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    Malnutrition Universal Screening Tool' ( MUST') : Nursing & Residential Care Homes

    Uploaded by

    Selvi Afnn
    This document contains a 'Malnutrition Universal Screening Tool' ('MUST') for a resident of a nursing or residential care home. It collects information such as height, weight, weight loss, acute illness and calculates a 'MUST' score to determine if the resident is at low, medium or high risk of malnutrition. Care plans are provided for each risk category, outlining recommended actions like ensuring fortified meals and snacks are offered, monitoring weight changes, and considering supplements or dietitian referrals if needed. The care plan should be completed, signed and dated, with the appropriate actions ticked once implemented.

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    © All Rights Reserved
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    Malnutrition Universal Screening Tool' ( MUST') : Nursing & Residential Care Homes

    Uploaded by

    Selvi Afnn
    232 views3 pages
    This document contains a 'Malnutrition Universal Screening Tool' ('MUST') for a resident of a nursing or residential care home. It collects information such as height, weight, weight loss, acute illness and calculates a 'MUST' score to determine if the resident is at low, medium or high risk of malnutrition. Care plans are provided for each risk category, outlining recommended actions like ensuring fortified meals and snacks are offered, monitoring weight changes, and considering supplements or dietitian referrals if needed. The care plan should be completed, signed and dated, with the appropriate actions ticked once implemented.

    Original Description:

    SKRINING GIZI

    Original Title

    form skrining must

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    This document contains a 'Malnutrition Universal Screening Tool' ('MUST') for a resident of a nursing or residential care home. It collects information such as height, weight, weight loss, acute illness and calculates a 'MUST' score to determine if the resident is at low, medium or high risk of malnutrition. Care plans are provided for each risk category, outlining recommended actions like ensuring fortified meals and snacks are offered, monitoring weight changes, and considering supplements or dietitian referrals if needed. The care plan should be completed, signed and dated, with the appropriate actions ticked once implemented.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    232 views3 pages

    Malnutrition Universal Screening Tool' ( MUST') : Nursing & Residential Care Homes

    Uploaded by

    Selvi Afnn
    This document contains a 'Malnutrition Universal Screening Tool' ('MUST') for a resident of a nursing or residential care home. It collects information such as height, weight, weight loss, acute illness and calculates a 'MUST' score to determine if the resident is at low, medium or high risk of malnutrition. Care plans are provided for each risk category, outlining recommended actions like ensuring fortified meals and snacks are offered, monitoring weight changes, and considering supplements or dietitian referrals if needed. The care plan should be completed, signed and dated, with the appropriate actions ticked once implemented.

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    Resident Name: ________________________

    Room Number: ________________________ ‘Malnutrition Universal Screening Tool’ (‘MUST’)


    Nursing & Residential Care Homes
    Height For instructions on completing ‘MUST’ please refer to the Care Home Malnutrition Resource
    □ Measured ………….. m Pack at http://www.westernsussexhospitals.nhs.uk/services/dietitians/information-care-homes/

    □ Ulna length ……….... cm = converted height ……..…… m If unable to obtain weight use clinical judgement for each step based on subjective
    measurement e.g. MUAC, visual impression, loose fitting clothing/jewellery/dentures to
    If new admission, note previous weight (kg)
    estimate risk category (LOW, MEDIUM or HIGH) for each step.
    (3-6 months ago if possible)
    ABBREVIATIONS: Date:
    < less than > more than Scales used: S C H S C H S C H S C H S C H S C H
    Scales: S=standing, C=chair, H=hoist
    Weight (kg):
    ONS: oral nutritional supplements
    or MUAC (cm)
    2
    Step 1 BMI >20kg/m Score = 0
    2
    See BMI Score BMI 18.5 – 20kg/m Score = 1
    2
    Chart BMI <18.5kg/m Score = 2
    Unplanned weight loss in the past 3-6 months
    (Compare highest weight in the past 6 months
    Step 2 with current weight to calculate score)
    See Weight Loss
    Score Chart <5% loss Score = 0
    5–10% loss Score = 1
    >10% loss Score = 2
    Step 3 Unlikely to apply in the community Score = 0
    If acutely ill and no intake for >5days Score =2
    Add steps 1, 2 & 3 together for ‘MUST’ score
    Step 4 Score 0 Low Risk
    ‘MUST’ Score Score 1 Medium Risk
    Score 2 or more High Risk
    Step 5 Care Plan See overleaf for recommended care planning guidelines for each risk category
    Signature:

    Designation:

    This screening tool should be used in conjunction with clinical judgement.


    Patients may require dietitian referral even if they are not at high risk of malnutrition e.g. disease-specific diet, dysphagia, tube feeding.

    For further information and supporting resources, please contact Western Sussex Hospitals Dietitians:
    St Richard’s Hospital Tel: 01243 831498 Email: wshnt.chichesterdietitians@nhs.net
    Worthing & Southlands Hospital Tel: 01903 286779 Email: worthing.dietitians@nhs.net

    The 'Malnutrition Universal Screening Tool' ('MUST') is adapted and reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition).
    For further information on 'MUST' visit www.bapen.org.uk.
    ‘MUST’ Care Plan
    Nursing & Residential Care Homes
    The management guidelines for each risk category are listed below. Date and sign the care plan, and tick the appropriate actions once they have been
    put into place. Further information on guidelines below can be found in the resource pack available at
    http://www.westernsussexhospitals.nhs.uk/services/dietitians/information-care-homes/

    Date:

    Score 0 Document nutritional aim & actions


    LOW RISK Rescreen monthly
    Document nutritional aims & actions
    Score 1 Consider underlying cause of malnutrition and treat/refer
    MEDIUM
    as appropriate
    RISK
    Consider food & fluid chart
    Offer 1 pint fortified milk daily
    Offer 2 nourishing snacks daily
    Offer 3 fortified meals daily
    Weigh & rescreen at least monthly

    Document nutritional aim & actions


    Score 2 Consider underlying cause of malnutrition and treat/refer
    HIGH as appropriate
    RISK
    Consider food & fluid chart
    Offer 1 pint fortified milk daily
    Offer 2 nourishing snacks daily
    Offer 3 fortified meals daily
    Offer over-the-counter supplement drink
    Weigh and rescreen at least monthly
    If no improvement consider treating as score 3 or more

    Care plan as per score 2 AND:


    Score Weigh and rescreen weekly
    3 or more
    HIGH RISK Consider one month trial of first line ONS in line with
    ONS formulary – discuss with GP
    If no improvement after one month on first line ONS
    consider referral to Dietitian – discuss with GP
    Completed by:
    Designation:
    ‘MUST’ Care Plan
    Nursing & Residential Care Homes
    Use the space below to document extra information regarding the care plan for your resident e.g. personal preferences, actions that work particularly
    well. You should also document if you decide that parts of the care plan are not suitable for your resident; for example, if weighing causes your resident
    a lot of pain/agitation, then weekly weighing may not be appropriate, but monthly weighing could be more suitable.

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