To be completed by the patient:

Weight: During the past two weeks my weight has:

decreased

not changed

increased

Food intake

As compared to my normal intake, I would rate my food intake during the past month as

unchanged

more than usual

less than usual

I am now taking

Check all that apply

normal food but less than normal amount

little solid food

only liquids

only nutritional supplements

very little of anything

only tube feedings or only nutrition by vein

Symptoms

I have had the following problems that have kept me from eating enough during the past two weeks

Check all that apply

no problems eating

no appetite, just did not feel like eating

nausea

constipation

mouth sores

things taste funny or have no taste

problems swallowing

pain

other (Examples: depression, money, or dental problems)

vomiting

diarrhea

dry mouth

smells bother me

feel full quickly

fatigue

Activities and Function:

Over the past month, I would generally rate my activity as:

normal with no limitations

not my normal self, but able to be up and about with fairly normal activities

not feeling up to most things, but in bed or chair less than half the day

able to do little activity and spend most of the day in bed or chair

pretty much bed ridden, rarely out of bed

To be completed by your doctor, nurse, dietitian, or therapist:

Scoring Weight Loss

To determine score, use 1-month weight data if available. Use 6-month data only if there is no 1-month weight data. Use points below to score weight change and add one extra point if patient has lost weight during the past 2 weeks.

10 % in 1 month OR 20 % or more in 6 months

5–9,9 % in 1 month or 10–19,9 % in 6 months

3–4,9 % in 1 month OR 6–9,9 % odr more in 6 months

2–2,9 % in 1 month OR 2–5,9 % or more in 6 months

0–1,9 % in 1 month OR 0–1,9 % or more in 6 months

Disease and its relation to nutritional requirements:

Check all that apply

Cancer

Presence of decubitus, open wound or fistula

AIDS

Presence of trauma

Pulmonary or cardiac cachexia

Age greater than 65

Chronic renal insufficiency

Other relevant diagnoses

Metabolic Demand

Score for metabolic stress is determined by a number of variables known to increase protein & caloric needs.

Fever and fever duration

no fever

fever: > 37,2 °C and < 38,3 °C OR duration: < 72 hours

fever: ≥ 38,3 °C and < 38,8 °C OR duration: 72 hours

fever: ≥ 38,8°C OR > 72 hours

Corticosteroids

no corticosteroids

low dose (< 10 mg prednisone equivalents/day)

moderate dose (≥ 10 mg und < 30 mg prednisone equivalents/day)

high dose (≥ 30 mg prednisone equivalents/day)

Physical Exam

Exam includes a subjective evaluation of 3 aspects of body composition: fat, muscle, & fluid. Since this is subjective, each aspect of the exam is rated for degree. Muscle deficit/loss impacts point score more than fat deficit/loss. Definition of categories: no abnormality, mild, moderate, severe. Rating in these categories is not additive but are used to clinically assess the degree of deficit (or presence of excess fluid).

Muscle Status

temples (temporalis muscle), clavicles (pectoralis & deltoids), shoulders (deltoids), interosseous muscles, scapula (latissimus dorsi, trapezius, deltoids), thigh (quadriceps), calf (gastrocnemius)

no abnormality

mild

moderate

severe

Fat Stores

orbital fat pads, triceps skin fold, fat overlying lower ribs

no abnormality

mild

moderate

severe

Fluid status

ankle edema, sacral edema, ascites

no abnormality

mild

moderate

severe

subjective evaluation

PG-SGA Global Assessment Categories

Stage A

Kategorie

Well-nourished

Weight

No weight loss OR recent non-fluid wt gain

Nutrient intake

No deficit OR Significant recent improvement

Nutrition Impact Symptoms (NIS)

None OR Significant recent improvement allowing adequate intake

functioning

No deficit OR Significant recent improvement

Physical Exam

No deficit OR chronic deficit but with recent clinical improvement

Stage B

Kategorie

Moderate/suspected malnutrition

Weight

≤ 5% loss in 1 month (≤10% in 6 months) OR Progressive weight loss

Nutrient intake

Definite decrease in intake

Nutrition Impact Symptoms (NIS)

Presence of NIS

functioning

Moderate functional deficit OR Recent deterioration

Physical Exam

Evidence of mild to moderate loss of muscle mass &/or muscle tone on palpation &/or loss of SQ fat

Stage C

Kategorie

Severely malnourished

Weight

> 5% loss in 1 month (>10% in 6 months) OR Progressive weight loss

Nutrient intake

Severe deficit in intake

Nutrition Impact Symptoms (NIS)

Presence of NIS

functioning

Severe functional deficit OR Recent significant deterioration

Physical Exam

Obvious signs of malnutrition (e.g., severe loss muscle, fat, possible edema)

BMI	Body Mass Index
ESPEN	European Society for Clinical Nutrition and Metabolism
ICD	International Statistical Classification of Diseases and Related Health Problems
NRS	Nutritional Risk Screening

PG SGA

To be completed by the patient:

Weight: During the past two weeks my weight has:

Food intake

I am now taking

Symptoms

Activities and Function:

To be completed by your doctor, nurse, dietitian, or therapist:

Scoring Weight Loss

Disease and its relation to nutritional requirements:

Metabolic Demand

Physical Exam

subjective evaluation

Evaluation
PG SGA

P.

PG SGA

No intervention required at this time.

Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as indicated by symptom survey and lab values as appropriate.

Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms.

Indicates a critical need for improved symptom management and/or nutrient intervention options.

Subjektive Einschätzung

Information NutriScreen

Recognised/validated and commonly used screening tools to identify patients with manifest malnutrition or at increased risk of malnutrition

References

List of abbreviations

A project by

PG SGA

To be completed by the patient:

Weight: During the past two weeks my weight has:

Food intake

I am now taking

Symptoms

Activities and Function:

To be completed by your doctor, nurse, dietitian, or therapist:

Scoring Weight Loss

Disease and its relation to nutritional requirements:

Metabolic Demand

Corticosteroids

Physical Exam

Muscle Status

Fat Stores

Fluid status

subjective evaluation

EvaluationPG SGA

P.

PG SGA

No intervention required at this time.

Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as indicated by symptom survey and lab values as appropriate.

Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms.

Indicates a critical need for improved symptom management and/or nutrient intervention options.

Subjektive Einschätzung

Information NutriScreen

Recognised/validated and commonly used screening tools to identify patients with manifest malnutrition or at increased risk of malnutrition

References

List of abbreviations

A project by

Einverständniserklärung

Evaluation
PG SGA