News

 by Gillian Robinson

Clinical Assessment Recognises Subtle Changes

Our eyes see what is familiar and what they expect to see.  Are we good at picking up subtle changes through your assessment processes and acting on them appropriately?  The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.

On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care.  During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all.  In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket.  I made the change during the lunch break.

When I entered the room after the lunch break three people commented straight away.  I saw a small number of puzzled looks but those nurses didn’t say anything.  Others didn’t seem to notice and didn’t make comment.  We had three distinct groups.  Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment!  Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day?  Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?

We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs.  Equally these two groups of people can complement each other.  Working separately they will each only see part of what needs managing.  Some over think and others don’t seem to think or reflect.  Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.

It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences.  There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.

What subtle changes are occurring with your residents that you haven’t noticed?  Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk?  Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?

in News
 by Gillian Robinson

Weight management goals in care planning

When care planning, the goals or objectives developed for each aspect of care need to be measurable.  This ensures you’re able to evaluate progress and determine whether the goal has been met or not.  The concern is making sure an appropriate goal is set.  While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays.  People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.

When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.

Ideal weight range in the care process: 

Body mass index is still helpful in determining healthy weights for older adults.  A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.

To work out the BMI: (weight/height²).  Example case:  height = 1.5m and weight = 45kg

  1. We need the height in metres and the weight in Kg.
  2. The height needs to be squared. So a height of 1.5m = 2.25 when squared.
  3. Then the BMI is the weight in Kg divided by the height²

Example:  weight = 45kg divided by 2.25 = BMI of 20kg/m².  This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.

An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg.  Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.

The ideal body weight may differ to the GOAL weight.  The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable.  The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight.  For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year.  Ideally they would gain weight to 50kg, but this is unrealistic.  The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg.  This would still mean the resident is underweight but is realistic in what can be achieved.  If the initial goal weight is achieved, a second goal weight may be identified.  This may be to stabilise weight at 44kg or to gain to 45kg.  etc…

This can work for overweight residents too.  Using the same example height of 1.5m.  Someone who weighs 78kg has a BMI of 34.6, and is obese.  However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care.  A more realistic GOAL weight would be weight stabilisation and then some weight loss.  5% weight loss can improve many health outcomes and this would be a realistic target.  Weight loss of 5% is still around 4kg, which is possible but still difficult.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

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Unwanted Weight Gain
 by Gillian Robinson

Unwanted Weight Gain in Aged Care Facilities

While most of the referrals for dietitian input in aged care facilities relates to unwanted weight loss, dietitians can be asked for input with residents who have unwanted weight gain.

What is overweight?

For many adults we use the Body Mass Index as a basis for identifying a ‘healthy weight range’.  The BMI is a ration of the person’s height to their weight.  (kg/m²)  The BMI is not without its limitations, but generally it is a useful tool in assessing if someone is within the recommended weight range (BMI 20 – 25kg/m²), below it (underweight and malnourished) or above it (overweight and obese).  For older adults, the ‘healthy weight range’ tends to shift upwards.  There is evidence older adults with a BMI between 22 – 27 kg/m², have a longer life expectancy.  There is evidence that older adults who have unwanted weight loss will reduce their life expectancy.

What is the aim?

The first question to ask is whether this weight gain is a cause for health concern, and if there are benefits gained from weight loss.  In some cases weight gain may lead to reduced mobility, worsening blood sugar control, exacerbation of shortness of breath and gastric reflux, problems in fitting clothes, problems with ill-fitting hoists, chairs, and increased difficulty with transfers.  If it agreed that weight loss would be beneficial, the first nutritional goal is to prevent further weight gain.  Aim to stabilise the current weight.  Weight loss may be the next goal once weight stabilisation is achieved.

How much weight to lose?

Stabilising the current weight is a good start.  If weight loss is desired, set a realistic weight goal with the resident.  Health benefits are noticeable with as little as 5% weight loss.  A 85kg woman losing around 4kg should notice some benefits.

The goal of weight loss it to be losing body fat, not body muscle.  If weight loss is too rapid, the risk is that significant muscle mass is lost.  This can lead to worse health outcomes.

Involving the resident who has unwanted weight gain

A discussion with the resident about whether they are noticing any effects from the weight gain, and whether they would like to try and prevent gaining more weight, is essential.  It may be useful to explain the expected health benefits possible with weight loss. Family may also like to be consulted, but the decision and the motivation really needs to come from the resident.

