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Nutrition and Swallowing Procedures Tools and templates

Summary: The Nutrition and Swallowing Procedures tools and templates provide resources to be completed when supporting a person with good nutrition and safe swallowing.

Tools and templates

Nutrition and Swallowing

1. My Eating and Drinking Profile2. Nutrition and Swallowing Risk Checklist3. Mealtime Management Plan – Oral Only4. Enteral Nutrition Plan – Nil by Mouth5. Enteral Nutrition Plan – Plus Oral Intake6. Food Diary7. Monitoring Daily Healthy Eating and Exercise8. Menu Planning Checklist9. Healthy Food Group Shopping List10. Food Safety Kitchen Equipment Checklist

Nutrition and Swallowing, Tools and templates, V1.3, June 2016

2

My Eating and Drinking Profile

Complete for a person who eats a normal diet as per Australian dietary standards. Where the person requires a modified diet or utensils, they must be referred to an allied health professional by their GP.

Refer to the Nutrition and Swallowing Procedures for guidance in completing the My Eating and Drinking Profile.

My details

Insert my photo

My name Date I was born

I like to be called:My CIS number:

My TRIM number:

Where I live My phone number

People who helped me create my profile

Creation / review date

Nutrition and Swallowing, Tools and templates, V1.3, June 2016 3

Signature(s) My signature

My allergies and medication

In RED CAPITAL LETTERS, list any food allergies here:

Describe any food allergy related PRN medications I have been prescribed:

All PRN medication must be administered as per GP or specialist’s recommendations.

Medication Refer to medication charts for medication preparation and timing.

Describe any special support I require for receiving medication:


My food and drink preferences

The food I like and dislike I like I dislike

Breakfast: Breakfast:

Lunch: Lunch:

Snacks: Snacks:

Dinner: Dinner:

The drinks I like and dislike

I like I dislikeBreakfast: Breakfast:

Lunch: Lunch:

Snacks: Snacks:

Dinner: Dinner:


My religious and cultural food / drink preferences

Food

Drink

Equipment Item Describe how I use the item

My usual eating and drinking equipment

Cutlery

Plate / bowl

Cup / glass

Clothes protector

Other


How to assist me Usual way Describe how I eat:

Independent

Assisted

Sit / stand beside me Left side Right side Sit / stand facing me

Other – describe:

Alertness & seating I should always be alert and awake before I eat or drink.Describe below whether I have a special chair to sit in to eat meals:


How to supervise me to eat and drink safely

The supervision I require to keep me and others safe

I require supervision while eating or drinking No Yes If yes, describe: e.g. 1:1 or line of sight

I will try to grab food or fluids No Yes If yes, describe:

I will try to re-distribute food or fluids No Yes If yes, describe:

The time I usually take to eat my meal is

Breakfast: Snacks:

Lunch: Drinks:

Dinner: Other:


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My favourite atmosphere

Creating the best atmosphere for me

Where do I like to sit for meals?(e.g. dinner table, certain spot at table, outside for lunch when possible)

The people I like to sit with

Other things I have preferences for

Lighting

Noise levels

Furniture layout

Table setting

Other


My communication style and behaviour

I have a Communication Profile Yes No Comment:

How I usually act before, during and after

mealtimes

e.g. show excitement, anticipation, agitation, impatience, specific intolerances, alertness

Before meals

During meals

After meals

This is how I show

I am full

I would like more food or drink

I need someone to help me

What I do like

What I do not like


How I like to be actively supported to participate

I like to participate in Menu planning: Please describe how I like to be offered choices and how I communicate my decisions / preferences

Activity Describe how I like to participate in this activity

Make a grocery list

Shopping

Setting the table

Clearing the table

Unpacking shopping

Organising the pantry

Food preparation & cooking

Wash up / load dishwasher

Wipe bench tops


http://images.google.com/imgres?q=participate&num=10&hl=en&sa=X&biw=1272&bih=835&tbs=itp:clipart&tbm=isch&tbnid=eU2A7soBL6QdBM:&imgrefurl=http://www.riddc.org/survey/index.html&docid=VYBHT8URpCpy9M&imgurl=http://www.riddc.org/survey/images/rainbowBeans.jpg&w=922&h=378&ei=t2yQUPD0MLGQiAf0pYDgBQ&zoom=1&iact=hc&vpx=445&vpy=379&dur=771&hovh=144&hovw=351&tx=202&ty=97&sig=112216865716891822178&page=1&tbnh=74&tbnw=180&start=0&ndsp=24&ved=1t:429,r:8,s:0,i:126

How I like to be actively supported to participateSweep / vacuum

dining area floors Other activities

My preferences for eating out

What atmosphere do I prefer when eating out?

