There are 12 areas of care need that are considered when a Decision Support Tool (DST) is completed and these are referred to as ‘care domains’:
4. Skin (including tissue viability)
7. Psychological and Emotional Needs
10. Drug Therapies and Medication
11. Altered States of Consciousness
12. Other significant care needs
The second care domain on the DST is ‘Nutrition – Food and Drink’. The DST states that ‘Individuals at risk of malnutrition, dehydration and/or aspiration should either have an existing assessment of these needs or have had one carried out as part of the assessment process with any management and risk factors supported by a management plan. Where an individual has significant weight loss or gain, professional judgement should be used to consider what the trajectory of weight loss or gain is telling us about the individual’s nutritional status’.
When considering Nutrition, there are 4 possible levels of need which could be selected – ranging from ‘No Needs’, ‘Low’, ‘Moderate’ and ‘High’ at the top end. Unlike some other care domains, with Nutrition, there is no ‘Severe’ or ‘Priority’ levels of need.
The relevant levels of need are defined in the DST as follows:
|Level of need
|Able to take adequate food and drink by mouth to meet all nutritional requirements.
|Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies).
Able to take food and drink by mouth but requires additional/supplementary feeding.
|Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.
Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.
|Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway.
Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers.
Nutritional status “at risk” and may be associated with unintended, significant weight loss.
Significant weight loss or gain due to identified eating disorder.
Problems relating to a feeding device (for example PEG) that require skilled assessment and review.
Let’s examine each level of need in more detail:
As would be expected, if an individual is drinking and eating normally, is able to feed themselves, and had no issues with their weight – this will be determined as having ‘No Needs’.
A level of ‘Low’ needs will arise in the following examples:
- ‘Needs supervision with meals’: This could be because the individual has a cognitive impairment which means that they need someone nearby to check that they are eating; to help them with aspects of their meal – such as cutting up food; or to make sure that they are not aggressive whilst eating.
Frequently, we see individuals with dementia who can feed themselves but need a little extra help or may need their hand steadying at times. Supervision could also be needed if the individual can become aggressive. For example, if they think someone else is going to take their food, or is known to throw food or steal another’s food. (TIP: this should also be considered in the Behaviour care domain).
- ‘Needs prompting with meals’: Prompting and encouragement may be needed, for example, if an individual has a short-term memory deficit causing them to forget to eat or drink or become distracted.
- ‘Needs feeding’: As an example, this will include a person who cannot feed themselves – perhaps because they can’t hold cutlery due to poor dexterity or poor coordination; or has lost the ability to feed themselves due to poor cognition, such as dementia or a brain injury. TIP: It is important to identify how long it takes to feed the person, because if it takes over half an hour, the level of need rises.
- ‘Needs a special diet’: This could be due to having food intolerances or allergies, or a diabetic diet.
- ‘Is able to take food and drink by mouth but requires additional or supplementary feeding’: For example, this could be because the individual has a low weight, and a dietician or GP has suggested extra snacks or supplements between meals.
A level of ‘Moderate’ needs will arise where an individual:
- ‘Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed’: The length of time it takes to complete a meal needs to be recorded in the clinical notes. TIP: If your relative takes a long time to be fed, it is important for assessment purposes to make sure that their carers record the average time taken.
- ‘Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG’: The full title for a PEG is a ‘Percutaneous Endoscopic Gastrostomy’. There is also a RIG or ‘Radiologically Inserted Gastrostomy’. Both forms of artificial feeding use a tube placed into the stomach to administer a person’s nutritional needs, when they are not able to take nutrition orally. To fit the tube, a small incision is made under local anaesthetic in the skin. The tube is passed into the mouth, down through the stomach and out through the incision. The feeding tube is specially designed to carry food and fluid in a liquid form. Specialised liquid nutrition, as well as fluids, are given through the tube. Feeding tubes are often used if the person has difficulties swallowing, for example after a stroke. As long as the feeding tube does not cause frequent difficulties, it will be considered ‘non-problematic’.
There might be issues around the tube being pulled out a lot if the individual is agitated or does not understand the reason for having the tube. Any difficulties with the tube should be recorded in the person’s care notes.
TIP: The individual should have a Care Plan that explains exactly what care is needed to manage the feeding tube.
