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          Journal of Parenteral and Enteral
                                                          Nutrition
                                                           http://pen.sagepub.com/ 
                                                                            
                                                                            
          A.S.P.E.N. Clinical Guidelines : Nutrition Screening, Assessment, and Intervention in Adults
    Charles Mueller, Charlene Compher, Druyan Mary Ellen and the American Society for Parenteral and Enteral Nutrition
                                                        (A.S.P.E.N.) Board of Directors
                                                  JPEN J Parenter Enteral Nutr 2011 35: 16
                                                       DOI: 10.1177/0148607110389335
                                                                            
                                              The online version of this article can be found at:
                                                   http://pen.sagepub.com/content/35/1/16 
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                                             The American Society for Parenteral & Enteral Nutrition 
                                                                            
                                                                            
                                                                            
                                                                            
                                                                            
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                                                      Downloaded from pen.sagepub.com at Vrije Univ Bibliotheek on July 14, 2011
             Clinical Guidelines                                                                                              Journal of Parenteral and 
                                                                                                                                     Enteral Nutrition
                                                                                                                                  Volume 35 Number 1
            A.S.P.E.N. Clinical Guidelines                                                                                         January 2011  16-24
                                                                                                                            © 2011 American Society for 
                                                                                                                         Parenteral and nteral Nutrition
                                                                                                                            1011014601103335
            Nutrition Screening, Assessment, and Intervention in                                                                 tt­€‚­enƒa„e­ubcom
                                                                                                                                             oƒted at
            Adults                                                                                                              tt­€onlineƒa„e­ubcom
            “ arleƒ —ueller… P ˜… ™˜… “NS˜– “ arlene “om­ er… P ˜… 
            ™˜… ŠA˜A… “NS˜… ž˜N– ˜ruyan —ary llen… P ˜… —PŸ… 
            ™˜… “NS… ŠA“N– and t e American Society for Parenteral 
            and nteral Nutrition ‰ASPN‹ œoard of ˜irectorƒ
            Financial disclosure: none declared.
                                                                                                                             1
                      utrition ƒcreenin„… aƒƒeƒƒment… and inter†ention            meaƒurementƒ– and laboratory data”  A nutrition aƒƒeƒƒ-
                      in ­atientƒ ‡it  malnutrition are ˆey com­onentƒ            ment  ­ro†ideƒ  t e  baƒiƒ  for  a  nutrition  inter†ention 
            Nof nutrition care ‰Ši„ure 1‹ Nutrition ƒcreenin„                    ‘ndeed…  t eƒe  definitionƒ  are  conƒiƒtent  ‡it   t e  Joint 
             aƒ been defined by t e American Society for Parenteral               “ommiƒƒion’ƒ inter­retation of a ƒcreen aƒ an inƒtrument 
            and nteral Nutrition ‰ASPN‹ aƒ “a ­roceƒƒ to iden-             uƒed to determine ‡ et er additional information ‰from 
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            tify an indi†idual ‡ o iƒ malnouriƒ ed or ‡ o iƒ at riƒˆ for          an aƒƒeƒƒment‹ iƒ re£uired to ‡arrant an inter†ention  