Few people Quiet environment Many people Loud environment

Describe:

What support items do I need to take?

Utensil Clothing protector

Modified plateModified cup

Plate guard Thickener / nutrition

supplements

Special food

Medication Webster-Pak® PRN (e.g. EpiPen®)

Other – describe:


My preferences for eating out

How do I prefer to communicateDo I use a communication device? Yes No

If yes, the communication device is located at:

Yes If yes, describe how I use it with people and how I like to be supported to use it.

How do I order my meal?

How do I like to pay for my meal?


My favourite meals when eating out

My favourite meals Describe:

My favourite drinks Describe:

Favourite venues Describe:

Getting there Describe how the person travels to the venue: (e.g. public transport, vehicle etc.)

This is how it looks to support me to eat my meals in the best way possible.


Use this area to add

photographs of the person

Nutrition and Swallowing Risk ChecklistInstructionsWhat is the purpose of the Checklist?

The Nutrition and Swallowing Risk Checklist (the Risk Checklist) is a way of screening people for difficulties related to nutrition and swallowing. It cannot make a diagnosis of a medical condition. A diagnosis can only be made by a health specialist.

The Risk Checklist was developed as a means of raising awareness of nutrition related problems in people with disability. It has been developed to be used by people who care for people with disability.

By asking questions about a person’s health, weight and their ability to eat and drink, the checklist will determine if further assessment and action is needed, including advice or assessment by a dietitian, speech pathologist or other health professional.

Who should complete it?

If you are completing the Risk Checklist you should know the person with a disability well. You may be the case manager or support worker. Collaboration with a parent or family member may be helpful in achieving the most accurate result.

Include the person with disability when completing the Risk Checklist.

How to complete it

Part 1 – Preliminary Profile - Gathers and evaluates information about the person’s weight and height. In this section you have to write in the information requested for some questions and tick the relevant box for others.

Part 2 – Nutrition and Swallowing Risk Checklist - Assesses if the person has indications of nutritional problems or swallowing difficulties that may affect their nutrition and health. Tick the relevant box for each question.

Part 3 – Summary of Results - Records descriptions of the risks or issues of concerns relating to questions answered with a ‘Yes’ or ‘Unsure / Do not know’. The GP should review the Summary of Results and prescribe action to be taken in the shaded ‘Further Action Required’ column.

Do not guess answers

Try to obtain all the information you need to complete the Risk Checklist. For example, you may need to look at the person’s weight records to work out if they have lost or gained weight over the past three months. If there are no records and you are not able to measure height or weight, you should still complete as much of Part 1 as you can, and then complete Part 2 to the best of your knowledge.


Use this area to add

photographs of the person

Be observant. Do not guess answers. Use your powers of observation to answer questions about how the person eats and drinks. If you are unsure or do not know the answer to a question, you may need to seek a line manager’s opinion. If the answers are still uncertain, tick the ‘Unsure / Do not know’ box and refer to a health professional for assistance.

Part 1 – Preliminary Profile

The Person Name:

Gender: Male FemaleDate of birth: Age:

CIS no.: TRIM no.:

Person responsible:

Address:

This address is: an independent residence

a family home

a supported accommodation service

other: specify ___________________________

Has the Risk Checklist been used before for this person? Yes No

If ‘Yes’, enter date when last Risk Checklist completed:

Person completing the Risk Checklist

Name:

Signature:

Date Checklist completed:

Relationship to the person:

support worker

case worker

nurse

parent

other (specify) __________________________

How long have you known the person?

less than 6 months

6 months – 1 year

1-2 years

2-5 years

more than 5 years


Part 1 – Preliminary Profile

Where is the Risk Checklist being completed?

the person’s home

the person’s school

the person’s work

a District office

Who is the person providing the information – so you can complete this Risk Checklist?

