- Email: [email protected]
Nutritional screening and assessment
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Seminars in Oncology Nursing, Vol 16, No 2 (May), 2000: pp 106-112
OBJECTIVES::: : :
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To review ~h~ cornpon~nts of nu- : ; :tritionalscre~ing; screening :::: measures a ~ tools, arwl the :: nurses'role in nutritional assessm~t.
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DATA SOURCES: Research studies, review articles;: and book chapters. ::
NUTRITIONAL SCREENING AND ASSESSMENT
CONCLUSIONS: Timely and appropriate nutritional interventions require the adoption of routine initial nutritional screening, referral for comprehensive nutritional assessments as needed, and continued re-sc~reening.
IMPLICATIONS FOR NURSING PRACTICE: Oneology nurses Should be prepared to contribute to a comprehensive nutritional assessment in their role as patient advocate and expert clinician.
From Nursing W~sdorn, New York, NY; : and the State Universlty of New York at Buffalo School of Nursing~ Buffalo, IWY. Kathleen McMahon, l~2q,MEd, M_A:Nurse Consultant, Ontology and l-hW/AjDS,Nurse Psychotherapist, Nursing Wischom~New : York, N);- Jean K. Brown, PhD, RN:Associate Professor, State University of New York at Buffalo School of Nursing, Buffalo, NY. Address reprin t requests to Kathleca McMah(m, RN, MEd, MA, Nursing Wisdom, 332 Spruce Mill Lane, Scotch Plains, NJ 07076.
i ¸ Gopyright ©2t'fgO ~v W,B. Saunders CompOmy 0749-2081/00/1602~002510.00/0 : doi:lO.iOSit/oni2000:5549:
KATHLEEN MCMAItON AND JEAN K. BROWN
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ALNUTRITION is historically recognized as an important contributor to morbidity, mortality, and decreased quality of life in patients with cancer. As early as 1932, an autopsy series of 500 patients with c a n c e r found that eachexia was the most frequent cause of death. 1 Weight loss has been described in the c a n c e r literature as a c o m m o n and early manifestation of cancer. Unexplained weight loss is considered a warning sign that should be investigated for a possible occult malignancy. 2 In the 1970s oncology researchers focused on the rates of malnutrition in hospitalized cancer patients and used a compelling and alarming poetic metaphor to describe the presence of malnutrition: "the skeleton in the hospital closet. ''3 Early hopes to reverse cancer-related malnutrition were focused on total parenteral nutrition, then called hyperalimentation. 4 Attempts to reverse severe nutritional depletion were generally unsuccessful, but astoundingly positive results were demonstrated in short bowel and fistula patients by total parenteral nutrition pioneers. These pioneers also contributed to a greater appreciation of the degree of malnutrition in cancer patients, identifying the importance of preventing malnutrition and the need for appropriate choices of nutrition repletion when necessary. During the 1980s and 1990s, several attempts were made to describe the importance of a careful evaluation of nutritional status and the development of interdisciplinary screening tools. 5-14 In a classic article, Maurice Shils 15 summarized principles of supportive nutrition that remain relevant and applicable today. As seen in Table 1, two of Shils' principles deal directly with screening and assessment: comprehensive investigation of the potential causes of malnutrition and early and periodic assessment_ Shils observed that the specific and generalized effects of cancer need to be evaluated as well as the nutritional effects of the t r e a t m e n t plan. He c o m m e n t e d that early assessments, preferably within 48 hours of hospital admission, should be performed and repeated every 2 weeks_ Because hospitalization is avoided or shortened in the current health care environment, the timing and frequency of
N U T RIT IO N AL S C R E E N I N G AND A S S E S S M E N T
T A B L E 1. Shil's TM Principles of Supportive Nutrition" Screening and Assessment A rationale and therapeutic approach for a patient requires an analysis of factors inducing depletion in the patient. Every patient should have an early and periodic assessment of nutritional status.
these r e e o m m e n d a t i o n s m a y vary. It r e m a i n s critieal, however, to continue to plan to detect nutritional deficits early in the course of the disease and regularly during the t r e a t m e n t plan. For example, c a n c e r patient screening should occur at the time of diagnosis, at the initiation of aggressive treatment, at any time when the treatm e n t plan is adjusted or revised, and at the development of a significant weight change of 2% to 5% Despite the fact that it has b e e n 20 years since Shils' principles were first published, study findings indicate insufficient progress in i m p l e m e n t i n g the screening and a s s e s s m e n t principles into c a n c e r care. la O n t o l o g y nurses have a critical role in nutritional screening and c o m p r e h e n s i v e nutritional a s s e s s m e n t and they should routinely include these principles of supportive nutritional care in their elinical practice. Thus, this article describes the goals and c o m p o n e n t s of nutritional screening, useful clinical screening m e a s u r e s and tools, and screening indications for identifying patients with nutritional risks. In addition, m a j o r c o m p o n e n t s of c o m p r e h e n s i v e nutritional assessm e n t are delineated and the role of the oneology nurse in this process is discussed. Finally, general nutritional counseling and issues relevant to research and clinical practice are examined. DEFINITIONS utritional screening is the process of discovering characteristics or risk factors k n o w n to be associated with nutritional problems. 17 The m a i n purpose of screening is to identify individuals who are potentially at risk. A simple tool, such as the P a t i e n t - G e n e r a t e d Subjective Global A s s e s s m e n t (PG-SGA), is often used for this purpose. C o m p r e h e n s i v e nutritional a s s e s s m e n t is a m o r e in-depth process than screening. It is the systematic, c o m p r e h e n s i v e process of determining the complex etiologic factors of individuals identified as "at risk" and of planning a course of
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action. 17 Similarly, the A m e r i c a n Dietetic Association has defined nutritional a s s e s s m e n t as "a c o m p r e h e n s i v e approach, c o m p l e t e d by a registered dietitian, to defining nutritional status that uses medical, nutritional, and medication histories; physical examination; a n t h r o p o m e t r i c m e a sures; and l a b o r a t o r y data. ''is The purpose of a c o m p r e h e n s i v e nutritional a s s e s s m e n t is to determ i n e the patient's c u r r e n t nutritional status and requirements, classify the degree of malnutrition, and institute t r e a t m e n t and intervention plans. In the ontology-specific context, nursing input into c o m p r e h e n s i v e nutritional a s s e s s m e n t is critical because nurses tend to have the m o s t holistic knowledge and unders tanding of patient problems. Moreover, o n t o l o g y specialty dieticians are not available in m a n y settings. Nurses can assess the likely course of disease and t r e a t m e n t , potential complications, and s y m p t o m s affecting nutrition. T h e y also can contribute to the d e v e l o p m e n t of short- and long-term nutritional goals, the design and i m p l e m e n t a t i o n of interventions, and timelines for evaluation of interventions. NUTRITIONAL SCREENING Go~lls
The three m a j o r goals of screeniug are to identify individuals at risk for malnutrition, prevent and/or treat malnutrition early, and modify t r e a t m e n t plans as needed, is Even if the initial screening reveals a satisfactory nutritional status, re-evaluation at regular intervals is required, as indicated by the d e v e l o p m e n t of new or worsening s y m p t o m s affecting nutrition or clinical and l a b o r a t o r y evidence of nutritional deterioration. >
Components of Nutritional Screening Screening focuses on gathering the most significant and available infomlation on nutritional status to identify patients who are at risk. This information includes weight change, food intake, symptoms affecting nutrition, functional status, and specific findings from the physical examination. In addition, some clinicians include biochemical indicators. As shown in Table 2, a variety of measures are used for the screening process_ Clinical judgement and experience are i m p o r t a n t factors in evaluating b o t h the subjective (eg, functional status and s y m p t o m s ) and the objective (eg, weight change and physical e x a m i n a t i o n ) screening data.
