營養篩檢工具在臨床護理的應用前言 營養篩檢工具 在臨床護理的應用 謝美玲石明煌 * 楊福麟 ** 中文摘要營養不良是醫院常見的問題, 住院病患的營養狀況, 會影響疾病的復原 住院日數及術後的併發症, 甚而增加病人的死亡率 營養照護是護理人員提供病患整體性照顧的一部份, 本文除了釐清營養篩檢 (nutritional screening) 與營養評估 (nutritional assessment) 之定義外, 並介紹營養不良通用篩檢工具 (malnutrition universal screening tool, MUST) 和入院營養篩檢工具 (admission nutrition screening tool, ANST) 目的是希望護理人員能即早發現具營養不良風險的病人, 適時轉知相關人員, 並提供合宜的營養介入措施, 以促進疾病的復原並提升病患的照顧品質 ( 志為護理, 2009; 8:2, 65-72.) 關鍵詞 : 營養不良 營養篩檢 營養評估 McWhirter & Pennington (1994) 40% 75% (malnutrition) 1) (over-nutrition) 2) (under-nutrition) 3) (impaired nutrient metabolism) 4) (ASPEN Board of Directors, 2002) (Edington, et al., 2000; Green & Watson, 2005) (Nightingale, 1859) (American Society for Parenteral and Enteral Nutrion, ASPEN, 2007) 慈濟大學護理學系講師花蓮慈濟醫院麻醉部 * 花蓮慈濟醫院外科加護病房 營養治療小組 ** 受文日期 :97 年 7 月 30 日修改日期 :97 年 11 月 21 日接受刊載 :98 年 2 月 5 日通訊作者地址 : 謝美玲 970 花蓮市中央路三段 701 號電話 :(03)8565301 轉 2234 電子信箱 :shaer@mail.tcu.edu.tw 第八卷第二期 65
營養篩檢工具在臨床護理的應用66 營養篩檢與營養評估之區別 (nutritional screening) (nutritional assessment) (ASPEN Board of Directors, 2002) 一 營養篩檢 24 (ASPEN Board of Directors, 2002; Green & Watson, 2005) 1) 2.) 3) 4) (Kondrup, Allison, Elia, Vellas, & Plauth, 2003) 二 營養評估 (American Diet Association, ADA)(1994) (Kondrup, et al., 2003) (anthropometric measurement) (biochemical measurement) (clinical method) (dietary assessment) (Lee & Nieman, 2006; Schneider & Hebuterne, 2000) 營養篩檢法 Rasmussen (1999) Danish
營養篩檢工具在臨床護理的應用 一 營養不良通用篩檢工具 (malnutrition universal screening tool, MUST) MUST (British Association for Parenteral and Enteral Nutrition, BAPEN) (MAG, 2003) - (proteinenergy malnutrition, PEM) (Weekes, Elia, & Emery, 2004) 2 (MAG, 2003) 1 (body mass index, BMI) BAPEN (olecranon process) (styloid process) (mid upper arm circumference, MUAC) BMI MUAC < 23.5 BMI < 20kg/m2 MUAC > 32.0 BMI > 30kg/m2 2 3 4 1-3 5 ( ) MUST 0 1 2 2 二 入院營養篩檢工具 (admission nutrition screening tool, ANST) 表一尺骨長度與身高對照表 男性身高 ( 公尺, m) <65 歲 1.94 1.93 1.91 1.89 1.87 1.85 1.84 1.82 1.80 1.78 1.76 1.75 1.73 1.71 >65 歲 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.67 尺骨長度 ( 公分, cm) 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 27.0 26.5 26.0 25.5 女性身高 ( 公尺, m) 男性身高 ( 公尺, m) <65 歲 1.84 1.83 1.81 1.80 1.79 1.77 1.76 1.75 1.73 1.72 1.70 1.69 1.68 1.66 >65 歲 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.66 1.65 1.63 <65 歲 1.69 1.67 1.66 1.64 1.62 1.60 1.58 1.57 1.55 1.53 1.51 1.49 1.48 1.46 >65 歲 1.65 1.63 1.62 1.60 1.59 1.57 1.56 1.54 1.52 1.51 1.49 1.48 1.46 1.45 尺骨長度 ( 公分, cm) 25.0 24.5 24.0 23.5 23.0 22.5 22.0 21.5 21.0 20.5 20.0 19.5 19.0 18.5 女性身高 ( 公尺, m) <65 歲 1.65 1.63 1.62 1.61 1.59 1.58 1.56 1.55 1.54 1.52 1.51 1.50 1.48 1.47 >65 歲 1.61 1.60 1.58 1.56 1.55 1.53 1.52 1.50 1.48 1.47 1.45 1.44 1.42 1.40 Reproduced with permission from BAPEN. Malnutrition advisory group(2003). Malnutrition Universal Screening Tool. 第八卷第二期 67
