Eventually, the
person will stop eating and drinking, and will not be able to swallow tablets. If they stop
drinking, their mouth may look dry, but this does not always mean they are dehydrated. It is
normal for all dying people eventually to stop eating and drinking
As a person is dying they may become much sleepier, spending more time asleep and can
be drowsy even when they are awake. If the person is conscious and they want something
to eat or drink, you can offer sips, provided they can still swallow. You can give some
comfort to a person with a dry mouth by:
offering a drink through a straw (or from a teaspoon or syringe)
placing ice chips in the mouth
applying lip balm
moistening the mouth with a damp sponge
o special kinds of sponge are available for this purpose,
o the person may bite on this at first, but keep holding it, as they will let go,
o sponges can be purchased (nursing homes) or ordered through community
nurses (residential homes)
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please note: syringes and oral sponges need to be used carefully as they can pose a
risk to the person, seek advice from the care home liaison nurse or community nurse
A resident approaching end of life should have an individualised plan of care. This should be
written in discussion with the resident and their family and address their care needs, choices
and wishes. This should include a discussion about eating and drinking. Key things to
remember are:
The dying person has a right to food and drink, if they would like this
They may decide not to have it, as they may not feel like eating or drinking, or
because they are struggling to swallow
If the person wishes and would benefit from other ways of receiving food and fluids,
this can be discussed with the GP or palliative care team. However, these are not
usually considered when a person is in the very final stages of life, as the body does
not require food or extra fluid at this time.
The supportive care home team can provide further advice and guidance around
individualised care planning and support with these discussions.
7.0 Oral and dental health
One of the key determinants of dietary variety in later life is good oral health. If dentures do
not fit very well or are uncomfortable, this will affect the residents’ desire and ability to eat.
Similarly, a sore mouth (for example: infection, ulcers, thrush, abscesses or decaying teeth)
will affect an individual’s desire and ability to eat. It is therefore important to ensure that
residents are supported to keep their mouths clean and healthy and that if problems are
suspected, a dentist or GP is contacted for advice.
The following guidance, published in ‘Delivering Better Oral Health’ (full reference below)1 is
recommended to maintain good oral health in adults:
Brush at least twice daily, with a fluoridated toothpaste
Brush last thing at night and at least on one other occasion
Use fluoridated toothpaste with at least 1350ppm fluoride
Spit out after brushing and do not rinse, to maintain fluoride concentration
The frequency and amount of sugary food and drinks should be reduced
This document also includes further guidance for individuals whose oral health is causing
concern and can be accessed online (see link at foot of page).
If a resident has Dementia, teeth brushing may be a challenge. They may not want to open
their mouth and they may resist their teeth being brushed. If the resident has dysphagia,
they may show signs of discomfort or coughing during brushing. In this situation, it may be
1
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/601833/delivering_better_oral_health_summary.pdf
18
beneficial to gain advice from a speech and language therapist on the best way to provide
oral care to residents.
The most significant effect of nutrition on teeth is the development of dental caries (tooth
decay), which can be affected by the frequency and amount of sugar intake, especially in the
absence of good oral hygiene. Root caries, in particular, occur more frequently in older
people because they are more likely to have exposed tooth roots as a consequence of
periodontal disease and gum recession.
Older people may also suffer from dental caries and periodontal disease as a result of:
Long term conditions that can limit an older person’s ability to carry out their usual
daily activities, which may impact on their oral hygiene routine and diet
Taking medication; for example those that cause a dry mouth or contain sugar
Between-meal snacks
Choice of snacks is important as many snacks do not need to contain extra sugar, see
examples in Appendix G. If you are concerned, discuss your resident’s diet with their
dentist, or ask the care home dietician for further advice.
If you’d like to understand more about providing mouth care, an e-learning module is
available on the e-learning for health website:
https://www.e-lfh.org.uk/programmes/improving-mouth-care/
8.0 Residents transferring between care settings
For residents who have an identified difficulty with either eating or drinking, it is important
that this information is communicated if the resident has to go to another care setting e.g.
hospital, outpatient appointment, day centre, hospice or other. Staff in these settings will be
responsible for ensuring your resident eats and drinks whilst they are there however they will
not know the specific preferences and care requirements for your resident. In these
situations, it is important to send with them the MUST score, swallowing/dietary
recommendations and copies of their nutrition and hydration care plans. For residents who
have particular needs, for example using adapted cutlery, a specific cup/plate or needing
thickener in their drinks, these aids should be transferred with the resident. This will ensure
your resident can maintain their nutrition and hydration whilst they are out of your care.
