Nutritional screening and assessment in cancer-associated malnutrition DVIES 2005

ARTICLE IN PRESS
European Journal of Oncology Nursing (2005) 9, S64–S73
www.elsevier.com/locate/ejon
Nutritional screening and assessment in
cancer-associated malnutrition
Michelle Davies
Haematology Department, Christie Hospital, Manchester, UK
KEYWORDS
Cancer-associated
malnutrition;
Screening;
Assessment;
Nurse;
Cost
Summary Up to 85% of all patients with cancer develop clinical malnutrition,
which negatively affects patients’ response to therapy, increases the incidence of
treatment-related side effects and can decrease survival. Early identification of
patients who are malnourished or at risk of malnutrition can promote recovery and
improve prognosis. In addition, early nutritional intervention is cost effective, as it
reduces complication rates and length of hospital stay. The development and use of
screening and assessment tools is essential for effective nutritional intervention and
management of patients with cancer.
Nutritional screening aims to identify patients who are malnourished or at
significant risk of malnutrition. Patients identified through screening require referral
to a dietician or specialist in nutrition for an in-depth nutritional assessment,
involving examination of medical, dietary, psychological and social history, physical
examination, anthropometry and biochemical testing. Interventions initiated after
nutritional assessment should be tailored to the individual and take into
consideration the patient’s prognosis. Nutritional care is a fundamental aspect of
nursing practice and nurses are ideally placed to play an essential role in the early
detection and screening of malnutrition in patients with cancer.
& 2005 Elsevier Ltd. All rights reserved.
Zusammenfassung Bei bis zu 85 % aller Patienten mit Krebserkrankungen treten
klinische Zeichen einer Mangelernährung auf. Eine Mangelernährung beeinträchtigt
das Ansprechen der Patienten auf die Therapie, erhöht die Inzidenz von
behandlungsassoziierten Nebenwirkungen und kann zu einer Verkürzung der
Lebensdauer führen. Eine möglichst frühzeitige Identifizierung von Patienten, die
an Mangelernährung leiden oder bei denen ein Risiko für eine Mangelernährung
besteht, kann eine klinische Besserung fördern und die Prognose positiv
beeinflussen. Darüber hinaus sind ernährungstherapeutische Maßnahmen kosteneffektiv, da sie die Häufigkeit von Komplikationen verringern und die Krankenhausverweildauer verkürzen. Die Entwicklung und Anwendung von Screening- und
Beurteilungsmethoden ist für die Wirksamkeit ernährungstherapeutischer Maßnahmen und das Management von Krebspatienten von entscheidender Bedeutung.
Tel.: +44 0 161 446 8093.
E-mail address: Michelle.Davies@christie-tr.nwest.nhs.uk.
1462-3889/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2005.09.005
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Nutritional screening and assessment in cancer-associated malnutrition
S65
Das Ziel eines Ernährungs-Screenings besteht darin, Patienten zu erkennen, die an
Mangelernährung leiden oder bei denen ein Risiko für eine Mangelernährung besteht.
Patienten, die mittels Screening identifiziert werden, müssen eine Diätberatung
oder einen Ernährungsspezialisten aufsuchen, um sich einer gründlichen Evaluation
des Ernährungszustandes zu unterziehen, einschließlich der Erhebung der medizinischen, diätetischen, psychologischen und sozialen Anamnese, einer körperlichen
Untersuchung sowie der Bestimmung anthropometrischer und klinisch-chemischer
Parameter. Therapeutische Interventionen, die sich aus der Evaluation des
Ernährungszustandes ergeben, müssen auf den einzelnen Patienten zugeschnitten
sein und die Prognose des Patienten berücksichtigen. Ernährungstherapeutische
Maßnahmen bilden einen wesentlichen Aspekt der Berufspraxis von Krankenpflegekräften. Diese sind ideal dafür geeignet, eine Schlüsselrolle bei der Früherkennung
und dem Screening einer Mangelernährung bei Krebspatienten zu spielen.
& 2005 Elsevier Ltd. All rights reserved.
