Innovations to support hydration care across health and social care

It is known that the primary cause of dehydration in elderly care is caused by a person not regularly drinking enough. Dehydration is a much-publicised national concern, associated with poor outcomes of care and acute hospital admissions. However, in November last year, NHS England stated that the scale of dehydration is not known; in comparison, it confirmed at least three million people are at risk of malnutrition. The stark comparison in information occurs because there is no nationally recognised screening tool to identify who is at risk of dehydration. An innovative nursing role, focused on finding solutions to reduce the risk of dehydration in the care of older and vulnerable persons, has led to the development of a simple dehydration screening tool called 'ROC to drink' (ROC stands for 'reliance on a carer'), which focuses on the level of support needed to drink. An innovative tea cup has been designed to help raise standards for monitoring drinks and raise awareness about intake.

Nasogastric tube feeding: a safe option for patients?

This article will show that fine-bore nasogastric tube feeding can be facilitated for patients when long term percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG) options are not suitable. How the safe replacement of these tubes is facilitated, and what instructions the patient and the nursing home are given to support patient care and safety are also discussed. The decision to support this type of feeding must be completely individualised, considering home and external support agencies available to each patient. The risk assessment completed to facilitate this has been based on the patients' individual circumstances, and a nasogastric tube home passport developed to help in the assessment and decision-making process. For fine-bore nasogastric tube feeding to be safe, it does have to be supported once the patient is discharged from the hospital. A good knowledge of the home support and carer support agencies, and what is available, should be discussed. Multidisciplinary team support is essential in ensuring a safe discharge can be planned and managed. Good patient risk assessment and nursing considerations are discussed to show how the challenges that may prevent a patient discharge with this type of feed are managed. This article will show how two very different patients discharges were facilitated by safe fine-bore nasogastric tube feeding in the community. Patient assessment and nursing considerations are discussed, as well as the importance of a multidisciplinary approach to show how this was successfully achieved in a local district hospital.

Identifying and managing malnutrition in the community

Malnutrition affects more than 3 million people in the UK, most of whom live in the community. Malnutrition is both a cause and consequence of disease and can lead to increased mortality and morbidity, delayed recovery from illness and impaired body function which can make carrying out activities of daily living difficult. Managing malnutrition in the community involves identifying malnutrition using a universally validated screening tool and implementing appropriate care plans according to the degree of malnutrition. Regional and local guidance can be used to assist healthcare professionals to prescribe appropriate oral nutritional supplements and monitor nutritional aims and goals.

[Principles of nutrition in patients with newly appointed stoma]

The treatment of intestinal stoma is often a difficult experience for patients and results in numerous problems in the physical, psychological and social aspects. Therefore, post-operative care of the patient with the newly appointed stoma should be taken by therapeutic team consisting of doctors, nurses, physiotherapists, dieticians, psychologists and social workers. Appropriate nutritional education of patients aims to improve their quality of life and to prevent from unpleasant ailments formed after the operation. The specific type of stoma may decide about certain dietary recommendations. The presented work provides a practical dietary recommendations for patients with newly appointed stoma.

Nutritional screening: a community dietitian's perspective

Malnutrition in the UK is well documented and highlighted by the British Association of Parenteral and Enteral Nutrition, who advocate the use of a screening tool to facilitate the identification and subsequent management of undernutrition. Nurses are ideally placed to support this process, but their role has many conflicting priorities. For nurses working in the community, there also exists the problem of identifying those who are at risk of undernutrition but remain unknown to nursing services. This article provides a review of malnutrition and nutrition screening and aims to promote a pragmatic approach to the identification and management of undernutrition in the community. The article concludes with a brief review of current opportunities for improving nutritional care in the community.

Understanding healthy pregnancies: the perspective of Inuit midwives in northwestern Quebec

INTRODUCTION

For 25 years, Inuit midwives have provided perinatal and newborn care for about 90% of the pregnancies in northwestern Quebec. Patients in this region continue to have high rates of preventable nutritional deficiencies. The objective of this study was to explore the perceptions of professional midwives and students about what makes a healthy pregnancy and a healthy newborn.

METHODS

We convened, via teleconference, a semistructured focus group with the local midwives and students. The conversation focused on local understanding of a healthy pregnancy and a healthy newborn, and the role of midwives in the communities.

RESULTS

Four midwives and 6 students took part in the focus group, representing 80% of local midwives and students. All of the participants were women, and their professional experience ranged from 3 to 25 years. Through inductive thematic analysis, it became apparent that personal experiences and professional training were important determinants of opinions. Midwives believed that the health of women and infants could be improved through better food selection, particularly reliance on traditional nutrient-rich food. They were aware that iron deficiency was a problem and that infants required vitamin D; however, they reported that supplement uptake was poor.