Just telling a resident they need to lose weight, or automatically changing their diet is not treating a resident with respect, nor providing care that is tailored to their needs.  You may feel that the ‘best’ option would be to lose weight. The resident may feel different. They have the right to choose what’s right for them.

What strategies may help unwanted weight gain?

Losing weight is hard.  There needs to be a reduction in the energy intake with an increase in energy output.  Changes to food and changes to levels of activity are needed for optimal results.  Activity and body movement are important in helping to maintain muscle mass.  The diet still needs to remain nutritionally adequate, especially in terms of protein to minimise the loss of body protein too.  Continue to offer quality protein foods, at main meals and tea meals.

An aged care facility menu is nutritionally balanced and tailored to ensure the nutritional needs of the residents are met.  Talk with the resident about what ideas they might be happy to try to help reduce their food intake.  Small changes eventually add up to significant calorie reduction.  Start with changing one or two things only in the diet.  If that is successful, add in other small changes.

Reducing Food Intake

  • Target between meal snacks such as morning tea, and/or afternoon tea. If the resident is not hungry at these times, he or she may be able to skip the food offered
  • Limit sweet drinks; offer water, ‘diet’ options and a sugar replacement in hot drinks
  • Reduce the frequency of desserts in the week, or offer lower calorie options such as fresh fruit, diet jelly, low fat yoghurt. Limit the use of cream on desserts.
  • Ensure the size of the main meal is a medium meal (not large), serve extra vegetables if the resident is wanting more food.
  • Look at the quantity of food eaten at meals. Reducing the amount slightly can help.
  • Target the amount eaten at ‘happy hours’ and other treat times
  • Try to encourage the resident to limit the amount of extra foods they may be buying and having in their room
  • Ask family and friends not to bring in food items. Suggest other options such as magazines, books, photo albums, flowers

Increasing activity levels

  • Encourage the resident to join in the home’s activities
  • Encourage the resident to walk more if possible, around the home, to the dining room, around the garden – short distances at first so they gain a sense of achievement
  • Family and friends may be able to help by joining the resident in walks or taking them on outings too

These are some ideas to try.  For more information and tailored nutritional advice contact your clinical dietitian.  If the resident is ready to make some changes, offer support and encouragement, to help enable their success.  Be positive.  As with all of us, sometimes we deviate from our own ‘diet’; we have a treat or a dessert or a second helping.  Don’t judge residents, or be so strict with restricting foods.  Avoid using phrases that suggest the resident is ‘being good’ or ‘being naughty’ in terms of whether they are following the agreed diet plan.  There are no ‘good’ foods and ‘bad’ foods.  And finally, weight loss takes time.  Simply stalling the weight increase is a significant achievement.  Long term encouragement and support is essential for successful and sustained weight loss.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

liz@canterburydietitians.co.nz

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 by Gillian Robinson

Is the company email the employers property?

In simple terms, a work or company email is an employer’s property in the same way a direct dial phone number, phone (mobile and/or land line) and any other piece of equipment or resource is.  Therefore, as a matter of principle, the employer is entitled to have access to that email address as necessary in order to conduct its business activities.  Correspondingly, employees are obliged to co-operate with any request for access.

Where issues can arise is when an employee is allowed to use their work email for personal emails.  This can either be set out in policy or implicit.  In this case, care needs to be taken to ensure that personal emails are not read.  The access should be limited to ensuring the employer can access business related emails.

If an employee is objecting to providing access to their work email, you can address this by confirming that as a matter or principle the work email address is the employer’s property and you require access to all work emails.  Reinforce with the employee, you will not be reviewing personal emails and they can either forward those emails to their personal email address, delete them etc (as noted below).  However, you will require their password and access as needed.

If an employee continues to resist, inform them you will be making arrangements with your IT service provider to gain access to the work email and given their lack of co-operation, suspending their personal use until further notice.  If this step is required, it’s advisable to contact your employment law adviser first in order to ensure clear and succinct written communications are provided in respect of this step.

To avoid issues in the future, if there is no policy in place, or if there is a policy in place which does not address it, in the first instance all employees should be told that:

(a)       Any work assigned email address is for work purposes;

(b)       That where necessary you will require employees to provide access in order for you to ensure that email communications are dealt with as needed and to provide for business continuity;

(c)       Personal emails received at the work email address can be forwarded to a personal email address, deleted, flagged or moved into a separate folder so they remain private; and

(d)       A policy will be introduced to clarify email and internet access shortly, or recirculate the current policy (updated if/as needed).

Noting point (d), if there is no policy in place, it would also be timely to introduce an email and internet policy specifying how the internet and email facilities can and will be used.  Alternatively, if there is a policy, but it does not cover this situation, the policy should be updated.