Introduction to nutritional screening and
assessment
It is widely recognised that diet and nutrition play
significant roles throughout the clinical course of
cancer. It has been reported that up to 85% of all
cancer patients develop a degree of clinical
malnutrition (Kern and Norton, 1988; Ollenschlager
et al., 1991). Approximately half of patients have
lost at least 5% of their pre-illness weight at
presentation, and virtually all patients with advanced cancer display this degree of weight loss
(Nixon et al., 1980). The pattern of weight loss
seen in cancer is different from that in patients
who lose weight through starvation, and forms part
of the syndrome of cancer cachexia. Cachexia is
characterised by anorexia, changes in taste perception, early satiety and fatigue, in addition to
weight loss (Fearon, 1992). Cachexia is a complex
and multifaceted syndrome; causal factors include
host inflammatory mediators produced in response
to the tumour, tumour-derived catabolic factors
and anticancer therapy (Barber et al., 1999;
Tisdale, 1999).
The risk of malnutrition and its severity are
affected by the tumour type, stage of disease and
the antineoplastic therapy applied (Shike and
Brennan, 1989). Moreover, cancer-associated malnutrition has many consequences, including increased risk of infection, reduced wound healing,
reduced muscle function and poor skin turgor
resulting in skin breakdown (Langer et al., 2001).
Malnutrition can also affect the patient’s response
to therapy (DeWys et al., 1980) and increase the
incidence of treatment-related side effects. It is
thought that death can be attributed to cancer
cachexia in a significant proportion of patients
(Buss, 1987).
In view of the serious consequences of poor
nutritional status, early identification of patients
with, or at risk of developing, malnutrition is
essential to enable appropriate intervention and
improve nutritional status. Clinical studies have
shown that early intervention is necessary if
nutritional support is to improve outcome (Ottery,
1994; Nitenberg and Raynard, 2000; MacDonald,
2003). Patients may present with obvious cancerassociated malnutrition or be at risk of developing
malnutrition during the course of their disease.
Screening of all patients can detect those at risk,
and prevent the onset or progression of malnutrition through appropriate interventions. Two main
evaluation processes exist to identify patients with,
or at risk of malnutrition: nutritional screening and
nutritional assessment.
Nutritional screening is the first step, and should
be applied to all patients with cancer. For
hospitalised patients, screening should be undertaken immediately following admission, and at
regular intervals thereafter. Patients attending
hospital regularly as outpatients also require
regular screening; this can be performed during
hospital visits and in the community. Primary care
patients are also at risk of developing malnutrition
and should be screened in the home by a community healthcare professional. Screening should
ideally be undertaken by a nurse and be a quick,
simple method of identifying patients with, or at
risk of developing malnutrition. The relevant
patients should then be referred to a dietician or
clinical nurse specialist (Fig. 1) for a more detailed
assessment of their nutritional status. Nutritional
screening and assessment will be discussed in detail
in this article.
Nutritional screening
The use of suitable nutritional screening methods is
fundamental for effective nutritional intervention
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M. Davies
Nutritional screening (might include):
• Body mass index (BMI)/body weight
• Unintended weight loss
• Impaired food intake
• Treatment plan
• Disease severity
Refer to dietitian or
clinical nurse specialist
Nutritional assessment (might include):
• History (medical, dietary, social)
• Physical examination
• Anthropometry (e.g. weight, height,
BMI, muscle strength, muscle loss)
• Biochemical tests (blood, urine)
Figure 1 Nutritional screening and assessment of patients with cancer. Screening identifies patients with, or at risk of
developing, malnutrition, who should then be referred to a dietetic specialist for more detailed assessment.
and management in patients with cancer. Nutritional screening aims to provide an indication of
the nutritional status of patients and assess
whether their nutritional needs are being met,
thereby identifying patients who are malnourished
or at significant risk of malnourishment. Vulnerable
patients can then be referred to a specialist for
detailed assessment. To achieve this, it has been
recommended that nutritional screening should be
performed on all patients on admission to hospital,
and at regular intervals thereafter to ensure any
nutritional decline due to therapy or disease
progression is identified as early as possible and
can be dealt with (Holder, 2003). Outpatients are
equally at risk, and require similar consideration;
therefore, screening should be incorporated into
hospital appointments or performed by healthcare
workers during home visits.