CONCLUSION

Concern was expressed about a decline in traditional beliefs and about unhealthy behaviours. Participants advanced strategies to promote knowledge locally (e.g., visual aids, local radio) to attempt to reduce rates of nutritional deficiencies.

Nutritional issues in infants with cancer

Cancer and cancer therapy may have adverse effects on food intake, absorption and metabolism resulting in malnutrition. Malnutrition can adversely affect tolerance of therapy and hence overall survival. Malnutrition is of particular concern in infants and young children due to limited reserves and the effect undernutrition can play on a patient's weight gain, growth, immune function and overall well-being.

Nurses' role in nutritional assessment and screening (second of a two-part series)

Nutrition is a key issue for healthcare professionals yet the management of nutritional problems by staff is often poor. Malnutrition is recognised as a significant risk for patients in hospital, a risk that nurses have a responsibility to monitor. The first article in this two-part series looked at initial assessment. This article looks at more specific tests that can be used to identify those at risk.

Omega-3 Fatty Acids as Adjunctive Therapy in Crohns Disease

Crohns disease is an inflammatory bowel disease that can have a significant impact on the health of those afflicted. The etiology of the disease is unknown, but genetic, environmental, dietary, and immunological factors are thought to be involved. Multiple nutrients can become depleted during active disease due to inadequate intake or malabsorption. Preventing these deficiencies is paramount in the care of those suffering from Crohns disease. Often the traditional treatments (medications) have limited effectiveness and negative side effects that inhibit their use. Enteral nutrition has promising therapeutic benefits, but its use is often limited to the pediatric population due to poor patient acceptability. Omega-3 fatty acids have been investigated for their anti-inflammatory properties as an alternative to traditional care. This article reviews the etiology of Crohns disease, nutritional deficiencies, traditional treatments, and the use of omega-3 fatty acids in the prevention of Crohns recurrence. The results from clinical trials have been conflicting, but a new fish oil preparation that limits the side effects of traditional fish oil therapy shows promise as an adjunctive treatment for Crohns disease. Continued research is needed to validate these findings.

Nutritional screening and assessment tools for older adults: literature review

AIM

This paper reports a literature review to examine the range of published tools available for use by nurses to screen or assess nutritional status of older adults, and the extent to which validity, reliability, sensitivity, specificity and acceptability of the tools has been addressed.

BACKGROUND

The incidence of malnutrition in older adults is high. One method by which malnutrition or risk of malnutrition can be detected is by the use of nutritional screening or assessment tools.

METHODS

A comprehensive literature review methodology was employed. A variety of electronic databases were searched for the period 1982-2002. Search terms incorporating nutrition, screening, validity, reliability and sensitivity and specificity were combined to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. In this paper, nutritional screening or assessment tools are described as tools which use a questionnaire-type format containing more than one risk factor for malnutrition, and give a quantitative or categorical assessment of risk.

RESULTS

Seventy-one nutritional tools were located, 21 of which were identified as designated for use with an older population. A wide variety of risk factors for malnutrition are used with the tools, ranging from objective measurements to subjective assessment. Some tools identify an action plan based on the score obtained. Many tools appear not to have been subjected to validity and/or reliability testing but are used clinically.

CONCLUSIONS

As malnutrition is present in the older adult population, nutritional assessment and screening tools can be useful to highlight those in need of a nutritional care plan. However, many have not been subjected to evaluation and consequently may not demonstrate sensitivity and/or specificity in clinical use. The decision to use a particular tool should therefore be considered carefully.

[Nursing diagnosis for allogeneic bone marrow transplantation patient: case study]

This case study aims at presenting the follow-up of a patient who underwent allogeneic bone marrow transplantation and the experience of the nursing team of the Centro de Transplante de Medula Ossea (Bone Marrow Transplantation Center) at the Hospital de Clínicas de Porto Alegre, Brazil, during the development of the systematization of the nurse practice emphasizing the period of elaboration of the nursing diagnosis. Twenty-six diagnosis established in this case are discussed and put together in the format of a table to allow the reader to have a view of their initial and ending periods, during the in-patient treatment time.