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Weight Change Weight and height measures provide a rapid, gross measure of body size and composition. From these two measures, ideal weight, body mass index, and p e r c e n t weight change can be calculate& It is i m p o r t a n t to actually measure weight and height w h e n e v e r possible rather than relying on the patient to provide these measurements. Weight m e a s u r e m e n t requires an accurate, calibrated scale with the patient removing shoes, overcoats, knapsacks or shoulder bags, and other items such as pocket change, keys, and heavy belt buckles. Height should be measured using a calibrated rule with the patient standing straight and with feet flat on the floor or platform. If height c a n n o t be m e a s u r e d due to the patient's condition, researchers have d e t e r m i n e d that a measure of arm span is a good surrogate for height. 2° To measure arm span, patients should hold their arms out at their sides with palms facing forward and arms parallel to the floor. A rule is t h e n used to measure from one middle fingertip to the other
middle fingertip across the shoulders at the clavicle level. The best approximation of height is obtained by using the following calculation: height (in) = (0.87 × arm span [in]) + 20_54. 2o To evaluate the patient's body size, the nurse compares the patient's current weight with the patient's ideal weight based on height and body frame size 21 or calculates body mass index. Ideal weight is calculated as 100 lb per 5 ft of height plus 5 lb for each additional inch of height for females and as 106 lb per 5 ft of height plus 6 lb for each additional inch of height for males. Ideal weight is adjusted -+10% depending on body frame. Body mass index is calculated by dividing weight in kilograms by height in meters squared (kg/m 2) or lb/in2/0.0014192. 22 A body mass index of less than 16 is classified as too lean, 16 to 19.9 as lean and underweight, 20 to 24.9 as desirable, and 25 or greater as overweight to obese. The p e r c e n t weight change from usual body weight is calculated by dividing the c u r r e n t measured weight by the usual weight and multiplying it by 100. 21 Percent weight change should be evaluated for differences from usual preillness weight, prediagnosis weight, and after diagnosis weight. Potential expansion of certain body c o m p a r t m e n t s due to ascites or e d e m a should be included in the analysis_ Weight loss of 2% to 5% is considered severe. The time period during which the percent weight change occurred should also be assessed_
Food Intake If food intake is less than usual or consists of little solid food and weight loss is evident, the patient is at nutritional risk and should be referred for a comprehensive nutritional assessment. Food intake is measured using 24-hour dietary recall, 3-day food records, direct observation, and food frequency questionnaires. 21,23 A 24-hour dietary recall is a quick, inexpensive, and easy method of assessing oral intake and is useful for patients in whom literacy is a concern. It can be easily adopted in community care, home care, and other settings. Limitations of this method include reliance on the patient's memory, mental status, honesty, and language skills. Additionally, the day chosen for recall m a y not be representative of the patient's normal intake. A more accurate approach to assessing food intake is a 3-day food record/diary including 1 weekend day to account for the considerable variation that has been found between food intake during the week and on weekends. 23,24 This will require higher levels of motivation on the part of both the nurse and the patient, but a potential bonus is that the data can be used to calculate
NUTRITIONAL
caloric intake should a more comprehensive assessment of food intake be needed. Food models, photographs of food, food scales, and measuring cups can be used to increase the accuracy of the data, but are more likely to be used during comprehensive nutritional assessments. Direct observation and food frequency questionnaires are used less frequently in clinical nutritional screening due to practical considerations. Direct observation of food intake can be used for hospitalized patients, but otherwise it has limited usefulness. Food frequency questionnaires assess how frequently the patient consumed a specific number of foods that are major sources of nutrients or are of particular concern. 23
Symptoms Affecting Nutrition Many cancer-related symptoms and treatment side effects have an impact on nutritional status. Anorexia has long been associated with poor nutritional status and is usually included in nutritional screening. 16 However, other symptoms also have been found to be associated with weight loss in patients with cancer. 16,2529 These include pain, fatigue, depression, infection, and alterations in the gastrointestinal tract (eg, stomatitis, dysphagia, vomiting, diarrhea, and constipation) and dyspnea. Symptom severity and the cumulative effect of several symptoms are indicators of nutritional risk. 26 Symptom checklists are used to determine the occurrence of symptoms affecting nutrition as well as their associated distress and severity. 17 The article by Grant and Kravits elsewhere in this issue discusses symptoms affecting nutrition in detail.
Functional Status Functional status has been strongly associated with weight loss in cancer patients. 29-3~ Two measures of functional status are very c o m m o n l y used to assess patients with cancer: the Karnofsky performance status scale and the Eastern Cooperative Oncology Group performance scale. Scores from these scales are often readily available in patient medical records. Another measure of functional status includes a self-care log. A self-care log may be used to determine functional status, activities of daily living, and the ability to procure, prepare, cook, and clean-up meals. Deficits in self-care ability may influence nutrition, especially if the patient has little or no family or community support.
Physical Examination Findings from the physical examination m a y reveal evidence of actual or potential malnutrition. When inspecting a patient's general appearance
SCREENING
AND ASSESSMENT
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and behavior, the nurse assesses for weakness, loss of body fat, loss of lean body (muscle) mass, and fluid status. The patient's mental status is observed for evidence of disordered affect, impaired mood, and alterations in orientation, memory, concentration, or thinking, which may reflect depression, delirium, dementia, or extreme malnutrition. When examining the patient's head, neck, and oral cavity, the nurse inspects for dehydration, stomatitis, xerostomia, and chewing or swallowing difficulties. In addition, an assessment is made of the musculoskeletal, nervous, and gastrointestinal systems, seeking evidence of muscle and fat loss, n e u r o m u s c u l a r dysfunction, liver disease, bowel obstruction, edema, aseites, dehydration, or other relevant considerations.