In a hospital environment, nutritional screening
should be performed by nurses who are in daily
contact with the patient. In the community, this
process could be incorporated into standard patient
health reviews and nursing care plans. Essentially,
nutritional screening should use a tool that is quick
and easy to perform by the nursing staff. It should
be sensitive, reliable and relevant to the target
group, and the results should guide non-dietetic
healthcare professionals, for example, nurses, to
the appropriate course of action, such as referral to
a specialist dietician or clinical nurse specialist, if
this is indicated.
Although no standardised nutritional screening
tool has been designed specifically for use in
patients with cancer, several exist and have been
shown to be effective in different patient groups
including primary care patients, hospital inpatients
and the elderly (Jensen, 1992; Russell, 2000; Green
and Watson, 2005). The most commonly used
screening tool is the Malnutrition Universal Screening Tool (MUST) (Stratton et al., 2004). Nutritional
screening tools typically use a questionnaire format
to examine factors known to lead to, or be
associated with, malnourishment. Such tools generally focus on body weight, weight loss and
appetite. It has been suggested (Lennard-Jones et
al., 1995) that patients should routinely be asked
the following four questions, which make up the
core principles of nutritional screening:
Have you unintentionally lost weight recently?
Have you been eating less than usual?
What is your normal weight?
How tall are you?
The latter enable Body Mass Index (BMI) to be
calculated (see below).
Additional observations, such as loose clothing or
jewellery, can also alert the healthcare professional
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Nutritional screening and assessment in cancer-associated malnutrition
to recent weight loss, and these findings may be
particularly useful in patients who cannot be
weighed.
Nutritional screening tools
Several screening tools have been developed over
the past two decades, however, until recently, most
have been too complex to be useful in routine
clinical practice. Ideally, a nutritional screening
tool will achieve a balance between ease of use and
the provision of sufficient data, to alert healthcare
professionals to the appropriate course of action.
The MUST has been developed by the British
Association for Parenteral and Enteral Nutrition in
the UK and is commonly used in many patient types
(Table 1) (Stratton et al., 2004). This tool is very
reliable and has been validated in a range of
healthcare settings by different healthcare professionals (Stratton et al., 2004), although its value
has not yet been established in patients with
cancer. A series of charts allows for rapid categorisation of patients based on BMI and weight loss,
and for conversion of knee height into stature,
where necessary. The tool can also be adapted to
specific situations and local needs, such as how to
proceed if the individual’s height and weight
cannot be reliably or easily obtained. MUST also
covers the management of obese patients and
those requiring special diets. Other nutrition
screening tools include The Nutrition Risk Index
(Wolinsky et al., 1990), used by dieticians and
Table 1
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nurses, and the Burton Score (Russell et al., 1998).
With certain tools, an appropriate course of action
can be suggested, dependent on the score
achieved.
Although the core principles of nutritional
screening apply to all patients, some patient groups
may require tailor-made screening tools. Rypkema
et al. (2004) developed a screening tool for use in
elderly patients, which included screening for
malnutrition, dehydration and dysphagia upon
admission, followed by immediate intervention
where required. Implementing this protocol was
found to prevent weight loss and achieve weight
gain, which was associated with a significantly
lower incidence of hospital-acquired infections
compared with standard care, demonstrating the
value of early nutritional screening.
The two simplest measures of the patient’s body
size and form, which will give indications of
nutritional status, are height and weight. When a
patient’s weight and height are known, the BMI can
be calculated and used to identify patients at risk
of malnutrition. BMI ¼ weight (kg)/height2 (m2),
and is an indicator of the chronic protein and
energy status of the individual. The BMI can be
compared with standard cut-off points (Table 2)
that classify individuals as severely underweight,
underweight, normal, overweight, obese and morbidly obese.
Although widely used, the BMI has several
limitations, which must be considered when using
it to assess nutritional status. For example, the cutoff points are arbitrary and based on young, healthy
adults, and may not be appropriate for patients
Steps for malnutrition universal screening tool.