[Common nutritional problems in the elderly: the experience of residents of a long-term care facility]

Nutrition is an unavoidable issue throughout the field of long-term care, occupying a key position in the system. Along with the current trends of population aging, chronic changes in morbidity, functional impairment of health, progressive complexity of care content, the elongation of the caring period and the consequences of these trends, the long-term care burden has become more challenging than ever. Nutrition is just one of many key issues presented by these challenges. The factors associated with nutritional problems are numerous and complex. Residents of long-term care facilities are both representative of elderly people generally and reasonably approachable, and therefore constitute a suitable sample for investigation. To grasp and define the causes of the nutritional problems, conduct periodic nutritional assessments, monitor diet & nutrition, and actively intervene to improve these areas, can be regarded as necessary if the needs of basic and advanced nutrition are to be met, and nutrition is to take its rightful place in the practice of long-term care. Nutritional problems usually consist of malnutrition from inappropriate intake, over-nutrition from over-intake, deficiency of special nutrients, and imbalance of intake from inappropriate ratio of food components. Associated factors include physiological change, morbid condition, medication, financial support and social support.

Clinical skills: importance of nutrition for acutely ill hospital patients

Providing good nutrition to patients in hospital has become a primary focus in many NHS trusts. Whether it is provided by hospital food or nutrition support, the impact of adequate food on patient outcome is now well documented. However, the physiological, social and economic consequences of malnutrition in hospitals must be acknowledged. This article provides an overview of the metabolic changes that occur during starvation in health and in illness. The methods used by different healthcare professionals to assess nutrition are summarized. A review of the range of nutrition support options available and indications for their use is provided. Hospital nutrition is considered in the context of recent national and international recommendations.

Attitudes of nursing staff towards nutritional nursing care

Fulfilling nutritional requirements in residents with eating problems can be a challenge for both the person in need of help and for the caregiver. In helping and supporting these residents, a positive attitude is assumed to be as important as practical skill. The aim of this study was to test the hypothesis that nutritional education and implementation of a nutritional programme would change the attitudes towards nutritional nursing care among nursing staff with daily experience of serving food and helping residents in municipal care. The study was carried out as a before and after experimental design. An attitude scale, staff attitudes to nutritional nursing care (SANN scale), was developed and used. The response on the scale gives a total SANN-score and scores in five underlying dimensions: self ability, individualization, importance of food, assessment and secured food intake. Nursing staff at eight different residential units (n = 176) responded to the attitude scale and, of these, staff at three of the units entered the study as the experimental group. After responding to the attitude scale, nutritional education was introduced and a nutritional programme was implemented in the experimental units. One year later, attitudes were measured a second time (n = 192). Of these, 151 had also responded on the first occasion. Education and implementation of a nutritional programme did not significantly change attitudes. Overall, nursing staff responded with positive attitudes towards nutritional nursing care. Most of the positive attitudes concerned items within the dimension importance of food. In contrast, items within self ability showed the lowest number of staff with positive attitudes.

Tackling undernutrition through appropriate supplement prescribing

Undernutrition has significant implications for patients' clinical condition and economical consequences for the NHS. However, due to continually increasing prescribing costs for sip feeds, treating undernutrition is often seen as very costly. An audit project in Lothian was undertaken to look at the appropriateness of sip feeds being prescribed. The project found there was a significant level of inappropriate prescribing with 30% of patients having their prescriptions for supplements stopped as they were deemed unnecessary. In view of this, the community dietitians involved developed and introduced a nutritional care pathway to allow a systematic and evidence-based approach to the identification and treatment of undernutrition.

Managing side effects of childhood cancer treatment

This article focuses on the nurse's role as a member of the supportive care team for the child diagnosed with cancer and the family. The most common side effects of the cancer treatment are discussed in depth in this article. The adequate management of the side effects experienced by the child receiving cancer therapy may greatly influence the child's quality of life.

Nutritional support in wound healing

Wounds place increased metabolic and hence nutritional demands on patients, which may not always be met, especially in older patients in the community. Patients may be deficient in carbohydrates, protein and amino acids, fatty acids and certain micronutrients. Nutritional support may be needed to promote wound healing. Nurses should be able to assess the risk of poor nutrition in patients with wounds and have a role in ensuring adequate nutrition through the normal diet or supplementation where necessary.

Nutrition in critical care

Many hospitalized patients with cancer are malnourished. Some become critically ill and experience delayed wound healing, loss of muscle strength, and reduced infection fighting ability as a consequence of the loss of nutritional reserves. Complications of critical illness may cause interruption in normal gastrointestinal function and result in shock, sepsis, hypochlorhydria, systemic inflammatory response syndrome, and other disorders. As a result, critically ill patients may require nutritional support.