Biochemical Indicators Some clinicians also include biochemical indicators in nutritional screening, but this information is not always readily available. The complexity of interpreting these data m a y make them more useful in the comprehensive nutritional assessment. In general, the serum transport proteins of albumin, prealbumin, transferrin, and retinolbinding protein are important indicators of nutritional status, e,~ Issues of availability, practical application, and clinician skill in interpreting these tests from a nutritional perspective may affect the utility of such measures. Albumin has a normal range of 3.5 to 5.0 g/dL and is affected by hydration, position, inflammation, infection, stress, and laboratory variability. 23 It has a half-life of approximately 2 to 3 weeks, which makes it useful for long-term nutritional evaluations but not as relevant for shorter-term evaluations_ Prealbumin has a half-life of 2 to 3 days and has a normal level of 300 _+ 5 ~xg/mL. Values must be evaluated with caution because it is affected by stress, trauma, inflammation, vitamin A deficiency, and cirrhosis in addition to depleted protein stores. Transferrin is an indicator of visceral protein deficiency. Its normal range is 200 to 300 mg/dL and it has a half-life of 8 to 10 days. A severe visceral protein deficiency is detectable when the level falls below 100 mg/dL; moderate deficiency is from 100 to 150 mg/dL. Depressed concentrations of transferrin are found in protein malnutrition, starvation, and during an acute inflammatory process. Retinol-binding protein bonds with prealbumin and transports vitamin A. Normal retinol-binding protein is 46 _+ 1 txg/mL. It has a half-life of 10 to 12 hours. High levels are associated with renal failure, whereas
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M c M A H O N AND B R O W N
depressed levels are found in malnutrition, liver disease, and hyperthyroidism.
The Patient-Generated Subjective Global A s s e s s m e n t Screening Tool One screening tool that includes many of the components of nutritional screening described above is the oncology-modified version of the PG-SGA. This tool was developed to help identify patients most at risk for malnutrition. The onepage PG-SGA incorporates a patient self-report of weight change, food intake, symptoms affecting nutrition, and functional status as well as the health care provider's brief physical examination results and evaluation of metabolic stress (eg, fever or steroid use). It is easy to use and was designed for a sixth- to eighth-grade reading level. It only takes a few minutes to complete and can be used routinely in all practice settings and by clinicians of various disciplines. This feature of the form helps promote multidisciplinary nutritional management. The PG-SGA engages patients in their own screening and initiates a management process that will require the patient's active involvement throughout their illness. The tool ends with the patient being categorized into one of three nutritional categories: wellnourished, moderately malnourished or suspected of being malnourished, and severely malnourished. Patients who are categorized as moderately or suspected of being malnourished or severely malnourished and whose treatment plan falls into a high-risk category for nutritional problems need to have a comprehensive nutritional evaluation and be evaluated by nutrition specialists. The ontology-modified PG-SGA 17 was developed by Ottery et a132 and has been validated in many oncology practice settings.
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COMPREHENSIVE NUTRITIONAL ASSESSMENT f the nurse's nutritional screening identifies a patient who is at nutritional risk, a request for a comprehensive nutritional assessment by a dietitian should be initiated. The major components of such an assessment are outlined in Table 3. Oncology nurses should be prepared to contribute to a comprehensive nutritional assessment in their role as patient advocate and expert clinician_ In addition, nurses can facilitate the dietitian's comprehensive nutritional assessment based on rapport established with the patient and family. This may be especially important when the dietitian explores potentially sensitive issues influ-
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encing food choices and style of eating, such as culture, financial constraints, preferred "comfort foods," tobacco/drug/alcohol use, lifestyle, religious issues, body image, and use of alternative
N U T R I T I O N A L S C R E E N I N G AND A S S E S S M E N T
therapies. 17 Nurses also can provide critical information on the patient's clinical status. In setting priorities for short- and long-term nutritional goals, a multidisciplinary approach is essential. The ontology nurse works with the physician or primary provider to coordinate the variety of services that may be required to effectively implement the plan. Patient and family participation in development and implementation of the plan is also essential for success_ The patient and family should agree on food choices, budgets, menus, and meal preparation_ Any changes made in the patient's eating patterns need to be supported by the patient's caregivers and household members.
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T A B L E 4. . . . . . Clinical Process for Nutritional Screening and Comprehensive Assessment Nutritional screening Identification of individuals at risk Referral for complete evaluation to dietician Multidisciplinary assessment using standard and specialized tools Identification of the patient's strengths and weaknesses Prioritization of short- and long-term goals Preparation of an interdisciplinary nutritional care plan Implementationof the plan Evaluation of the current nutritional plan Follow-up, re-evaluation, and modification as necessary
GENERAL NUTRITIONAL COUNSELING ll patients diagnosed with c a n c e r need instruction about healthy eating principles. T h e y need to know which nutrients are important and why, how frequently to eat and in what amounts, and how to use vitamin and mineral supplements judiciously. Basic food and water safety considerations need to be reviewed. These include safe food storage, food preparation, considerations for travel and dining out, and the use of filtered water, if applicable. A recent review identified m a n y nutrition informational materials for patients and families -~-~ that are useful in clinical practice. Classroom and individual instruction also m a y be available for patients through community-based organizations and agencies. The ontology nurse can advocate for these services and/or conduct classes in a nurse-managed clinic for new patients. Teaching food safety in a home care e n v i r o n m e n t and starting a cooking class at a clinic are two creative examples initiated by nurses, el
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RESEARCH AND CLINICAL ISSUES A
review of the literature revealed a substantial lack of research on nutritional screening, assessment, and interventions in the c a n c e r population. One study of non-small cell lung cancer patients found that the nutritional assessments conducted by health care providers were rarely, if ever, sufficiently comprehensive. 16 Most assessments included weight change and anorexia or decreased food intake. Other important factors, such as past medical history, eating patterns, social and demographic information, a targeted physical examination relevant to nutrition, and potential nutritional problems, were not included
in clinicians' assessments. In addition, evaluations of the effectiveness of the nutritional interventions were recorded for only 44% of the subjects and described to be effective in only 15% of subjects. The authors c o m m e n t e d that nurses would have a greater impact on nutritional outcomes if they focused on potential nutritional problems in addition to the nutritional problems already present. This means that assessment indicators must be broadened and systematic patient evaluation in the clinical setting needs to occur. Moreover, it would be useful to determine what outeomes are most important for patients with cancer who experience nutritional p r o b l e m s J 6 Is body weight an important end point and within what criteria? What impact do changes in nutritional status and weight stabilization have on quality of life in this population? What is the pattern of nutritional depletion in various t r e a t m e n t protocols? Based on this evidence of insufficient clinical nutritional assessment, how can the routine nutritional screening and comprehensive nutritional assessment described and s u m m a r i z e d in Table 4 be successfully implemented in ontology practice? Nutrition is a multidisciplinary activity in which oneology nurses have a critical role. Thus, representatives from relevant disciplines including nursing, medicine, nutrition services, pharmacy, and social services should work together to answer three questions: Who should c o n d u c t and be accountable for nutritional screening, referrals for comprehensive nutritional assessment, and comprehensive nutritional assessments? When should these activities be done? and How should they be done? In addition, a multidiseiplinary task force or the agency's quality improvement team could evaluate current practice, make reeommenda-
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McMAHON AND BROWN
t i o n s for q u a l i t y i m p r o v e m e n t s , and evaluate o u t c o m e s of n e w p o l i c i e s a n d p r o c e d u r e s . CONCLUSION arly and routine nutritional screening with c o m p r e h e n s i v e n u t r i t i o n a l a s s e s s m e n t s of p a t i e n t s s c r e e n e d as " a t r i s k " a r c c r u c i a l to a d d r e s s ing nutritional challenges and deficits before they c o n t r i b u t e f u r t h e r to w o r s e n e d d i s e a s e a n d t r e a t ment outcomes and compromise functional status a n d q u a l i t y of life. B e c a u s e m u l t i d i s c i p l i n a r y c o o p e r a t i o n is e s s e n t i a l i n a n y e f f e c t i v e n u t r i t i o n a l program, agency administrators need to consider t h e b e s t s y s t e m - w i d e a p p r o a c h to e n h a n c e t h e
E
clinical, educational, and quality assurance programs in nutritional ontology. Specific recommendations for n u r s e s i n c l u d e e s t a b l i s h i n g n u t r i t i o n a l s c r e e n i n g i n all c l i n i c a l s e t t i n g s , a b r o a d e n i n g of t h e a s s e s s m e n t c o n t e n t and process, and strengthening the value placed on proactive and early nutritional interventions a n d w e i g h t s t a b i l i z a t i o n . A d v o c a c y is n e e d e d for more clinical nursing research on cancer-related nutritional problems, to confront existing attit u d e s a b o u t t h e f u t i l i t y of n u t r i t i o n a l c a r e t h a t m a y be reflected in ontology nurses' clinical priorities, a n d for a s u s t a i n e d i m p r o v e m e n t in n u t r i t i o n a l s t a n d a r d s of c a r e i n o n e o l o g y n u r s i n g a n d t h e nursing profession.
