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.
[Face to face or telephone] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) consultation to [Name and role of staff member present] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) at [Name of care or nursing home](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) [Names and roles of any other individuals present at the visit](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Patient seen in best interest.
Referred on [Date of referral] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) by [Name and role of referrer] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) for [Reason for referral](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Anthropometry
Most recent weight: [Most recent weight in kg](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Height: [Height in cm and/or feet and inches](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
BMI: [Body mass index](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
MUST: [MUST score and category](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Weight history: [Previous weight recordings with dates](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
MUAC: [Mid-upper arm circumference in cm with date of measurement](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Anthropometry impression: [Clinical impression of anthropometry including percentage weight loss in the last 3 and 6 months, when weight loss started, and причин if known](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Biochemistry: [Relevant laboratory values](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
BMs: [Blood glucose or BM readings](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Clinical: [Recent clinical updates including any hospitalisations, scans, investigations, visits or comments from other professionals, infections, or other clinically relevant events](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
PMHx: [Past medical history](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Relevant medications: [Current medications](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Nutritional supplements: [Supplement name, energy in kcal, protein in grams, and volume in ml](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Capacity: [Whether the patient has capacity — yes or no](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Skin integrity: [Current skin status and any pressure areas or wounds](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Dentition: [Condition of teeth, dentures, and oral health](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Bowels: [Bowel habit including frequency and consistency](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Mobility: [Current mobility level and any mobility aids used](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else keep heading but leave blank.)
Social History
[Summary of social situation including residency status, family visits, and social interactions](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Dietary
Is patient on fortified diet? [Yes or no](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Assistance with eating? [Yes or no, and nature of assistance if described](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Allergies: [Known food and drug allergies and nature of reactions](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
IDDSI: [SALT review date, recommended IDDSI fluid level and diet level. If not known to SALT, write "Normal diet and fluids - not known to SALT"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Dietary intake
Breakfast: [Breakfast details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Mid-morning snack: [Mid-morning snack details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Lunch: [Lunch details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Mid-afternoon snack: [Mid-afternoon snack details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Evening meal: [Evening meal details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Supper: [Supper or evening snack details](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Fluid intake: [Total daily fluid intake](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Diet summary: [Qualitative summary of overall dietary intake and patterns](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Estimated nutritional intake: Energy – [Total estimated kcal] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) kcal, Protein – [Total estimated protein in grams] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) g, Fluids – [Total estimated fluid in ml] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) ml
Estimated nutritional deficit: [Estimated energy deficit in kcal] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) kcal, [Estimated protein deficit in grams] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) g protein, [Estimated fluid deficit in ml] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) ml
Daily estimated nutritional requirements based on [Most recent weight in kg] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) kg:
Energy: [Energy requirement per kg based on BMI: 20–25 kcal/kg if BMI above 18.5, or 25–30 kcal/kg if BMI below 18.5] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) kcal/kg x [Physical activity level: 1, 1.1, 1.2, or 1.4] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) PAL = [Total energy requirement in kcal] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) kcal
Protein: 1.2–1.5 g/kg = [Total protein requirement in grams] g(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Fluid: 30 ml/kg = [Total fluid requirement in ml] ml(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Consultation summary: [Summary of the key points discussed during the consultation](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
PASS Statement: [Dietetic problem] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) related to [aetiology] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) as evidenced by [signs and symptoms](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
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. [First plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
2. [Second plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
3. [Third plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
4. [Fourth plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
5. [Fifth plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
6. [Sixth plan point](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
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.(Only include if oral nutritional supplements are included in the plan, else omit this sentence entirely.)
