eating and drinking difficulties in adults with … · eating and drinking difficulties in adults...

EATING AND DRINKING DIFFICULTIES

IN ADULTS WITH A LEARNING DISABILITY

Introduction

Referral

Specialist Assessment

Review

Management

Screening Assessment

Discharge

Referral to

Other

Services

Skills and

Competency

Framework

Standards and

Guidance

http://www.leicspart.nhs.uk/Library/ReferralFormsforLocalityTeams.pdf

Aiming to minimise the risks and maximise

independence and nutrition when eating

and drinking

EATING AND DRINKING DIFFICULTIES

IN ADULTS WITH A LEARNING

DISABILITY

Information for

Professionals

Information for

Carers

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These leaflets may help you to decide whether to refer:

Eating and Drinking information leaflet Information for Carers (From NPSA 2007) If you decide you need further help, use the appropriate referral form for where you live. You can fill it in and send it to the address given or ask your GP to make the referral. If the person to be referred is coughing when eating or drinking, it would be helpful to have a record of coughing incidents to bring with you to the appointment. If the person has choked, check with this alert document what to do. You could complete a choking incident form to bring with you to the appointment. If the person is losing weight or refusing food, you could complete a Food diary chart to bring with you to the appointment. The Food First leaflet will give you some tips to keep a person’s weight healthy until your appointment. Further information for carers link A10

You may find the following websites helpful

NPSA npsa.nhs.uk

MENCAP www.mencap.org.uk

Alzheimers society www.alzheimers.org.uk

Caroline Walker trust www.cwt.org.uk

BILD www.bild.org.uk

Rett UK www.rettuk

Information for Carers

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d/m/y Date

Time

Food

Drink

No problem

A little cough

Cough and effort

Initials

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Problems with swallowing food and drink

(dysphagia) can be life threatening.

If you are concerned that someone is having difficulty when

eating or drinking, first decide –

Is it an emergency?

ALERT

Yes This is life

threatening e.g.

difficulty breathing,

turning blue, choking,

severe distress

whilst eating or

drinking.

What should you

do? Use your first aid

procedures.

Call for an

ambulance.

Later make a full

report of the

incident and tell your

GP about the

incident.

No - any of these signs whilst eating

may suggest problems with swallowing:

coughing, choking, some distress, face

reddening, eyes watering, nose running,

or breathlessness. In this case refer to

Speech and language therapy (SALT)

(See below).

Swallowing difficulties are often

associated with other health problems.

If you are concerned about the person’s

general health, contact the GP as soon

as possible.

Make a referral to Speech and

language therapy through the Learning

Disability Team for an assessment.

(SALT does not respond to emergency

referrals and you may have to wait for

up to a month to see someone)

If the person has an eating and

drinking plan and you are not sure of the

recommendations or think the plan

needs updating contact the Learning

disability team.

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Continued overleaf………

DATE: DATE:

BREAKFAST BREAKFAST

Cereal 0 1/4 1/2 3/4 All Cereal 0 1/4 1/2 3/4 All

Toast / bread (no of slices) 0 1/4 1/2 3/4 All Toast / bread (no of slices) 0 1/4 1/2 3/4 All

Marg ( ) Preserves ( ) tick if yes Marg ( ) Preserves ( ) tick if yes

Other 0 1/4 1/2 3/4 All Other 0 1/4 1/2 3/4 All

SNACK 0 1/4 1/2 3/4 All SNACK 0 1/4 1/2 3/4 All

LUNCH teaplate size portion YES / NO LUNCH teaplate size portion YES / NO

Main course 0 1/4 1/2 3/4 All Main course 0 1/4 1/2 3/4 All

Potato / rice 0 1/4 1/2 3/4 All Potato / rice 0 1/4 1/2 3/4 All

Vegetable 0 1/4 1/2 3/4 All Vegetable 0 1/4 1/2 3/4 All

Dessert / fruit 0 1/4 1/2 3/4 All Dessert / fruit 0 1/4 1/2 3/4 All



EVENING MEAL teaplate size portion YES / NO EVENING MEAL teaplate size portion YES / NO

Sandwich 0 1/4 1/2 3/4 All Sandwich 0 1/4 1/2 3/4 All







Leicestershire Partnership Trust

FOOD CHART

NAME………………………………………………….. WARD……………………………………………………. Please Record (a) Type of food e.g. Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements

Side 1

EVALUATION Action taken following evaluation of 4 days intake : Qualified nurse signature..................…………………………………... Eating well and no weight loss – discontinue Poor intake, refer to screening tool action plan Continue to monitor

DATE: DATE:

BREAKFAST BREAKFAST

Cereal 0 1/4 1/2 3/4 All Cereal 0 1/4 1/2 3/4 All

Toast / bread (no of slices) 0 1/4 1/2 3/4 All Toast / bread (no of slices) 0 1/4 1/2 3/4 All

Marg ( ) Preserves ( ) tick if yes Marg ( ) Preserves ( ) tick if yes



LUNCH teaplate size portion YES / NO LUNCH teaplate size portion YES / NO







EVENING MEAL teaplate size portion YES / NO EVENING MEAL teaplate size portion YES / NO

Sandwich 0 1/4 1/2 3/4 All Sandwich 0 1/4 1/2 3/4 All







FOOD CHART Side 2

NAME………………………………………………….. WARD……………………………………………………. Please Record (a) Type of food e.g. Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements

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Introduction / Overview

Referral Forms

Eating and Drinking Leaflet

Triaging Referrals

List of Foundation Workers

ICD10 Codes

List of medications that may affect swallowing

Information for Professionals

Referrals may come from a GP

GP Referral Protocol (from NPSA 2007)

