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Objectives

n Malnutrition in hospitals

n Purpose of doing nutrition screening and assessment

n Definition

n Principle of Nutrition Screening

n Methods of Nutrition Screening

Nutrition Screening n Practice

n Assignment
Mira Mutiyani
6 March 2017
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Malnutrition in hospital Malnutrition in hospital

Malnutrition remains a significant problem in hospital despite the growing

body of evidence describing both its clinical and economical consequences.
The prevalence of hospital malnutrition is reported to range between 20%
and 50%.
Consequences of malnutrition result in increased mortality, duration and
intensity of treatment, cost, and length of hospital stay. Norman K, et al, 2007

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Optimal nutrition status Malnutrition in hospital

n Malnutrition has been

described as the imbalance
between intake and
requirement

n results in altered metabolism,

impaired function and loss of
body mass or as a state of
nutrition in which a deficiency
or imbalance of energy, protein,
and other nutrients

n causes measurable adverse

effects on tissue and/or body
form.

Nutrition Screening/2017/MM Mahan L.K, 2016 Nutrition Screening/2017/MM Mahan L.K, 2016

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Cause of malnutrition Development of deficiency

Most chronic or severe

diseases cause anorexia
which results in
malnutrition.
Malnutrition together with
stress-related catabolism
caused by inflammation
increases the risk for
infections, organ
dysfunction and impaired
healing.
This again as all other
severe acute illnesses can
be a trigger for
inflammatory response and
consecutively result in
starvation and catabolism
Vicious circle of the development and progression of disease-related malnutrition. which further aggravates
malnutrition.
Nutrition Screening/2017/MM Norman K, et al, 2007 Nutrition Screening/2017/MM Mahan L.K, 2016

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+ Kesimpulan dari forum diskusi tentang Malnutrisi di RS
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Prognostic impact of malnutrition

n Malnutrition affects
morbidity by impaired
wound healing and immune Semua pasien pada awal masuk RS perlu dilakukan skrinning gizi untuk
system with increased rate mendeteksi pasien yang berisiko mempunyai masalah gizi
of infectious and non-
infectious complication rate
and a general impairment
of convalescence. Alat skrinning harus mudah dan dapat diterima serta teruji validitasnya

n The increased morbidity

results in increased
mortality, duration and Skrining gizi dengan parameter klinik, yaitu usia, IMT, kehilangan BB, dan
intensity of treatment, and asupan makan serta parameter lab, yaitu albumin, limfosit dan kolesterol
length of hospital stay.

n These consequences of
malnutrition result in Skrinning harus diulang secara periodik
increased treatment costs.

(Lorenzo dkk, 2005)

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Nutrition screening

n To provide cost-effective nutrition

services in todays health care
environment it is important first
Physical
to screen patients to and those who conditions
are at nutritional risk. Psychologic Abnormal
and social laboratory
factors values

n Nutrition risk is determined through Food and

Determine
a nutrition screening process. nutrient
nutrition Medications
intake risk
patterns

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+ ESPEN guidelines for nutrition screening recommend a continuity of

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issues to be considered in all patients admitted to hospital

The nutritional care process including screening, planning, and monitoring according to ESPEN guidelines.
Notes: REQ(requirements of energy and protein), feeding (i.e, food, supplements, tube feeding, and parenteral nutrition), monitoring (weight and food
registration).

Rasmussen H.H, 2010

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Definition Nutrition screening

n Nutrition screening: the process of identifying patients, n Identify patients who are at risk of:
clients, or groups who may have a nutrition diagnosis and
benefit from nutrition assessment and intervention by a Developing nutrition related complications
registered dietitian nutritionist (RDN) (Mahan L.K, 2016). Getting more malnourished during hospital Fungsi fisik
membaik
stay
n Skrinning atau penapisan: penggunaan tes atau metode
diagnosis lain untuk mengetahui apakah seseorang n Characteristics:
memiliki penyakit atau kondisi tertentu sebelum
menyebabkan gejala apapun (Kamus kesehatan). Simple
Rapidly done
n Skrinning gizi minimal dilakukan dalam waktu 24 jam Covers the whole patient population Lama
perawatan
Komplikasi
penyakit
Outcome
terhitung saat pasien masuk ke RS (JCAHO, DeBruyne et.al, berkurang menurun
2008).
n Ultimate goal: nutrition management
prioritization of patients
n Informasi yang digunakan pada skrinning gizi: diagnosis
penyakit, informasi riwayat penyakit, penilaian fisik dan
tes laboratorium saat pasien di RS, dan kuisioner yang n Goal: memprediksi probabilitas membaik
dibagikan. atau memburuknya outcome yang
Kesembuhan
berkaitan dengan faktor gizi dan dipercepat
mengetahui pengaruh dari intervensi gizi.