9.0 How to utilise the NICE quality standards for Nutrition
The NICE quality standard for nutrition support covers adults in hospital and the community
who are at risk of malnutrition or who have become malnourished, and adults who are
receiving oral nutrition support, enteral or parenteral nutrition. It requires that all care
services take responsibility for the identification of people at risk of malnutrition and provide
nutrition support for everyone who needs it. The 5 quality standards are:
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1: People in care settings are screened for the risk of malnutrition using a validated
screening tool.
2: People who are malnourished or at risk of malnutrition have a management care plan that
aims to meet their nutritional requirements.
3: All people who are screened for the risk of malnutrition have their screening results and
nutrition support goals (if applicable) documented and communicated in writing within and
between settings.
4: People managing their own artificial nutrition support and/or their carers are trained to
manage their nutrition delivery system and monitor their wellbeing
5: People receiving nutrition support are offered a review of the indications, route, risks,
benefits and goals of nutrition support at planned intervals.
The quality standards can help you in the following ways:
measure the quality of care
demonstrate you provide quality care
identify gaps and areas for improvement
understand how to improve care
An audit tool has been developed to support you to assess the service you provide against
the quality standards (Appendix I). Further information about using NICE quality standards
can be found at https://www.nice.org.uk/standards-and-indicators/how-to-use-quality-
standards#initial.
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References:
British Association of Parenteral & Enteral Nutrition (online). 2011. The ‘MUST’ Explanatory Booklet. Available at: http://www.bapen.org.uk/screening-and-must/must
Malnutrition Task Force (online). Preventing Malnutrition in Later Life. Available at: www.malnutritiontaskforce.org.uk
National Association of care catering (online). 2011. Dysphagia Diet Food Texture Descriptors. Available at: http://www.thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20Industry%20Final%20-%20USE.pdf
National Institute for Health and Care Excellence (online). 2006. Clinical guideline 32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Available at: www.nice.org.uk/guidance/cg32
National Institute for Health and Care Excellence (online). 2012. Nutrition support in adults: Quality standard. Available at: https://www.nice.org.uk/guidance/qs24/resources/nutrition-support-in-adults-pdf
Public Health England (online). 2017. Delivering better oral health: an evidence-based toolkit for prevention: Summary guidance tables. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/601833/delivering_better_oral_health_summary.pdf
The Alzheimer’s Society (online). Eating and Drinking. Available at: https://www.alzheimers.org.uk/info/20029/daily_living/10/eating_and_drinking
The National Council for Palliative Care (online). 2015. What to expect when someone important to you is dying: A guide for carers, families and friends of dying people. Available at: http://www.ncpc.org.uk/sites/default/files/user/documents/What_to_Expect_FINAL_WEB.pdf
Acknowledgements:
This guidance document was supported by information provided by the community dietetics team at South Essex Partnership University NHS Foundation Trust and the care home dietician from Newcastle-Gateshead Care Home Vanguard.
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Appendix A: Example food and drink record charts
22
23
24
Res ident's Name:
How to complete: Week beginning:
For each meal write down what was eaten and the quantity of the meal eaten (tick box)
Day Sunday Monday Tuesday
1/4 1/4 1/4
1/2 1/2 1/2
3/4 3/4 3/4
Al l Al l Al l
None None None
Snack
1/4 1/4 1/4
1/2 1/2 1/2
3/4 3/4 3/4
Al l Al l Al l
None None None
Snack
1/4 1/4 1/4
1/2 1/2 1/2
3/4 3/4 3/4
Al l Al l Al l
None None None
Breakfast
Lunch
Amount Eaten
(Tick Box)
Amount Eaten
(Tick Box)
Amount Eaten
(Tick Box)
Dinner
Supper / Snack
Food Chart
25
Day Wednesday Thursday Friday Saturday
1/4 1/4 1/4 1/4
1/2 1/2 1/2 1/2
3/4 3/4 3/4 3/4
Al l Al l Al l Al l
None None None None
Snack
1/4 1/4 1/4 1/4
1/2 1/2 1/2 1/2
3/4 3/4 3/4 3/4
Al l Al l Al l Al l
None None None None
Snack
1/4 1/4 1/4 1/4
1/2 1/2 1/2 1/2
3/4 3/4 3/4 3/4
Al l Al l Al l Al l
None None None None
Amount
Eaten
(Tick Box)
Amount
Eaten
(Tick Box)
Breakfast
Lunch
Amount
Eaten
(Tick Box)
Amount
Eaten
(Tick Box)
Dinner
Supper /
Snack
Food Chart Res ident's Name:
Week beginning:
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Appendix B: UTI reference card
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Appendix C: BAPEN Malnutrition Universal Screening Tool (6
pages)
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29
30
31
32
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Appendix D: Basic Food Fortification
Fortifying is when small quantities of regular foods, such as cream, milk powder, butter or
milk are added to a food dish to increase the energy and nutrient content without increasing
the portion size. This means that every mouthful your resident eats is full of nourishment.