            malnutrition to determine if a detailed nutrition aƒƒeƒƒ-             Nutrition aƒƒeƒƒment ­erformed by a nutrition ƒu­­ort 
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            ment  iƒ  indicated”   ‘n  t e  ’nited  Stateƒ…  t e  Joint          clinician iƒ a ri„orouƒ ­roceƒƒ t at includeƒ obtainin„ diet 
            “ommiƒƒion mandateƒ nutrition ƒcreenin„ ‡it in 24  ourƒ               and medical  iƒtory… current clinical ƒtatuƒ… ant ro­omet-
                                                     2
            of admiƒƒion to an acute care center  ” e „oal of nutrition          ric  data…  laboratory  data…  ­ yƒical  aƒƒeƒƒment  informa-
            aƒƒeƒƒment iƒ to identify any ƒ­ecific nutrition riƒˆ‰ƒ‹ or           tion…  and  often  functional  and  economic  information– 
            clear e•iƒtence of malnutrition Nutrition aƒƒeƒƒmentƒ may            eƒtimatin„ nutrient re£uirementƒ– and… uƒually… ƒelectin„ 
            lead  to  recommendationƒ for im­ro†in„ nutrition ƒtatuƒ              a treatment ­lan “linical ƒˆill… reƒource a†ailability… and 
            ‰e„… ƒome inter†ention ƒuc  aƒ c an„e in diet… enteral or             t e ƒettin„ determine t e ƒ­ecific met odƒ uƒed to ­er-
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            ­arenteral nutrition… or furt er medical aƒƒeƒƒment‹ or a             form  a  clinical  nutrition  aƒƒeƒƒment       †idence-baƒed 
                                                  3-5
            recommendation for reƒcreenin„  Nutrition aƒƒeƒƒment                 “linical ¤uidelineƒ for ƒ­ecific diƒeaƒeƒ and conditionƒ 
             aƒ  been  defined  by  ASPN  aƒ  “a  com­re enƒi†e             may identify aƒƒeƒƒment ­arameterƒ a­­ro­riate to t oƒe 
            a­­roac   to  dia„noƒin„  nutrition  ­roblemƒ  t at  uƒeƒ  a          conditionƒ  ‘n  addition…  reaƒƒeƒƒment  and  monitorin„ 
            combination  of  t e  follo‡in„€  medical…  nutrition…  and           met odƒ  are  an  e•tenƒion  of  t e  aƒƒeƒƒment  ­roceƒƒ 
            medication  iƒtorieƒ– ­ yƒical e•amination– ant ro­ometric            ‡it in o†erall nutrition care ‰Ši„ure 1‹ Aƒ illuƒtrated in 
                                                                                  Ši„ure 1… clinical aƒƒeƒƒment ‰includin„ reƒcreenin„ and 
                                                                                  reaƒƒeƒƒment‹ iƒ a continuouƒ ­roceƒƒ
            Šrom t e “ arleƒ —ueller… P ˜… ™˜… “NS˜… Nutrition ™eƒearc                 •­ertƒ define malnutrition aƒ “an acute… ƒubacute or 
            —ana„er…  “linical  and  ”ranƒlational  Science  “enter…  šeill       c ronic ƒtate of nutrition… in ‡ ic  †aryin„ de„reeƒ of 
            “ornell —edical “olle„e… 1300 ›orˆ A†enue… œo• 14… Ne‡ ›orˆ…         o†ernutrition or undernutrition ‡it  or ‡it out inflam-
            N› 10065                                                             matory acti†ity  a†e led to a c an„e in body com­oƒition 
                                                                                                                 1
            “ arlene “om­ er… P ˜… ™˜… ŠA˜A… “NS˜… ž˜N… ’ni†erƒity                and diminiƒ ed function”  Parameterƒ uƒed to dia„noƒe 
            of Pennƒyl†ania Sc ool of Nurƒin„… “laire — Ša„in Ÿall… 41          malnutrition in t e ƒcreenin„ and aƒƒeƒƒment ­roceƒƒeƒ 
            “urie œoule†ard… P iladel­ ia… PA 1104-421                         reflect bot  nutrition intaˆe and ƒe†erity and duration of 
            —ary  llen  ˜ruyan…  P ˜…  —PŸ…  ™˜…  “NS…  ŠA“N…  œroad             diƒeaƒe ” eƒe factorƒ may lead to c an„eƒ in body  abi-
            S­ectrum “ommunicationƒ… 236 šoodƒtocˆ A†enue “larendon               tuƒ and metabolic alterationƒ aƒƒociated ‡it  ­oor out-
            Ÿillƒ… ‘ž 60514                                                      come An ‘nternational “onƒenƒuƒ ¤uideline “ommittee 
            Addreƒƒ correƒ­ondence to€ “ arlene “om­ er… P ˜… ™˜… ŠA˜A…            aƒ ­ro­oƒed an a­­roac  to dia„noƒin„ malnutrition in 
            “NS˜… ž˜N… ’ni†erƒity  of  Pennƒyl†ania  Sc ool  of  Nurƒin„…         adultƒ  baƒed  on  etiolo„y…  t uƒ  inte„ratin„  t e  ­reƒent 
            “laire  —  Ša„in  Ÿall…  41  “urie  œoule†ard…  P iladel­ ia…  PA   underƒtandin„ of inflammatory reƒ­onƒeƒ to diƒeaƒe and 
            1104-421– e-mail€ com­ erc¡nurƒin„u­ennedu                                …
                                                                                  trauma  ” e committee ­ro­oƒed t e follo‡in„ nutrition 