Assessment/action
Score
Step 1
BMI (kg/m )
420 ¼ 0, 18.5720 ¼ 1,
o18.5 ¼ 2
Step 2
Weight loss (unplanned weight loss in past 3–6 months)
o5% ¼ 0, 5–10% ¼ 1,
410% ¼ 2
Step 3
Acute disease effect (acute illness with no nutritional
intake 45 days)
2
Step 4
Overall risk of malnutrition (add scores from Steps 1–3)
0 ¼ low risk, 1 ¼ medium
risk, X2 ¼ high risk
Step 5
Management guidelines provided for each risk category
(low risk: routine clinical care; medium risk: observe,
treat if no improvement; high risk: treat, unless
detrimental or no benefit expected)
2
Instructions given for alternative measurments and use of subjective criteria if weight and height cannot be obtained.
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Table 2
M. Davies
BMI cut-off points.
BMI (kg/m2)
Interpretation
o16
16–19
20–25
26–30
31–40
440
Severely underweight
Underweight
Normal range
Overweight
Obese
Morbidly obese
with cancer due to the effects of the disease.
Hydration status can have a large impact on body
weight; some patients with cancer experience
oedema, with changes in normal intracellular fluid
to protein ratio occurring either as a result of
disease or treatment. This can give an incorrect
weight and, therefore, BMI. In the case of large,
solid tumours, tumour mass may contribute o10%
of total body mass in children and 4–5% in adults,
which can also mask loss of weight and lean body
mass. Individuals with extremes of stature may
have a BMI that lies outside the normal range for
the population as a whole, while still having good
nutritional status and stable weight. Thus, additional methods of nutritional screening might be
necessary, however, these also have limitations.
Measurement of the patient’s weight as a
percentage of their ideal body weight can be used,
although this is subject to errors, as establishment
of standard values for ideal weight is problematic.
For these reasons, measurement of weight loss,
such as current body weight compared with
usual weight is used most often; it also has the
advantage of using the patient’s usual weight as the
comparator.
Assessment of changes in body weight over time
can be a more informative indicator of nutritional
decline. Although affected by short-term fluctuations, such as changes in fluid balance, assessment
of changes over time take into account the time in
which weight loss has occurred; this has been
shown to be important in the assessment of
nutritional status, with rapid weight loss indicative
of more severe malnutrition (Ottery, 1995; Nitenberg and Raynard, 2000).
Nutritional assessment
All patients identified as malnourished, or at risk of
malnutrition following nutritional screening, should
be referred for a complete nutritional assessment
performed by an appropriate healthcare profes-
sional, such as a dietician or other specialist in
nutrition. Nutritional assessment is more in-depth
and complex than screening, and involves the use
of several measures to determine nutritional
status. The purposes of such assessments are to
confirm the presence, extent, degree of severity,
and type of malnutrition; determine the nutritional
needs of the patient and the nutritional support
required; provide the basis of the treatment plan
and monitor the progress of those receiving nutritional support, and to determine whether their
nutritional needs are being met.
Nutritional assessment should accurately determine the nutritional status of the patient. Although
there is no generally accepted method of assessing
nutritional status, the assessment should determine whether the individual is in a good or bad
state of nutrition. Aspects such as the patient’s
physiological requirements, nutritional intake,
body composition and functional status should be
considered, and the findings interpreted together.
Individual circumstances will dictate the parameters and assessment methods used; these usually
encompass a combination of objective and subjective parameters, including:
clinical considerations
physical considerations
psychological considerations
dietary considerations
anthropometric considerations
biochemical and haematological considerations.
The initial assessment should serve as the basis
for planning nutritional intervention, and assessment should be repeated regularly to determine
the efficacy of nutritional support. The basic
assessment techniques are as follows:
1. history taking (medical, psychological, dietary
and social history)
2. physical examination (disease status, fluid balance and functional assessment)
3. anthropometry (weight, height and body composition)
4. biochemical assessment (blood and urine parameters).
Nutritional assessment is most informative when
performed repeatedly to assess changes over time.