Some examples of how easy it is to fortify a diet with common foods:
FOOD One Serving Calories Protein
Skimmed milk powder 1 tbsp. (9g) 30 3.3 g
Skimmed milk powder 1 tsp (3g) 10 1.1g
Butter/Margarine 1 tsp (5g) 35 0g
Full Cream Milk 8 tbsp. (120g) 72 4g
Double Cream 1 tbsp. (16g) 79 0.2g
Single Cream 1 tbsp. (16g) 30 1g
Cheddar Cheese 10g 42 2.5g
Jam, Honey 1 heaped tsp 50 0g
Sugar 1 tsp 20 0g
Fortified recipes:
Porridge with Whole Milk (150g) Add 2 tsp milk powder,1 tsp double cream, 1 tsp sugar and 2 chopped dates: 368kcal and 10.9g protein (before fortification: 170kcal and 7.2g protein)
White Sauce with Whole Milk (30g) Add 1 tsp double cream, 2 tsp milk powder and 10g cheddar cheese: 157kcal and 6.2g protein (before fortification: 45kcal and 1.3g protein)
Scrambled Egg with Whole Milk (120g) Add 1 tsp butter, 2 tsp milk powder and 45g cream cheese: 603kcal and 15.8g protein (before fortification: 308kcal and 13.1g protein)
Boiled Carrots (30g) Add 1 tsp of butter and 2 tsp of honey: 90kcal and 0.2g of protein (before fortification: 7kcal and 0.2g protein)
Custard with Whole Milk (150g) Add 2 tsp milk powder and 2 tsp double cream: 262kcal and 7.3g protein (before fortification): 142kcal and 4.7g protein)
Mashed Potato (60g) Add 1 tsp butter, 2 tsp milk powder and 1 tsp double cream: 170kcal and 3.5g protein (before fortification: 62kcal and 1.1g protein)
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How to make a large batch of Fortified Milk:
Add 4 tablespoons of dried skimmed milk powder to 1 pint of full fat milk and blend/mix until
smooth. Chill in the fridge and then use on cereals, in porridge, to make up sauces, soups,
desserts, jellies, or milky drinks, etc.
Difference in Nutrition with full fat milk vs fortified full fat milk:
Pint of Full Fat Milk Pint of full fat milk with skimmed milk powder
Calories = 380 Calories =565
Protein = 18g Protein = 40g
A glass of full fat milk has the same calories as eight cups of tea! When possible try to serve
nourishing drinks in place of tea or coffee.
Difference in Nutrition in Tea and Coffee using full fat milk vs fortified full fat milk:
Tea or Coffee with normal milk (no sugar) Tea or Coffee with fortified milk (and 2 sugars)
Calories = 15 Calories = 75
Protein = 1g Protein = 4g
More Tips for fortifying Foods:
Simply add dried skimmed milk powder directly to soups, puddings, custards, mashed
potatoes – use 2-3 teaspoons of powder per portion of food
Be sure you are using full fat and full sugar products rather than ‘diet’ ‘reduced/low fat’ or
‘low sugar’ varieties. Full fat/sugar options will provide more calories.
Adding knobs of butter, margarine, and oils like vegetable, rapeseed or olive oil will add
flavour and calories to foods such as vegetables, mashed potato, and jacket potatoes.
Adding grated cheese to soups, mashed potato, scrambled eggs, etc. will also provide extra
calories and flavour.
Use your imagination and knowledge of each resident’s likes and dislikes to add extra
calories and protein to dishes when fortification is needed!