(tick more than 1 box if needed)

self

the person

parent

close relative

close friend

other (specify) ____________________________

Weight information Current weight without shoes: (kg) _______________

Refer to Section 3.3 in the Nutrition and Swallowing Guidelines for information about accurately measuring a person’s weight.

Date measured:

If you have no information about the person’s weight – why not?

Weight change over the past 3 months:

gained

lost

Do you have weight records for the past 3 months? Yes No

Height information Current height standing without shoes (cm) ________.

Refer to Section 3.4 in the Nutrition and Swallowing Guidelines for information about accurately measuring a person’s height.

If you have no information about the person’s height, or are unable to measure their height – why not?

Children

For children and young people aged under 18 years, their growth rate should be assessed by a GP, paediatrician, early childhood nurse or dietitian every year.

Has this happened? Yes No


Using the weight and height information:

If the person is an adult, mark the spot on the chart below where their height and weight meet.

Weight for Height Chart

Calculate the person’s BMI:

1. Access the website: http://www.mydr.com.au/tools/bmi-calculator.

2. Enter the person’s height in centimetres.

3. Enter the person’s weight in kilograms.

4. Click on ‘Calculate BMI’ and enter below.

The person’s BMI:

The person’s weight and height must be recorded in their Weight Chart.

Where the GP or specialist has provided a specific weight chart or assessment tool instead of the BMI, complete the chart and attach to the Risk Checklist.


Part 2 Nutrition and Swallowing Risk Checklist

Tick an answer box for each question. The explanations beneath each question and the Nutrition and Swallowing Procedures references will help you complete the checklist. There are 24 questions.

Question 1

If the person is a child, (i.e. under 18 years of age) have they lost weight or failed to gain weight over the last three months?

Not applicable

Yes

No

Unsure / Do not know

Question 2

Is the person underweight?

Tick the ‘Yes’ box if either of the following apply:

The person is an adult and their weight on the Weight for Height Chart is in the ‘underweight’ or ‘very underweight’ range;

When you look carefully at the person (adult or child), their bone structure is easily defined under their skin. This can indicate significant loss of fat tissue and is easily checked by looking around the person’s eyes and cheeks. Other areas to check include the shoulders, ribs and hips.

Yes

No


Question 3

Has the person had unplanned weight loss or have they lost too much weight?

Tick the ‘Yes’ box if any of the following apply:

The person’s weight loss is undesirable or has been unexpected;

The person is under 18 years of age and there is weight loss in two or more consecutive months;

The person has lost weight in two or more consecutive months and is not on a monitored weight loss program.

Yes

No



Question 4

Is the person overweight?


The person is an adult (i.e. over 18 years of age) and their weight on the Weight for Height Chart is in the overweight or obese range;

The person (adult or child) appears to have rolls of body fat.(e.g. around the abdomen)

Yes

No


Question 5

Has the person had unplanned weight gain or have they gained too much weight?


The person’s weight gain is undesirable or has been unexpected;

The person is not on a weight gain program and their clothes no longer fit.

Yes

No


Question 6

Is the person receiving tube feeds?

Tick the ‘Yes’ box if the person is receiving naso-gastric, naso-duodenal or gastrostomy feeding.

Yes

No


Question 6a

If you answered ‘Yes’ to question 6, does the person also receive food or drink through the mouth?

Tick the ‘Yes’ box if the person receives any food or drink by mouth, in addition to tube feeding.

If the person is receiving tube feeds and no other food by mouth, then answer only questions 10, 13, 14, 16,18 and 19.

Not applicable

Yes

No



Question 7

Is the person physically dependent on others in order to eat or drink?

Tick the ‘Yes’ box if:

The person cannot put food or drink into their own mouth and someone else is needed to feed them;

The person is dependent on assistance during a meal (e.g. guidance with utensils).

Yes

No


Question 8

Has the person had a reduction in appetite or food or fluid intake?


The person is not eating or drinking as much as they usually do and this is unintentional;

The person appears unwilling to take most food offered to them and the equivalent of six large glasses of fluid each day.