營養篩檢工具在臨床護理的應68 0 分 / 低度風險常規性臨床照護. 重覆篩檢 : 住院病患每週一次 護理之家住民至少每月一次 社區民眾 >75 歲者每年一次 營養不良通用篩檢工具 (Malnutrition Universall Screening Tool, MUST) 用評估步驟及計分方式 步驟 1 步驟 2 BMI 分數 + 體重喪失分數 + 過去 3-6 個月 BMI kg/m 2 分數 非計畫性體重喪失 >20(>30 肥胖者 ) =0 分 % 分數 18.5-20 =1 分 <5 =0 分 <18.5 =2 分 5-10 =1 分 >10 =2 分 步驟 4 營養不良整體性風險 加總並計算出營養不良整體性風險分數 0 分 低度風險 1 分 中度風險 2 分或 2 分以上 高度風險 步驟 5 處置指引 1 分 / 中度風險觀察. 記錄住院或護理之家個案之飲食日誌三天. 若個案情況有改善或有適當的飲食攝入再續觀察 ; 若未改善, 依醫院政策進行臨床密切觀察. 重覆篩檢 : 住院病患每週一次 護理之家住民至少每月一次 所有具有營養不良風險之處置方式 :. 治療潛在性的狀況, 視個案需求提供有關食物選擇及攝食相關訊息的諮詢及建議. 記錄營養不良的種類. 依機構政策, 記錄所需要的特殊飲食 步驟 3 急性疾病影響分數 如果病人正處於急性疾病狀態和已經或 >5 天不會有營養攝入, 評為 2 分 等於或大於 2 分 / 高度風險治療. 轉介營養師 營養治療小組或啟動機構處理流程. 增進或增加整體性的營養攝取. 監測和審視治療計畫 : 除非營養支持是有害或沒有預期性的益處, 如瀕死病患, 否則醫院每週一次 護理之家和社區每月一次 肥胖個案 :. 記錄肥胖現況, 此類個案若有營養不良情形, 先處理營養不良問題後再治療肥胖問題 個案在照顧機構的轉介過程中, 需重新評估並確認營養風險狀況 資料參考 :Reproduced with permission from BAPEN. Malnutrition advisory group(2003). Malnutrition Universal Screening Tool. 圖一 Malnutrition universal screening tool (MUST)
營養篩檢工具在臨床護理的應用入院營養篩檢工具 (Admission nutrition screening tool) A. 診斷如果病人有下列任何一種診斷, 圈選出來後無需繼續評估, 直接跳至項目 E, 判斷病人 處於營養風險 吸收不良 (Malabsorption): 口炎性腹瀉 (celiac sprue), 潰瘍性結腸炎 (ulcerative colitls), 克隆氏症 (Crohn s disease), 短腸症候群 (short bowel syndrome) 多重性創傷 (Multiple trauma): 非開放性頭部外傷 (closed-head injury), 穿刺性創傷 (penetrating trauma), 多發性骨折 (multiple fracture) 惡病質 (Cachexia): 暫時性虛耗 (temporal wasting), 肌肉虛耗 (muscle wasting), 癌症 (cancer), 心臟病 (cardiac) 神經性厭食症 (Anorexia nervosa) 貪食症 (bulimia nervosa) 褥瘡 (Decubitus ulcers) 過去一年曾接受腹部大手術 傷口癒合不良 (Nonhealing wounds) 糖尿病 (Diabetes) 肝癌末期 (End-stage liver disease) 腎病末期 (End-stage renal disease) 昏迷 (Coma) B. 營養攝入史如果病人至少出現下列任何一種症狀, 圈選出來後無需繼續評估, 直接跳至項目 E, 判斷病人 處於營養風險 腹瀉 : 有 2 天的腹瀉量各大於 500mL 嘔吐 : 超過 5 天 攝入量減少 : 攝入未達平日的一半量, 且已超過 5 天 C. 理想體重標準如果目前體重小於理想體重的 80%, 無需繼續評估, 直接跳至項目 E, 判斷病人 處於營養風險 D. 體重史. 最近出現任何非計畫性體重喪失情形? 否 是, 約 Kg, 是從過去 週或 月前開始的. 目前體重 : Kg; 平常體重 : Kg; 身高 : cm. 體重喪失百分比 : ( 平常體重 目前體重 ) 平常體重 100= % 體重喪失將喪失體重百分比與下表進行比較, 圈出合適的選項 : 發生期間明顯體重減輕 (%) 嚴重體重減輕 (%) 1 週 2-3 週 1 個月 3 個月 5 個月以上 1-2 2-3 4-5 7-8 10 >2 >3 >5 >8 >10 如果病人出現明顯或嚴重的體重喪失, 直接跳至項目 E, 判斷病人 處於營養風險 E. 護理評估依據上述指引, 圈選出一個屬於病人現處的營養風險狀況? 低營養風險 處於營養風險 資料參考 :Reproduced permission from Kovacevich, et al. (1997). Nutriton risk classification: A reproducible and valid tool for nurses. Nutrition in Clinical Practice, 12(1), 20-25. 圖二 Admission nutrition screening tool (ANST) 第八卷第二期 69
營養篩檢工具在臨床護理的應用70 ANST Kovacevich (1997) (diagnosis) (nutrition intake history) (ideal body weight standard) (weight history) ( ) (interobserver) 97.3% (sensitivity) 84.6% (reproducibility) 48 (low nutritional risk) (at nutritional risk) 結論 (Arrowsmith, 1999) 致 謝 (BAPEN) MUST (ESPEN) Mette Holst 參考資料 American Society for Parenteral and Enteral Nutrition (ASPEN). (2007). Standards of practice for nutrition support nurses. Nutrition in Clinical Practice, 22(4), 458-465. American Diet Association. (1994). Identifying patients at risk: ADA s definitions for screening and nutrition assessment. Journal of American Diet Association, 94, 838-839. Arrowsmith, H. (1999). A critical evaluation of the use of nutrition screening tools by nurses. British Journal of Nursing, 8(22),1783-1490. ASPEN Board of Directors. (2002). Guideline for the use of parenteral, enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26(1), 9SA-12SA. Edington, J., Boorman, J., Durrant, E. R., Perkins, A., James, R., & Thomson, J. M., et al. (2000). Prevalence of malnutrition on admission to four hospitals in England. Clinical Nutrition, 19(3), 191-195. Green, S. M., & Watson, R. (2005). Nutritional screening and assessment tools for use by nurses: literature review. Journal of Advanced Nursing, 50(1), 69-83. Kondrup, J., Allison, S. P., Elia, M., Vellas, B., & Plauth, M. (2003). ESPEN guideline for nutrition screening 2002. Clinical Nutrition, 22(4), 415-421. Kovacevich, D. S., Boney, A. R., Braunschweig, C. L., Perez, A., & Stevens, M. (1997). Nutrition risk classification: a reproductive