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Appendix E: Replacing oral nutritional supplements with
nourishing drinks
Nourishing drinks can provide your resident with extra energy and calories as well as fluid to
keep them well hydrated. Keep in mind that many people fill up on drinks like tea, coffee,
Oxo, Bovril and water when they are feeling unwell. While there’s nothing wrong with these
drinks, and they do provide hydration, they actually offer little nutritional value. A more
nourishing option for residents who need it will provide far more energy and protein. In fact,
you may be able to replace a supplement with a nourishing drink. This will ensure that
your resident is still getting appropriate nourishment and hydration.
If your resident has been drinking Complan shakes (387 calories and 15.6g protein) or
Aymes shakes (388 calories and 15.8g protein), try:
If your resident has been drinking Fortisips (300 calories and 12g protein), try:
If your resident has been eating Forticreme desserts (200 calories and 11.9g protein), try:
Yogurt and Berry Smoothie
(384 calories and 22.5g protein)
1 small pot of Greek yoghurt
Handful frozen berries
1 small banana
150 mls full cream milk (blue top)
Combine and blend until smooth.
Malt Honey Milkshake
(291 calories and 8g protein)
200 mls full cream milk (blue top)
1 tablespoon honey
1 scoop ice cream
1 teaspoon (5g) malted milk powder (e.g. Horlicks)
Combine and blend for 15 seconds.
Chocolate/Strawberry Mousse (makes 4)
(Approx. 225 calories and 7g protein)
1 packet of instant mousse mix
¼ pint (145 mls) of whole milk
¼ pint (145 mls) evaporated milk
Mix all ingredients together. Pour into 4 bowls. Chill until set. Adding 1 tablespoon of double or whipped cream adds extra 120 calories.
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HOME-MADE NOURISHING DRINKS
The recipes below are quick and easy to make and provide ideas for maximizing fluid intake while also providing energy and protein.
Yoghurt and Berry Smoothie
Small pot of Greek Yogurt
Handful of frozen berries
1 small banana
150 mls full cream milk (blue top)
Blend until smooth Approx. 384 calories and 22.5g protein
Malt Honey Milkshake
200 mls full cream milk (blue top)
1 tablespoon honey
1 scoop ice cream
1 teaspoon (5g) malted milk powder (e.g. Horlicks)
Blend for 15 seconds Approx. 291 calories and 8g protein
Hot Chocolate
150 mls (1/4 pint) full cream milk
1 heaped tablespoon milk powder
2 tablespoons whipping or double cream
3 teaspoons of hot chocolate powder
Heat all ingredients together until simmering.
Approx. 450 calories and 5g protein
Milky Coffee
150 mls (1/4 pint) full cream milk
1 heaped tablespoon of milk powder
2 tablespoons of cream
1 teaspoon of coffee powder
Mix milk, cream, milk powder together. Heat until simmering. Add coffee powder and stir.
Approx. 350 calories and 4.5g protein
Banana Smoothie
200 mls full cream milk (blue top)
1 small ripe banana
1 scoop ice cream
1 teaspoon sugar
Mash banana, add all ingredients, blend and serve chilled.
Approx. 277 calories and 6g protein
Fruit Blast
100 mls fresh fruit juice
100 mls lemonade
1 scoop ice cream
1 tablespoon sugar
Mix together and serve chilled Approx. 216 calories and 0g protein
Orange Flavour Drink
150 mls of orange juice
1 banana
1 tablespoon of honey
4 teaspoons tinned peaches (in syrup)
Blend for 15 seconds. Approx. 300 calories and 2g protein.
Juice-style Nourishing Drink
180 mls fruit juice
1 sachet of egg white powder
40 ml cordial or squash
Mix cordial or squash into egg white (do not whisk!) then gradually add in fruit juice.
Approx. 256 calories and 9g protein
Pineapple Yoghurt Drink (makes 2 servings)
300 mls (1/2 pint) full cream milk
1 pot (50 g) thick/creamy fruit yoghurt
1 heaped tablespoon milk powder
1 tablespoon sugar
3 pineapple rings from tin
Blend for 15 seconds. Serve chilled. Approx. 345 calories and 15g protein per serving
Plain Old Milkshake
200 mls full cream milk
2 heaped tablespoons of milk powder
Milkshake syrup/powder to taste (e.g. Crusha or Nesquik)
Whisk milk and milk powder together. Add flavouring. Serve chilled.
Approx. 300 calories and 10g protein
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SUPERSHAKES
Super Shakes provide 500 calories or more in a single serving. They may be the boost your resident needs to gain weight. Always use super shakes or any nourishing drink recipe in addition to a balanced meal.
