Maintaining adequate nutrition and hydration status is crucial to promoting quality of life and positive outcomes for each resident. Poor nutritional status can lead to adverse health effects, including decreased strength and functional abilities, depression, increased risk for falls, infections, pressure ulcers, delayed healing, prolonged recovery time and higher risk of rehospitalization.
Interdisciplinary Approach
SNFs are required to provide the necessary care and services to ensure each resident can maintain adequate nutrition and hydration unless their clinical condition or personal preferences dictate otherwise. Quality of life and nutritional status can be significantly enhanced through an interdisciplinary, person centered and individualized approach to care delivery. This process includes a comprehensive assessment of nutritional status and related risk factors, developing and implementing relevant person-centered interventions, evaluating their effectiveness and revising the care plan as necessary. Documentation should support the comprehensive assessment, care planning process and individualized treatment interventions that align with each resident’s needs and preferences. Components of a Comprehensive Nutritional Assessment
- General appearance: Describe the resident’s overall appearance, including the skin, nails, hair, oral health and condition of teeth. Provide objective measurements of weight, height and body mass index (BMI)
- Medical history: Include information on medical conditions, allergies and medications that may impact nutritional status, as well as functional ability related to self-feeding and safe swallowing.
- Laboratory/diagnostic findings: Assess lab results such as serum albumin and prealbumin level. Review diagnostic swallow studies as indicated.
- Current Medical Treatments: Consider that impact of ongoing medical treatments on nutritional status
- Dietary practices: Collect information about the resident’s current food and fluid intake. Understand eating habits, personal and cultural preferences and restrictions and integrate this information into the care plan.
- Food Security: Assess the access to food and any challenges related to food security in the home setting before admission or with planned discharges to the community.
Care planning
The components of the comprehensive assessment form the foundation for developing an individualized care plan that addresses each resident’s specific needs and preferences related to nutrition. The care plan must identify the causes and risk factors of impaired nutritional status, outline resident-specific preferences and goals, and identify resident specific interventions aimed at meeting these goals. Interventions should be tailored to the individual needs and nutritional concerns of the resident. The care plan should be continuously monitored and evaluated for ongoing appropriateness and modified as needed.
Take Action
Invite your team to join Proactive on August 20, 2024 for Documentation for Nutrition/Hydration Services. Learn more and register at Documentation in Depth – Proactive LTC Consulting (proactiveltcexperts.com).
Written by Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant
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