Role of Primary Care

Or referrals may come from other incidents or indicators

Inpatient or residential homes using the

Malnutrition Universal Screening Tool

MUST

Or people who have had choking incidents

Alert Leaflet

Useful Websites

NPSA npsa.nhs.uk

MENCAP www.mencap.org.uk

Alzheimers society www.alzheimers.org.uk

Caroline Walker trust www.cwt.org.uk

BILD www.bild.org.uk

Rett UK www.rettuk


NUTRITIONAL SCREENING TOOL (MUST)

COMPLETE ON FIRST SCREEN - DATE :

Current Weight

_______ kg

Measured / Recall PLEASE CIRCLE

Height

______ m

Measured / Recall PLEASE CIRCLE

Body Mass Index (BMI)

______

USE CHART TO

CALCULATE FROM CURRENT WEIGHT

AND HEIGHT

Weight 3-6 months ago

_______ kg

Measured / Recall

/ Don’t Know PLEASE CIRCLE

% Weight Loss Change in weight

YES / NO / Don’t know

IF YES USE CHART TO CALCULATE % USING CURRENT AND PREVIOUS

WEIGHT

MUST SCORE

DATE

A BMI Less than 18.5 = 2 Between 18.5 and 20 = 1 More than 20 = 0

Please circle score

2 1 0

2 1 0

2 1 0

2 1 0

B % Weight loss NB Oedema may mask loss of muscle weight

More than 10% = 2 Between 5 and 10% or visual loss of weight if not known = 1 Less than 5 = 0

2

1 0

2

1 0

2

1 0

2

1 0

C Starvation score

NO or likely to be NO Intake for > 5days: YES = 2

NO = 0

2 0

2 0

2 0

2 0

TOTAL RISK LOW = 0 MEDIUM = 1 HIGH = 2

Add scores to give RISK If score 1 or more start Nutrition Treatment plan overleaf. If no improvement or score > 4 refer to Dietitian

Write in

total score

NUTRITIONAL TREATMENT PLAN STARTED? YES NO NOT NEEDED

Please circle

SIGN

WEIGH PATIENT WEEKLY AND DOCUMENT ON WEIGHT CHART

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Please place client / service user label

here.

Repeat MUST weekly or if condition changes – Using new weight Nursing Nutrition Care Plan For Patients At ‘Medium or High Risk’ Of

Malnutrition.

Complete detailed Nutrition Checklist Tool

Order a special diet if appropriate e.g. Gluten free, diabetic.

Refer onto Eating and Drinking pathway (LD clients) or write appropriate treatment plan

Assist with ordering suitable meal choices (Suggest High Energy ( ) main courses and puddings and ‘Chefs Specials’ - see ward menus for details). Or fortify foods prepared according to instructions provided (see home hand book).

Offer the patient additional items for snacks between meals.

Encourage milk and milky drinks.

Offer 1 Build up drink per day (savoury or sweet) Unless contraindicated e.g. renal disease, lactose intolerant, milk allergy or patients following low residue diets. Contact ward Dietitian for advice.

Offer assistance with eating and drinking, when required or follow eating and drinking plan or treatment plan

Treat underlying conditions such as nausea, vomiting, diarrhoea, constipation.

Commence food and drink record charts for all meals and snacks. REVIEW INTAKE AFTER FOUR DAYS, if intake remains minimal, and a referral has not already been made, refer to your ward or community dietitian.

Refer to your ward Dietitian if: o MUST score is greater than 4 o Tube feeding needs considering o Nil By Mouth > 5 days o MUST score increases or there is no improvement on medium/high risk nutrition

care plan o Specialist advice is required following diagnosis, or a full nutritional assessment is

required in response to clinical judgment.

Repeat weight and MUST weekly – if weight drops >1kg/week refer to your ward Dietitian

Ensure that prior to discharge the patient is reviewed by the ward Dietitian. This will ensure the

patient receives appropriate advice for home, and the need for any supplements can be

assessed.

MEDIUM/HIGH RISK

If Dietetic referral is required please document

DATE made and SIGN here.

Nutrition Checklist

ABILITY TO EAT / / Suggested action

Able to eat independently

Poor dentition/chewing problems Consider referral to community dentist

Ill fitting dentures Consider referral to community dentist

Poor oral hygiene Consider referral to community dentist

Requires help with feeding Develop treatment plan for behaviours

Swallowing problems Refer to Speech and Language Therapist

Choke risk Refer to Speech and Language Therapist

SYMPTOMS/SIDE EFFECTS OF DRUGS

Nausea Request review of meds

Vomiting Request review of meds

Constipation Request review of meds

Diarrhoea Request review of meds

PSYCHOLOGICAL STATE

Does not enjoy mealtimes Offer support during meal times

Mental state not affecting food intake

Loss of interest in food

Disruptive behaviour at meal times Develop treatment plan for behaviours

Easily distracted by noise /other clients Develop treatment plan for behaviours

Regurgitates/ self induces Develop treatment plan for behaviours

History of erratic or chaotic eating

Severe depression

Mild anxiety/confusion relating to food

Paranoia relating to food Offer support during meal times

Extreme anxiety/agitation Offer support during meal times

APPETITE AND DIETARY INTAKE

Normal appetite, all meals eaten

On special diet, eg. supplements, liquidized Follow nutrition care plan

Reduced appetite, ½ - ¾ of meals eaten Follow nutrition care plan

Poor appetite, less than ½ of meals eaten Follow nutrition care plan

Can manage finger foods Contact catering

Has particular cultural dietary requirements Contact catering

Seems to have foods they do not like Discuss with relations/carers

Needs specially adapted cutlery Refer to OT for assessment

SKIN TYPE

Healthy

Oedematous

Poor wound healing/

Grade 4 pressure ulcers Refer to tissue viability nurse

Dry and flaky

OTHER ISSUES

Difficulties with posture when eating Refer to Physiotherapy department

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If any of these phrases or terms are used in a referral contact a Foundation Worker before the next locality MDT meeting:

