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Principles of good nutrition and hydration.

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Principles of good nutrition and hydration.

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Malnutrition is responsible for an increase in hospital admissions and an increase in the length of stay for many patients.

A balanced diet, adequate portion sizes and a sufficient intake of fluids are the principles of good nutrition and hydration.

A core role for the healthcare professional is to ensure that as part of the recovery process and care planning principles, the patient is encouraged to maintain a good diet and fluid intake in order to support the body to heal and repair.

Different types of diet

Many health conditions can be improved by the intake of a modified diet. For example:

a fall in levels of ostrogen in perimenopause or testosterone in prostate cancer treatment; this will affect bone density, requiring more vitamin D-rich foods and a dietary supplemen.

The pancreas and liver are organs that play a role in converting food nutrients into a useable format for cells; health conditions affecting these will have a significant impact.

Health conditions that affect appetite directly or as a consequence of wanting to avoid symptoms, such as inflammatory bowel disease diarrhoea and painful gut spasms, can be addressed by changing foods and using suitable treatments.

Diets can be modified - For instance, in the form of: an increased level of protein for cell repair lower-cholesterol foods as a treatment for heart disease.

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Find out more about dysphagia, where you have problems swallowing.

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consider carefully whether the patient needs a fluid balance chart.

Record clearly.

Only use figures, do not state PU’d or “wet pad”, or PU’d in toilet - these are not accurate.

For patients wearing pads - pads can be weighed dry, weight written on pad. Pad weighed when soiled and 1mg=1ml.

Catheters - document amount each time catheter is emptied.

Ensure running total completed - concerns/discrepancies will be noticed earlier.

Ambulatory patients - offer containers to pass urine in. Empty container can be weighed and then when full, weighed - 1g = 1ml.

Know the volume of the cups/jugs given.

Know whether your patient is on fluid restriction.

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Collect and test specimens - urine and faecal.

Monitor fluid intake and output - reflect healthcare sector standards practice.

Promoting adequate nutrition and hydration.

Dietary planning with calculations for calorie intake (patients with continence issues, post-surgical patients).

Individual’s ability to swallow is monitored and assessed (also use MDT).

Appropriate support is given with eating and drinking.

Appropriate equipment is provided to support individuals to be independent when eating and drinking.

Appropriate food/drink provided (dietary needs, religious requirements).

Potential effects of medication on eating and drinking are considered.

When to escalate concerns.

How observations may change in regards to fluid balance.

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WHO: Assistive Technology tutorial series - Eating with angled spoon and plateguard

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WHO: Assistive Technology tutorial series -  Thick handled cutlery to eat a meal

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WHO: Assistive Technology tutorial series - Using spoon with cuff to bring food to mouth

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WHO: Assistive Technology tutorial series - Drinking with a 2 handled cup

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WHO: Assistive Technology tutorial series - Drinking with a cut-away cup

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Capillary Refill Time Test: Normal vs Abnormal - Nursing Clinical Skills

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What Is Normal Skin Turgor? - Nursing Knowledge Exchange

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collection of stool specimen | Nursing | Osmosis

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Scenario 1: Post-operative patient

Patient: 45-year-old, day 1 post-appendectomy.

A. 08:00

BP: 110/72

HR: 88

Temp: 37.4°C

Resp: 16

SpO₂: 98% RA

Urine output: 45 mL/hr overnight

Notes: Patient alert, mild abdominal discomfort, sipping water.

B. 14:00

BP: 98/66

HR: 104

Temp: 37.8°C

Resp: 20

SpO₂: 96% RA

Urine output: 25 mL/hr

Notes: Complains of dizziness on standing, reduced oral intake. Skin slightly dry.

C. 20:00

BP: 86/60

HR: 118

Temp: 38.1°C

Resp: 24

SpO₂: 95% RA

Urine output: 15 mL/hr

Notes: Patient pale, dry lips, tachycardic, feels lightheaded when sitting. Nurse escalates to medical team. IV fluids commenced.