Yes

No


Question 9

Does the person follow, or are they supposed to follow, a special diet?

Tick the ‘Yes’ box if they are on, or are supposed to be on, any of the following dietary plans:

Pureed, minced, chopped or soft foods;

Thickened fluids;

Weight reduction or weight-increasing;

Low fat;

Vegetarian;

Low cholesterol or cholesterol-lowering;

Diabetic;

Any other diet which modifies or restricts foods or food choices.

Yes

No



Question 10

Does the person take multiple medications?

Tick the ‘Yes’ box if:

The person is usually on more than one type of medication.

Yes

No


Question 11

Does the person select inappropriate foods or behave inappropriately with food?


The person over-consumes alcohol or coffee, tea and cola drinks;

The person eats non-food items such as dirt, grass or faeces;

The person drinks excessive amounts of fluid;

The person steals or hides food.

Yes

No


Question 12

Does the person usually exclude foods from any food group?

Tick the ‘Yes’ box if the person usually excludes all foods from one or more of the following groups of food:

Bread, cereals, rice, pasta, noodles;

Vegetables, legumes;

Fruit;

Milk, yogurt, cheese;

Meat, fish, poultry, eggs, nuts, legumes.

Yes

No


Question 13

Does the person get constipated?


The person’s bowel movements are irregular, painful and sometimes infrequent;

Laxatives, suppositories or enemas are required to maintain regular bowel movements.

Yes

No



Question 14

Does the person have frequent fluid-type bowel movements?

Yes

No


Question 15

Does the person have mouth or teeth problems that affect their eating?


The person’s teeth are loose, broken or missing;

The person’s lips, tongue, throat or gums are red and inflamed or ulcerated;

The person has a malocclusion (upper and lower teeth do not meet) and this affects their ability to chew.

Yes

No


Question 16

Does the person suffer from frequent chest infections, pneumonia, asthma or wheezing?


The person has had frequent chest infections or pneumonia;

The person is usually ‘chesty’ or has difficulty clearing phlegm;

The person has asthma or wheezes.

Yes

No


Question 17

Does the person cough, gag and choke or breathe noisily during or after eating food, drinking, or taking medication?


The person sometimes coughs or chokes during or several minutes after eating, drinking or taking medication;

The person’s breathing becomes noisy after eating or drinking or while talking;

The person gags on eating, drinking or taking medication.

Yes

No



Question 18

Does the person vomit or regurgitate on a regular basis?

(Note: This question is not applicable to infants under 12 months of age)

Tick the ‘Yes’ box if either :

The person vomits or regurgitates (i.e. brings up) food, drink or medication more than once per day or on a regular basis;

The person takes anti-reflux medication;

The person clears their throat often or burps often.

Not applicable

Yes

No


Question 19

Does the person drool or dribble saliva when resting, eating or drinking?


The person drools or dribbles saliva at rest or mealtimes;

The person’s clothes or protective napkins/bibs frequently need changing because of drooling.

Yes

No


Question 20

Does food or drink fall out of the person’s mouth during eating or drinking?


The person is unable to close their mouth and this causes food, drink or medication to fall out of their mouth;

The person cannot keep their head upright and food, drink or medication falls out of their mouth;

The person’s tongue pushes food, drink or medication out of their mouth;

The person’s mouth continuously needs to be wiped or they need to wear a cloth to protect their clothes during mealtime.

Note that this question does not relate to the person’s manual dexterity or ability to place food in their mouth.

Yes

No



Question 21

If the person eats independently, do they overfill their mouth or try to eat very quickly?

Tick the ‘Yes’ box if the person eats independently and any of the following apply:

The person tries to cram or ‘stuff ’ their mouth before attempting to chew or swallow;

The person tries to swallow too much food before they have chewed it properly;

The person usually finishes all of their main meal in less than five minutes.

Not applicable

Yes

No


Question 22

Does the person appear to eat without chewing?

(Note: This question does not apply to people on a pureed diet)


The person sucks their food instead of chewing;

The food remains in the person ‘s mouth for a long period of time before being swallowed;

The person swallows their food whole without chewing.

