Appendix C
NUTRITIONAL ASSESSMENT PROTOCOL
Name ___________________________________________________________
Date ___________________________________________________________
Diagnosis ______________________________________________________
________________________________________________________________
________________________________________________________________
- A. HISTORY
- Actual Body Weight ________kg UBW ________kg
- Height ________cm Age ________
- Weight Change: past 6 mo _________kg = _________% loss
- past 2 wk increase no change decrease
- Dietary Intake (relative to normal):
- no change change: duration = ______weeks
- type: suboptimal solids full liquids hypocaloric liquids starvation
- Calories _________________ Minerals ________________
- Protein __________________ Vitamins ________________
- EFA ____________________ Tr Elements _____________
- Capacity for Oral Intake: normal
- suboptimal: duration of disability = _____weeks
- good potential to return to normal in ____weeks
- limited potential to return to normal in ____weeks
- permanent GI disability
- GI Symptoms (of >2 weeks):
- none ___ nausea ___ vomiting ___ diarrhea ___ anorexia ___
- Functional Capacity: _____ no dysfunction
- dysfunction: duration = _________weeks
- type = work ambulation bedridden
- Status of GI Tract:
- intact ___ contiguous bowel ___
- gastrectomy ___ ileostomy ___
- small bowel resection ___ jejunostomy
- duodenum _______cm colostomy ___
- jejunum _______cm obstruction ___
- iluem _______cm fistula ___
- ileo-cecal valve ___ radiation exposure ___ type _______________
- large bowel resection: complete __ partial __last treatment ___________
- Medications:
- B. PHYSICAL (for each trait specify: 0=normal, 1+=mild,
2+=moderate, 3+=severe)
| |
| _____ loss of subcutaneous fat |
_____ ascites |
| _____ pallor |
_____ muscle wasting |
| _____ glossitis |
_____ dry, dull hair |
| _____ ankle edema |
_____ cheilosis |
| _____ petechia |
_____ sacral edema |
| _____ scaly dermatitis |
_____ bruisability |
- C. LABORATORY
- Albumin _______g/dL Transthyretin _______mg/dL
- D. METABOLIC DEMANDS
- ____ no stress _____ low stress _____ high stress
- E. OVERALL NUTRITION RATING (select one)
- A = well nourished
- B = moderately (or suspected of being) malnourished
- C= severely malnourished
- F. NUTRITION SUPPORT RX: PN RX:
- Resting energy expenditure ________________________________kcals
- TEE ____________________kcals
- Nutrient deficits requiring repletion:
- protein/24hr __________gms fluid/24hr____________cc
Table of Contents | Appendix D