Scenario 2: Elderly patient with vomiting & diarrhoea

Patient: 78-year-old admitted with 24-hour history of gastroenteritis.

A. 09:00

BP: 124/78

HR: 92

Temp: 37.0°C

Resp: 18

SpO₂: 97% RA

Urine output: 35 mL/hr overnight

Notes: Feeling weak, nausea improving. Taking sips of water.

B. 15:00

BP: 102/70

HR: 108

Temp: 37.6°C

Resp: 22

SpO₂: 96% RA

Urine output: 20 mL/hr

Notes: Dry mucous membranes, increasing thirst, has not eaten lunch. Carer reports reduced confusion compared to baseline.

C. 22:00

BP: 88/62

HR: 124

Temp: 38.3°C

Resp: 26

SpO₂: 95% RA

Urine output: 10 mL/hr

Notes: Patient drowsy but rousable, flushed, capillary refill >3s. Escalated to senior nurse/doctor. IV fluids started.

Scenario 3: Young adult with sepsis concern

Patient: 22-year-old with tonsillitis, admitted with poor oral intake.

A. 07:00

BP: 112/74

HR: 98

Temp: 38.0°C

Resp: 18

SpO₂: 97% RA

Urine output: 40 mL/hr

Notes: Alert, feverish, sore throat, drinking small amounts.

B. 13:00

BP: 96/68

HR: 112

Temp: 38.5°C

Resp: 22

SpO₂: 95% RA

Urine output: 25 mL/hr

Notes: Increasing fatigue, lying in bed, skin warm to touch, lips dry.

C. 19:00

BP: 84/58

HR: 130

Temp: 39.2°C

Resp: 28

SpO₂: 94% RA

Urine output: 10 mL/hr

Notes: Confused and restless, skin mottled, radial pulse weak. Doctor informed urgently. IV fluids commenced.

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Urinalysis - urine dipstick test - video

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Urinalysis - urine dipstick test - video

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Urinalysis | Urine Dipstick Test | OSCE Guide | UKMLA | CPSA | PLAB 2

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Newcastle Hospitals NHS Foundation Trust

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Swallowing Disorders (ENT) - Newcastle Hospitals NHS Foundation Trust

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Dysphagia is a disorder of swallowing. One of the most common dysphagi symptoms we see is the sensation of food sticking in the throat.

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Swallowing and Oral Symptoms :: South Tyneside and Sunderland NHS Foundation Trust

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Cancers and their treatments can cause a sore mouth and throat, this can make chewing and swallowing more difficult. You should speak to your doctor or nurse if you or someone you care for, have difficulty swallowing or problems with your mouth so you can get the help you need.

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Video - Living with swallowing difficulties

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Video - Living with swallowing difficulties

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Newcastle Hospitals NHS Foundation Trust

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A videofluoroscopic swallow study (VFSS) is a moving x-ray examination of the mouth and throat.

Why do I need a VFSS?

Your speech and language therapist has assessed that you or your child might have having swallowing difficulties.

The x-ray will determine if there is a problem and if so what type of food and fluid are safest to eat, and whether there are any techniques to increase swallowing safety.

What happens during the VFSS?

You will be cared for by one or two speech and language therapists and a radiographer.

The speech and language therapists will prepare the food and fluids, guide you or your child through the assessment and interpret the findings.

The radiographer will operate the x-ray machine and recording equipment, take the x-ray and discuss interpretation with the speech and language therapist.

Other professionals may be invited to the appointment if needed, e.g. physiotherapist or local speech and language therapist.

Family/carers are encouraged to be involved in the examination, because involvement and understanding is important in helping you to accept any changes to your diet that may be needed.

The procedure will take approximately 30 minutes.

You or your child may need to remove some clothing and wear a gown if the radiographer feels it is appropriate. Otherwise, a gown will be worn over the top of clothes just to protect your clothing from spills.

Make sure you don't wear anything around the neck area which will impact the view of the x-ray. Necklaces and earrings which will need to be removed.