Medical, dietary and social history
A review of the patient’s medical history may
identify high-risk conditions, as well as highlight
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Nutritional screening and assessment in cancer-associated malnutrition
current and prior illnesses that may impact on
nutritional status. A thorough dietary history is
essential and should include assessment of current
food and fluid intake, previous intake, and any
recent changes should be noted. From this, an
indication of the patient’s macro- and micronutrient intakes can be gained. In cases where deficits
are detected, some form of supplementation may
be advised. In addition, the assessment should aim
to detect food aversions, intolerances and problems with feeding, such as taste changes (Baker
et al., 2002). The patient’s social history may also
provide insights into failure or inability to obtain or
prepare adequate food. Psychological problems in
response to illness can also affect nutritional
intake, and therefore, should also be considered.
In cases where problems are apparent, referral to a
specialist in this area can benefit the patient.
Physical examination
Reduced skeletal muscle mass and function are also
good indicators of malnutrition. Pre-operative grip
strength has been shown to correlate with postoperative complications and poor surgical outcome
(Mahalakshmi et al., 2004). However, grip strength
can be distorted by concurrent diseases, such as
arthritis or conditions causing impaired muscle
function, which must be considered when performing this type of physical examination. Exercise
tolerance, based on the patient’s opinion of their
ability to carry out normal day-to-day tasks, or
objective assessment of the time taken to complete assigned physical tasks, is also an indicator of
physical function. Respiratory muscle strength can
be assessed by measurement of lung function, for
example, peak flow, although this is rarely carried
out in practice. Immune function is impaired in
malnourished individuals and can be used to
indirectly assess nutritional status (Hudgens
et al., 2004): total lymphocyte counts of o2.0 109/L and o0.9 109/L are indicators of mild and
severe malnutrition, respectively. However, some
haematological malignancies, immunosuppressive
drugs and infections affect lymphocyte counts,
limiting the usefulness of this technique. Again,
this is rarely used as an assessment technique in
practice.
S69
water (Sarhill et al., 2003). Weight changes, when
measured accurately and regularly, are valuable
indicators of nutritional risk, and are considered
more informative than one-off assessments of BMI.
Weight changes provide information on the duration and extent of weight loss over time, and as
such are highly valuable. Although, weight and
height are among the simplest and least invasive
anthropometric measurements, there are occasions
when they are less useful, for example in fluid
imbalances or when patients are unable to stand.
Several techniques are available to measure body
composition; however, all have limitations with
regard to applicability to nutritional assessment, as
reviewed by Jensen (1992). For example, BMI cutoff points are arbitrary and based on young, healthy
adults; large tumours can contribute considerably
to body mass; hydration status can affect body
composition. Repeated, direct measurement of
body fat or lean tissue mass (mid-upper arm
circumference, triceps skin-fold) allows mapping
of changes in an individual, and may be particularly
important in patients with cancer, in whom large
tumours can contribute to body weight.
Biochemical assessment
The most common biochemical measurements used
to assess nutritional status are blood parameters
such as serum albumin, pre-albumin and iron
levels. Biochemical and haematological parameters
are subject to homeostatic mechanisms and may be
altered by underlying disease and/or treatment.
This can make interpretation difficult and lead to
false conclusions regarding nutritional status. For
example, in cancer, serum albumin often reflects
acute effects of treatment or disease, rather than
nutritional status, therefore albumin alone is not a
good indicator of nutritional status. Biochemical
assessments can also be expensive and are often
not performed if interpretation is problematic.
However, abnormal measurements of markers, such
as serum ferritin, add value to the nutritional
assessment, particularly when other parameters
are difficult to interpret.