REFERENCES 1. Warren S: The immediate cause of death in cancer. Am J Med Sci 184:610-615, 1932 2. Homburger F, Fishman WH (eds): The Physiopathology of Cancer. New York, NY, Hoeber-Harper, 1953 3. Butterworth CE Jr: The skeleton in the hospital closet. Nutr Today 9:4-8, 1974 4. Costa G: Cachexia, the metabolic component of neoplastic diseases. Cancer Res 37:2327-2335, 1977 5. Coats KG, Morgan SL, Bartollucci AA, et al: Hospitalassociated malnutrition: A reevaluation 12 years later. J Am Diet Assoc 93:27-33, 1993 6. DeWys WD, Begg C, Lavin PT, et al: Prognostic effect of weight loss prior to chemotherapy in cancer patients. Am J Med 69:491-497, 1980 7. Costa G, Donaldson SS: Effects of cancer and cancer treatment of the nutrition of the host. N Engl J Med 300:1471-1474, 1979 8. Christensen KS: Hospitalwide screening increases revenue under prospective payment system. J Am Diet Assoc 86:1234-1235, 1986 9. Robinson G, Goldstein M, Levine GM: Impact of nutritional status on DRG length of stay. J Parenter Enteral Nutr 11:49-51, 1987 10. Rifler J: Malnourished patients feed rising costs: Study. Hospitals March 5:86, 1986 11. Klidjian AM, Archer TJ, Foster KJ, et al: Detection of dangerous malnutrition. J Parenter Enteral Nutr 6:119-121, 1982 12. McLaren DS, Mequid MM: Nutritional assessment at the crossroads. J Parenteral Enteral Nutr 7:575-579, 1983 13. Long JM: Opening the closet door: The key is education. J Parenteral Enteral Nutr 6:280-286, 1982 14. Roubenoff R, Roubenoff RA, Preto J, et al: Malnutrition among hospitalized patients: A problem of physician awareness. Arch Intern Med 147:1462-1465, 1987 15. Shils ME: Principles of nutritional therapy. Cancer 43:2093-2103, 1979 16. Brown JK, Radke KJ: Nutritional assessment, intervention, and evaluation of weight loss in patients with non-small cell lung cancer. Oncol Nurs Forum 25:547-553, 1998 17. MeMahon K, Decker G, Ottery FD: Integrating proactive nutritional assessment in clinical practices to prevent complications and cost. Semin Onco125:20-27, 1998 (suppl 6) 18. Gilbride JA, Castro J: Malnutrition in the hospital, in Simko MD, Cowell C, Gilbride JA (eds): Nutrition Assessment:
A Comprehensive Guide for Planning Interventions (ed 2). Gaithersburg, MD, Aspen Publishers, 1995, pp 25-40 19. Ottery FD: Rethinking nutritional support of the cancer patient: The new field of nutritional oncology. Semin Oncol 21:770-778, 1994 20. Brown JK, Whittemore KT, Knapp TR: Is arm span an accurate measure of height in young and middle aged adults? Clin Nurs Res 9:84-94, 2000 21. Casey KM: Malnutrition associated with HIV/AIDS. Part Two: Assessment and interventions. J Assoc Nurses AIDS Care 8:39-48, 1997 22. Jequier E: Energy, obesity, and body weight standards. Am J Clin Nutr 45:1035-1047, 1987 23. Lee RD, Nieman DC: Nutritional Assessment. St Louis, MO, Mosby, 1996 24. Garrow JS: Obesity and Related Diseases. Edinburgh, UK, Churchill Livingstone, 1988 25. Ottery FD: Supportive nutrition to prevent oaohexia and improve quality of life. Semin Oncol 22:98-111, 1995 (suppl 3) 26. Brown JK, Radke KJ: Symptoms associated with weight loss in lung cancer patients. Proceedings of the American Cancer Society Nursing Research Conference. Atlanta, GA, American Cancer Society, 1994 27. Grosvenor M, Buloavage L, Chlebowski RT: Symptoms potentially influencing weight loss in a cancer population. Correlations with primary site, nutritional status, and ehemotherapy administration. Cancer 63:330-334, 1989 28. Haylock PJ, Hart LK: Fatigue in patients receiving localized radiation. Cancer Nurs 2:461-467, 1979 29. Sarna L, Lindsey AM, Dean H, et al: Weight change and lung cancer: Relationships with symptom distress, functional status, and smoking. Res Nuts Health 17:371-379, 1994 30. Brown JK: Precancer factors and outcomes of weight loss in adults with lung cancer. Dissertation Abstracts International 52:2989B, 1991 (abstr) 31. Sama L, Lindsey AM, Dean H, et al: Nutritional intake, weight change, symptom distress, and functional status over time in adults with lung cancer. Oncol Nurs Forum 20:481-489,1993 32. Ottery FD, Kasenic S, DeBolt S, et al: Volunteer network accrues over 1900 patients in 6 months to validate standardized nutritional triage. Proo Am Soc Clin Onoo117:73a, 1998 (abstr 282) 33. Brown JK, Hartmuller VW: Nutritional resources for patients with cancer and health professionals. Cancer Pract 6:125-128, 1998
Seminars in Oncology Nursing, Vol 16, No 2 (May), 2000: pp 106-112
OBJECTIVES::: : :
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To review ~h~ cornpon~nts of nu- : ; :tritionalscre~ing; screening :::: measures a ~ tools, arwl the :: nurses'role in nutritional assessm~t.
