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.

• 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.

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.

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.