Cancer-specific screening and
assessment
Anthropometry
Anthropometric assessment (e.g. BMI, mid-upper
arm circumference, skin-fold thickness) includes an
appraisal of the patient’s weight, height and body
composition, that is, lean body mass, fat stores and
Cancer cachexia requires specific methods of
screening and assessment, owing to the impact of
not only the tumour on nutritional status, but also
to that of the anticancer treatments. Several tools
have been developed specifically for patients with
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cancer, including the Oncology Screening Tool (OST)
(MSKCC, Clinical Dietitian Staff 1994–1995), which
can be used in different clinical settings, such as
inpatient or outpatient clinics, or at home. The
OST, which is normally conducted by a nurse or
dietician, screens patients for weight loss and a 2week or more history of decreased food intake,
nausea/vomiting, diarrhoea, mouth sores and
difficulty in chewing or swallowing. Patients are
classified as low or medium-to-high risk, with the
latter group receiving a full nutritional assessment
by a dietician within 24 h. Confirmation of patients
with low-risk status is performed on day 6, and
patients are reclassified if necessary. The Modified
Patient Generated Subjective Global Assessment
may also compose part of the complete nutritional
assessment (Ottery, 1996). The patient completes
the first part of the assessment, which surveys their
weight (current, 1 month previously, 6 months
previously), height, change in food intake over the
past month, symptoms that have affected eating
habits (lack of appetite, nausea, constipation,
taste, pain, dry mouth), and general activity and
function (normal, fairly normal, able to do a little,
rarely out of bed). The healthcare professional
then assigns scores to the domains assessed by the
patient and completes worksheets assessing weight
loss, disease category and comorbidities, metabolic
demand, and physical exam. A three-level rating is
determined (Stages A, B or C) and the appropriate
form of nutritional intervention established
(Ottery, 1996).
The functional capacity of the patient should be
assessed in conjunction with nutritional assessment
to ensure that the nutritional intervention is
tailored to, and appropriate for, the individual
patient. The Karnofsky Performance Status (KPS)
Scale is widely used to measure physical functioning, as well as medical care requirements in
patients with cancer (Yates et al., 1980; Mor
et al., 1984; however, it has been postulated that
the KPS may have difficulty assessing clinical
change over time (O’Dell et al., 1995) and the
procedure for scoring the instrument has not been
validated (Schag et al., 1984). The scale ranges in
10-point increments from 100 (normal, no complaints, no evidence of disease) through to 0
(dead). A reduction in function is generally related
to the cumulative physiological and psychological
effects of the disease, while performance status
has been shown to be an important predictor of
response to therapy and survival (Maurer and Pajak,
1981).
The assessment of a patient’s quality of life
provides important data regarding the patient’s
perception of their health, as well as information
M. Davies
on the impact of malnutrition and nutritional
support, and whether this is appropriate for the
patient. The European Organisation for Research
and Treatment of Cancer Core Quality of Life
Questionnaire (EORTC QLQ-30) is a validated,
reliable measure of quality of life in patients with
cancer (Aaronson et al., 1993). The instrument
contains five functional scales (physical, role,
emotional, cognitive and social), three symptom
scales (fatigue, pain and emesis) and one global
scale. These three scales together produce a score
in the range 0–100. Quality of life questionnaires
specific for certain cancers have also been developed (Kaptein et al., 2005; Avis et al., 2005).
Potential benefits of nutritional
screening
The key advantage of nutritional screening is that it
can identify patients at risk of, or experiencing,
nutritional deficits before progression to malnutrition. Therefore, screening may help to prevent the
onset of malnutrition. Early identification allows
for early intervention with nutritional supplementation to prevent malnutrition and the ‘vicious
circle’ of disease from developing. In contrast, in
patients with advanced cancer, nutritional intervention may only achieve weight stabilisation,
rather than reversal of weight loss, suggesting
early intervention is more beneficial to the patient
(MacDonald, 2003).
Nutritional support is known to have significant
advantages for the patient. Through improving
nutritional status, nutritional support has been
shown to improve many outcomes, including
immune function, survival and quality of life
(Tchekmedyian, 1995; Bozzetti, 2001; Rypkema
et al., 2004). Furthermore, early nutritional interventions have been shown to reduce morbidity and
mortality, as well as healthcare costs (Reilly et al.,
1988; Chima et al., 1997; Rypkema et al., 2004).
Nutritional screening may also facilitate recovery:
for example, diaphragmatic and other respiratory
muscle dysfunction can contribute to respiratory
arrest, the need for intubation or the inability to
extubate a patient post-operatively or during
oncological complications. Importantly, this deterioration in functional status can result in delays in
therapeutic intervention or even the exclusion of
therapies due to standard protocol exclusion
criteria of performance status. Survival benefits
following chemotherapy have also been identified
in patients with gastrointestinal cancer who had
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Nutritional screening and assessment in cancer-associated malnutrition
not lost weight at presentation compared with
those who had (Andreyev et al., 1998).
