NUTRITIONAL SCREENING
Malnutrition in the hospital setting exists today despite numerous advances in the medical and nutritional arenas. Surveys have found that 40-50% of patients admitted to hospitals are at risk for malnutrition and up to 12% are severely malnourished. These statistics probably represent a fair number of the patients who transfer from the acute care wards to the rehabilitation unit for ongoing treatment. These patients tend to be debilitated as well.
Nutritional screening has become a primary tool to identify at-risk patients and should be performed when the patient is admitted to a rehabilitation unit. While a standard nutritional screening tool has not been established, there are several tools available that can be incorporated easily into routine clinical practice.
It is often necessary at a minimum to do a mini-nutritional assessment of the patient at the point of admission into a rehabilitation unit, since poor nutritional status could lead to greater debility and an inability to fully participate in intensive in-patient rehabilitation therapies.
Assessments include the following:
Nutrition Screening Initiative (NSI) (1990) - This tool offers bilevel screening, using the Body Mass Index (BMI) and a subjective interview on level I.
Anthropometric data, laboratory data, clinical history, and medication history are added on level II.
Prognostic Nutritional Index (PNI) (1980) - This screening model relates the risk of operative morbidity and mortality to baseline nutritional status.
Nutrition Risk Index (NRI) (1991) - This screen calculates the risk of malnutrition using weight and albumin levels.
Subjective Global Assessment (SGA) (1982) - This assessment tool maintains that a "carefully performed history and physical are sufficient for nutritional assessment."
The history factor reviews weight change, dietary intake, gastrointestinal (GI) symptoms, functional capacity, and disease state in relation to nutritional requirements.
The physical examination looks at loss of subcutaneous fat, muscle wasting, edema, and ascites.
SCREENING CRITERIA
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifies that nutritional screening should be completed within 24 hours of admission of all hospital patients.
This standard ensures that nutrition is addressed early and that intervention is provided in a timely manner and on an ongoing basis.
Patients considered to be at nutritional risk may exhibit any of the following:
Ø Actual or potential for developing malnutrition
o Involuntary weight loss
§ Loss of more than 10% of usual body weight within 6 months
§ Loss of more than 5% of usual body weight within 1 month
§ Patient at 20% more or less than ideal body weight (IBW)
o BMI <18; BMI is calculated using the equation Wt (kg)/ht (m2).
Ø Visceral protein depletion
o Serum albumin <3.5 g/dL
o Serum transferrin <200 mg/dL
o Serum cholesterol <160 mg/dL
o Serum prealbumin <15 mg/mL
o Creatinine Height Index (CHI) <75%
Ø Altered diet - The patient is receiving total parenteral nutrition (TPN) or enteral nutrition (EN).
Ø Inadequate nutrition intake resulting from any of the following factors:
o Orders for nothing by mouth (NPO) x 3 days
§ Clear liquid diet x 5 days
§ Malabsorptive disorder
§ Impaired ability to ingest
§ Increased metabolic requirements
o GI disturbances
§ Nausea
§ Vomiting
§ Diarrhea
§ Constipation