Berry Delight
2 x 50g pots of fromage frais yoghurt
100 ml cranberry juice
5 tablespoons double cream
1 tablespoon strawberry milkshake powder
Combine and serve. No blender needed.
Approx. 550 calories and 13g protein
Peanut Butter Shake (not for those with nut allergy!)
250 ml fortified milk
1 scoop ice cream
1 mashed banana
1 tablespoon peanut butter
1 teaspoon honey or sugar
Blend for 15 seconds Approx. 510 calories and 22g protein
Nice ‘n’ Nutty (not for those with nut allergy!)
200 mls whole milk
2 tablespoons double cream
2 tablespoons condensed milk
2 tablespoons hazelnut chocolate spread
1 tablespoon dried milk powder
Whisk together. Approx. 580 calories and 15g protein
Bourbon Cream Dream
4 bourbon cream biscuits, crushed into fine crumbs
200 mls whole milk
2 tablespoons condensed milk
1 tablespoon dried milk powder
Mix well.
Try replacing biscuits with custard creams or gingernuts for a change.
Approx. 560 kcals and 17g protein
DAIRY-FREE SUPER SHAKE
For your residents who dislike milk or have a dairy intolerance and also need extra calories to gain weight.
Virgin Pina Colada
100 ml tinned coconut milk
100 ml pineapple juice
2 ½ tablespoons apricot jam
2 ½ tablespoons icing sugar
1 tablespoon golden syrup
Combine and serve. Approx. 520 calories, 0g protein
Lemon and Lime Sublime
100 ml lemonade
100 ml lime cordial
2 ½ tablespoons lemon curd
2 ½ tablespoons icing sugar
1 tablespoon golden syrup
Whisk together and pour through strainer to serve.
Approx. 500 calories and 0g protein
Eton Mess
2 meringue nests (approx. 30 g)
150 ml soya milk
2 ½ tablespoons strawberry milkshake powder
2 ½ tablespoons strawberry jam
1 ½ tablespoons icing sugar
Blend for 15 seconds. Approx. 520 calories, 6.5g protein
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Appendix F: Using finger foods
Finger foods are a great way to promote eating when your resident simply cannot stay at the
table or when a change from the ‘norm’ is needed. Everyone can enjoy them and your
resident’s independence is increased. Remember to consider what consistency diet your
resident is on before offering these as some of the foods below will not be suitable for those
with dysphagia.
Tips for Success with Finger Foods
When preparing finger foods, think about convenience, size and shape. It’s important
that foods are not too big or too small.
Ensure that foods are easy for your residents to handle.
Temperature – ensure cooked food has cooled enough to hold comfortably in the
hand and to eat.
Leaving the skin on fruit will make it easier to hold and less slippery.
Be sure to peel hardboiled eggs before serving them as a finger food!
If offering sandwiches, ensure that the filling is moist so that the sandwich stays
together.
The following make great finger foods;
Apple Slices Banana Biscuits Cakes Carrot Sticks Celery Sticks Cereal Bars Cheese Cubes Cherry Tomatoes Chicken Drumsticks Chips
Crumpets Cucumber Fish Fingers Grapes Hardboiled Eggs Meatballs Pizza Slices Sandwiches Sausages Small Potatoes Toast
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Appendix G: Using snacks
Snacking between meals is very helpful if your resident has a small appetite, is easily
distracted during mealtimes or gets tired trying to eat a whole meal. Snacking helps to
increase the overall intake of food and nutrients and providing several smaller meals is as
good as providing 3 larger ones.
Tips for success with Snacks
Get to know your residents favourite foods and if possible, provide what they enjoy
the most.
Try to provide 2-3 snacks between meals in addition to the normal diet
Encourage small amounts to be eaten regularly- for instance, breakfast, morning tea,
lunch, afternoon tea, dinner and supper
Use snacks like those listed below, a biscuit with a cup of tea does not provide
enough calories or nutrition!
The following make great snacks;
Cheese and crackers
Dried fruit and nuts
Muesli bar or flapjack
Small packet of crisps
Sandwich with meat/cheese
Piece of fruit
Chocolate biscuits
Crackers and dip
Crumpets with spread
Cheese on toast
Scone with clotted cream and jam
Baked beans on toast
Scrambled eggs
Tinned fruit and ice cream
White crustless sandwich with creamy filling, like egg or tuna mayo/cream cheese/jam/smooth peanut butter
Very soft pastry/pie (not crumbly) softened with custard/cream
Soft moist cake/muffin
Yoghurt
Custard
Chocolate or fruit mousse
Milky Pudding
Mashed Banana and Custard
Creamed Rice
Jelly and ice cream
Fromage frais
Crème Caramel
Self-saucing pudding
Porridge/soggy cereal with milk/double cream
Soup with Milk/Double Cream
Glass of Full Fat Milk (blue top)
Glass of fortified milk
Glass of fruit juice
Fruit smoothie
Milkshake
Soft drinks or cordials
Nourishing drinks (see Appendix E).