Above article kindly contributed by: Dean Kilpatrick (Special Counsel – Employment), Anthony Harper Law,  For more information contact –  Email

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 by Gillian Robinson

Using physiotherapy assistants in residential care

 

Employing a physiotherapy assistant (PTA) is a fantastic and cost effective way to implement physiotherapy programmes. Many residential care facilities contract in physiotherapy services at an hourly rate, often for only a few hours per week. Supporting this service by having an employee who can accompany the physio on their visit, and then put the exercise programmes in place supports real outcomes for residents.  When I quote for services to residential care facilities I always put a persuasive argument in place for them to appoint a PTA at the same time.

Of concern is that we sometimes visit facilities who have a physiotherapy assistant employed but no contracted physiotherapy hours. Why is this a problem and what are the consequences? The problem lies with the fact that “Physiotherapist” is a legally protected title and to practice in New Zealand you must be registered and hold a practising certificate. If there is any perception that the person is a physiotherapist or is carrying out ‘physiotherapy’ then this is illegal and the fine can be up to $10 000. The key word here is perception. Below are some examples that I have come across where I believe the work was illegal.

– A GP requested a physio assessment of a resident with a sore shoulder. This assessment was carried out by an overseas qualified   physio working as a PTA in a facility;

– A PTA doing exercises with a resident and the family said “she is having her physiotherapy session so we will wait”;

– Staff referring to their physiotherapy assistant as the “physiotherapist” in conversations.

Physiotherapy New Zealand has written guidelines for using a physiotherapy assistant (this covers the term rehab assistant also). The guidelines state that a client must have:

– An assessment by a NZ registered Physiotherapist and a treatment plan;

– Ongoing monitoring of the physiotherapy status and needs of the client.

The physiotherapy assistant must have strict boundaries which include being deemed competent by a supervising physiotherapist, not advancing or changing the treatment plan without written and verbal instruction from the physiotherapist, not offering any advice or opinion (other than reiterating the physiotherapist’s advice). They must have a clear written job description and adequate support. The work they carry out is the responsibility of the supervising physiotherapist which means only the physiotherapist can prescribe treatments which they have observed the physiotherapy assistant. Competency must be confirmed in respect of each individual treatment plan. This even includes simple exercises such as a walking programme.

We also recommend to our facilities that they consider getting a uniform that clearly designates the person as a ‘physiotherapy assistant’ and a name badge with this written. This helps greatly with the problem of other peoples ‘perception’ as already mentioned. We also recommend and provide separate documentation forms for PTAs.

Being a physiotherapy assistant is usually a very rewarding job but can be isolating for staff as they are usually the only one in their facility and often also have hours as a carer. It is good practice to support them with ongoing training and regular supervision with a physiotherapist that is not just focussed on their clinical role.

On the Go Physio offer regular training for physiotherapy assistants including a full day conference later in 2017. To find out more about the pending conference go here and request details.

This article kindly contributed by Jessie Snowdon – Physiotherapist,  founder and director of On the Go Physio. She graduated from Otago University in 1998 and has worked in Christchurch, Edinburgh and London in a variety of roles

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 by Gillian Robinson

Influenza season

Prepared for winter coughs and colds?

Winter is fast approaching and now is the time to be preparing your facility for the season’s usual crop of influenza, coughs and colds.

Last year the elderly were hit hard with, not just influenza, but also other respiratory viral infections. Many were admitted to hospital with complications such as pneumonia.

The predominant circulating influenza strain in 2016 was Influenza A, H3N2, different from the previous year’s Influenza A, H1N1. Although covered by the vaccine, last year’s predominant strain changed slightly from what was covered in the vaccine and there were numerous reports of laboratory confirmed cases of young vaccinated adults who still acquired influenza. Despite this, vaccination still affords some protection and symptoms are less severe than without it. This is the same for the elderly whose uptake of the influenza vaccine is not so good – experts agree that there are still benefits from the elderly having an annual influenza vaccine.

Some of the other respiratory viruses last year that caused severe disease in our elderly included coronavirus, rhinovirus and parainfluenza.