:: :: ::::~ : :
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DATA SOURCES: Research studies, review articles;: and book chapters. ::
NUTRITIONAL SCREENING AND ASSESSMENT
CONCLUSIONS: Timely and appropriate nutritional interventions require the adoption of routine initial nutritional screening, referral for comprehensive nutritional assessments as needed, and continued re-sc~reening.
IMPLICATIONS FOR NURSING PRACTICE: Oneology nurses Should be prepared to contribute to a comprehensive nutritional assessment in their role as patient advocate and expert clinician.
From Nursing W~sdorn, New York, NY; : and the State Universlty of New York at Buffalo School of Nursing~ Buffalo, IWY. Kathleen McMahon, l~2q,MEd, M_A:Nurse Consultant, Ontology and l-hW/AjDS,Nurse Psychotherapist, Nursing Wischom~New : York, N);- Jean K. Brown, PhD, RN:Associate Professor, State University of New York at Buffalo School of Nursing, Buffalo, NY. Address reprin t requests to Kathleca McMah(m, RN, MEd, MA, Nursing Wisdom, 332 Spruce Mill Lane, Scotch Plains, NJ 07076.
i ¸ Gopyright ©2t'fgO ~v W,B. Saunders CompOmy 0749-2081/00/1602~002510.00/0 : doi:lO.iOSit/oni2000:5549:
KATHLEEN MCMAItON AND JEAN K. BROWN
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ALNUTRITION is historically recognized as an important contributor to morbidity, mortality, and decreased quality of life in patients with cancer. As early as 1932, an autopsy series of 500 patients with c a n c e r found that eachexia was the most frequent cause of death. 1 Weight loss has been described in the c a n c e r literature as a c o m m o n and early manifestation of cancer. Unexplained weight loss is considered a warning sign that should be investigated for a possible occult malignancy. 2 In the 1970s oncology researchers focused on the rates of malnutrition in hospitalized cancer patients and used a compelling and alarming poetic metaphor to describe the presence of malnutrition: "the skeleton in the hospital closet. ''3 Early hopes to reverse cancer-related malnutrition were focused on total parenteral nutrition, then called hyperalimentation. 4 Attempts to reverse severe nutritional depletion were generally unsuccessful, but astoundingly positive results were demonstrated in short bowel and fistula patients by total parenteral nutrition pioneers. These pioneers also contributed to a greater appreciation of the degree of malnutrition in cancer patients, identifying the importance of preventing malnutrition and the need for appropriate choices of nutrition repletion when necessary. During the 1980s and 1990s, several attempts were made to describe the importance of a careful evaluation of nutritional status and the development of interdisciplinary screening tools. 5-14 In a classic article, Maurice Shils 15 summarized principles of supportive nutrition that remain relevant and applicable today. As seen in Table 1, two of Shils' principles deal directly with screening and assessment: comprehensive investigation of the potential causes of malnutrition and early and periodic assessment_ Shils observed that the specific and generalized effects of cancer need to be evaluated as well as the nutritional effects of the t r e a t m e n t plan. He c o m m e n t e d that early assessments, preferably within 48 hours of hospital admission, should be performed and repeated every 2 weeks_ Because hospitalization is avoided or shortened in the current health care environment, the timing and frequency of
N U T RIT IO N AL S C R E E N I N G AND A S S E S S M E N T
T A B L E 1. Shil's TM Principles of Supportive Nutrition" Screening and Assessment A rationale and therapeutic approach for a patient requires an analysis of factors inducing depletion in the patient. Every patient should have an early and periodic assessment of nutritional status.
these r e e o m m e n d a t i o n s m a y vary. It r e m a i n s critieal, however, to continue to plan to detect nutritional deficits early in the course of the disease and regularly during the t r e a t m e n t plan. For example, c a n c e r patient screening should occur at the time of diagnosis, at the initiation of aggressive treatment, at any time when the treatm e n t plan is adjusted or revised, and at the development of a significant weight change of 2% to 5% Despite the fact that it has b e e n 20 years since Shils' principles were first published, study findings indicate insufficient progress in i m p l e m e n t i n g the screening and a s s e s s m e n t principles into c a n c e r care. la O n t o l o g y nurses have a critical role in nutritional screening and c o m p r e h e n s i v e nutritional a s s e s s m e n t and they should routinely include these principles of supportive nutritional care in their elinical practice. Thus, this article describes the goals and c o m p o n e n t s of nutritional screening, useful clinical screening m e a s u r e s and tools, and screening indications for identifying patients with nutritional risks. In addition, m a j o r c o m p o n e n t s of c o m p r e h e n s i v e nutritional assessm e n t are delineated and the role of the oneology nurse in this process is discussed. Finally, general nutritional counseling and issues relevant to research and clinical practice are examined. DEFINITIONS utritional screening is the process of discovering characteristics or risk factors k n o w n to be associated with nutritional problems. 17 The m a i n purpose of screening is to identify individuals who are potentially at risk. A simple tool, such as the P a t i e n t - G e n e r a t e d Subjective Global A s s e s s m e n t (PG-SGA), is often used for this purpose. C o m p r e h e n s i v e nutritional a s s e s s m e n t is a m o r e in-depth process than screening. It is the systematic, c o m p r e h e n s i v e process of determining the complex etiologic factors of individuals identified as "at risk" and of planning a course of
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action. 17 Similarly, the A m e r i c a n Dietetic Association has defined nutritional a s s e s s m e n t as "a c o m p r e h e n s i v e approach, c o m p l e t e d by a registered dietitian, to defining nutritional status that uses medical, nutritional, and medication histories; physical examination; a n t h r o p o m e t r i c m e a sures; and l a b o r a t o r y data. ''is The purpose of a c o m p r e h e n s i v e nutritional a s s e s s m e n t is to determ i n e the patient's c u r r e n t nutritional status and requirements, classify the degree of malnutrition, and institute t r e a t m e n t and intervention plans. In the ontology-specific context, nursing input into c o m p r e h e n s i v e nutritional a s s e s s m e n t is critical because nurses tend to have the m o s t holistic knowledge and unders tanding of patient problems. Moreover, o n t o l o g y specialty dieticians are not available in m a n y settings. Nurses can assess the likely course of disease and t r e a t m e n t , potential complications, and s y m p t o m s affecting nutrition. T h e y also can contribute to the d e v e l o p m e n t of short- and long-term nutritional goals, the design and i m p l e m e n t a t i o n of interventions, and timelines for evaluation of interventions. NUTRITIONAL SCREENING Go~lls
The three m a j o r goals of screeniug are to identify individuals at risk for malnutrition, prevent and/or treat malnutrition early, and modify t r e a t m e n t plans as needed, is Even if the initial screening reveals a satisfactory nutritional status, re-evaluation at regular intervals is required, as indicated by the d e v e l o p m e n t of new or worsening s y m p t o m s affecting nutrition or clinical and l a b o r a t o r y evidence of nutritional deterioration. >
Components of Nutritional Screening Screening focuses on gathering the most significant and available infomlation on nutritional status to identify patients who are at risk. This information includes weight change, food intake, symptoms affecting nutrition, functional status, and specific findings from the physical examination. In addition, some clinicians include biochemical indicators. As shown in Table 2, a variety of measures are used for the screening process_ Clinical judgement and experience are i m p o r t a n t factors in evaluating b o t h the subjective (eg, functional status and s y m p t o m s ) and the objective (eg, weight change and physical e x a m i n a t i o n ) screening data.