Nutrition and the older adult

The importance of ensuring adequate nutrition in older people is often acknowledged but, the evidence suggests, theory is not always matched by practice. This article describes causes of malnutrition in older adults and discusses nursing strategies to prevent it occurring.

Antiretroviral-related nutritional problems: closing the science and practice gap

Close collaboration between clinicians and researchers is essential for the development of databased strategies for antiretroviral-related nutritional problems. By working together to conduct feasible clinical intervention studies and to apply research findings to practice, clinicians and researchers can provide more efficient and effective nursing interventions to manage these rapidly emerging nutritional disorders.

Reliability and validity of the nutritional form for the elderly (NUFFE)

AIM

The aim of this study was to test the reliability and validity of the Nutritional Form for the Elderly (NUFFE).

BACKGROUND

The prevalence of undernutrition among older people in nursing homes and hospitals reaches high levels. Assessment of older patients' nutritional status is an important task for nurses in clinical care. To use a simple nutritional assessment instrument for older people is one approach for nurses. Examples of such instruments are the well validated Mini Nutritional Assessment (MNA) and the newly developed NUFFE.

METHODS

A total of 114 consecutively chosen, newly admitted older patients in an elder care rehabilitation ward in western Sweden were interviewed using the NUFFE and MNA. Arm and calf circumferences, body mass index (BMI), and presence of pressure sores and skin ulcers were noted as part of the MNA on admission. Weight was monitored and BMI calculated on discharge. Serum albumin levels on admission and discharge were used if these were available in the records. Reliability of the NUFFE was measured as homogeneity. Criterion related validity, concurrent validity, construct validity, and predictive validity were assessed with different statistical methods. The regional research ethics committee approved the study.

RESULTS

The results showed that the NUFFE is a fairly reliable and valid instrument for identifying actual and potential undernutrition among older patients.

CONCLUSION

The NUFFE is a simple tool for nurses to use to assess older patients with the aim of detecting undernourished individuals and those at risk for undernutrition. When doing a nutritional assessment with the NUFFE, the BMI ought also to be calculated. The assessment could also be combined with food intake recording for a period of time.

Chronic renal failure, nursing diagnoses and interventions

Chronic renal failure (CRF) is a clinical condition resulting from a multitude of pathologic processes which lead to derangement and insufficiency of renal excretory and regulatory functions (uraemia). There are normally two million glomeruli in both the kidneys of an adult, which filter an average amount of 120 ml of blood per minute. This filtration is called glomerular filtration rate (GFR). In the case of damaged parenchyma tissues due to renal disease, the filtration rate goes down to 20-30 ml per minute. This is when findings and symptoms of renal failure come about. In the case of a filtration rate less than 10 ml (GFR< 10 ml/min), a patient is understood to have reached the final stage of renal failure. At this stage, fluid and electrolyte balance is disturbed, azotemia increases and systemic manifestations (uraemia) occur (1,2). Renal failure is a condition in which the kidneys cannot fulfil their function of discharging metabolic waste and of maintaining the fluid and electrolyte balance. It can be divided into two groups: acute and chronic. This paper discusses the etiology, pathophysiology and signs and symptoms f CRF as well as the diagnosis and interventions required by nurses. Deficit, nursing priority and intervention are discussed in relation to patient problems.

A concept analysis of malnutrition in the elderly

PURPOSE

Malnutrition is a frequent and serious problem in the elderly. Today there is no doubt that malnutrition contributes significantly to morbidity and mortality in the elderly. Unfortunately, the concept of malnutrition in the elderly is poorly defined. The purpose of this paper is to clarify the meaning of malnutrition in the elderly and to develop the theoretical underpinnings, thereby facilitating communication regarding the phenomenon and enhancing research efforts.

SCOPE, SOURCES USED

Critical review of literature is the approach used to systematically build and develop the theoretical propositions. Conventional search engines such as Medline, PsyINFO, and CINAHL were used. The bibliography of obtained articles was also reviewed and additional articles identified. Key wards used for searching included malnutrition, geriatric nutrition, nutritional status, nutrition assessment, elderly, ageing, and weight loss.

CONCLUSIONS

The definition of malnutrition in the elderly is defined as following: faulty or inadequate nutritional status; undernourishment characterized by insufficient dietary intake, poor appetite, muscle wasting and weight loss. In the elderly, malnutrition is an ominous sign. Without intervention, it presents as a downward trajectory leading to poor health and decreased quality of life. Malnutrition in the elderly is a multidimensional concept encompassing physical and psychological elements. It is precipitated by loss, dependency, loneliness and chronic illness and potentially impacts morbidity, mortality and quality of life.

