Nutritional Assessment – GCCNurseJobs.com Clinical Guide

MUST Tool — 5-Step Malnutrition Universal Screening

Step 1 — BMI Score

>20 = 0 | 18.5–20 = 1 | <18.5 = 2

Step 2 — Weight Loss Score

<5% = 0 | 5–10% = 1 | >10% = 2 (unintentional, past 3–6 months)

Step 3 — Acute Disease Effect

If acutely ill AND no nutritional intake >5 days = add 2

Step 4 — Total Score

0 = Low risk | 1 = Medium risk | ≥2 = HIGH risk → refer dietitian

Step 5 — Management

Low: routine re-screening. Medium: observe, document intake. High: refer, improve intake, set goals.

Nutritional Requirements

25–35

kcal/kg/day (energy)

0.8–1.5

g/kg/day (protein)

30–35

mL/kg/day (fluid)

Higher protein needs: burns (1.5–2 g/kg), critical illness, wound healing, renal patients on dialysis. Adjust for obesity using adjusted body weight.

Anthropometric Measurements

BMI — Weight(kg)/Height(m)². <18.5 = underweight; >30 = obese
MAMC (Mid-Arm Muscle Circumference) — Reflects muscle mass; useful when weight unreliable
Triceps Skinfold — Estimates subcutaneous fat; measured with calipers
Calf circumference — Sarcopenia marker in elderly; <31 cm = risk
Waist circumference — Central obesity: >102 cm (M) / >88 cm (F)

Biochemical Markers

Albumin — Poor Acute Marker

Half-life 21 days. Low albumin reflects inflammation and illness severity (negative acute-phase protein), NOT recent nutritional status. Do NOT use to monitor short-term nutritional response.

Prealbumin — Better Acute Marker

Half-life 2 days. More responsive to short-term nutritional changes. Still affected by inflammation. Useful for monitoring response to nutrition support over days.

Other Markers

Transferrin: t½ 8 days — moderate sensitivity
CRP: confirms inflammation context
U&E, Mg, PO4: essential for refeeding monitoring

Enteral vs Parenteral Nutrition

Enteral Nutrition — PREFERRED

Maintains gut integrity and mucosal barrier
Prevents bacterial translocation
Cheaper; fewer infections than TPN
Routes: NGT, NJT, PEG, PEJ, jejunostomy
Use if GI tract functional

Parenteral Nutrition (TPN)

Only when GI tract non-functional or inaccessible
Indications: short bowel, paralytic ileus, bowel obstruction, severe malabsorption
Risks: CLABSI, hyperglycaemia, liver disease, refeeding syndrome
Central line required for full TPN

NGT Safety — pH Checking Protocol

Before EVERY feed — mandatory check

Aspirate at least 0.5–1 mL gastric contents
Test with pH indicator paper (NOT litmus)
pH <5.5 = gastric placement confirmed → SAFE to feed
pH ≥6 = do NOT feed — seek medical review / X-ray confirmation
If no aspirate obtained: do NOT feed; try repositioning, try again in 30 min
Proton pump inhibitors and antacids can raise pH — note and document

Refeeding Syndrome

Life-threatening electrolyte shifts when reintroducing nutrition to chronically malnourished/starved patients. Caused by intracellular shift of phosphate, potassium, and magnesium upon glucose reintroduction, causing hypophosphataemia.

Critical Rule: Thiamine BEFORE Refeeding

Give thiamine (Vitamin B1) 200–300 mg IV/orally before restarting feeds. Prevents Wernicke's encephalopathy triggered by glucose load.

Risk Factors

BMI <16 or >15% weight loss
Negligible intake >5 days
Anorexia nervosa
Alcoholism
Post-bariatric surgery

Monitoring Protocol

Phosphate daily for days 1–5
Potassium, magnesium, glucose
Start feeds at 5 kcal/kg/day — increase slowly
Replace electrolytes proactively

GCC-Specific Nutritional Issues

Vitamin D Deficiency — ~90% of GCC Population

Despite abundant sunlight, cultural dress codes (full body covering), indoor lifestyles, and avoidance of direct sun result in severe Vitamin D deficiency across GCC. Routine supplementation and screening required. Impacts bone health, immune function, and mood.

Double Burden of Malnutrition

GCC faces both undernutrition (in migrant labour populations, elderly, hospital patients) and overnutrition/obesity (sedentary lifestyle, high-sugar diet, T2DM rates among highest globally). Nurses must screen for both ends of the spectrum.

Halal Nutritional Supplements Required

All nutritional supplements and enteral feeds must be halal-certified for Muslim patients. Some commercial feeds contain porcine gelatin or alcohol. Verify with pharmacy/dietitian. Halal-certified alternatives are increasingly available in GCC markets.

GCC Clinical Notes

Fasting during Ramadan affects nutritional intake timing and quantity. Hospitalised patients may refuse to eat during daytime hours. Coordinate enteral feeds at night (between Iftar and Suhoor). Nutritional adequacy must be maintained — involve dietitian for all tube-fed patients during Ramadan.

Migrant workers from South and Southeast Asia may have poor baseline nutrition. Limited food variety in labour accommodation, language barriers to accessing healthcare, and lack of awareness of services contribute to undernutrition risk. Screen proactively on admission.

Key Exam Points

MUST score ≥2 = HIGH risk — immediate dietitian referral
Albumin = POOR acute nutritional marker (reflects inflammation, t½ 21 days)
Prealbumin = BETTER acute marker (t½ 2 days)
Thiamine must be given BEFORE refeeding starts — prevents Wernicke's
Monitor phosphate DAILY for first 5 days in refeeding syndrome risk patients
Enteral > parenteral when GI tract is functional
NGT aspirate pH <5.5 = safe; pH ≥6 = do NOT feed
Energy requirement: 25–35 kcal/kg/day; protein 0.8–1.5 g/kg/day

Practice MCQs

1. A patient has a BMI of 17.5 and has lost 12% body weight over 3 months. Their MUST score is:

2. Which biochemical marker is most useful for monitoring short-term nutritional recovery?

3. A malnourished patient is about to restart feeds after 10 days of starvation. The FIRST action before commencing feeds is:

4. Which route of nutrition is preferred when the gastrointestinal tract is functional?