                                                                               16
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                                                                                             A.S.P.E.N. Clinical Guidelines / Mueller et al    1
                      
                                                   3
            Figure .    Nutrition care al„orit m
             dia„noƒeƒ€  ‰1‹  starvation-related  malnutrition…  ‡ ic   iƒ        ” eƒe inƒtrumentƒ ‡ere „enerally de†elo­ed to ­redict or 
             c ronic ƒtar†ation ‡it out inflammation… ‰2‹ chronic dis-            aƒƒeƒƒ undernutrition ¥†ernutrition and obeƒity are „en-
             ease–related malnutrition… ‡ ere inflammation iƒ c ronic             erally  aƒƒeƒƒed  uƒin„  t e  body  maƒƒ inde• andor ‡aiƒt 
             and of mild to moderate de„ree… and ‰3‹ acute disease or             circumference „uidelineƒ in ”able 2
             injur–related malnutrition… ‡ ere inflammation iƒ acute                  ” eƒe “linical ¤uidelineƒ ‡ill com­are clinical out-
             and ƒe†ere                                                          comeƒ aƒƒociated ‡it  ­ubliƒ ed nutrition ƒcreenin„ and 
                 ‘nflammation and related com­enƒatory mec aniƒmƒ                 aƒƒeƒƒment toolƒ and t e im­act of furt er clinical aƒƒeƒƒ-
             aƒƒociated ‡it  diƒeaƒe or in‚ury may cauƒe anore•ia and             ment and nutrition inter†ention on clinical outcomeƒ
             alterationƒ  in  body  com­oƒition and ƒtreƒƒ metaboliƒm 
             —etabolic alterationƒ  aƒƒociated  ‡it   inflammation  are 
             ­redominantly cytoˆine mediated and ­erƒiƒt aƒ lon„ aƒ                                          Methods
             t e  inflammatory  ƒtimuluƒ  iƒ  ­reƒent  ” eƒe  metabolic 
             alterationƒ include ele†ated ener„y e•­enditure… lean tiƒ-           ASPN conƒiƒtƒ of  ealt care ­rofeƒƒionalƒ re­reƒentin„ 
             ƒue cataboliƒm ‰­roteolyƒiƒ‹… fluid ƒ ift to t e e•tracellular       t e diƒci­lineƒ of medicine… nurƒin„… ­ armacy… dieteticƒ… 
             com­artment… acute ­ aƒe ­rotein c an„eƒ… and  y­er„ly-              and  nutrition  ƒcience  ” e  miƒƒion  of  ASPN  iƒ  to 
             cemia ˜ecreaƒed ƒynt eƒiƒ of ne„ati†e acute ­ aƒe ­ro-              im­ro†e ­atient care by ad†ancin„ t e ƒcience and ­ractice 
             teinƒ ‡ill reƒult in reduced ƒerum albumin… tranƒferrin…             of nutrition ƒu­­ort t era­y ASPN †i„orouƒly ‡orˆƒ to 
             ­realbumin… and retinol bindin„ ­rotein concentrationƒ               ƒu­­ort £uality ­atient care… education… and reƒearc  in t e 
             t at  are  ­otent  indicatorƒ  of  ­oor  outcome  ‘ndeed…           fieldƒ of nutrition and metabolic ƒu­­ort in all  ealt care 
             e•­ertƒ  a†e ad†iƒed t at albumin and ­realbumin not be              ƒettin„ƒ ” eƒe “linical ¤uidelineƒ ‡ere de†elo­ed under 
             uƒed in iƒolation to aƒƒeƒƒ nutrition ƒtatuƒ becauƒe t ey            t e  „uidance  of  t e  ASPN  œoard  of  ˜irectorƒ 
             are  fundamentally  marˆerƒ  of  inflammatory  metabo-               Promotion of ƒafe and effecti†e ­atient care by nutrition 
                  -11
             liƒm    Poƒiti†e acute ­ aƒe ­roteinƒ ƒuc  aƒ “-reacti†e            ƒu­­ort ­ractitionerƒ iƒ a critical  role  of ASPN  ” e 
             ­rotein are alƒo ­otent ­redictorƒ of morbidity and mortal-          ASPN  œoard  of  ˜irectorƒ   aƒ  ­ubliƒ ed  “linical 
                                                                         10                                 26-2
             ity and are ele†ated in t e ­reƒence of inflammation                ¤uidelineƒ ƒince 16         ASPN e†aluateƒ in an on„o-
                 ”able 1 liƒtƒ ƒcreenin„ and aƒƒeƒƒment inƒtrumentƒ               in„ ­roceƒƒ ‡ en indi†idual “linical ¤uidelineƒ ƒ ould be 
                                                 12
             commonly cited in t e literature  and uƒed in t e articleƒ           u­dated
            e†aluated for t eƒe “linical ¤uidelineƒ ” e table ƒe„re-                  ” eƒe ASPN “linical ¤uidelineƒ are baƒed u­on 
            „ateƒ ­arameterƒ uƒed in t eƒe inƒtrumentƒ t at are ­ri-              „eneral concluƒionƒ of  ealt  ­rofeƒƒionalƒ ‡ o… in de†el-
            marily related to ant ro­ometry and diet… ­rimarily related           o­in„ ƒuc  „uidelineƒ…  a†e balanced ­otential benefitƒ to 
            to ƒe†erity of illneƒƒ ‰diƒeaƒe and trauma‹… or ot er ‰includ-        be  deri†ed  from  a  ­articular  mode  of  medical  t era­y 