Not applicable

Yes

No


Question 23

Does the person take a long time to eat their meals?


The person eats independently and they take more than 30 minutes to eat meals;

The person is dependent on someone to feed them and it takes a long time to feed them the whole meal;

The person appears to tire as the meal progresses and may not finish their meal.

Yes

No



Question 24

Does the person show distress during or after eating or drinking?


The person appears distressed while they eat or drink;

The person appears distressed immediately after or shortly after eating or drinking;

Sometimes while distressed the person refuses food or spits out food.

Yes

No



Part 3 – Summary of Results

Name of the person: Date:

Complete the table below for any questions answered with a ‘Yes’ or ‘Unsure/ Do not know’ response by describing the risk identified or issue of concern in the ‘Comments’ column. Take the completed Risk Checklist and this summary to the appointment with the GP.

File the completed checklist and summary in the person’s Health and Wellbeing Plan – Part C.

Question

No.Comments

Further Action Required

(GP to complete)


Question

No.Comments

Further Action Required

(GP to complete)


Part 4 – Risk Checklist Verification

Note: Support workers completing this section are verifying that:

the Risk Checklist has been completed

all relevant referrals have been actioned

the person’s My Safety Plan has been updated if required

the Nutrition and Swallowing Risk Checklist is filed in the person’s My Health and Wellbeing Plan.

Name Position Signature Date

The person (if they are able)

Person completing the Nutrition and Swallowing Risk Checklist

Person/s assisting with completion of the Nutrition and Swallowing Risk Checklist

Line Manager

- REMEMBER, IF ANYTHING CHANGES, RE-DO THE NUTRITION AND SWALLOWING RISK CHECKLIST -


The Mealtime Management Plan – Oral Only template has been provided to assist the allied health professional (AHP) and support workers to record the person’s mealtime management requirements and preferences.

Where required, the GP or AHP should add or subtract sections to suit the person’s support needs.

Name of person: CIS No.:

Preferred name: TRIM No.:

Address: Date of birth:

Phone No.:

Person responsible:

This is a new plan Date This is a review Date

Mealtime Management Plan prepared by

Name: Profession:

Contact details:

Name: Profession:

Contact details:

Name: Profession:

Contact details:

30Nutrition and Swallowing, Tools and templates, V1.3, June 2016

Insert a photographof the person

Mealtime Management Plan – Oral Only

Summary of important issues

Allergies

Precautions In RED CAPITAL LETTERS, list any food allergies here

Response Strategies

PRN Medication All PRN medication for allergy must be administered as per GP or specialist recommendations

MedicationsRefer to the person’s medication chart or Webster-pak® signing sheet for medication preparation and timing.

Special support required to receive medication


Description: Eating Drinking

Consistency

1

Description Eating Drinking

Alertness Comments regarding level of alertness at mealtimes

Amounts Refer to dietetic recommendations

Refer to dietetic recommendations

Special diet

Examples:Weight reductionWeight maintenancePhenylketonuriaLactose free

Utensils / equipment(Insert photos if appropriate)

Positioning During Meals1 http://www.speechpathologyaustralia.org.au/resources/terminology-for-modified-foods-and-fluids



(Insert photos if appropriate) After Meals

Assistance required

(insert photos if appropriate)

Likes

Dislikes

Religious and cultural preferences

Oral careRefer to oral care plan = maintain oral hygiene at all times

Communication

This is how the person communicates(Refer to communication profile)

Feeling full

Would like more to eat or drink

Needing help

Likes something

Dislikes something

Other


Behaviour

This is how the person usually behaves

Before meals

During meals

After meals

Other

Supervision required during mealtimes

While eating and drinking

To prevent grabbing food and fluids

To prevent sharing food with others

Preferences

Time taken to eat meals

Breakfast

Lunch

Dinner

Snacks

Drinks

Other

Environment / atmosphere

Noise level

Table setting

Position at the table

Companions

Lighting

Furniture Layout

Other


Preferences

ParticipationMenu planning

Meal preparation

Eating out

Best atmosphere

Favourite meal

Favourite drink

Favourite venues

Support items to take

Photograph

This is how it looks to support the person to eat their meals in the best way possible.