Aspiration

Recurrent chest infections

Difficulty swallowing

Choking

Coughing around mealtimes

Dysphagia If the Referral from another Speech and Language Therapist you should contact your link Speech and Language Therapist as soon as possible with the referral details. You should try and contact the therapist in your area but if you are unsuccessful or if there is currently no therapist in your area you should try and contact another therapist on the list below. You should also send the details to the admin staff for registering and it should be brought to the next MD Team Meeting. If the referral is an emergency, advise the referrer to contact emergency services and to inform the GP, see the ALERT leaflet for more details. Jan 2012

Referrals to Eating and Drinking Care Pathway

Trigger Guidelines

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There may be many contributory diagnoses for a person with

learning disability.

The most frequently used ICD10 codes are:

R13

Dysphagia

ICD10 Codes

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MEDICATIONS AND DYSPHAGIA/ SWALLOWING RISKS [Some of the medications that can impact swallowing and why this happens]

Dysphagia as a side effect of medication

• Medications that affect the smooth and striated muscles of the esophagus that are involved in swallowing may cause dysphagia.

Medications with anticholinergic or antimuscarinic effects

Benztropine mesylate (Cogentin) given for movement related effects caused by some psychotropic meds

Oxybutynin (Ditropan) improves bladder capacity

Propantheline (Pro-Banthine) inhibits the release of stomach acid

Tolterodine (Detrol) affects bladder capacity

Medications that cause dry mouth (xerostomia) may interfere with swallowing by impairing the person’s ability to move food

Medications that cause Dry mouth (xerostomia)

ACE Inhibitors- used for high blood pressure Captopril (Capoten)

Lisinopril (Prinivil, Zestril)

Antiarrythmics- cardiac preparations Disopyramide (Norpace)

Mexiletine (Mexitil)

Procainamide (Procan)

Antiemetics- used for nausea Meclizine (Antivert)

Metoclopramide (Reglan)

Prochlorperazine (Compazine)

Antihistamines and decongestants- used for

cold symptoms

Chlorpheniramine (Chlor-Trimeton)

Diphenhydramine (Benadryl)

Pseudoephedrine (Sudafed)

Calcium channel blockers- used for chronic

chest pain due to angina

Amlodipine (Norvasc)

Diuretics- given to get rid of excess fluid in

body

Ethacrynic adic (Edecrin)

SSRIs (Selective serotonin reuptake inhibitors)-

antidepressant medications

Citalopram (Celexa)

Fluoxetine (Prozac)

Nefazodone (Serzone)

Paroxetine (Paxil)

Sertraline (Zoloft)

Venlafaxine (Effexor)

* see also Antipsychotic/ Neuroleptic medication list below

Local anaesthetics such as Novocain which is often used for dental work may temporarily cause a loss of sensation that may affect swallowing before it wears off.

Antipsychotic/ Neuroleptic medications given for treatment of psychiatric disorders may affect swallowing as many of them produce dry mouth and some of them can cause movement disorders that impact the muscles of the face and tongue which are involved in swallowing.

Dysphagia as a complication of the therapeutic action of the medication

• Medications that depress the Central Nervous System (CNS) can decrease awareness and voluntary muscle control that may affect swallowing.

Medications that depress the CNS

Antiepileptic drugs- for seizures Carbamazepine (Tegretol) Gabapentin (Neurontin) Phenobarbital Phenytoin (Dilantin) Valproic acid (Depakote)

Benzodiazepines- antianxiety drugs Alprazolam (Xanax) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan)

Narcotics- for pain relief Codeine (Tylenol #3) Fentanyl (Duragesic) Propozyphene (Darvon, Darvocet)

Skeletal muscle relaxants- relieves muscle spasms and relaxes muscles

Baclofen (Lioresal) Cyclobenzaprine (Flexeril) Tizanidine (Zanaflex)

Medications that can cause esophageal injury and increase risk

• Some medications can cause dysphagia because of injury to the esophagus caused by local irritation. This can happen because the person is in a reclining position shortly after taking the medication or because an inadequate amount of fluid is taken with the medication. In both instances, the medications remain in the esophagus too long, potentially causing damage and affecting swallowing.

Antipsychotic/ Neuroleptic medications

Chlorpromazine (Thorazine) Olanzapine (Zyprexa)

Clozapine (Clozaril) Quetiapine (Seroquel)

Fluphenazine (Prolixin) Risperidone (Risperdal)

Haloperidol (Haldol) Thioridazine (Mellaril)

Lithium (Eskalith, Lithobid) Thiothizene (Navane

Loxapine (Loxitane) Trifluoperazine (Stelazine)

Other medications such as high dose steroids and chemotherapeutic (anti-cancer) preparations

may cause muscle wasting or damage to the esophagus and may suppress the immune system making the person susceptible to infection. Reference: Balzer, KM, PharmD, “Drug-Induced Dysphagia”, International Journal of MS Care, page 6, Volume 2 Issue 1, March 2000. (http://www.mscare.com/a003/page_06.htm) DMR Health Standard 07-1 Guidelines for Identification and Management of Dysphagia and Swallowing Risks Attachment A

Drugs that may cause esophageal injury

Acid- containing products Clindamycin (Cleocin) Doxycycline (Vibramycin) Erythromycin (Ery-tabs, E-mycin) Tetracycline (Sumycin)

Aspirin Bayer aspirin and generic brands

Bisphosphonates- given for osteoporosis Alendronate (Fosamax)

Iron containing products FeoSol, Feratab, Slow-FE, Fer-Iron etc.

