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1、最全的营养评估量表-CAL-FENGHAI-(2020YEAR-YICAI)_JINGBIAN1.首次风险筛查需要询问以下内容并进行判断:BMI 23G营养筛查评分（小计最高分为14分）总分：12分以上：正常或无危险性不需要完全评价11分以下：可能存在营养不良，继续评价第二步营养评价评分H生活能否自理（不住院或在家被护理）0二不能 1二能I每天服药超过3种0二是1二不是J皮肤压疮或溃疡0-有1-无K每天进餐次数0=1餐1=2餐2=3餐L选择（蛋白质类摄入情况）每天至少一次奶制品（牛奶、乳酪、酸乳酪） 是？否？每周至少两次或更多的豆类或蛋类是？否？每天有肉、鱼或禽类是？否？二选择答案为“是”的有
2、0或1个二选择答案为“是”的有2个二选择答案为“是”的有3个M每天两次或更多次的水果或蔬菜0二不是1二是N每天饮水量（水、果汁、咖啡、茶、牛奶等）二不到3杯=35 杯二5杯以上O进食方式0二不能自己进食，需帮助1二能自己进食，但有些困难2二能自己进食，无困难P自己对营养状况的观点0二自己认为有营养不良1二不清楚是否有营养不良2二认为自己没有营养不良的问题Q与同龄人比较认为自己的健康状况怎样二不好二不知道二还好二比较好R上臂围（MAC） cm0二不到211二21222二大于22S小腿围（CC） cm0二小于311二大于31营养评价（满分为16分）总分营养筛选分（G项）总分营养评价和营养筛选分（G
3、项）合计作为总评价（满分为30分）总分表示营养不良的得分17分存在营养不良危险17分以下 营养不良三、PG-SGA评分标准（肿瘤患者营养状况评估）表1体重丢失评分体重丢失包括急性和亚急性两种情况，亚急性是指过去1个月体重丢失情 况，只有在不能获得1个月体重丢失的情况下需要包括过去6个月体重丢失的 情况。急性：指过去2周的体重丢失，在亚急性的基础上增加1分。如过去2 周体重不变或增加不计分。1个月体重丢失情况评分6个月体重丢失情况10%420%3%2%1%0%表1评分二急性+亚急性二分表2疾病状态评分以下病情情况每项计1分分类计分癌症1AIDS1肺源性或心、源性恶液质1出现褥疮、开放伤口或痿1存
4、在创伤1年龄在65岁以上1表2计分 分表3代谢应激评分代谢应激评分是评估各种已知的可增加蛋白质和热卡需要的因素。如一病人体 温102度（3分），长期使用强的松10mg/天（2分），这部分的评分为5 分。应激因素没有（0分）轻度（1分）中度（2分）高度（3分）发热没有发热99VTV101101WTV102TN102发热持续时间没有发热72小时激素没有使用激 素低剂量V 10mg强的松/天N10mg20(30肥胖者) 18.5-2018.5数分分分 o 1 2 分一一二一一遏去3-6侗月 非言十重性髓重曳失 分数 =0分 二1分 二2分%10如果病人正虚於 急性疾病状熊和已睡 或5天不畲有管.泰
5、拗入章平舄2分。僵I案在照的介遇程中,需重新言平估莹碓学忍管赛凰险状况。资料参考：Reproduced with pennission from BAPEN. Malnutrition advisory group(2003). Maliiutiirion Universal Screening Tool.管赛不良通用筋检工具(Malnutrition Universall Screening Tool, MUST)言平估步及言十分方式步豚3急性疾病影署分敷W Malnutrition universal screenine tool (MUST)七、营养风险指数(nutritional ri
6、sk Index, NRI)是由美国退伍军人协会肠外营养研究协作组于1991年开发的，主要用于临 床腹部大手术和胸外科术前病人全肠外营养支持效果的评价。根据血清清蛋白 浓度，体重减少百分比进行营养风险评估NRI的敏感性和特异性很好，可预 测病人的并发症。有研究发现，NRI与病死率和住院时间延长相关，但与感染 率无关。主要不足的是，需要根据病人目前和既往体重，病人由于疾病原因出 现水肿，则会影响测量结果。此外，应激对血清清蛋白浓度的影响也使NRI筛 查方法应用受到限制。计算公式为：NRI二%清蛋白浓度+%目前体重/既往体重。NRI :无营养不良NRI :中等风险NRI22-3通2-3H固月4-5
7、53僧1月7-88月以上1010如果病人出现明或最重的樱重表;失，直接跳至项目E，判新病人“虚於管番凰险。E. 理言平估依撮上述指引，圈邀出一倨I眉於病人琨虚的磐番SI险状况？口低管赛国险口虚於管播且险it 料参考：Reproduced pennission from Kovacevich, et al. (1997). Nutriton risk classification: A reproducible and valid tool for nurses. Nutrition in Clinical Practice, 72(1), 20-25.阚二 Admission nutritio
8、n screenin a tool (ANST)Tool and Resource Evaluation TemplateAdapted by NARI from an evaluation template created by Melbourne Health.Some questions may not be applicable to every tool and resource.Naine and purposeNiirnn of theesource; Simplified Nuitntiona Appetite Questionnaire SNAQ)Authors) of rh
9、e rrecmmc: M. Wilson, D. Thomas, L. Rubemsteini et alPlease state why the resource was developed and whcit gap h proposes to fill: This tooll wasdesigned to assess appetite and predict weight lass in older people. This allows fopre-emptive identification and management. Any health worker can use thi
10、s screening tool It has been demonstrated to be simple, quick and predictive of weigiht loss.Target audience (the tool is to be used by)Please check all that apply: Health service users Carers Medical staff Nursing staff区 Any member of an interdisciplinary team Medictil specialist，pl一se spKify： Spec
11、ific allied health staff,旭rse 叩wcify: Other, pl的g 叩如fy:I arget population/settiiig (to be used on/in)Is the resource targeted for a specific setting? Please check all that apply: Emergency Departmentacute El In patient subacute AmbulatoryO-ther, please specify: Residential CareThe SIMAQ was develope
12、d for use in comimuimity-dwelling older people and residential care esidents.For which DrticuSr health service users would you use thisesource (e.g, a： DersQni withsuspecgd cognitive impBiirnient)?Difficult to uise in patients witlh communication difficiulties and/or cognitive impairment.Structure o