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Appendix H: Food texture descriptors for dysphagia diets.
From the National association of care catering, full guidance available from:
http://www.thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20Ind
ustry%20Final%20-%20USE.pdf
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44
45
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Appendix I: Audit tool using NICE Quality Standards
Guidance: To complete this audit, you will need to review resident assessments and care plans and observe practice at meal and snack times.
NB: Quality standard 4 is not included as it is not very relevant to care home settings
QS 1: People in care settings are screened for the risk of malnutrition using a validated screening tool. Screening is carried out by health and social care professionals who have undertaken training to use a validated screening tool Staff have access to calibrated equipment to enable accurate screening (e.g. weighing scales suitable for all residents)
Q1. Number of residents who have been screened using MUST in the last month X 100 = % of residents who have been screened.
Total number of residents Q2. How confident are you that ALL of your staff who complete a MUST assessment have been trained to use it? Not at all confident 1 2 3 4 5 6 7 Very confident Q3.
Do you have equipment for weighing residents who are: Mobile/ able to stand Less mobile/ sitting Immobile/ hoist
Yes/ No Yes/ No Yes/ No
When was the weighing equipment last calibrated for accuracy?
QS 2: People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their complete nutritional requirements. Care settings are able to provide appropriate nutrition support including artificial feeding when needed. NB: Artificial feeding is not included in this audit tool
Q4. Number of residents at risk of malnutrition (MUST score 1 or 2) and have a comprehensive nutrition management care plan X 100 = % of residents with
Total number of residents who are at risk of malnutrition a nutrition care plan Q5. How confident are you that ALL of your residents who require support to eat receive the required level of support at every meal? Suggestion: Observe a number of residents who require support at mealtimes Not at all confident 1 2 3 4 5 6 7 Very confident Q6. How confident are you that ALL of your residents who have additional food requirements (e.g. snacks, fortified food, nourishing drinks, supplements etc.) receive these?
Person completing:
Date of completion:
Nutritional screening tool used if not MUST:
47
Suggestion: Observe a number of residents who require additional food items, review snack provision- does it include a range of energy-dense snacks (e.g. cake, full fat yoghurt, chocolate, nuts, fruit and cream)? Not at all confident 1 2 3 4 5 6 7 Very confident
QS 3: All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable), documented and communicated in writing within and between settings.
Residents screened for the risk of malnutrition have their results and nutritional support goals (if applicable) documented in their care plan. Residents screened for the risk of malnutrition have their results and nutritional support goals (if applicable) communicated in writing within and between settings.
Q7. Number of residents with an up to date MUST score documented on the older persons assessment form (or equivalent) X 100 = % of residents with a
Total number of residents with an up to date MUST score documented result Q8. Consider the last few residents who were admitted to hospital, how confident are you that their comprehensive nutrition management care plan went with them to hospital? Not at all confident 1 2 3 4 5 6 7 Very confident
QS 5: People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals. Residents receiving nutrition support who have the indications, route, risks, benefits and goals of their nutrition support reviewed at planned intervals.
Q9. Number of residents with a comprehensive nutrition management care plan that has been reviewed and updated in the last month X 100 = % of residents with
Total number of residents with a comprehensive nutrition management care plan a planned review Q.10. Consider the residents who are under the care of a dietician, how confident are you there is a documented planned review date? Not at all confident 1 2 3 4 5 6 7 Very confident
Tips for observing practice: When observing what happens in your care home around nutrition support and at mealtimes, consider the following best practice recommendations:
People should be encouraged to consume some form of nourishment ‘little and often’, e.g. every 2-3 hours throughout the day o What is the meal/snack pattern and frequency?
Providing energy-dense and nutrient-dense foods, snacks and drinks is an important strategy to increase calories/protein, without increasing volume and impacting on appetite
o are snacks energy-dense, are nourishing drinks provided at least once per day, is food fortification being used, if so what and how? o If a resident refuses a meal, are they offered a suitable alternative e.g. nourishing drink?