You or your child will be appropriately positioned standing or seated close to the x-ray machine. If you or your child are a wheelchair user and it is not possible to remain seated· in your own chair, help is available by a member of staff or a hoist to transfer you from your chair to the x-ray seat. Please let us know in advance if you will need help.

If you or your child has a feeding tube in your nose or stomach it does not have to be removed.

You or your child will be given small amounts of liquid, and different textured food as appropriate, coated in a paste that will show up on the x-ray. It tastes chalky but is not unpleasant. During eating and drinking, x-ray pictures will appear on a television monitor showing the swallow.

You or your child's mouth will be able to rinse your mouth as soon as the examination is finished.

What are the risks?

We are all exposed to natural background radiation every day of our lives. Each x-ray examination gives us a small additional dose. This dose varies with each type of examination. Everything is done within the x-ray department to minimise this dose.

Are there people who are not suitable for VFSS?

You will not be suitable to have a VFSS if you are:

Pregnant

Medically unstable and fluctuating level of consciousness

Unable to maintain an appropriate position

Extreme distress or anxiety

Are known to have had an adverse reaction to barium before

Are nil-by-mouth for reasons other than swallowing problems.

Do I need any special preparation before the examination?

You do not need to go without food or fluids before the examination as it is not essential to have an empty stomach.

What happens after the VFSS?

We will discuss the results with you briefly immediately after the x-ray. Your report will be sent to your speech and language therapist and your GP.

Your speech and language therapist will get in touch with you to discuss the results and implications in more detail if this is needed. We can send a copy of the report to you.

What if I have a Percutaneous Endoscopic Gastrostomy (PEG)?

If you or your child have a PEG, please let the speech and language therapist know when you arrive.

Please bring equipment with you to flush your PEG following the assessment. You will need to flush the PEG 2-3 times during the 2 hours following the assessment using 50mls of water. If you have any concerns following the assessment about your PEG please contact the PEG team.

I need an ambulance. Can you arrange this?

If you need an ambulance, you (or someone on your behalf) must contact North East Ambulance Patient Transport Service on 0191 264 8870

Please contact them with at least three working days' notice. Please inform the department if you are arriving by ambulance.

Further information

For any queries please contact your speech and language therapist.

Denton Park: 0191 213 8841

RVI: 0191 282 4324

Freeman: 0191 213 8270

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Videofluoroscopic Swallow Study (VFSS) - Newcastle Hospitals NHS Foundation Trust

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A videofluoroscopic swallow study (VFSS) is a moving x-ray examination of the mouth and throat. Your speech and language therapist has assessed that you or your child might have having swallowing difficulties.

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Videofluoroscopic Swallowing Study (VFSS) | Danielle Marks

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VFSS Swallowing Study: Videofluoroscopic Swallowing Study

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Scenario 1: Mr. Ahmed

Background: 72-year-old male admitted with left-sided weakness following a suspected stroke. Past medical history includes hypertension and atrial fibrillation.

Assessment:

He is alert and able to sit upright with support.

Voice sounds hoarse and weak when asked to say “aaah.”

Struggles to manage oral secretions, with drooling observed.

Water Swallow Test: Not performed (stopped at pre-assessment due to failed criteria).

Plan of Action / Care Plan:

Record patient NIL BY MOUTH.

Provide IV fluids as per doctor’s orders to maintain hydration.

Maintain oral hygiene regularly.

Refer immediately to Speech and Language Therapy (SLT) for formal swallowing assessment.

Inform stroke specialist doctor/consultant of findings.

Liaise with nursing staff to ensure no oral intake until reviewed by SLT.

Scenario 2: Mrs. Green

Background: 80-year-old female admitted following a transient ischemic attack (TIA). Past medical history: type 2 diabetes, mild COPD.

Assessment:

Alert, able to sit upright independently.

No changes in voice or difficulty handling saliva.

Water Swallow Test (teaspoon x3):

Swallowed water, but had delayed coughing after the second teaspoon.

Mild voice change after coughing.

Plan of Action / Care Plan:

STOP test immediately.

Record patient NIL BY MOUTH.

Refer to Speech and Language Therapy (SLT) urgently for swallow assessment.