Insert a photo(s) of the person to document:

safe and appropriate position for eating and drinking equipment required, use of clothing protectors, utensils and aids.

Date photo taken: Photo taken by:


Review of Plan Set Review Date Profession (AHP)

Signature

As needed review This plan will be reviewed following a problem being identified, re-completion of the Nutrition and Swallowing Risk Checklist, and advice from the person’s GP

Note: if the person appears to have difficulty with any support prescribed, immediately contact the health professional responsible for the development of this plan for advice.

Plan endorsement

The person (if they are able): Date:

Family/Guardian or person responsible: Date:

Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:

Line Manager:(position) Name:

Signature: Date:


A copy of the Mealtime Management Plan must be provided to any person(s) or organisation(s) who provides support to the person during mealtimes.

Support provider Date provided Provided to (name)

Day placement

School / education centre

Family

Friends

Centre based respite

Holiday provider

Other – list below

Consent for sharing this information should be obtained from the person or person responsible


SUPPORT WORKER ENDORSEMENT

I have read and understood the Mealtime Management Plan and am able to implement it. I have received practical training in mealtime management as per requirements in this plan. I understand my duty of care regarding positioning, support and monitoring of risk for this person.

Name: Signature: Date:


















A new page must be completed anytime the person’s Mealtime Management Plan changes.


The Enteral Nutrition Plan – Nil by Mouth template has been provided to assist the GP and or allied health professional (AHP) to record the person’s enteral nutrition requirements.

Note: Only an accredited practising dietitian (APD) can develop and review a person’s enteral diet.

Where additional detail is required, or not needed, theGP or AHP can alter the template to suit the person’s requirements.




Phone No.:

Person responsible:

This is a new plan Date: This is a review Date:

Enteral Nutrition Plan prepared by:

Name: Profession:

Contact details:

Name: Profession:

Contact details:

Name: Profession:

Contact details:

Allergies:Precautions In RED CAPITAL LETTERS, list any food allergies here



Enteral Nutrition Plan – Nil by Mouth

Response strategies

PRN medicationAll PRN medication for allergy must be administered as per GP or specialist recommendations

Medications:

Refer to the person’s medication chart or Webster-pak® signing sheet for medication preparation and timing.


Water amount given between each medication

Enteral Nutrition

Type of diet:Continuous / Intermittent/ Bolus

Equipment required

Delivery route

Formula

Rate / volume / breaks / frequency

Total volume feed per day

Flush water

Environment

Alertness

Positioning for enteral


Enteral Nutrition

feeding – during and after feedsThe person must be upright or at least 30°for 30 minutes post enteral feeds.

Risks

Likes

Dislikes

Oral care

Stoma care

Procedure if tube is dislodged

Procedure if tube is blocked

Safety

Use of gloves / hand washing

Storage and expiry of food

Food safety and hygiene

Cleaning and storage of equipment

Other

Communication

This is how the person Likes something:


communicates(Please refer to the person’s communication profile for in-depth information)

Dislikes something:

Something is wrong:

Other:

Behaviour


Before a meal:

After a meal:

Other:

Preferences


Noise level:

Table setting:

Position at the table:

Companions:

Lighting:

Furniture layout:

Other:

Participation Meal preparation:

Eating out:(where possible)

Favourite place:

Best atmosphere:

Best time of day:

Things to take:

Other:

Equipment and supply

Contact details Company:


for food and equipment supply Contact person:

Phone:

www:

email:

address:

PhotographThis is how it looks to support the person to eat their meals in the best way possible.


safe and appropriate position for tube feeding

equipment required, use of clothing protectors and aids.


Review of plan


Set review: Date: Profession: (AHP)

Signature:

As needed review: This plan will be reviewed following

a problem being identified while following this plan a new risk being identified through the Nutrition and Swallowing Risk Checklist advice from the person’s GP/ allied health professional


Plan endorsement



Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:


Signature: Date:

A copy of the Enteral Nutrition Plan must be provided to any person(s) or organisation(s) who provides support for the person to receive enteral nutrition.