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Transferrin Retinol bindingprotein
Weight Change Weight and height measures provide a rapid, gross measure of body size and composition. From these two measures, ideal weight, body mass index, and p e r c e n t weight change can be calculate& It is i m p o r t a n t to actually measure weight and height w h e n e v e r possible rather than relying on the patient to provide these measurements. Weight m e a s u r e m e n t requires an accurate, calibrated scale with the patient removing shoes, overcoats, knapsacks or shoulder bags, and other items such as pocket change, keys, and heavy belt buckles. Height should be measured using a calibrated rule with the patient standing straight and with feet flat on the floor or platform. If height c a n n o t be m e a s u r e d due to the patient's condition, researchers have d e t e r m i n e d that a measure of arm span is a good surrogate for height. 2° To measure arm span, patients should hold their arms out at their sides with palms facing forward and arms parallel to the floor. A rule is t h e n used to measure from one middle fingertip to the other
middle fingertip across the shoulders at the clavicle level. The best approximation of height is obtained by using the following calculation: height (in) = (0.87 × arm span [in]) + 20_54. 2o To evaluate the patient's body size, the nurse compares the patient's current weight with the patient's ideal weight based on height and body frame size 21 or calculates body mass index. Ideal weight is calculated as 100 lb per 5 ft of height plus 5 lb for each additional inch of height for females and as 106 lb per 5 ft of height plus 6 lb for each additional inch of height for males. Ideal weight is adjusted -+10% depending on body frame. Body mass index is calculated by dividing weight in kilograms by height in meters squared (kg/m 2) or lb/in2/0.0014192. 22 A body mass index of less than 16 is classified as too lean, 16 to 19.9 as lean and underweight, 20 to 24.9 as desirable, and 25 or greater as overweight to obese. The p e r c e n t weight change from usual body weight is calculated by dividing the c u r r e n t measured weight by the usual weight and multiplying it by 100. 21 Percent weight change should be evaluated for differences from usual preillness weight, prediagnosis weight, and after diagnosis weight. Potential expansion of certain body c o m p a r t m e n t s due to ascites or e d e m a should be included in the analysis_ Weight loss of 2% to 5% is considered severe. The time period during which the percent weight change occurred should also be assessed_
Food Intake If food intake is less than usual or consists of little solid food and weight loss is evident, the patient is at nutritional risk and should be referred for a comprehensive nutritional assessment. Food intake is measured using 24-hour dietary recall, 3-day food records, direct observation, and food frequency questionnaires. 21,23 A 24-hour dietary recall is a quick, inexpensive, and easy method of assessing oral intake and is useful for patients in whom literacy is a concern. It can be easily adopted in community care, home care, and other settings. Limitations of this method include reliance on the patient's memory, mental status, honesty, and language skills. Additionally, the day chosen for recall m a y not be representative of the patient's normal intake. A more accurate approach to assessing food intake is a 3-day food record/diary including 1 weekend day to account for the considerable variation that has been found between food intake during the week and on weekends. 23,24 This will require higher levels of motivation on the part of both the nurse and the patient, but a potential bonus is that the data can be used to calculate
NUTRITIONAL
caloric intake should a more comprehensive assessment of food intake be needed. Food models, photographs of food, food scales, and measuring cups can be used to increase the accuracy of the data, but are more likely to be used during comprehensive nutritional assessments. Direct observation and food frequency questionnaires are used less frequently in clinical nutritional screening due to practical considerations. Direct observation of food intake can be used for hospitalized patients, but otherwise it has limited usefulness. Food frequency questionnaires assess how frequently the patient consumed a specific number of foods that are major sources of nutrients or are of particular concern. 23
Symptoms Affecting Nutrition Many cancer-related symptoms and treatment side effects have an impact on nutritional status. Anorexia has long been associated with poor nutritional status and is usually included in nutritional screening. 16 However, other symptoms also have been found to be associated with weight loss in patients with cancer. 16,2529 These include pain, fatigue, depression, infection, and alterations in the gastrointestinal tract (eg, stomatitis, dysphagia, vomiting, diarrhea, and constipation) and dyspnea. Symptom severity and the cumulative effect of several symptoms are indicators of nutritional risk. 26 Symptom checklists are used to determine the occurrence of symptoms affecting nutrition as well as their associated distress and severity. 17 The article by Grant and Kravits elsewhere in this issue discusses symptoms affecting nutrition in detail.
Functional Status Functional status has been strongly associated with weight loss in cancer patients. 29-3~ Two measures of functional status are very c o m m o n l y used to assess patients with cancer: the Karnofsky performance status scale and the Eastern Cooperative Oncology Group performance scale. Scores from these scales are often readily available in patient medical records. Another measure of functional status includes a self-care log. A self-care log may be used to determine functional status, activities of daily living, and the ability to procure, prepare, cook, and clean-up meals. Deficits in self-care ability may influence nutrition, especially if the patient has little or no family or community support.
Physical Examination Findings from the physical examination m a y reveal evidence of actual or potential malnutrition. When inspecting a patient's general appearance
SCREENING
AND ASSESSMENT
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and behavior, the nurse assesses for weakness, loss of body fat, loss of lean body (muscle) mass, and fluid status. The patient's mental status is observed for evidence of disordered affect, impaired mood, and alterations in orientation, memory, concentration, or thinking, which may reflect depression, delirium, dementia, or extreme malnutrition. When examining the patient's head, neck, and oral cavity, the nurse inspects for dehydration, stomatitis, xerostomia, and chewing or swallowing difficulties. In addition, an assessment is made of the musculoskeletal, nervous, and gastrointestinal systems, seeking evidence of muscle and fat loss, n e u r o m u s c u l a r dysfunction, liver disease, bowel obstruction, edema, aseites, dehydration, or other relevant considerations.
