NH template

NH template Face to face consultation to Dr. Thomas Kelly, Dietitian, at Green Valley Nursing Home. Present were Mrs. Eleanor Vance (patient's daughter) and Mr. John Smith (Head Nurse). Patient seen in best interest. Referred on 1 November 2024 by Dr. Sarah Jenkins, GP for unintentional weight loss and poor oral intake. Anthropometry Most recent weight: 48.5 kg Height: 155 cm (5 feet 1 inch) BMI: 20.2 MUST: 2 (Medium Risk) Weight history: 52 kg (01/05/2024), 50 kg (01/08/2024) MUAC: 22 cm (01/10/2024) Anthropometry impression: The patient has experienced a 6.7% weight loss in the last 6 months (from 52kg to 48.5kg). Weight loss started approximately 6 months ago, attributed to reduced appetite and difficulty chewing. Biochemistry: HbA1c 6.5%, Albumin 3.2 g/dL, CRP 8 mg/L. BMs: Fasting BMs consistently between 6.5-7.0 mmol/L. Clinical: Patient recently discharged from hospital following a chest infection. No recent scans or investigations. Comments from nursing staff indicate fluctuating appetite and occasional confusion. No active infections identified. PMHx: Type 2 Diabetes Mellitus, Mild Cognitive Impairment, Osteoarthritis. Relevant medications: Metformin 500mg BD, Donepezil 5mg OD, Paracetamol 1g QDS PRN. Nutritional supplements: Ensure Plus (Strawberry Flavour), 300 kcal, 12 g protein, 200 ml. Capacity: Yes Skin integrity: Intact, no pressure areas or wounds observed. Dentition: Wears full upper and lower dentures, reports discomfort with chewing tough foods. Bowels: Daily bowel movements, soft consistency. Mobility: Independent with walking using a frame. Social History Patient resides alone but has daily visits from her daughter, Mrs. Vance, who assists with meals and personal care. Enjoys occasional social interactions with other residents in the nursing home. Dietary Is patient on fortified diet? Yes Assistance with eating? Yes, requires some prompting and assistance with opening containers. Allergies: Penicillin (rash), no known food allergies. IDDSI: Normal diet and fluids - not known to SALT Dietary intake Breakfast: Small bowl of porridge with milk, half a slice of toast with jam. Mid-morning snack: None. Lunch: Small portion of pureed chicken and mashed potatoes, small fruit yoghurt. Mid-afternoon snack: None. Evening meal: Small portion of soft fish with vegetables, custard. Supper: Hot chocolate. Fluid intake: Approximately 1000 ml (including tea, hot chocolate, water). Diet summary: Overall intake is suboptimal, particularly protein and energy. Patient struggles with texture of some foods and has a poor appetite, leading to frequent unfinished meals. Estimated nutritional intake: Energy – 1200 kcal, Protein – 45 g, Fluids – 1000 ml Estimated nutritional deficit: 600 kcal, 25 g protein, 500 ml Daily estimated nutritional requirements based on 48.5 kg: Energy: 25–30 kcal/kg x 1.1 PAL = 1600-1800 kcal (Average 1700 kcal for calculation) Protein: 1.2–1.5 g/kg = 58-73 g (Average 65 g for calculation) Fluid: 30 ml/kg = 1455 ml Consultation summary: Patient is experiencing unintentional weight loss due to poor oral intake and reduced appetite. Current nutritional intake is below requirements, contributing to a medium MUST risk. Patient has capacity and family is supportive. Denture discomfort affects food choices. Current ONS is being provided. PASS Statement: Unintentional weight loss related to inadequate oral intake and reduced appetite as evidenced by 6.7% weight loss in 6 months, MUST score 2, and dietary intake assessment showing significant energy and protein deficits. Aim: To optimise oral intake to support weight gain and prevent further nutritional losses via a food first approach and oral nutritional supplements. Plan 1. Increase current ONS to 2 bottles per day (Ensure Plus) to provide additional 600 kcal and 24g protein. To be taken between meals. 2. Recommend softer textured foods and finely minced meats for main meals to address denture discomfort. Liaise with catering staff. 3. Fortify meals with butter, cream, and cheese where appropriate to boost energy and protein content. 4. Encourage regular snacks, such as full-fat yoghurt, cheese and crackers, or fortified soups, between meals. 5. Review patient's fluid intake and encourage sips of water, dilute juice, or milky drinks throughout the day to reach target of 1455ml. 6. Re-weigh in 4 weeks to monitor progress and adjust plan as needed. Discharge Plan: Discharge patient from the Community Nutrition Support Service. Please refer to the service if there is: - Further weight loss of greater than 5% within the next 3–6 months - Development of a pressure ulcer grade 2 or above If oral nutritional supplements are not tolerated, the GP should review and manage accordingly.