Support provider: Date provided: Provided to (name):

Day placement


Family

Friends


Holiday provider



Support Worker Endorsement


I have read and understood this Enteral Nutrition Plan and am able to implement it. I have received practical training in mealtime management as per requirements in this plan. I understand my duty of care regarding positioning, support and monitoring of risk for this person.



















A new page must be completed anytime the person’s Enteral Nutrition Plan changes.


Name:Time Before feed

water flush (ml) Formula Volume of formula (ml)

After feed water flush (ml) Medication Progressive Total

Volume (ml) Rate ml/h

1:002:003:004:005:006:007:008:009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:0024:00

Regime provides: Total input over 24hrs: Total output: Balance over 24hrs:

Positive or negative balance:


The Enteral Nutrition Plan – Plus Oral Intake template has been provided to assist the GP and or allied health professional (AHP) to record the person’s enteral nutrition and oral intake requirements.

Note: Only an accredited practising dietitian (APD) can develop and review a person’s enteral diet.

Where additional detail is required, or not needed, the GP or AHP can alter the template to suit the person’s requirements.




Phone No.:

Person responsible:

This is a new plan Date: This is a review Date:

Enteral Nutrition Plan prepared by:

Name: Profession:

Contact details:

Name: Profession:

Contact details:

Name: Profession:

Contact details:



Enteral Nutrition Plan – Plus Oral Intake

Allergies:

Precautions: In RED CAPITAL LETTERS, list any food allergies here:

Response Strategies:

PRN medication All PRN medication for allergy must be administered as per GP or specialist recommendations

Medications:

Refer to the person’s medication chart or Webster-pak® signing sheet for medication preparation and timing.


Water amount given between each medication

Enteral Nutrition

Type of diet:Continuous / Intermittent/ Bolus

Equipment required

Delivery route

Formula

Rate / volume / breaks / frequency

Total volume feed per day

Flush water

Environment

Alertness

Positioning for enteral feeding – during and after


Enteral Nutrition

feedsThe person must be upright or at least 30°for 30 minutes post enteral feeds.

Risks

Likes

Dislikes

Stoma care

Procedure if tube is dislodged

Procedures if tube is blocked:

Safety

Use of gloves / hand washing

Storage and expiry of food

Food safety and hygiene

Cleaning and storage of equipment

Other


Oral Intake

Description: Eating Drinking

Consistency

2

2 http://www.speechpathologyaustralia.org.au/resources/terminology-for-modified-foods-and-fluids



Alertness Comments re level of alertness at mealtimes

AmountsRefer to dietetic recommendations

Refer to dietetic recommendations

Special diet

Examples:Weight reductionWeight maintenancePhenylketonuriaLactose free

Utensils / equipment(Insert photos if appropriate)

Positioning(Insert photos if appropriate)

For oral intake – during meal

After meal

Assistance required

(insert photos if appropriate)

Likes

Dislikes

Religious and cultural preferences

Oral careRefer to oral care plan = maintain oral hygiene at all times


Communication

This is how the person communicates:(Please refer to the person’s communication profile for in-depth information)

Likes something

Dislikes something

Something is wrong

Still hungry

Feeling full

Other

Behaviour


Before meals

During meals

After meals

Other

Supervision required during mealtimes

While eating and drinking

To prevent grabbing food and fluids

To prevent sharing food with others

Time taken to eat meals

Breakfast

Lunch

Dinner

Snacks

Drinks

Other


Preferences


Noise level

Table setting

Position at the table

Companions

Lighting

Furniture Layout

Other

ParticipationMenu planning

Meal preparation

Eating out(where possible)

Favourite place

Favourite meal

Favourite drink

Best atmosphere

Support items to take

Equipment and supply

Contact details for food and equipment supply

Company:

Contact person:

Phone:

www:

email:

address:


PhotographThis is how it looks to support the person to eat their meals in the best way possible.


safe and appropriate position for tube feeding and eating and drinking

equipment required, use of clothing protectors and aids.



Review of plan

Set review: Date: Profession: (AHP)

Signature:

As needed review: This plan will be reviewed following

a problem being identified while following this plan a new risk being identified through the Nutrition and Swallowing Risk Checklist advice from the person’s GP/ allied health professional


Plan endorsement



Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:

Profession: Date:

Name: Signature:


Signature: Date:

A copy of the Enteral Nutrition Plan must be provided to any person(s) or organisation(s) who provides support for the person to receive enteral nutrition.