            in„  ­ yƒical  and  ­ƒyc olo„ical  †ariableƒ‹  —alnouriƒ ed          a„ainƒt certain riƒˆƒ in erent ‡it  ƒuc  t era­y Ÿo‡e†er… 
            ƒtateƒ are aƒƒociated ‡it  metabolic alterationƒ cauƒed by            t e ­rofeƒƒional ‚ud„ment of t e attendin„  ealt  ­rofeƒ-
                                                                             
            diƒeaƒe-  and  trauma-tri„„ered  inflammatory  reƒ­onƒe              ƒional iƒ t e ­rimary com­onent of £uality medical care 
                                                         Downloaded from pen.sagepub.com at Vrije Univ Bibliotheek on July 14, 2011
             1  ournal o Parenteral and Enteral Nutrition / Vol 35… No 1… January 2011
                                    ale .    Selected Nutrition Screenin„ and Aƒƒeƒƒment ‘nƒtrument Parameterƒ
                                                                                                                                    ¥t er ‰P yƒical… 
                                                           Ant ro­ometry andor ˜iet-                                          Pƒyc olo„ical Variableƒ or 
             ‘nƒtrument                                               ™elated                      Se†erity of ‘llneƒƒ                 Sym­tomƒ‹
             Screening tools
                                                  13
             œirmin„ am Nutrition ™iƒˆ Score            šei„ t loƒƒ… œ—‘… a­­etite…         Streƒƒ factor… ‰ƒe†erity of  
                                                           ability to eat                      dia„noƒiƒ‹
                                            14
             —alnutrition Screenin„ ”ool                A­­etite… unintentional ‡ei„ t 
                                                           loƒƒ
             —alnutrition ’ni†erƒal Screenin„           œ—‘… c an„e in ‡ei„ t               Preƒence of acute diƒeaƒe
             ”ool15
             —aaƒtric t ‘nde•16                         Percenta„e ideal body ‡ei„ t        Albumin… ­realbumin… lym-
                                                                                               ­ ocyte count
                                             1
             Nutrition ™iƒˆ “laƒƒification              šei„ t loƒƒ… ­ercenta„e ideal                                        ¤aƒtrointeƒtinal function
                                                           body ‡ei„ t… dietary intaˆe
             Nutritional ™iƒˆ ‘nde•1                   Preƒent and uƒual body ‡ei„ t       Albumin
                                                 1
             Nutritional ™iƒˆ Screenin„ 2002            šei„ t loƒƒ… œ—‘… food intaˆe       ˜ia„noƒiƒ ‰ƒe†erity‹
             Pro„noƒtic ‘nflammatory and                                                    Albumin… ­realbumin… 
             Nutritional ‘nde•20                                                               “-reacti†e ­rotein… α1-acid 
                                                                                               „lyco­rotein
             Pro„noƒtic Nutritional ‘nde•21             ”rice­ƒ ƒˆin fold                   Albumin… tranƒferrin… ƒˆin  
                                                                                               ƒenƒiti†ity
                                      22
             Sim­le Screenin„ ”ool                      œ—‘… ­ercenta„e ‡ei„ t loƒƒ         Albumin
             S ort Nutrition Aƒƒeƒƒment                 ™ecent ‡ei„ t  iƒtory… a­­etite… 
             §ueƒtionnaire23                               uƒe of oral ƒu­­lement or 
                                                           tube feedin„
             Nutrition assessment tools
                                             24
             —ini Nutritional Aƒƒeƒƒment                šei„ t data…  ei„ t… mid-arm        Albumin… ­realbumin…             Self-­erce­tion of nutrition 
                                                           circumference… calf circum-         c oleƒterol… lym­ ocyte       and  ealt  ƒtatuƒ
                                                           ference… diet  iƒtory… a­­etite…    count
                                                           feedin„ mode
                                              25
             Sub‚ecti†e ¤lobal Aƒƒeƒƒment               šei„ t  iƒtory… diet  iƒtory        Primary dia„noƒiƒ… ƒtreƒƒ le†el P yƒical ƒym­tomƒ  
                                                                                                                                 ‰ƒubcutaneouƒ fat… muƒ-