Subjective global assessment of nutrition a useful diagnostic tool for nurses?

Malnutrition in maintenance haemodialysis (HD) patients is closely related with morbidity and mortality in this population.

AIM OF THE STUDY

To evaluate feasibility, performance and information given by SGA (subjective global assessment), a semi-quantitative method of nutritional evaluation (based on a medical questionnaire and a simple clinical examination) carried out by a group of 12 nurses.

METHOD

In March 1999, a feasibility study was organised to evaluate 9 patients during HD. Since July 1999, a nutritional evaluation of all the patients meeting the required parameters (e.g. duration of HD > 6 months, day sessions) has been set up every 4 months.

RESULTS

In March 1999, preliminary results demonstrated an average learning time per SGA of 15'. In July 1999, 32 patients were evaluated, albuminemia (micromol/l) and pre-albuminemia (g/l) were analysed according to the SGA classification (A = good nutrition, B= light to moderate malnutrition, C= severe malnutrition). The albuminemia and the prealbuminemia of patients A (respectively 541+/-45 and 0.37+/-0.10) were higher than those of patients B (482+/-41 and 0.31+/-0.01), and those of patients C (381+/-54 and 0.19+/-0.1), by variance analysis (p < 0.0001). The information drawn from the SGA reveal a severe malnutrition, a light to moderate malnutrition, and good nutrition in respectively 13%, 63% and 25% of the patients, and a noticeable muscular atrophy (moderate to severe) in 43% of cases. Anorexia and major gastro-intestinal symptom (nausea, vomiting, and diarrhoea) are found in 14% of cases.

CONCLUSION

Beside traditional methods of screening and evaluation of malnutrition in HD patients, the use of SGA by a nursing team uncovers useful information on nutritional status of patients, especially in areas lacking facilities such as a laboratory, dietetic department or permanent presence of doctors.

Improving the nutritional status of people with dementia

The attention given to the nutritional needs of older adults receiving hospital care has been the subject of research over recent years. It has been suggested that older people are suffering from malnutrition as a result of poor nursing care. Those involved in care of persons with dementia are faced with considerable difficulty when trying to respond to their nutritional care needs and there is concern that there may come a time when the care team will withdraw food and fluid. However, in Southern Derbyshire we believe that we now have a set of standards for nutritional care of older adults with dementia that can ensure adequate and good nutrition despite the numerous and complex problems posed by dementia. This article discusses the progress of a sample of 20 residents of a long-stay ward over a period of 6 years and shows how a multidisciplinary team accessed, developed and applied an evidence base to practice to the benefit of the sample group. The outcomes show that malnutrition can be reversed, and that people who are considered to be in the final stages of dementia can improve their nutritional status.

Malnutrition in patients suffering from chronic heart failure; the nurse's care

Chronic heart failure is associated with a bad prognosis with considerably shortened survival and repeated hospitalisations. Patients suffering from heart failure also have symptoms that can affect their food intake, for example, tiredness when strained, breathing difficulties and gastrointestinal symptoms like nausea, loss of appetite and ascites. Pharmacological therapy can lead to a loss of appetite, which will make the intake of food inadequate to fill the required energy and nutritional needs. The nurse's interest in and knowledge of diet issues can improve these patients' nutritional status. The aim of this literature review was to describe the nurse's interventions regarding malnutrition in patients suffering from chronic heart failure. The literature search gave 13 articles, which were analysed, and sentences whose content was related to the aim were identified. Three areas of content appeared; drug treatment and consequences, gastrointestinal effects, and information and education. The results show that the nutritional status of these patients can be significantly improved by means of simple nursing interventions. Future research should focus on controlled experimental studies to evaluate differences in body weight, body mass index and quality of life between patients suffering from chronic heart failure, who are taking part in a fully enriched nutrition intervention, and patients suffering from chronic heart failure, who are eating their normal diet.

Managing people on sip feeds in the community

Community nurses often have the difficult task of identifying and coordinating the care of under-nourished patients in the community. Studies have shown that patients who are underweight are likely to visit to their general practitioner more often, need more medication and be admitted to hospital. Nutritional sip feeds have been shown to clinically benefit underweight patients suffering from chronic conditions as well as the older people. Adapting ordinary food to meet the patient's nutritional requirements should be considered first, but sip feeds provide an additional source of nutrients when this proves insufficient. All patients on sip feeds should have a clear aim for this nutritional intervention (e.g. the healing of a pressure area) and be monitored regularly.