Inform medical team (stroke specialist doctor and ward team).

Provide mouth care and monitor for signs of aspiration (wet cough, chest changes).

Liaise with dietitian once SLT has completed assessment to plan safe nutrition.

Scenario 3: Mr. Thompson

Background: 65-year-old male admitted with right-sided weakness and slurred speech. Past medical history: hyperlipidaemia, previous myocardial infarction.

Assessment:

Alert, oriented, upright with support.

No voice weakness, no difficulty handling oral secretions.

Water Swallow Test:

Teaspoon x3: no delay, no coughing, no choking.

Controlled sips from a glass x3: no issues observed, clear voice afterwards.

Outcome: Passed the swallow screen.

Plan of Action / Care Plan:

Patient may commence oral intake with diet and thin fluids (Level 0).

Start with Level 6 diet initially, then progress to Level 7 regular diet if no further difficulties arise.

Supervise first main meal to check for ongoing tolerance.

Continue to monitor for any signs of aspiration (wet voice, coughing with meals).

Liaise with MDT: inform ward nurse, update medical notes, dietitian aware of intake.

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Gastrostomy button with feed via syringe

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Gastrostomy button with feed via syringe

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PEG - Percutaneous Endoscopic Gastrostomy

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PEG - Percutaneous Endoscopic Gastrostomy

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PEG J /PEJ - Percutaneous Endoscopic Jejunostomy feeding tube

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PEG J /PEJ - Percutaneous Endoscopic Jejunostomy feeding tube

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Yellow Playful Clinic Patient Satisfaction Medical Infographic

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Malnutrition Universal Screening Tool (MUST)

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Malnutrition Universal Screening Tool (MUST)

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Communication with individuals with dysphagia

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Communication with individuals with dysphagia

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Torbay and South Devon NHS Foundation Trust

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Care of the Elderly helping communication support videos

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As part of our care and treatment programmes, we have prepared some videos that will help people who have difficulty communicating for a variety of reasons.

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Nasogastric (NG) Tube Insertion - OSCE Guide | UKMLA | CPSA | PLAB 2

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Type of continence problem, i.e. main complaint

Information about the onset, duration and current presentation of the symptoms and whether related to a specific event/condition, as well as effect on current quality of life and current management

Complete medical, surgical, obstetric, neurological and mental health history, details of any allergies, mobility, dexterity, and cognitive issues, body mass index (BMI) or social issues. These can cover environmental factors that may affect continence, e.g. access to toilets, i.e. due to stairs, access to carers at appropriate times, sharing rooms/facilities, chair/bed heights, toilet height, space to accommodate equipment (e.g. walking aids/wheelchairs), floor surfaces, and unclear signage (adapted from Staskin et al, 2013; National Institute for Health and Care Excellence [NICE], 2010; 2014; 2015; Yates, 2018)

Details of all medication, including over-the-counter medication, herbal remedies and recreational drug use.

These findings can be supported by some basic investigations, including (Yates, 2019a; Colley, 2020):

A completed bladder and/or bowel chart/diary (usually three days for bladder and one week for bowel problems), or some form of observational chart completed by carers/healthcare professionals if an individual is unable to complete their own chart

Details of fluid intake (including amount and type of fluids) and dietary intake to establish a baseline or any triggers relating to problem

Dipstick urinalysis — used at an initial continence assessment only as a screening rather than diagnostic test. This assists to rule out dehydration and other medical issues, including renal problems, diabetes and potential urinary tract infections (UTIs)

Bladder scans — if presenting with symptoms of poor flow, feelings of incomplete emptying and recurrent UTIs, or there is an underlying neuropathy

Examinations (vaginal/rectal/abdominal/neurological), if required, but should only be performed by a competent healthcare professional.

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Nutritional Requirements by age - British Nutrition Foundation.

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Nutritional Requirements by age - British Nutrition Foundation.

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Dietary Requirements - Public Health England

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Dietary Requirements - Public Health England

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Screening for Malnutrition using ‘MUST’ | Nutricia UK

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This e-learning module is intended for healthcare professionals and is designed to support your knowledge of screening and managing malnutrition.