Methylxanthines- bronchodilators Theophylline (Theo-Dur, Unidur, Slo-Bid)

Nonsteroidal anti-inflammatory drugs- relieves pain

Ibuprofen (Advil, Motrin) Naproxen (Aleve, Naprosyn)

Potassium chloride supplements K-Dur, K-tabs, Klor-Con, Slow K, etc.

Vitamin C (ascorbic acid) supplements Allbee with C Vitamin C tabs, etc.

When an individual is referred to the Eating and Drinking Care

Pathway, a trained Foundation Worker will contact the person

or carers to arrange to carry out a Screening Assessment.

The Foundation Worker will leave Initial Assessment

recommendations at the first visit and then report back findings

from the assessment to the Locality LD team for further in depth

discussion

Screening Assessment Outcomes

Screening Assessment

If there are no further actions

needed after the screening

assessment, a discharge letter

is sent from the Locality LD

team

Further action needed after

screening will result in referral

on to the appropriate

professional member of the

Locality LD team for specialist

assessment

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Skills and Competency

Framework

Interdisciplinary Dysphagia Competence Framework

(2009) Embed J2 here prob as externl link

Training for competencies

Awareness (Under development)

Carers

Foundation Worker

Specialist

Consultant

The consultant is required to carry out complex case work and

advanced assessments. If FEES and Videofluoroscopy are available

the consultant should be able to implement an assessment if

appropriate ( see competences from RCSLT).

The consultant also progresses work at a strategic level and work with

other services.

Currently there are no clear courses, although Manchester Metropolitan

University does offer an Advanced Dypshagia practitioner level course.

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Foundation Workers are trained according to the Interdisciplinary

Dysphagia Competencies

Foundation Worker Training

Foundation workers receive an initial days training

This training takes one day. In the morning, presentations

are received from each of the different members of the

ALD team on their role in the E&D care pathway

FW’s receive annual updates which focus upon

Refreshing of process and theory

Updating on new process and new theory

Peer support and feeding back into the pathway

New issue information

2011 Focus on supplements in diets

2012 Focus on role of FW and choke reporting

Each professional is specialist in their own field

This is the point where each professional is specialist in their own field. For instance the OT would not be expected to do a specialist dysphagia (swallowing) assessment but would be the appropriate specialist professional for recommending the independence support for safe eating and drinking. Only the SLT would have specialist swallowing assessment skills. Each other professional has their specialist skill (see ‘Roles’ in the SEAD Pathway) Specialist swallowing skills are acquired locally by a qualified speech and language therapist who has attended and passed a Post graduate training course, having had some years experience. DMU provide a week-long course which includes a six-month period of mentoring and is fully assessed by the university through assignments.

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Specialist Dysphagia Workers

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Screening Assessment Tools may

Include

Case History Mealtime Observation

Protocol Guidelines MUST Screening Tool

Food Diary Cough Recording Chart

Choke Recording Forms List of medications that

may affect swallowing

DIS DAT Other Useful Leaflets

Capacity Assessment Consent form (from NPSA 2007)

Best Interest Documents Morgan Risk Assessment

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Community Team for People with Learning Disabilities Mansion House, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF Tel: 0116 225 5200 Fax: 0116 225 5202

Eating and Drinking Case History Name: Preferred Name:

D.O.B. NHS Number:

Refer to core information: Health and social needs section and the HONOS section. Clients concerns about their eating and drinking

Carers main concerns around eating and drinking Name of carer:

Consent: Consent gained: Yes No (how was consent gained? If not, why?)

Refer to Core Information: Social Circumstances section for Weekly schedule and names of specific support workers ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………


here

Client Name: DOB: NHS Number:

Weight and appetite

1 Current weight without shoes:

2 BMI if known (Body Mass Index):

3 Has the MUST screening tool been completed with the client?

Yes/No/Don’t Know.

4 Has there been any unplanned weight loss in the last 6 months? If yes, how much?


Action: Refer to Dietician if unplanned weight loss of more than 5%

5 Has the person gained weight? If yes…

Yes/No/Don’t know.

Is the person’s weight gain affecting physical or mental health? Yes/No/Don’t Know.

Please give details: - Are there any known causes for weight gain?

Yes/No/Don’t know.

Please give details:-

Action: Refer to Community Nurse/ and/or Dietician if there are concerns

6. Have there been any changes to the person’s appetite, level of alertness or stamina during eating/drinking?


Please give details: -

Action: If yes, go to GP for blood tests and/or ask for a medication review


Dentition and general health

7. Does the person have rotten teeth, sensitive teeth or ill fitting dentures?

Yes/No/Don’t know

8. Does the person have dentures? Do they fit well? If yes, do they consistently wear them for eating and drinking?

Yes/No/Don’t know Yes/No/Don’t know

Action: Any problems, make an appointment with your Dentist

9. Does the person have ulcers, sore mouth, discoloured tongue and bad breath?

Yes/No/Don’t know

Action: If yes, check mouth care, check for constipation, dentist appointment.