Basic care involves daily flushing of the PEG/RIG with water. It may be that the individual with the PEG/RIG can take care of this themselves, but if not, a carer will need to undertake this care.
NG tubes (nasogastric tubes) may also be used as another means of artificial feeding. Here the tube is inserted into the nasal passage down to the stomach and liquid nutrition is put into the tube with a syringe.
A level of ‘High’ will arise once the need goes beyond ‘Moderate’. This will include:
- ‘Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway’: Dysphagia means swallowing difficulty. Some people have difficulty swallowing certain consistencies of food or fluids and may need to be given an altered consistency diet, such as thickened liquids or purified meals. Signs of dysphagia can include:
- coughing or choking when eating or drinking
- a ‘gurgly’, wet-sounding voice when eating or drinking
- being unable to chew food properly
- bringing food back up, sometimes through the nose
- a sensation that food is stuck in your throat or chest
- persistent drooling of saliva
What is skilled intervention? This could be a carer needing to manage dysphagia (see signs above) because the individual cannot do it themselves, and there is still regular evidence of dysphasia even with modifications to the consistency of the food or fluids. Often, individuals with dysphagia will have been assessed by a Speech and Language Therapists (SALT) to determine their ability to swallow different consistencies and to advise on the best consistency for the person.
SALT may make other recommendations, for example, for the person to be fed upright, or to stay upright for a given time post-meals or fluids, or to use a specific drinking vessel etc. An individual with a deteriorating swallow might need more than one assessment from SALT to ensure the consistency of their diet remains appropriate for their ability to swallow. TIP: If a person is assessed for CHC funding and there is evidence of dysphasia, but SALT have not already carried out an assessment, the NHS’s Assessor should request a review by SALT before concluding their assessment.
What is aspiration? This is where food or fluids enter the lungs. It can cause coughing or gurgling sounds and can result in chest infections and aspiration pneumonia, and cause chest sepsis and fatality.
- ‘Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers’: When an individual is unable to take fluids orally, fluids can be administered artificially, either intravenously or by infusion, into the subcutaneous tissues – a process known as Hypodermoclysis. Fluids are infused into the subcutaneous space via small-gauge needles that are typically inserted into the thighs, abdomen, back, or arms.
- ‘Nutritional status “at risk” and may be associated with unintended, significant weight loss’: If there are concerns about a person’s nutritional status, carers should be completing the MUST (Malnutrition Universal Screening Tool). The MUST is a five-step screening tool used to identify adults who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a Care Plan. If a person scores ‘1’ on the MUST they are ‘at risk’; scores of 2 or above indicate they are high risk of malnutrition and should be referred to a dietician. For more information, a copy of the MUST can be downloaded at https://www.bapen.org.uk/pdfs/must/must_full.pdf
What is significant weight loss? This could be anything above 5% of body weight lost in the past 3-6 months.
- ‘Significant weight loss or gain due to identified eating disorder’: See above for significant weight loss or gain. Examples of an eating disorder could include: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, other specified feeding and eating disorder, pica and rumination disorder.
- ‘Problems relating to a feeding device (for example PEG) that require skilled assessment and review’: This could include, for example:
- Bleeding and perforation (hole in the wall of your bowel or intestine).
- Infection near the incision.
- Frequent blockages
- Feeding intolerance
TIP: There will need to be some clinical judgment as to whether the problems are serious enough or frequent enough to meet the ‘High’ level of need.
Things that can make care around nutritional intake more difficult or more time consuming:
TIP: As with all the care domains in the DST, issues within this domain need to be considered in conjunction with the other needs in other domains, taking an holistic approach.
So, for example, a person who needs to be fed and has no sight, or no hearing, or no cognitive ability, might be more difficult or more time consuming to feed.
Similarly, if a person is immobile, it might be more difficult to position them correctly for meals, drinks or feeding, particularly if they also have dysphagia. If they are aggressive during feeding this may also cause additional difficulties.
These are all issued that should be considered in the conjunction with the 4 Key Characteristics.
For more information and reading around the subject, take a look at these helpful blogs:
You must ensure that whatever the nutritional problem or risk, the care needed to meet those needs is properly recorded in the care notes and considered in conjunction with the other care domains.
For further reading in our ‘TIPS on assessing…’ series:
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