From an economic standpoint, early nutritional
intervention has been shown to be cost-effective,
as well as beneficial. Reilly et al. (1988) conducted
a retrospective study of 771 patient records in two
acute care hospitals and concluded that the costs
associated with malnutrition, in cancer and noncancer patients, including length of hospital stay
and complication rate, warranted early detection
and aggressive treatment. Rypkema et al. (2004)
showed that early nutritional intervention in older
patients in hospital is cost effective and beneficial
to the patient, achieving weight gain and lowering
hospital-acquired infections. It has also been shown
that patients identified as at risk of malnutrition
require a significantly longer hospital stay and have
higher costs and home healthcare needs than those
not at risk of malnutrition (Chima et al., 1997).
These studies highlight the importance and benefits
of early nutritional screening, not only to the
patient, but also to the healthcare provider.
Continued monitoring of nutritional
status
Nutritional screening and assessment do not end
with the instigation of nutritional support. Regular
monitoring should be performed to ensure that
nutritional intervention is effective and the patient
is not experiencing further nutritional decline or
complications. Nutritional support programmes
implemented after nutritional screening and assessment should be tailored to the individual and
take into consideration the patient’s prognosis,
treatment, gut function, ability to feed, religious
and personal taste preferences. Options for nutritional support include oral, enteral feeding tube,
and total parenteral nutrition. The method and
frequency of continued nutritional assessment will
differ between patients and depend on their
clinical condition, stability and type of nutritional
support.
The role of the nurse in nutritional
screening
Nurses play a crucial role in the early detection of
nutritional decline, as well as the identification of
patients at risk of developing malnutrition. Thorough nutritional screening should ideally be carried
out by nurses when patients are admitted to
hospital, and throughout their hospital stay, in
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order to effectively plan their nutritional care.
Importantly, nursing staff are on-hand and have
contact with patients on a daily basis, making them
ideally placed to identify changes in patient’s food
intake and general well-being. Regular monitoring
of patients receiving care in their own home should
not be ignored as these patients may be at
particularly high risk of malnutrition. Nurses are
also ideally placed to screen such patients for signs
of malnutrition. For example, nutritional screening, including assessment of weight loss, could be
easily incorporated into domestic visits to primary
care patients. Ideally, weighing should be performed weekly, and can be particularly informative
if done so at the same time of day, when the
patient is wearing the same clothes, and using the
same scales. More regular weighing could cause the
patient to become anxious about their weight and
upset if poor progress or decline is evident
(Anthony and Montagna, 2000).
Nurses should monitor factors that contribute to
decreased food intake, such as nausea, vomiting,
and pain, and ensure that factors contributing to
debilitation levels are considered and corrected
(Dell, 2002). Early identification of patients with
declining nutritional status allows the nurse to alert
the appropriate expert, such as the doctor, clinical
nurse specialist or dietician, before malnutrition
develops. Through close, regular monitoring of
patients, nurses can also ensure that the nutritional
support strategy employed is effective, and the
correct course of action is taken to tailor nutritional support to the individual patient. Successful
nutritional support can be ensured through liaison
with other healthcare professionals, such as doctors and dieticians (Holder, 2003).
Conclusions and recommendations
Careful evaluation of nutritional status through
nutritional screening and assessment is essential to
identify malnourished patients or those at risk of
becoming malnourished. Through screening and
assessment, early nutritional interventions can be
implemented, which can improve response to
treatment, performance status, quality of life and
reduce morbidity and mortality in patients with
cancer. Nurses play a vital role in the identification
of malnourished patients, the continued assessment of those at risk of developing malnutrition,
and the evaluation of the efficacy of nutritional
intervention strategies. Screening is, therefore,
not only important for the patient–in whom
nutritional support can improve outcomes such as
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quality of life, decrease length of hospital stay and
achieve psychological benefits—but is also beneficial to the healthcare provider. Early interventions, made possible as a result of screening, can be
of considerable financial benefit to the healthcare
provider, reducing costs through shorter periods of
hospitalisation, fewer complications and other
indirect costs.
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