10. Does the person have any problems taking medication? Please give details: -

Yes/No/Don’t know

Action: ask GP/pharmacist for alternative forms; refer to SALT

11. Has the person had any recent hospital admissions or diagnostic procedure? Please give details: -

Yes/No/Don’t know

12. Current Medication: [Listed in core information]

Add additional information re dose, form of medication and date last reviewed

Add a * to any medication that has changed in the last 6 months.


13. Medical condition: conditions that may contribute to or be affected by the ability to eat and drink

Does the person have any of the following? [Refer to HONOS section of the core information]

Respiratory Details including Treatment Actions if unresolved issue

Asthma

Go to GP or Respiratory Nurse if involved.

Shortness of Breath

Go to GP/Sprint team

Respiratory tract/chest infections How many in the last 6 months: - How many in the last 12 months: -

Go to GP

Pneumonia

Go to GP

Bronchitis

Go to GP

COPD

Go to GP

Difficulties coughing out phlegm / Secretions in upper airway.

Referral for chest physiotherapy

Pooling of saliva/excessive dribbling

Referral for chest physiotherapy

Other

Digestion Details including Treatment Actions if unresolved issue

Vomiting and regurgitation

Go to GP


Hernia

Go to GP

Urinary infections

Go to GP

Constipation or Diarrhoea

Go to GP

Acid reflux

Go to GP

Indigestion

Go to GP

Other gastro-intestinal problems

Go to GP/specialist consultant

Physical

Poor alignment and symmetry of body segments

Refer to Physiotherapy

Altered movements due to muscle tone or reflexes?


Physical continued Details including Treatment Actions if unresolved issue

Difficulties controlling head position and seating balance.


Any paralysis

GP or refer to Physiotherapy


Cleft palate

Refer to SALT

Oedematous or poor wound healing

GP/district nursing/dietician

Diabetes

GP

Dehydration – dry skin, lips or mouth; less alert, constipation etc

Increase fluids if possible Refer to Dietician

Neurological

Dementia

Check if on the Dementia Pathway. GP, CLDN or psychiatry

Parkinson’s

GP, CLDN or psychiatry

Epilepsy: increased signs of seizures/jerks

Check if on Epilepsy Pathway and refer to person who is managing Epilepsy. GP, CLDN or psychiatry

Other Details including Treatment Actions if unresolved issue

Behavioural issues e.g. Pica, taking food not prepared for them, rushing, distracted disorientated etc.

Refer to Community Team

Mental illness e.g. increasingly anxious and mealtimes, depression etc

GP, CLDN or psychiatry

Other conditions known to affect eating & drinking, such as Rett, cerebral palsy, anxiety, depression

Refer to Psychiatrist. Go to GP Refer to Dietician


Information about meal/drink times

14. How do you and the person communicate at meal times e.g. choice, knowing what will happen and when etc? Please give details: -

15. Does the person have an Eating and Drinking Plan?

Please attach copy.

Yes/No/Don’t Know

16. Please describe the person’s table, seating and positioning at meal times. Are there any problems in relation to this? Please give details: -

16. How long does the person take to eat a usual meal? What is the speed of eating? Are there rests or pauses? Does this vary throughout the day/week?

17. What kind of food and drink does the person have? (Include preferences; soft or pureed food; thickened drinks; dietary or cultural requirements; allergies or intolerances.)

18. Are you aware of any other preferences the person has around meal times, e.g. tastes, textures, environment or who they sit with etc? Please give details: -


19. Is the person able to get their food to their mouth? What equipment is your client currently using? (e.g. plates, cutlery, cups, mats, individualised furniture etc) Do they overfill their mouth? Have there been any changes in skill level in relation to this?

22. Who regularly supports the person and manager details, if relevant? What is the usual staff:client ratio at a meal and time allowed for meal?

23. Where does the person currently go to have their meals? – note on timetable in core information if relevant.

24. Do you regularly see any of the following … food or drink comes out of his/her nose or mouth during eating and drinking food or tablets become stuck on the roof of their mouth, teeth or gums after or during eating? If so,

please describe where the food sticks and how you and/or the person frees up the food the person has difficulty chewing? the person has tears, effort to swallow, reddening face, wheezy/gurgling sound or coughing shortly after eating food or

drinking?

25. Has the person choked recently (e.g. within the last month). If yes please give details. (Has a choking incident form been completed? Do you need to complete an e-irf?)


Does the individual show any worries or fears or become distressed at mealtimes? Yes / No If yes, please state frequency – occasionally / sometimes / always. Is there any other information you think may be relevant to this assessment, e.g. person awaiting treatment/intervention?

Signed: …………………………… signed by (print name): …………………… Dated: ……………………………… Profession: ……………………………… Name of person information collected from: …………………………………Relationship to Client: ………………………….. Place information collected from: …………………………………………………..

Actions By Whom Target Date Date Completed

Signature


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Eating and Drinking

Initial Observation

Name: D.O.B.:

NHS Number: Date:

Place of Observation:

Consent: Consent gained: Yes No (if not, why, how was consent gained)

Activity Comments

Type of Food/Meal

Type of Drink

Amount of food/drink eaten:

Environment

Equipment used

Mobility/Seating and Positioning

Ability/Skill level to feed self, including speed

of eating


here

Name: DOB: NHS Number:

Level of Staff support/type of support

Behaviour e.g. Distractions, concentration,

refusal, distress

Emotional Response

Risks when eating and drinking

(Refer to questions 4, 9, 10, 11, 12 of Eating

and Drinking Assessment)

How did Carers respond to any incidents

observed?

Actions

Action

By Whom

Target Date

Date

Completed

Signature

Signed: …………………………… Name in Capitals: …………………………………….. Dated: ………………………….. Profession: ……………………………………..