 

Check list for winter virus planning

  • Encourage and offer seasonal influenza vaccination to both staff and residents
  • Ensure hand sanitiser is available for visitors at the entrance of the home
  • Consider displaying a poster discouraging visitors with symptoms – a poster is available from CDHB communications
  • Remind staff and residents about good cough etiquette / respiratory hygiene
  • Have a good stock of tissues and hand sanitiser for residents
  • Remind staff to stay off work if sick – no-one wants their germs!
  • Educate staff about S&S of influenza – not all residents will display fever or cough
  • Keep residents in their rooms if symptomatic and introduce droplet precautions, i.e. droplet masks for staff providing cares
  • If you suspect an outbreak then confirm the outbreak[1] and introduce control measures[2]

Ensure all infections are logged into you infection register (for HCSL QA online uses – this is part of your infection log process) – remember your outbreak notification requirements as per your policies and procedures.  If you would like more assistance with this please contact us.

 

This article kindly contributed by: Ruth Barratt RN, BSc, MAdvPrac (Hons) – Independent Infection Prevention & Control Advisor (Canterbury)

Infectprevent@gmail.com

[1]  Infection Prevention & Control Guidelines for the management of a respiratory outbreak in ARC / LTCF

[2] A Practical Guide to assist in the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Australia

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 by Gillian Robinson

Infection Prevention and Control – 2017 review

Antimicrobial stewardship for aged residential care  

The below article was contributed by Ruth Barrett – RN, BSc, MAdvPrac (Hons); Independent Infection Prevention & Control Advisor

 

What is your New Year resolution for 2017 in the world of infection prevention and control (IPC)? If you haven’t thought of it I would suggest looking at antimicrobial stewardship in your facility.

I was fortunate to attend a recent international IPC conference in Melbourne (ACIPC Conference 2016) and was pleased that aged residential care was a popular theme for both oral presentations and posters. One of the topical subjects was feedback from the first survey of antimicrobial use in residential care facilities in Australia. The results of this research are freely available and make interesting reading[1][2]. A good deal of the findings could equally apply to ARC in New Zealand.

Antimicrobial resistance and antimicrobial stewardship are two topics that go hand in hand.

As rates of antibiotic resistant bacteria continue to rise in New Zealand, then the responsibility for and management of the use of antibiotics becomes more important. Aged residential care (ARC) facilities are an important reservoir for MDRO transmission within the community. In the ARC setting, there are frequent transfers between the acute hospital setting and back to the rest home. This along with an over-use of antibiotics in the community can lead to a higher prevalence of multi-drug resistant organisms (MDRO) in ARC.

Even if a resident does not usually receive antibiotics, the resident is still at risk of picking up an MDRO if a lot of antibiotics are used. Managers, nurses and carers who work in a residential care facility all have apart to play in reducing the amount of antibiotics used and minimising the increase and spread of MDRO.

 

Some of the ways you can do this include-

  • Ensuring hand hygiene compliance is high for all staff and providing hand sanitiser close at hand for carers.
  • Using other specific contact precautions to control the spread of MDRO in your facility according to local policy.
  • Not using topical antimicrobial creams unless prescribed e.g. don’t routinely use Mupiricin (Bactroban) on wounds.
  • Only sending wound swabs, urines etc if there are obvious signs and symptoms of infection.
  • Recognising influenza or other respiratory outbreaks earlier to avoid secondary chest infections in the elderly, which would require antibiotics. Remember that in the winter season, many respiratory infections are caused by viruses and do not need antibiotic treatment.
  • Ensuring the residents finish their course of antibiotics.
  • Monitoring infections using a surveillance programme.
  • Monitoring the incidence of MDRO in the facility.
  • Accessing specialist IPC advice if infection or MDRO rates are of a concern.

 

So why don’t you make antimicorbial stwardship your IPC focus for 2017?

 

Contributed by:

Ruth Barratt RN, BSc, MAdvPrac (Hons)

Independent Infection Prevention & Control Advisor

Infectprevent@gmail.com

 

[1] Antibiotic use in residential aged care facilities, Australian Family Physician, Volume 44, No.4, April 2015

[2] Antimicrobial Stewardship in Residential Aged Care Facilities. Result of survey.

 

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 by Gillian Robinson

Moving and Handling in residential age care

Moving and Handling and the Health and Safety Act

Thanks to Jessie Snowdon, Physiotherapist for contributing the below article – 

 

All managers will be acutely aware of the Health and Safety at Work Act 2015 (HSWA) and the responsibilities of, and potential penalties, for PCBUs (persons conducting a business or undertaking).

The HSWA requires businesses to ensure, as far as reasonably practicable, the health and safety of its workers. This includes safe systems of work, equipment, training and monitoring the health of workers. These processes are all included in the policies and procedures designed specifically for residential aged care facilities by HCSL.