                                                                                                                                 cle ‡aƒtin„… anˆle edema… 
                                                                                                                                 ƒacral edema… aƒciteƒ‹… 
                                                                                                                                 functional ca­acity… „aƒ-
                                                                                                                                 trointeƒtinal ƒym­tomƒ
             œ—‘… body maƒƒ inde•
                      ale .    ¥beƒity “laƒƒification and ™iƒˆ                       œecauƒe „uidelineƒ cannot account for e†ery †ariation in 
                                                                                        circumƒtanceƒ… t e ­ractitioner muƒt al‡ayƒ e•erciƒe ­ro-
                                                                    2
             ¥beƒity “laƒƒ                              œ—‘… ˆ„m                       feƒƒional  ‚ud„ment  in  t eir  a­­lication  ” eƒe  “linical 
             ’nder‡ei„ t                                   ¨15                        ¤uidelineƒ are intended to ƒu­­lement… but not re­lace… 
             Normal                                      15–24                      ­rofeƒƒional trainin„ and ‚ud„ment
             ¥†er‡ei„ t                                   25–2                            ” eƒe “linical  ¤uidelineƒ  ‡ere  created  in  accord-
             ¥beƒity… claƒƒ ‘                             30–34                       ance  ‡it   ‘nƒtitute  of  —edicine  recommendationƒ  aƒ 
             ¥beƒity… claƒƒ ‘‘                            35–3                       “ƒyƒtematically de†elo­ed ƒtatementƒ to aƒƒiƒt ­ractitioner  
             ¥beƒity… claƒƒ ‘‘‘                             ≥ 40                        and ­atient deciƒionƒ about a­­ro­riate  ealt care for 
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             Ÿi„  ™iƒˆ                          šaiƒt “ircumference… cm                 ƒ­ecific    clinical    circumƒtanceƒ”          ” eƒe  “linical 
                                                         —en ª 102                      ¤uidelineƒ are for uƒe by  ealt care ­rofeƒƒionalƒ ‡ o 
                                                        šomen ª                       ­ro†ide nutrition ƒu­­ort ƒer†iceƒ and offer clinical ad†ice 
             œ—‘… body maƒƒ inde•                                                      for mana„in„ adult and ­ediatric ‰includin„ adoleƒcent‹ 
             Ada­ted  from€  “linical  ¤uidelineƒ  on  t e  ‘dentification…             ­atientƒ in in­atient and out­atient ‰ambulatory…  ome… 
             †aluation… and ”reatment of ¥†er‡ei„ t and ¥beƒity in Adultƒ…             and ƒ­eciali¦ed care‹ ƒettin„ƒ ” e utility of t e “linical 
             ” e †idence ™e­ort N‘Ÿ Publication No -403… Se­tember                ¤uidelineƒ iƒ atteƒted to by t e fre£uent citation of t eƒe 
             1… National ‘nƒtitute of Ÿealt  National Ÿeart… œlood… and             documentƒ in ­eer-re†ie‡ed ­ublicationƒ and t eir fre-
             žun„ ‘nƒtitute  in  coo­eration  ‡it   t e  National  ‘nƒtitute  of        £uent uƒe by ASPN memberƒ and ot er  ealt care 
             ˜iabeteƒ and ˜i„eƒti†e and «idney ˜iƒeaƒeƒ                                ­rofeƒƒionalƒ in clinical ­ractice… academia… reƒearc … and 
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...Journal of parenteral and enteral nutrition http pen sagepub com a s p e n clinical guidelines screening assessment intervention in adults charles mueller charlene compher druyan mary ellen the american society for board directors jpen j parenter nutr doi online version this article can be found at content published by www sagepublications on behalf additional services information email alerts cgi subscriptions reprints journalsreprints nav permissions journalspermissions downloaded from vrije univ bibliotheek july volume number january nteral tt enae ubcom oted onlineae arle ueller ns arlene om er aa ruyan ary llen an t aspn oard irector financial disclosure none declared utrition creenin aement interention meaurement laboratory data ae atient it malnutrition are ey onent ment roide bai nof care iure ndeed ee definition conitent joint been defined ommiion inter retation creen intrument roce to iden ued determine et tify indiidual o i malnouri ed or ri re uired arrant if detailed erfor...

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