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Principle of nutrition screening Screening and Assessment

n Screening and
Actual condition? : BB, TB, IMT. Pengukuran LILA (jika assessment are integral
tidak dapat dilakukan pengukuran BB dan TB) parts of the nutrition care
process (NCP)
Is the condition stable? : kehilangan BB, jika kehilangan
BB 5% atau lebih selama 3 bulan maka dianggap n Nutrition risk is
signifikan determined through a
nutrition screening
Will the condition worsen? : pertanyaan tentang asupan process.
makan yang menurun (bisa saat di RS atau riwayat gizi).
Apabila asupan makan < kebutuhan penurunan BB

Will the disease process accelerate nutritional

deterioration? : penyakit menyebabkan peningkatan
kebutuhan dan penurunan nafsu makan

(Rasmussen, 2010). Mahan L.K, 2016

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Nutritional Assessment Difference between nutrition screening and

assessment

n Usually done on patients identified to be nutritionally Nutrition screening Nutrition assessment

at risk by the screening process n Immediate n Longer time
n More in-depth nutritional evaluation of the patient n Minimum measurements n More measurement done
nutritional status
Collect and evaluate clinical conditions, diet, body n Least expense n A bit more expensive
composition and biochemical data, among others
n Information: concise n Information: more in depth
Classify patients by nutritional state: well-nourished or
malnourished

n Determines the severity of malnutrition

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+ Nutritional screening tools for hospitalized children
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Methods of nutrition screening

n Children who are admitted to the hospital are at
a risk of developing under nutrition, especially
children with an underlying disease.

n High percentages of both acute and chronic

under nutrition have been reported in various
Western countries for many years.

n 20-50% of children the nutritional status

deteriorates during admission.

n In France, Sermet-Gaudelus et al. (2000) found

62% of children had lost weight during their
hospital stay negative consequences for the
child, underlining the importance to careful

Children Adults Elderly

monitor.

Several nutritional screening tools have been

developed for hospitalized children in the last
years.

Joosten K F.M and Hust J.M, 2013

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+ Nutritional screening tools for hospitalized children

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+ Screening tools for children admitted to the hospital and
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their aim
The goals of each screening tool Comparison of screening tools according to 4 main
principles of a screening tool (ESPEN)

1. NRS: Nutrition Risk Score;

NRS
2. PNRS: Pediatric Nutritional Risk
Score;
3. STAMP: Screening Tool for the
STRONGkids PNRS
Assessment of Malnutrition in
Paediatrics;
Nutritional 4. SGNA: Subjective Global
screening
tools Nutritional Assessment;
5. PYMS: Paediatric Yorkhill
PYMS STAMP
Malnutrition Score;
n PRNS screening can be completed after 48 hour whereas in the other five tool screening can be done and completed directly on
6. STRONGkids: Screening Tool for admission.
Risk Of Impaired Nutritional n When choosing a nutritional screening tool, consider the different purposes and applications of the tool in relation to what you want
to achieve in your practice.
SGNA Status and Growth. n STRONGkids seems to be the most practical, easy and reliable tool for assessment of nutritional risk
n PYMS can be used for both the determination of nutritional risk and actual nutritional status

Joosten K F.M and Hust J.M, 2013 Joosten K F.M and Hust J.M, 2013
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+ NRS: Nutrition Risk Score

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+ Screening Tool for the Assessment of Malnutrition in
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Paediatrics (STAMP)

Kesimpulan: Skor NRS: 0-3 tidak beresiko malnutrisi; skor 4-5 beresiko
sedang, skor > 7 resiko tinggi
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+ Subjective Global Nutritional Assessment (SGNA)

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+ Subjective Global Nutritional Assessment (SGNA)
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Nutrition Screening/2017/MM Donna J. Secker, 2011 Nutrition Screening/2017/MM Donna J. Secker, 2011

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+ Paediatric Yorkhill Malnutrition Score (PYMS)

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+ Nutritional screening tools for adults
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(evaluated by the Academy Nutrition and Dietetics (AND).

Nutrition Risk Screening (NRS 2002): screening

Subjective Global Assessment (SGA): a tool that
uses weight history, diet history data, stress level,
and primary diagnosis along with physical
symptoms to assess nutritional status (Mueller et al,
2011).
tool that is useful for medical-surgical hospitalized
patients (AND, 2015).
Its purpose to detect the presence of under nutrition
and the risk of developing under nutrition in the
hospital setting

Nutrition screening tools

Malnutrition Universal Screening Tool (MUST) by

Malnutrition Screening Tool (MST) by Ferguson
(1999); useful for the acute hospitalized adult
population
Stratton and colleagues (2004): assess for
malnutrition rapidly and completely; can be used by
professionals of different disciplines (AND, 2015).
It purpose to detect under- nutrition on the basis of
knowledge about the association between impaired
nutritional status and impaired function

Mahan L.K, 2016

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+ Nutrition Risk Screening 2002 (NRS-2002)

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+ Nutrition Risk Screening 2002 (NRS-2002)
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Rasmussen H.H, 2010 Rasmussen H.H, 2010

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Malnutrition screening tool (MST)

n The parameters include recent weight loss and recent poor dietary intake. The tool is useful
for the acute hospitalized adult population and was the only one of the 11 evaluated by the
EAL shown to be valid and reliable for identifying problems in acute care and hospital-based
ambulatory care settings (AND, 2013b; Box 4-1).

