The nurse is performing a nutritional assessment. what should be included? select all that apply.

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Page 2

Nutritional Risk Screening 2002. APACHE: acute physiology and chronic health evaluation; BMI: body mass index; COPD: chronic obstructive pulmonary disease; ONS: oral nutritional supplement.

Pre-Screening
Is the BMI of the patient < 20.5 kg/m2Yes
Did the patient lose weight in the past 3 months?Yes
Was the patient’s food intake reduced in the past week?Yes
Is the patient critically ill?Yes
If yes to one of those questions, proceed to screening.
If no for all answers, the patient should be re-screened weekly.
Screening
Nutritional statusscoreStress metabolism (severity of the disease)score
None0None0
Mild Weight loss >5% in 3 months OR

50–75% of the normal food intake in the last week

1Mild stress metabolism1
Patient is mobileIncreased protein requirement can be covered with oral nutrition

Hip fracture, chronic disease especially with complications e.g., liver cirrhosis, COPD, diabetes, cancer, chronic hemodialysis

Moderate2Moderate stress metabolism2
Weight loss >5% in 2 months OR

BMI 18.5–20.5 kg/m2 AND reduced general condition

OR

25–50% of the normal food intake in the last week

Patient is bedridden due to illness Highly increased protein requirement, may be covered with ONS

Stroke, hematologic cancer, severe pneumonia, extended abdominal surgery

Severe Weight loss >5% in 1 month OR

BMI <18.5 kg/m2 AND reduced general condition

OR

0–25% of the normal food intake in the last week

3Severe stress metabolism Patient is critically ill (intensive care unit) Very strongly increased protein requirement can only be achieved with (par)enteral nutrition

APACHE-II >10, bone marrow transplantation, head traumas

3
Total (A)Total (B)
Age
<70 years: 0 pt
≥70 years: 1 pt
TOTAL = (A) + (B) + Age
≥3 points: patient is at nutritional risk. Nutritional care plan should be set up
<3 points: repeat screening weekly