Support provider: Date provided: Provided to (name):

Day placement


Family

Friends


Holiday provider




Support worker endorsement

I have read and understood this Enteral Nutrition Plan and am able to implement it. I have received practical training in mealtime management as per requirements in this plan. I understand my duty of care regarding positioning, support and monitoring of risk for this person.



















A new page must be completed anytime the person’s Enteral Nutrition Plan changes.


Name:Time Before feed

water flush (ml) Formula Volume of formula (ml)

After feed water flush (ml) Medication Progressive Total

Volume (ml) Rate ml/h

1:002:003:004:005:006:007:008:009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:0024:00

Regime provides: Total input over 24hrs: Total output: Balance over 24hrs:

Positive or negative balance:


Food diary

Name:__________________________ Date: ____________

Meal Food and Drinks

Amount consumed Time Assisted

by:Breakfast

Morning Tea

Lunch

Afternoon Tea

Dinner

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Supper

Monitoring daily healthy eating and exercise

Name:__________________________ Date:________________

Mealtime

Record all foods and drinks daily

Food group checklistTick each item you consumed. Boxes indicate the minimum serves per day each item should

be consumed. Refer to Australian Dietary Guidelines for serving sizes.

Breakfast: Breads and cereals

Tick how many servings of breads and cereals you ate (you should have 4)

Morning tea: Fruit

Tick how many servings of fruit you ate(you should have 2)

Lunch: Vegetables

Tick how many servings of vegetables you ate (you should have 5)

Afternoon tea: Dairy

Tick how many servings of dairy you ate

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(you should have 2-3)

Dinner: Meat

Tick how many servings of meat and poultry, fish, egg, legumes and nuts you ate (you should

have 2)

Treats: Treats

Tick how many servings of treat foods you had e.g. sweet foods, fatty foods, alcohol, chocolate

Supper: Exercise

Did you do some exercise today? Yes No What did you do?

How long did you exercise?

Menu planning checklistThis checklist is a tool that can be used to ensure everyone’s needs are being met through menu planning. This is a general guide however, if a person has specific needs, please refer to their My Eating and Drinking Profile / Mealtime Management Plan or allied health practitioner recommendations.

Use the checklist to ensure menus are planned in a healthy way.

Considerations Yes No

When possible, has each person been included when making the menu?

Have each person’s special considerations been accounted for?

Is the menu appropriate for the season? (e.g. warmer meals in Winter)

Does the menu provide variety in all food groups?

Do the meals look good to eat?

Is the menu suitable for the available cooking equipment, time available and capabilities of those cooking?

Are healthy choices available?

Unsaturated fats and oils such as olive oil are used instead of saturated fats such as butter

No more than 2 out of 7 dinner meals are high in fat (i.e. only 2 dinners have more than 20g of fat per 100g)

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Red meat is included 3 times weekly

Vegetables are included – at least 4-5 serves daily

Fruit is included - 2 serves daily

Dairy is included - at least 2 serves daily

Breads and cereals are included - at least 2-3 serves daily

Wholegrain / wholemeal/ high fibre breads and cereals are included daily

High fibre cereals (over 8g of fibre per 100g serve) with low sugar content (under 10g/100g) are chosen 4 times weekly.

Healthy food group shopping list

Shopping List Date: ______________

Breads Flour

Cereals

Fruit

Vegetables

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MeatEggs

Legumes

Dairy Cheese

Milk Yoghurt

SugarOils

Other

Food safety kitchen equipment checklist

Items required

Disposable gloves – Non Latex, Non powdered

Food safety thermometer

Paper Towel

Blue or brightly coloured bandaids

Waterproof Apron

Bleach

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Red chopping board – raw meat

Blue chopping board – raw fish

Yellow chopping board – cooked meats

Green chopping board – fruit & vegetables

White chopping board – breads & dairy

Food grade food storage containers

Disinfectant hand wash

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bowel chart - web viewif yes, the communication device is located at: ... it cannot make a...

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