Mahan L.K, 2016 Mahan L.K, 2016

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+ Subjective Global Assessment (SGA)

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+ Subjective Global Assessment (SGA)
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+ Pengembangan Simple Nutrition Screening Tool (SNST)

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Kuisioner skrinning gizi baru (SGB)

Dikembangkan oleh: Dr. Susetyowati, DCN., M.Kes (Staf pengajar di PS Gizi Kesehatan FK UGM Yogyakarta)

Variabel Pertanyaan Skor

Di Indonesia belum ada Kondisi pasien sekarang Apakah pasien terlihat kurus? Ya=1
alat skrinning paling Tidak=0
NRS-2002 (ESPEN) tepat dan dapat diterima
semua kalangan Penurunan berat badan Apakah pakaian anda terasa lebih Ya=1 Cut-off risiko
MUST oleh British longgar? Tidak=0 malnutrisi dari
Association of Parenteral SNST:
and Enteral Nutrition
(BAPEN) 0-2 kategori
Apakah akhir-akhir ini anda kehilangan Ya=1
tidak
SNAQ berat badan secara tidak sengaja (3-6 Tidak=0
berisiko
MST oleh Australia bulan terakhir)?
malnutrisi
Penurunan asupan makan Apakah anda mengalami penurunan nafsu Ya=1 3-6 kategori
Metode skrinning yang Dikembangkan Simple
makan selama 1 minggu terakhir? Tidak=0 berisiko
sudah Nutrition Screening Tool
direkomendasikan: (SNST) malnutrisi
Riwayat penyakit Apakah anda merasa lemah, loyo, dan Ya=1
tidak bertenaga? Tidak=0
Membandingkan 4 metode
skrinning gizi: NRS-2002, Apakah anda menderita suatu penyakit Ya=1
MUST, SNAQ, MST dan SGA yang mengakibatkan adanya perubahan Tidak=0
sebagai gold standard jumlah atau jenis makanan yang anda
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Nutritional screening tools for Elderly Nutritional Risk Index (NRI)
Protein-energy malnutrition (PEM) is a common disorder in the elderly.

Estimations of the prevalence of PEM vary (20 78% in elderly medical patients) n NRI = (1.159 x Albumin) + (41.7 x berat sekarang/berat biasa)
Untuk mengidentifikasi

Nutritional
masalah gizi pada usia lanjut
Berhubungan dengan
n Ket:
Risk Index indikator klinis dan biokimia n Albumin: albumin serum (g/L)
(NRI) Dikembangkan oleh Veteran
Affairs Total Parenteral n Berat biasa: didefinisikan sebagai berat stabil lebih dari 6 bulan sebelum masuk
Cooperative
RS (Gibson, 2005)
Untuk populasi usia lanjut
Menggunakan indikator
biologis: serum albumin dan
berat badan n Kategori ambang batas pengukuran NRI menurut Gibson, 2005 adalah sbb:
Ada modifikasi metode NRI:
Geriatric indikator BB dan
Nutrition pengukuran TB melalui
Risk Index pengukuran tinggi lutut Status Gizi Ambang Batas
Konversi TB dan TL :
persamaan Chumlea
BB dengan formula Lorents
Tidak ada malnutrisi > 100
(Wlo)
Pasien di bangsal bedah Malnutrisi ringan 97.5 - 100
Malnutrisi sedang 83.5 94.7
Mini Banya digunakan di RS untuk
Nutritional pasien lansia
Malnutrisi berat < 83.5
Assessment Cukup sederhana, lengkap
(MNA) untuk menilai status gizi

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Geriatric Nutrition Risk Index (GNRI) Mini Nutritional Assessment (MNA)

n GNRI = (1.489 x Albumin g/l) + (41.7 x berat badan/berat

badan ideal)

n Kategori ambang batas pengukuran GNRI adalah sbb:

Kategori GNRI
Berisiko tinggi < 82
Berisiko sedang 82 - < 92
Berisiko rendah 92 - 98
Tidak berisiko > 98

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References

n Hammond K.A, Mahan L.K, 2016. Intake: Analysis of the Diet. Krauses.
Food and the Nutrition Care Process, 14th ed. Elsevier.

n Joosten K F.M, Jessie M. Hulst J.M, 2014. Review Nutritional screening

tools for hospitalized children: Methodological considerations. Clinical
Nutrition 33 (2014) 1-5.

n Secker D.J, Jeejeebhoy A.N, 2012. How to Perform Subjective Global

+
Nutritional Assessment in Children. Journal of the Academy of Nutrition
and Dietetics.

n Kondrup J, et al, 2003. ESPEN Guidelines for Nutrition Screening 2002.

Clinical Nutrition (2003) 22(4): 415421.

n Susetyowati, 2014. Penerapan Skrining Gizi di Rumah sakit. Gadjah Mada

University Press.

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