Biochemical Indicators Some clinicians also include biochemical indicators in nutritional screening, but this information is not always readily available. The complexity of interpreting these data m a y make them more useful in the comprehensive nutritional assessment. In general, the serum transport proteins of albumin, prealbumin, transferrin, and retinolbinding protein are important indicators of nutritional status, e,~ Issues of availability, practical application, and clinician skill in interpreting these tests from a nutritional perspective may affect the utility of such measures. Albumin has a normal range of 3.5 to 5.0 g/dL and is affected by hydration, position, inflammation, infection, stress, and laboratory variability. 23 It has a half-life of approximately 2 to 3 weeks, which makes it useful for long-term nutritional evaluations but not as relevant for shorter-term evaluations_ Prealbumin has a half-life of 2 to 3 days and has a normal level of 300 _+ 5 ~xg/mL. Values must be evaluated with caution because it is affected by stress, trauma, inflammation, vitamin A deficiency, and cirrhosis in addition to depleted protein stores. Transferrin is an indicator of visceral protein deficiency. Its normal range is 200 to 300 mg/dL and it has a half-life of 8 to 10 days. A severe visceral protein deficiency is detectable when the level falls below 100 mg/dL; moderate deficiency is from 100 to 150 mg/dL. Depressed concentrations of transferrin are found in protein malnutrition, starvation, and during an acute inflammatory process. Retinol-binding protein bonds with prealbumin and transports vitamin A. Normal retinol-binding protein is 46 _+ 1 txg/mL. It has a half-life of 10 to 12 hours. High levels are associated with renal failure, whereas
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M c M A H O N AND B R O W N
depressed levels are found in malnutrition, liver disease, and hyperthyroidism.
The Patient-Generated Subjective Global A s s e s s m e n t Screening Tool One screening tool that includes many of the components of nutritional screening described above is the oncology-modified version of the PG-SGA. This tool was developed to help identify patients most at risk for malnutrition. The onepage PG-SGA incorporates a patient self-report of weight change, food intake, symptoms affecting nutrition, and functional status as well as the health care provider's brief physical examination results and evaluation of metabolic stress (eg, fever or steroid use). It is easy to use and was designed for a sixth- to eighth-grade reading level. It only takes a few minutes to complete and can be used routinely in all practice settings and by clinicians of various disciplines. This feature of the form helps promote multidisciplinary nutritional management. The PG-SGA engages patients in their own screening and initiates a management process that will require the patient's active involvement throughout their illness. The tool ends with the patient being categorized into one of three nutritional categories: wellnourished, moderately malnourished or suspected of being malnourished, and severely malnourished. Patients who are categorized as moderately or suspected of being malnourished or severely malnourished and whose treatment plan falls into a high-risk category for nutritional problems need to have a comprehensive nutritional evaluation and be evaluated by nutrition specialists. The ontology-modified PG-SGA 17 was developed by Ottery et a132 and has been validated in many oncology practice settings.
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COMPREHENSIVE NUTRITIONAL ASSESSMENT f the nurse's nutritional screening identifies a patient who is at nutritional risk, a request for a comprehensive nutritional assessment by a dietitian should be initiated. The major components of such an assessment are outlined in Table 3. Oncology nurses should be prepared to contribute to a comprehensive nutritional assessment in their role as patient advocate and expert clinician_ In addition, nurses can facilitate the dietitian's comprehensive nutritional assessment based on rapport established with the patient and family. This may be especially important when the dietitian explores potentially sensitive issues influ-
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encing food choices and style of eating, such as culture, financial constraints, preferred "comfort foods," tobacco/drug/alcohol use, lifestyle, religious issues, body image, and use of alternative
N U T R I T I O N A L S C R E E N I N G AND A S S E S S M E N T
therapies. 17 Nurses also can provide critical information on the patient's clinical status. In setting priorities for short- and long-term nutritional goals, a multidisciplinary approach is essential. The ontology nurse works with the physician or primary provider to coordinate the variety of services that may be required to effectively implement the plan. Patient and family participation in development and implementation of the plan is also essential for success_ The patient and family should agree on food choices, budgets, menus, and meal preparation_ Any changes made in the patient's eating patterns need to be supported by the patient's caregivers and household members.
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: .....
T A B L E 4. . . . . . Clinical Process for Nutritional Screening and Comprehensive Assessment Nutritional screening Identification of individuals at risk Referral for complete evaluation to dietician Multidisciplinary assessment using standard and specialized tools Identification of the patient's strengths and weaknesses Prioritization of short- and long-term goals Preparation of an interdisciplinary nutritional care plan Implementationof the plan Evaluation of the current nutritional plan Follow-up, re-evaluation, and modification as necessary
GENERAL NUTRITIONAL COUNSELING ll patients diagnosed with c a n c e r need instruction about healthy eating principles. T h e y need to know which nutrients are important and why, how frequently to eat and in what amounts, and how to use vitamin and mineral supplements judiciously. Basic food and water safety considerations need to be reviewed. These include safe food storage, food preparation, considerations for travel and dining out, and the use of filtered water, if applicable. A recent review identified m a n y nutrition informational materials for patients and families -~-~ that are useful in clinical practice. Classroom and individual instruction also m a y be available for patients through community-based organizations and agencies. The ontology nurse can advocate for these services and/or conduct classes in a nurse-managed clinic for new patients. Teaching food safety in a home care e n v i r o n m e n t and starting a cooking class at a clinic are two creative examples initiated by nurses, el
A
RESEARCH AND CLINICAL ISSUES A
review of the literature revealed a substantial lack of research on nutritional screening, assessment, and interventions in the c a n c e r population. One study of non-small cell lung cancer patients found that the nutritional assessments conducted by health care providers were rarely, if ever, sufficiently comprehensive. 16 Most assessments included weight change and anorexia or decreased food intake. Other important factors, such as past medical history, eating patterns, social and demographic information, a targeted physical examination relevant to nutrition, and potential nutritional problems, were not included
in clinicians' assessments. In addition, evaluations of the effectiveness of the nutritional interventions were recorded for only 44% of the subjects and described to be effective in only 15% of subjects. The authors c o m m e n t e d that nurses would have a greater impact on nutritional outcomes if they focused on potential nutritional problems in addition to the nutritional problems already present. This means that assessment indicators must be broadened and systematic patient evaluation in the clinical setting needs to occur. Moreover, it would be useful to determine what outeomes are most important for patients with cancer who experience nutritional p r o b l e m s J 6 Is body weight an important end point and within what criteria? What impact do changes in nutritional status and weight stabilization have on quality of life in this population? What is the pattern of nutritional depletion in various t r e a t m e n t protocols? Based on this evidence of insufficient clinical nutritional assessment, how can the routine nutritional screening and comprehensive nutritional assessment described and s u m m a r i z e d in Table 4 be successfully implemented in ontology practice? Nutrition is a multidisciplinary activity in which oneology nurses have a critical role. Thus, representatives from relevant disciplines including nursing, medicine, nutrition services, pharmacy, and social services should work together to answer three questions: Who should c o n d u c t and be accountable for nutritional screening, referrals for comprehensive nutritional assessment, and comprehensive nutritional assessments? When should these activities be done? and How should they be done? In addition, a multidiseiplinary task force or the agency's quality improvement team could evaluate current practice, make reeommenda-
112
McMAHON AND BROWN
t i o n s for q u a l i t y i m p r o v e m e n t s , and evaluate o u t c o m e s of n e w p o l i c i e s a n d p r o c e d u r e s . CONCLUSION arly and routine nutritional screening with c o m p r e h e n s i v e n u t r i t i o n a l a s s e s s m e n t s of p a t i e n t s s c r e e n e d as " a t r i s k " a r c c r u c i a l to a d d r e s s ing nutritional challenges and deficits before they c o n t r i b u t e f u r t h e r to w o r s e n e d d i s e a s e a n d t r e a t ment outcomes and compromise functional status a n d q u a l i t y of life. B e c a u s e m u l t i d i s c i p l i n a r y c o o p e r a t i o n is e s s e n t i a l i n a n y e f f e c t i v e n u t r i t i o n a l program, agency administrators need to consider t h e b e s t s y s t e m - w i d e a p p r o a c h to e n h a n c e t h e
E
clinical, educational, and quality assurance programs in nutritional ontology. Specific recommendations for n u r s e s i n c l u d e e s t a b l i s h i n g n u t r i t i o n a l s c r e e n i n g i n all c l i n i c a l s e t t i n g s , a b r o a d e n i n g of t h e a s s e s s m e n t c o n t e n t and process, and strengthening the value placed on proactive and early nutritional interventions a n d w e i g h t s t a b i l i z a t i o n . A d v o c a c y is n e e d e d for more clinical nursing research on cancer-related nutritional problems, to confront existing attit u d e s a b o u t t h e f u t i l i t y of n u t r i t i o n a l c a r e t h a t m a y be reflected in ontology nurses' clinical priorities, a n d for a s u s t a i n e d i m p r o v e m e n t in n u t r i t i o n a l s t a n d a r d s of c a r e i n o n e o l o g y n u r s i n g a n d t h e nursing profession.