Within the residential care industry staff are exposed to significant hazards daily in terms of patient handling and manual handling for kitchen/laundry staff.  Moving and handling is a hazardous task – it is repetitive, can involve high force (heavy residents) and frequently involves awkward postures. The likelihood of injury for both care staff and residents is high and the consequences can be serious, meaning that moving and handling is a high risk activity.

When we consider moving and handling in this light, managers need to be confident that they have safe systems. Consider how each resident’s transfer abilities are assessed. How is this documented and communicated? How do you know you have the correct equipment on site and how do you ensure that you have enough equipment in order for staff to be able to access it when they need it?

Our experience shows that often if the equipment is not available many staff will do an unsafe transfer in order to save time.  How do you ensure new staff are competent prior to undertaking moving and handling tasks? How do you ensure that existing staff are up-skilled? How do you implement the New Zealand guidelines? And how do you monitor your systems, equipment and training? These are questions all managers should be able to answer.

‘On the Go Physio’ carries out Moving and Handling training in over 15 facilities in Canterbury and offer training to representatives from many others. We offer tailored packages which can include up-skilling your whole team, or training your own moving and handling trainers and assessors. We can review your training and orientation systems and assist in equipment trials. If you are interested in discussing your facilities requirements to help you ensure your staff, and resident’s, health and safety contact us here.

For residential care specific policies and procedures related to safe moving and handling, along with related forms for use, contact HCSL here.

 

Contributed by: Jessie Snowdon (Senior Physiotherapist and Director)

‘On the Go Physio Ltd’

PO Box 32 004, Christchurch 8147

Ph: 0800 000 856 or Mobile: 021 030 9061

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 by Gillian Robinson

Food Safety in residential aged care

Cooling and Reheating Meals

Thanks to Liz Beaglehole – Registered Dietitian for contributing the below article –

 

With the introduction of the Food Act 2014 and the requirement for most aged care facilities to have registered their food control plan (FCP) by March 2018, I thought I would write this article on a common kitchen practice that will require review. This relates to one important key component of food safety.

FCP’s are included in the policy and procedure documentation provided by HCSL specifically designed for residential care facilities.

In many facilities the main meal is served in the middle of the day and the tea meal served at night.  The main cook of the day will prepare the tea meal earlier in the afternoon, and then finish his or her shift.  The tea meal will be reheated by the afternoon staff and served to the residents.

The process of cooking, cooling and reheating requires careful control of the food safety risk.  Many tea options are protein or carbohydrate based; macaroni cheese, egg dishes, savoury mince, chicken options – all of which are high risk foods for bacteria growth.

Foods need to be cooled quickly to avoid time and temperature abuse, which may allow bacteria growth.  The guidelines state that when cooling hot cooked foods, the food must cool to at least 21° within the first two hours, and then cool to below 5° in four more hours.  Overall, the food must be out of the danger zone (between 5°C and 60°C) within six hours.

A functioning chiller should allow cooked foods to cool within this timeframe.  Using domestic fridges that are overcrowded, may mean the cooling guidelines are not met.  Using shallow dishes rather than large deep dishes will also allow foods to cool faster.

The food control plan will specify the process the site kitchen must follow with regards to cooling of cooked food.  Temperatures during cooling will need to be checked and recorded to ensure the time / temperature targets are met.

Prior to serving, the food must be reheated to above 75°C.

Some sites choose to hold the prepared food hot until service.  Food must be held hot at a temperature of at least 60°C, usually in a bain-marie or oven at 70°C.  Any food held below 60°C for more than 2 hours, must be thrown out.  Note that holding foods hot for this period of time may affect the food quality.

Main Points:

  • Food safety risk with cooling and reheating foods must be managed with FCP
  • Cool cooked food to below 21°C in 2 hours and below 5°C in 4 hours
  • Reheat foods to above 75°C before service
  • Hold hot prepared foods at 60°C or more
  • Document food temperatures and any corrective action
  • Review corrective action implementation to ensure they have been effective

 

Article contributed by:

Liz Beaglehole

NZ Registered Dietitian

Canterbury Dietitians

Email: liz@canterburydietitians.co.nz

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 by Gillian Robinson

Unintentional weight loss

A very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.

Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.

If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.

Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’.  Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.

Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.

Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss.  This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau.  Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable.  These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.

Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis.  Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.

If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations.  Ensure any recommendations are followed as directed.

Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals.  Return to monthly monitoring of weight at this stage.  Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.

Case Study:

An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her.  She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow.  The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food.  Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain.  Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg.  At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family.  Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were.  Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat.  It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves.  Getting the basics right is a good place to start.

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