Learning Disability Team Mansion House Leicester Frith Hospital Groby Road Leicester LE3 9QF Tel: 0116-225-5200 Fax: 0116-225-5202

Eating and Drinking

Initial Observation Guidelines

Activity Examples Suggested Activity Type of Food/Meal Food eaten. Cultural requirements.

Is it pureed/mashed, diabetic? Allergies, gluten free. Amount given. Did the client choose?

Refer to Salt and/ or dietician

Type of Drink Hot/Cold; Thickened; Amount given

Refer to Salt and or dietician

Amount of food/drink eaten Is this documented for the person?, is this usual for the person. Is the person over/under weight.

Refer to MDT

Environment Where did the person sit?, consider time, noise, lighting, colour . Who did they sit with / people in the room. Background influences, eg. TV, radio, door bell, other people in the room causing a distraction.

Refer to OT

Equipment Used Plate, cup, cutlery, mat, apron, chair/table, any individual furniture?

Refer to OT

Mobility/Seating and Positioning

Posture, head position, gross motor skills. Position and impact on persons eating/drinking ability. Best position for the client.


Ability/ Skill level to feed self, including speed of Eating

Speed of eating, ability to initiate task, sequence, problem solve, continue with task to completion. Hand grip, fine motor skills, ability to load cutlery, ability to put cutlery in mouth, over fill mouth?

Refer to OT

Level of Staff support/type of support.

Number of Staff. Were staff consistent or did they leave the room or divide their attention between different clients. Full physical assistance, hand over hand support, verbal prompts, supervision. Staff position when assisting the person

Refer to OT and or Salt

Behaviour e.g. Distractions, concentration. Refusing foods

Ability to sit and remain seated at the table. Awareness of the task. Distracted away from the task. Ability to attend to the task?. Social skills/interaction, did the person refuse food and or drink. Taking food from others.

Refer to relevant professional provide advice

Emotional response.

Did the person become distressed by food drink, activity, staff, other people etc.

Refer to relevant professional stated above/discuss with MDT

Risks when eating & drinking (Refer to questions 4, 9, 10, 11, 12 of Eating & Drinking Assessment)

Signs of tears in eyes, effort to swallow, reddening face, wheezy/gurgling sound, coughing during/shortly after eating/drinking. Ability to chew/swallow. Emotional behaviour.

Refer to Salt and/ or Physiotherapy

How did carers respond to any incidents observed?. eg, choking aspiration (behavioural)

Refer to relevant professional stated above/discuss with MDT

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Leicestershire Partnership NHS Trust

Fluid Chart

Date: Date:

Patients Name DOB Consultant Named Nurse

Fluid Intake Target (mls) Supplements (see Dietary Prescription Chart)

Dislikes

Comments

Time Type of Fluid Offered (Record if Refused)

Fluid Intake

Urinary Output


Fluid Intake

Urinary Output

01.00 01.00 02.00 02.00 03.00 03.00 04.00 04.00 05.00 05.00 06.00 06.00 07.00 07.00 08.00 08.00 09.00 09.00 10.00 10.00 11.00 11.00 12.00 12.00 13.00 13.00 14.00 14.00 15.00 15.00 16.00 16.00 17.00 17.00 18.00 18.00 19.00 19.00 20.00 20.00 21.00 21.00 22.00 22.00 23.00 23.00 24.00 24.00

Totals Totals

Leicestershire Partnership NHS Trust

Fluid Chart

Evaluation – Fluid Chart to be evaluated at least every fourth day

Patients Name DOB Consultant Named Nurse

Fluid Intake Target (mls) Supplements (see Dietary Prescription Chart)

Dislikes

Comments

Date: Date:


Fluid Intake

Urinary Output


Fluid Intake

Urinary Output

01.00 01.00 02.00 02.00 03.00 03.00 04.00 04.00 05.00 05.00 06.00 06.00 07.00 07.00 08.00 08.00 09.00 09.00 10.00 10.00 11.00 11.00 12.00 12.00 13.00 13.00 14.00 14.00 15.00 15.00 16.00 16.00 17.00 17.00 18.00 18.00 19.00 19.00 20.00 20.00 21.00 21.00 22.00 22.00 23.00 23.00 24.00 24.00

Totals Totals

Side 1

Date of Evaluation: Evaluated By:

Action required ( please tick ) Yes - see care plan No – discontinue Continue to monitor

Signature of Qualified Nurse:

Side 2

Thank you for taking the time to fill in this form. We will direct this form to a professional who can look at the details with you and decide on an appropriate response. The professional will ring you in the next week. If you have not heard from us, please call Sue Challis on 0116 225 5812

Action Date and sign

Choke report received on

Choke report logged and copy to SEAD

Action: sent to which SLT Name of SLT

SLT’s action

Response sent to (Home/ other/reporter) Letter or other. Saved where?

Was a referral needed? (details)

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Other Useful Leaflets

Alert

Foods which give a high risk of choking

Supporting people who eat and drink too

fast

What is Dysphagia?

Supporting people with Dementia to eat

and drink

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was visited today by to assess their eating and drinking. The following recommendations have been made. A full report and eating and drinking care plan will be produced shortly/This will be the final version

Initial Assessment recommendations for:

_____________________________________

NHS Number _________________ DOB __________

Current:

Actions / recommendations:

Drinks

Current:


Current:


Equipment

Current:


Assistance required

Current:


Position Things to look out for

Current:


Any problems please contact:

………………………………………………...

Telephone number:………………………….

