Physical and Social Need of a Patient via the Application

This essay will aim to outline a physical and social need of a patient via the application of the Malnutrition Universal Screening Tool (MUST) and how these needs would be met. It will also discuss the effectiveness, advantages and disadvantages of the tool and argue if the tool is deemed holistic or if it needs to be.

The nursing assessment tool is a central component of nursing practice, used for planning and implementation of patient centred care. Bell states that the ability to use an assessment tool appropriately and the application of suitable interventions for the results are vital. The MUST tool was developed to help recognise adults who are underweight and at risk of malnutrition, as well as those who are obese. Through the application of the MUST tool this essay will discuss a social and physical need arising from the assessment and how these needs were met, incorporating the patient’s social circle and members of the MDT, whilst questioning the advantages and disadvantages of the tool. The essay will also question the holistic nature of the MUST and examine if it needs to be.

Ali was a 69-year-old patient with carcinoma of the tongue and lymph nodes. He had been admitted due to weight loss from reduced oral intake and poor pain management. The MUST assessment was performed to identify whether this patient was malnourished or at risk of malnutrition. The MUST tool includes 5 steps that allows the health care professional to gather nutritional samples, taking into account the impact of acute illness, assessing the overall risk score or malnutrition category and finally implementing a suitable treatment plan.

The collection of Ali’s weight and height revealed a BMI reading of 15, which scored the highest points available on the tool indicating that he was malnourished and underweight. Step 2 calculated that since the inception of radiotherapy treatment, 3 months ago, he had lost 6% of his body weight, scoring another point on the tool. The third step asks if there would be further minimal nutritional intake for the next 5 days, scoring two further points on the tool. Step 4 calculated that Ali’s overall MUST score was 5, the maximum being 6 (see appendix).

The overall result of the MUST tool indicated that Ali was considered high risk of malnutrition. The physical consequences of being malnourished led to Ali having breathing difficulties and having an increased risk of chest infection and respiratory failure. He also struggled to stay warm as a result of having less muscle and tissue mass, which increased the threat of hypothermia.

The physical needs of the patient that the tool had indicated was that Ali’s BMI, along with his history of weight loss put him at a high risk of malnourishment and that enteral feeding may be required. Steps 3 and 4 of the tool confirmed that as he was almost at the maximum level of malnourishment that could be recorded and that there would be further minimal nutritional intake for the next 5 days; a dietetic referral should be made. Hutchinson & Wilson claim that if a patient is believed to be at risk or incapable to meet their nutrition and hydration needs orally, they should be considered for nasogastric feeding within 24 hours and a referral for dietetic should be made accordingly. Following a meeting between the dietetics team and MDT, it was decided that the information gathered on the MUST tool was enough to warrant the patient have nasogastric feeding tube fitted.

Whilst NICE hold that screening for the threat of malnourishment in a hospital is essential for allowing early and successful interventions, Porter et al have found that nurses felt completion of a MUST form was too arduous a task, part of an unending catalogue of nursing duties to be completed on admission of a patient and believed it to be the responsibility of the dietitians. They continued that the outcome of a MUST assessment will only give an indication as to the nutritional status of the patient; it will not indicate symptoms, previous medical history or social issues. Arrowsworth (1999) contends that the nurse’s medical judgment should remain vital and that the information collected on a nursing assessment should only play a rudimentary part in the complete care given.

By developing a rapport with the patient whilst performing the MUST assessment, the issue of not managing the pain sufficiently surfaced. Whilst it is not a question directly associated with the tool, it prompted the conversation relating to the patient’s social and home life. The increased pain from the cancer along with living alone without family nearby had made it difficult for Ali to remain on top of his medication. Henry et al state that the nursing assessment should be used as a patient interview where introductions are made and rapport building allows the patient to be as comfortable as possible, permitting personal information to be shared.

Hirase et al found that chronic pain was substantially related to social issues such as, seldom leaving the property and infrequently visiting family or friends. In light of this information a District Nurse referral was made so that Ali could receive support with managing his pain. District nurses play a critical part in patient’s care pathways by meeting their needs in the community. The fact that Ali had been living in isolation for an extended period of time, meant the there may have been repercussions on his mental health. To this end, Ali was signposted to Age UK, who provide life-enhancing services, such as a befriending service to support people in later life. The advantages that a befriending service has is on emotional and psychological wellbeing, and reduced social isolation is exceptional.

Unplanned weight loss is an important indicator of nutritional risk; similarly, in some patients, suboptimal oral health can have a significant effect on their ability to eat. In this case being able to identify the need of nutrition using the MUST had to be complimented with an understanding of physical and social factors that could be causing that need. The amount of unplanned weight lost in step 2 of the MUST tool helps to focus on the patient holistically.

Boléo-Tomé et al argue that it is the nursing approach and care given that is required to be holistic, not the tool itself. They maintain that the MUST tool offers an overall picture of the patient’s nutritional risk from BMI, unplanned weight lost and further nutritional intake. They go on to state that the logarithm of the tool calculates a score and the patient care plan is implemented depended on what that score is. Conversely, Stratton et al found that the MUST had substantial predictive value for clinical outcomes of patients. 

Allowing for the coordination of nursing care in direct accordance with individual and specific needs of the patient. In isolation, the MUST tool does not consider the patient holistically as it is only concerned with the nutritional status. However, the MUST tool is not designed to be used as a stand-alone assessment. Guidelines in Practice say that the assessment forms part of the patient interview which allows the health care professional to build a complete picture of the patients physical, social, psychological and spiritual needs when assessing, planning and delivering care.

Through the application of the MUST tool this essay has discussed how the malnutrition of the patient highlighted a physical need and how that physical need could increase risk of chest infection, respiratory failure and hypothermia. Hutchinson & Wilson outlines the importance of MDT referrals and how a referral from the dietetic team that led to a nasogastric feeding tube being inserted to combat the significant weight loss. Hirase et al (2019) states that the social issue of isolation and loneliness had prevented the patient from remaining in control of his pain relief medication and had thus prevented from him from eating and therefore leading to extreme weight loss. 

Gardner & Barnes declared the need to incorporate other health care professional via the district nurse referral and the signposting to third party organisations such as Age UK. Boléo-Tomé et al looked at the question of the holistic nature of the MUST tool and stated that it does not consider the patient holistically as it is only concerned with the nutritional status. While Stratton et al contend that the MUST is essential for planning holistic care and Guidelines in Practice concur that if the care given is to be holistic, then the MUST tool is integral in the planning of that care.