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Discover the benefits of at-home urinalysis tests for monitoring your health. Learn how they check for disorders and support your overall well-being.

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Emptying a Urinary Catheter Drainage Bag

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Measuring and Recording Urine Output from catheter - video

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Measuring and Recording Urine Output from catheter - video

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Improve Article 👀

The ability to accurately measure and record urine output is a key clinical skill all healthcare professionals should possess. The rate of urine output can provide insights into how well the kidneys and other organs are being perfused, allowing for early recognition of deteriorating patients (e.g. sepsis, haemorrhage).

This guide provides a step-by-step approach to measuring and recording urine output.

Gather equipment

Gather the relevant equipment for measuring urine output:

Urine output recording document

Measuring device: either a 1000 mL graduated cylinder for a patient using a bedpan or a collection bag for a patient with an indwelling catheter

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "Today, I would like to measure your urine output. This will involve measuring how much urine is present in your bedpan to get an understanding of how well your kidneys are working."

Gain consent to proceed with urine output measurement.

Obtaining the sample

Urine may initially be obtained in a number of ways including:

An indwelling urinary catheter

Bedpan (for immobile patients)

Various other types of urinary collection containers that the patient may use themselves if able to

Measuring & recording output

Urinary catheter

If the patient has a urinary catheter in place, then urine output can be measured by observation of the measurement markings on the collection device.

Some catheters have a single bag which all urine drains into immediately, whereas others have a separate chamber that urine drains into first. This first chamber can then be emptied by opening the valve, allowing the urine to move into the larger catheter bag.

Catheters with a separate measurement chamber can make it easier to assess a patient's rate of urine output.

To measure the patient's urine output:

1. Note the time at which the patient's catheter bag/chamber was last emptied.

2. Inspect the catheter bag/chamber at eye level and note the volume of urine present (typically in millilitres).

3. Record the volume of urine on the relevant urine output chart and the time of the measurement. You should also calculate the rate of urine output (see below).

4. If the catheter bag is full, this should be emptied after your recording. If the patient has a separate urine collection chamber device, the valve should be opened to allow the chamber to empty into the catheter bag and the valve should then be closed.

Other urinary collection devices

If the patient does not have a catheter and urine is instead being collected in a container (e.g. bedpan) you can measure the urine output as follows:

1. Note the time at which the patient last passed urine.

2. Don gloves

3. Carefully pour the contents of the urine collection container into a graduated measurement cylinder. Ensure there is no splashing or spilling of the bedpan contents.

4. Inspect the graduated measurement cylinder at eye level and note the volume of urine present (typically in millilitres).

5. Dispose of the urine into a toilet and clean the graduated measurement cylinder appropriately.

6. Remove and appropriately dispose of gloves and wash your hands.

7. Record the volume of urine on the relevant urine output chart and the time of the measurement. You should also calculate the rate of urine output (see below).

Calculating the rate of urine output

To calculate the rate of urine output, divide the volume of urine produced by the number of hours that have elapsed since the bag/chamber was last emptied (e.g. 80ml over 2 hours = 40ml/hour).

Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours. ¹

Oliguria is defined as the production of inadequate volumes of urine (<500 ml/day in adults, <0.5 mL/kg/hour in children, and <1.0 mL/kg/hour in infants). ¹

To complete the procedure...

Explain to the patient that the procedure is now complete.

Discuss the urine output result with the patient, including any further steps that may need to occur (e.g. further investigations, initiation of intravenous fluids).

Thank the patient for their time.

References

Centers for Disease Control and Prevention. Urine Output. 2020. Available from: [LINK].

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Measuring & Recording Urine Output - OSCE Guide | Geeky Medics

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Improve Article 👀 The ability to accurately measure and record urine output is a key clinical skill all healthcare professionals should possess. The rate of urine output can provide insights into how well the kidneys and other organs are being perfused, allowing for early recognition of deteriorating patients (e.g. sepsis, haemorrhage).