營養篩檢工具在臨床護理的應用and valid tool for nurses. Nutrition in Clinical Practice, 12(1), 20-25. Lee, R. D., & Nieman, D. C. (2006). Nutritional assessment. McGraw-Hill Science Engineering: Boston. Malnutrition Advisory Group (MAG). (2003). The MUST explanatory booklet: A guideline to the malnutrition universal screening tool (MUST) for adult. British Association for Parenteral and Enteral Nutrition. Redditch: UK. McWhirter, J. P., & Pennington, C. R. (1994). Incidence and recognition of malnutrition in hospital. British Medical Journal, 308, 945-948. Nightingale, F. (1859). Notes on Nursing: What It Is and What It Is Not. London: Hanson & Son. Rasmussen, H. H., Kondrup, J., Ladefoged, K., & Staun, M. (1999). Clinical nutrition in Danish hospital: a questionnaire based investigation among doctors and nurses. Clinical Nutrition, 18(3), 153-158. Schneider, S. M., & Hebuterne, X. (2000). Use of nutritional scores to predict clinical outcomes in chronic diseases. Nutritional Reviews, 58, 31-38. Weekes, C. E., Elia, M., & Emery, P. W. (2004). The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN). Clinical Nutrition, 23(5), 1104-1112. 大家愛心相連, 福田就會遍佈全球, 世界也會因此變得祥和 ~ 證嚴法師靜思語 ~ If we can join together in love and harmony, we will be able to reach out and alleviate suffering around the world, and with that, the world will become more peaceful and harmonious. ~ Dharma Master Cheng Yen ~ 第八卷第二期 71
營養篩檢工具在臨床護理的應用72 The Application of Nutritional Screening Tools in Nursing Practice ABSTRACT Malnutrition is the common problem in hospital, the nutritional status of hospitalized patients will affect the disease recovery, length of stay, surgery complications, and even increasing the death rate. Nutritional care is one part of holistic nursing care, this article would like to present the difference between nutritional screening and nutritional assessment, as well as introduce malnutrition universal screening tool (MUST) and admission nutrition screening tool (ANST). Hopefully, this article will assistant nurses to detect the adult patients in the status of malnutritional risk earlier in order to provide appropriate nutritional intervention to promote disease recover and improve the quality of patient care. (Tzu Chi Nursing Journal, 2009; 8:2, 65-72.) Mei-Lin Hsieh Ming-Hwang Shyr* Fwu-Lin Yang** Key words: malnutrition, nutritional screening, nutritional assessment. Lecturer, Department of Nursing, Tzu Chi University Department of Anesthesiology, Buddhist Tzu Chi General Hospital* Department of Surgical Intensive Care Unit & Team of Nutritional Support, Buddhist Tzu Chi General Hospital** Received: July 30, 2008 Revised: November 21, 2008 Accepted: February 5, 2009 Address correspondence to: Mei-Lin Hsieh, 701, Sec 3, Chung-Yang Rd. Hualien 970, Taiwan (R.O.C.) Tel: 886(3) 8565301 ext. 2234 E-mail: shaer@mail.tcu.edu.tw