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Discharge is considered when

The individual is stable

Carers are confident and competent to carry out the Eating and Drinking Plan

Carers know how to review the Eating and Drinking Plan and know how and when to re-refer

When all these criteria are met, the individual is discharged and the information is relayed back to the GP and the Locality LD team

Discharge

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Specialist Assessment

Who may be involved in Specialist

Assessment?

What may be included in Specialist

Assessment?

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Individual

Knowledge of own likes, dislikes,

preferences, aspirations

(Person Centred Plan and

Health Action Plan)

Who may be involved in assessment?

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Speech and Language Therapist

Assesses communication and

swallowing

Occupational Therapist

Assess functional skill level and

functional positioning in order to

maximise independence and

enable the individual’s skill level

within eating and drinking

Dietician

Assesses nutritional needs

Outreach Team

Assess significant behaviour

issues

Community LD Nurse

WAITING FOR INFO

Carer

Knowledge of the person and their likes

and dislikes, trialling treatment providing

direct support

Psychologist

LEADS TO BLANK

Health Facilitator

D19

Psychiatrist

Mental Health assessment if there are valid

concerns about conditions such as depression,

mania, psychosis, or and eating disorder that may

be impacting nutritional intake

Acute Liaison Nurse

Physiotherapist

Assesses positioning, posture and

management of secretions

The assessment will be person-centred

and tailored to individual needs and may include:

What may be included in

Specialist Assessment?

Direct Observation

Capacity

Sensory

Mental Health

Cognitive

Nutritional

Communication

Risk

Environmental

Case History

Psychological

Positioning

Physiological

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The Occupational Therapist considers the impact of physical, cognitive, perceptual, sensory and behavioural factors in the assessment and management of individuals with eating and drinking difficulties. This also reflects the environmental and social factors which affect the individual’s skills. This may involve:

Liaison with other professionals in the assessment of an individual’s positioning needs. This includes the use of appropriate seating and other physical supports to facilitate safe and effective eating and drinking.

Facilitation of independence through the use of adaptive equipment and education of individuals and their carer’s in appropriate feeding techniques, and the method and level of support required.

Assessment of individual’s cognitive and perceptual skills in relation to the task, such as understanding of sequence, orientation, problem solving and spatial awareness.

Assessing the impact of the individual’s behaviour, psychological and other social factors in order to promote safe and effective eating and drinking.

Assessment of individual’s sensory skills and needs.

The above are considered within the context of an individual’s environment with regards to the influences this has upon their skills and ability to function as independently as possible. Occupational Therapists will monitor and review recommendations made in line with the MDT Care Pathway. Some OTs are trained to have the required competency level for a Foundation Dysphagia Practitioner as part of the eating and drinking care pathway.

Eating and drinking OT assessment Eating and drinking OT assessment Sensory OT assessment 5c

Occupational Therapists Role in

Eating and Drinking

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Occupational Therapist Assessment

Name: NHS Number:

Occupational Therapy

Eating and Drinking Assessment

NAME: D.O.B:

ADDRESS: NHS NO:

THERAPIST:

Other professionals agencies involved:

Is there a past meal time plan? If yes date of plan:

KEY:

√ √ Independent

√ X V Minimum assistance, verbal

√ X P Minimum assistance, physical

X X Maximum assistance

TASK KEY COMMENTS

MOTOR SKILLS

Stamina/Tolerance

Strength

Fine Motor Skills

Movement

Grip

Gross Motor Skills

Movement

Position/Balance

Sensory Skills

Visual

Tactile

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Olfactory

Auditory

Gustatory

Proprioception (vestibular)

TASK KEY COMMENTS

COGNITIVE SKILLS

Attention/Awareness

Initiation

Continues with task and continues to the end.

Comprehension

Memory

Sequencing

Decision Making

Problem Solving

Orientation

PERCEPTUAL SKILLS

Visual e.g. Colour, depth,

figure ground, and form size and consistency.

Spatial e.g. scanning and

tracking, body position.

ADDITIONAL INFORMATION COMMENTS

General Behaviour e.g. risks to

health or chocking, mood, engagement, mental health, emotional state.

Social Skills

Environmental Factors e.g.

physical, distractions, other people in the environment.

Dietary Considerations

TASK KEY COMMENTS including type and level of support by carers, carer

positioning etc.

TASK ANALYSIS

Component

Equipment currently in use

Pick up cutlery

Preparation of food

Load Cutlery

Cutlery to mouth

Eating

Food spillage

Speed of eating

Cutlery to plate

Drinking

Considerations Equipment Considerations Materials:

Angles:

Size:

Shape:

Colour:

Weight:

Positioning Considerations

Environmental Considerations

Additional Considerations

E.g. task breakdown, intervention plan, staff training and support.

Therapist signature …………………………………………

Date …………………………………………

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This is an in-house, non-standardised, assessment and observations sheet to inform

Occupational Therapists clinical reasoning for intervention and recommendations

The Role of the Dietitian

Role Definition

Assess individual to ensure that their diet is providing everything

that they need to remain healthy. They advise on ways to make

changes to improve the overall balance of the diet.

The Role of the Dietitian

Dietitians interpret the science of nutrition into practical

advice and guidance to enable people to make appropriate

lifestyle and food choices whilst taking into account the

individual’s circumstances and preferences.

This may involve:

Meeting with the individual to discuss diet and any alterations that may be required

Discussions with carers or other professionals to help facilitate changes

Advice around menu planning

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The Speech and Language Therapist

Works with:

Communication Difficulties

Swallowing Difficulties

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The pathway is person-centred, so this means that throughout the whole

pathway, the person should be included, informed and involved in decision

making at every level.