REFERENCES 1. Warren S: The immediate cause of death in cancer. Am J Med Sci 184:610-615, 1932 2. Homburger F, Fishman WH (eds): The Physiopathology of Cancer. New York, NY, Hoeber-Harper, 1953 3. Butterworth CE Jr: The skeleton in the hospital closet. Nutr Today 9:4-8, 1974 4. Costa G: Cachexia, the metabolic component of neoplastic diseases. Cancer Res 37:2327-2335, 1977 5. Coats KG, Morgan SL, Bartollucci AA, et al: Hospitalassociated malnutrition: A reevaluation 12 years later. J Am Diet Assoc 93:27-33, 1993 6. DeWys WD, Begg C, Lavin PT, et al: Prognostic effect of weight loss prior to chemotherapy in cancer patients. Am J Med 69:491-497, 1980 7. Costa G, Donaldson SS: Effects of cancer and cancer treatment of the nutrition of the host. N Engl J Med 300:1471-1474, 1979 8. Christensen KS: Hospitalwide screening increases revenue under prospective payment system. J Am Diet Assoc 86:1234-1235, 1986 9. Robinson G, Goldstein M, Levine GM: Impact of nutritional status on DRG length of stay. J Parenter Enteral Nutr 11:49-51, 1987 10. Rifler J: Malnourished patients feed rising costs: Study. Hospitals March 5:86, 1986 11. Klidjian AM, Archer TJ, Foster KJ, et al: Detection of dangerous malnutrition. J Parenter Enteral Nutr 6:119-121, 1982 12. McLaren DS, Mequid MM: Nutritional assessment at the crossroads. J Parenteral Enteral Nutr 7:575-579, 1983 13. Long JM: Opening the closet door: The key is education. J Parenteral Enteral Nutr 6:280-286, 1982 14. Roubenoff R, Roubenoff RA, Preto J, et al: Malnutrition among hospitalized patients: A problem of physician awareness. Arch Intern Med 147:1462-1465, 1987 15. Shils ME: Principles of nutritional therapy. Cancer 43:2093-2103, 1979 16. Brown JK, Radke KJ: Nutritional assessment, intervention, and evaluation of weight loss in patients with non-small cell lung cancer. Oncol Nurs Forum 25:547-553, 1998 17. MeMahon K, Decker G, Ottery FD: Integrating proactive nutritional assessment in clinical practices to prevent complications and cost. Semin Onco125:20-27, 1998 (suppl 6) 18. Gilbride JA, Castro J: Malnutrition in the hospital, in Simko MD, Cowell C, Gilbride JA (eds): Nutrition Assessment:
A Comprehensive Guide for Planning Interventions (ed 2). Gaithersburg, MD, Aspen Publishers, 1995, pp 25-40 19. Ottery FD: Rethinking nutritional support of the cancer patient: The new field of nutritional oncology. Semin Oncol 21:770-778, 1994 20. Brown JK, Whittemore KT, Knapp TR: Is arm span an accurate measure of height in young and middle aged adults? Clin Nurs Res 9:84-94, 2000 21. Casey KM: Malnutrition associated with HIV/AIDS. Part Two: Assessment and interventions. J Assoc Nurses AIDS Care 8:39-48, 1997 22. Jequier E: Energy, obesity, and body weight standards. Am J Clin Nutr 45:1035-1047, 1987 23. Lee RD, Nieman DC: Nutritional Assessment. St Louis, MO, Mosby, 1996 24. Garrow JS: Obesity and Related Diseases. Edinburgh, UK, Churchill Livingstone, 1988 25. Ottery FD: Supportive nutrition to prevent oaohexia and improve quality of life. Semin Oncol 22:98-111, 1995 (suppl 3) 26. Brown JK, Radke KJ: Symptoms associated with weight loss in lung cancer patients. Proceedings of the American Cancer Society Nursing Research Conference. Atlanta, GA, American Cancer Society, 1994 27. Grosvenor M, Buloavage L, Chlebowski RT: Symptoms potentially influencing weight loss in a cancer population. Correlations with primary site, nutritional status, and ehemotherapy administration. Cancer 63:330-334, 1989 28. Haylock PJ, Hart LK: Fatigue in patients receiving localized radiation. Cancer Nurs 2:461-467, 1979 29. Sarna L, Lindsey AM, Dean H, et al: Weight change and lung cancer: Relationships with symptom distress, functional status, and smoking. Res Nuts Health 17:371-379, 1994 30. Brown JK: Precancer factors and outcomes of weight loss in adults with lung cancer. Dissertation Abstracts International 52:2989B, 1991 (abstr) 31. Sama L, Lindsey AM, Dean H, et al: Nutritional intake, weight change, symptom distress, and functional status over time in adults with lung cancer. Oncol Nurs Forum 20:481-489,1993 32. Ottery FD, Kasenic S, DeBolt S, et al: Volunteer network accrues over 1900 patients in 6 months to validate standardized nutritional triage. Proo Am Soc Clin Onoo117:73a, 1998 (abstr 282) 33. Brown JK, Hartmuller VW: Nutritional resources for patients with cancer and health professionals. Cancer Pract 6:125-128, 1998