13、f toolQWebsiteEducation packageVideo Pamphlet0 Assessment toolScreening toolMethodology Resource guideAwareness raisingresource (posters etc.)Other,皿洞瞒 sd如fy:Please steatehe sHq of dieesoiirce 何g, number of 口minutes t。read):;The SNAQ consists of four questions.Availability and cost of toolIs the res
14、ource readily available?区Yes No Unknown Not applicable Is there a cost for the resource? DYes 区 Nd Unknown Not applicable Please stale how to get The resoiiirce:Provided below:Simplified Nutrition知 Appetite QuestionnaireIt is also available on the internet at: htlp:www.s 1 u.edu/re，dstorym隹wslink/63
15、49Applicability (o rural settings and culturally and lingoisticallv diverse populationsIs the resource suitable for use in rural health services eBg. (he necessary staff are usually avaihble in rural settings)?区 Yes No Unknown Not applicableIs the resource available in different languages? Yes 区 No
16、Unknown Not applicableIs the content appropriate for different cultural groups?区 Yes No Unknown Not applicable Must be able to speak EnglishPers on-centred principlesDoes the resource adhere to/promote person-centred health care?区Yes INo Unknown Not applicableTrainingIs additional training necessary
17、 to use the resource?requirementsYes 区No Unknown Not applicableIf applicable, please state how extensive anv trainhiq is, and what resources are required:Administration detailsHow long does the resource take to use?因0-5 mins 05-15 mins 15-25mins 25mins +Can the resource be used as a standalone, or m
18、ust it be used in conjunction with other tools, resources, and procedures? Standalone区 Must be used with other resources, pleiisN spucify: A positive result (score 60 years).Face ValidityDoes the resource appear to meet the intended purpose? 国 Yes No Unknown Not applicableReliabilityHas the reliabil
19、ity of the resource been reported? Yes 口 No 区 Unknown Not applicableIf jappliciiblG pl仕ease stme whiat has been reported:StrengthsWhat are the strengths of the resource? Is the resource easy to understand 臼nd use? Are instructions provided on how to u&e the resource? Is the resource visually well pr
20、esented images, colour, font type/ size)? Doe& the resource use older friendly terminology (where relevant)! avoiding jargon?Please stete iinv other known strengths. usinQ dut points; Quick & simple. Free. Sensitive. Can be used by any health professionaL Pre-empts weight loss and allows for the ide
21、ntificationi of anorexia. Does not require any ainthropometrical or biochemical measiiremierits.LimitationsWhat are the limitations of the tooH/resource? Is the toolfresource difficult to understand and use? Are instructions provided on how to use the tool/resource? Is the tool/resource poorly prese
22、nted (iinages, colour, font type/ size)? Does the tool/resource use difficult to ii nd erst and jargon?Please state anv other known limitations, msinci dot points: Difficult to use in patients with communication difficulties such as delirium, dementia, hearing impairments or of non English-speaking
23、backgrooimds. Not specificaOy designed foacute。solb-acute popuilation.References and further readingSupgrting references and assgkited reeidlinq.1. Wilson M? Thomas D, Rubenstein L, Chibnall J? Anderson S, Baxi A, Diebold M & Morely J. (2005 Appetite assessment: simple appetite questionnaire predict
24、s weight loss in communiftydwelling adults and nursing home residents American Journal of Clinical Nutrition 2005;82: 1074-61Administration Instructions： Ask the subject to complete the questionnaire by circling the correct answers and then tally the results based upon the following numerical scale: a = 1, b = 2, c = 3, d = 4, e = 5. The sum of the scores for the individual items constitutes the SNAQ score.SNAQ score W 14 indicates significant risk of at least 5% weight loss within six months1. My appetite isa. very poor