Communication is very important at mealtimes and when drinking.

It is important to gives choices about the meal, and help people to

know when the meal is anticipated.

It is important to know the person’s likes and dislikes- this should be

available in the person’s Person-Centred Plan

It is important to know when the person may be distressed- a DisDAt

tool may be useful here. (please embed link to DISDAT tool which

has been included elsewhere in pathway)

It is important to know when the person is trying to communicate such

as ‘stop’, ‘wait I am not ready’, ‘more please’, ‘I don’t want that!’ This

should be included in the person’s communication passport if they

have one. (please link to page for communication passport)

What Specialist assessment and intervention may the SLT do?

If the person’s communication requires specialist involvement, the Speech

Therapist may do a specialist communication assessment of understanding

and use of language.

The therapist may work with the support team to write a communication

passport for the individual and may also write a detailed report. ( link to

communication passport page)

The SLT will work with professionals and carers to help them understand

the best ways to involve you and communicate with you.

The SLT may recommend that a person needs supporting methods of

communication alongside speech such as using symbols, photos, pictures,

signing or other ways.

The SLT would support you and the carer to use these.

Communication Difficulties

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How will the Speech therapist(SLT) assess swallowing?

Speech therapy assessment may include

Taking a detailed case history

Observing the person eating various textures and or drinking fluid

textures.

Observing the person eat a meal in their usual environments.

Detailed communication assessment of the carer and persons

interactions

Using Cervical Auscultation to listen to the sounds of breathing and

swallowing in the person’s throat. This means placing a stethoscope

on the person’s neck whilst swallowing whilst the therapist listens

carefully.

The speech therapist may also use a Pulse Oximeter to observe any

effect of eating and drinking on respiration and blood oxygen levels.

This entails clipping a monitor on to the person’s finger or ear or toe.

The speech therapist may suggest more detailed videofluoroscopic

assessment.

Cough and choke charts

Develop sensitive idea of food s managed or not

What will the Speech therapist do to help?

A Speech therapist assesses risks of swallowing: swallowing disability may

contribute to getting infections of the chest (chest infections) or lung

(pneumonia). Speech therapists work with the person, their carers and the

wider team to lessen risks of aspiration, choking or getting chest infections

and promote dignity, independence and enjoyment of the meal. The

speech therapist will try to accommodate the person’s wishes and cultural

needs.

Swallowing Difficulties

The SLT may suggest ways to make swallowing safer and better for you:

Modifying the texture of food or drink by using thickeners

Changing the speed of putting food/drink into the mouth

Changing the environment

Trying different ways to get food/fluid into the mouth

What if a person is at very high risk of aspiration and all other

adaptions have been tried and the difficulty persists? The speech

therapist may recommend that non-oral feeding is considered ( please put

link to Enteral feeding pathway /document here).

If enteral feeding goes ahead, the speech therapist could support the

person through this process, and would work out safe oral intake after the

PEG has been inserted.

The Speech therapist may also recommend referral on to other specialist

services or further tests from the GP. The Speech therapist would ask the

person’s permission and would liaise with the GP.

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Accessible Information

Videfluoroscopy is radiographic imaging of the person’s swallow.

The person is required to attend an acute hospital in Leicester with a carer.

The person needs to give their consent to the procedure on the day.(unless it has been

decided the assessment is in the best interest of the person)

The staff team are fully trained: a combination of Speech therapist or Radiologist and

radiographer carry out the examination.

In advance, the SLT would work with carers to choose the best textures to trial and the

best ways in which to do this.

The person brings food and drink of a pre-arranged texture for the person to eat or drink.

The food or drink is mixed with a radiographic substance, depending on the risks

identified.

The person is seated between the camera and a monitor. As the person swallows, the

clinicians can observe and interpret the recording.

The SLT or Radiologist writes the report, sending a copy to the person and their GP.

Link to VF competences

Videofluroscopy

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The Learning Disability Acute Liaison Nurse (ALN’S) Team

The team consists of three nurses with a learning disability background. The team members are: Katrina Dickens – Lead Nurse, Louise Hammond, and Lindsey Heald. The ALN’s are employed by the University Hospitals of Leicester Trust to help support patients with a learning disability who access the acute hospitals. This may be related to emergency admissions or via the planned care route. The role of the ALN’s means that they will need to interact with acute nursing staff, residential carers/supported living staff; families or carers; community learning disability teams and social workers. Once a patient has been identified to the ALN’s they will undertake a “meet and greet” visit. The ALN’s will follow the patients’ progress from admission to discharge. The ALN’s will also undertake the Learning disability Screening Tool if there are patients considered to have a learning disability but there may be some uncertainty. The work of the ALN’s focuses around the recommendations that were established under the Six Lives Report:

Accessible information within hospitals.

Complaints and experiences relating to people with learning disabilities and their carers.

Consent and capacity.

Reasonable adjustments.

the reasons for admission in relation to geographic areas on a yearly basis

To submit a yearly report to the Commissioners.

Learning Disability Awareness Training to the UHL staff.

The Learning Disability Acute Liaison Nurses can be contacted on: 0116 258 4382.

If they are not available, please leave a message on the answer machine

The things I do well

The things that are important to/for me

.

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Health Action Plan Profile “ADD NAME”

“Add date plan started”

My health need:

Identified problem:

INSERT PICTURE

The things I want to try/ need to do

How best to support me

Who was involved in writing this plan:

Who can see this plan:.

Date What’s working

What’s Not working

Date Key Action’s from Health Appointment

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