Important: this practice guideline applies to care provided to all individuals within the rochester area, including those who are members of a rochester area managed care plan

Approach to Adult Patient Unable to Maintain Nutrition ____________________________________________________________ ______________________ □ Weight Change □ Body Mass Index □ Lab Tests: albumin, prealbumin, cholesterol, lymphocyte count □ Hydration Status (skin turgor, heart rate, BUN/creatinine) □ Urine Output □ Other: ______________________________________________________________________ Comments about above factors: _____________________________________________________________________ _______________________________________________________________________________________________ Factors that Impede Ability to Take in Food □ Physical Limitations □ Pain □ Visual Problems □ Chewing Problems: mouth, teeth, dentures □ Swallowing Problems: cough after/while eating, holding bolus, pocketing, position while eating or being fed □ Nausea/Vomiting □ Constipation □ Candidiasis □ Shortness of Breath □ Dementia, Depression, Anxiety □ Communication Problems □ Neurological Conditions □ Other: ______________________________________________________________________ Comments about above factors: ______________________________________________________________________ _______________________________________________________________________________________________ □ Stage of Illness : advanced or end stage illness □ ADL Score (please refer to Appendix G for Clinical Frailty Scale): current ____________ □ ADL Score: 1 month prior to admission ____________ □ Constipation/Fecal Impaction □ Other: ______________________________________________________________________ Comments about above factors: ______________________________________________________________________ _______________________________________________________________________________________________ □ Sedatives: lorazepam, clonazepam, etc. □ Antipsychotics: risperidone, quetiapine, aripiprazole, etc. □ Cholingerics for Alzheimer’s and other dementias: donepezil, galantamine, rivastigmine □ Anticholingerics: tolterodine, oxybutynin chloride □ GI irritants or anorexigencis: NSAIDs, COX IIs, bisphosphonates, opioids, digoxin, theophylline, antibiotics, iron, calcium, memantine, SSRIs □ Other: ______________________________________________________________________ Comments about medications: ________________________________________________________________________ ________________________________________________________________________________________________ Correctable Conditions Identified and Acted Upon and Additional Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Evaluating Clinician: ________________________________________ _______________ ___________________ Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Approved April 2013. Next scheduled review by April 2015.

Source: http://www.compassionandsupport.org/pdfs/professionals/life_sustaining/Checklist_for_Global_Assessment.pdf