Why Nutrition Screening Is Examined
Malnutrition affects approximately 30% of hospital inpatients and is associated with impaired wound healing, increased infection risk, longer hospital stays, and higher mortality. OSCEs test it via: structured history and screening tool calculation, communication stations (explaining a feeding tube to a patient), and clinical reasoning (a patient is losing weight — assess and manage).
💡 Tip
Every patient admitted to hospital should have a MUST score calculated within 24 hours — this is a NICE quality standard. If asked what you would do for a newly admitted patient, always mention nutritional screening.
The MUST Score — Malnutrition Universal Screening Tool
Developed by BAPEN (British Association for Parenteral and Enteral Nutrition). Validated across hospital and community settings.
Step 1: BMI Score
| BMI (kg/m2) | Score |
|---|---|
| Above 20 | 0 |
| 18.5-20 | 1 |
| Below 18.5 | 2 |
Step 2: Unintentional Weight Loss Score
| % weight loss in 3-6 months | Score |
|---|---|
| Under 5% | 0 |
| 5-10% | 1 |
| Over 10% | 2 |
Step 3: Acute Disease Effect
| Situation | Score |
|---|---|
| Patient is acutely ill AND has been or is likely to have no nutritional intake for more than 5 days | +2 |
| Otherwise | 0 |
Total Score and Action
| Total MUST | Risk | Action |
|---|---|---|
| 0 | Low | Routine hospital care — re-screen weekly |
| 1 | Medium | Observe — document dietary intake for 3 days; refer to dietitian if no improvement |
| 2 or above | High | Treat — refer to dietitian, nutritional support (oral supplements plus/minus enteral/parenteral feeding) |
Nutritional History — Key Areas
🧠 Mnemonic
WIDE SPAT — nutritional history domains:
- W eight change (unintentional loss — amount and timeframe)
- I ntake (what and how much they are eating and drinking)
- D ysphagia or difficulty swallowing
- E nergy level and functional impact
- S ymptoms (nausea, vomiting, diarrhoea, pain on eating)
- P references, restrictions, and cultural considerations
- A ppetite change
- T eeth and dental health (mechanical barriers to eating)
Additional relevant history:
- Alcohol intake (empty calories, displaces nutrition, causes B1/B12/folate deficiency)
- Social history: who does the shopping and cooking? Can they afford food?
- Medical conditions affecting absorption: Crohn's disease, coeliac disease, post-gastrectomy, liver disease
Clinical Signs of Malnutrition
| System | Signs |
|---|---|
| General | Weight loss, muscle wasting (temporalis, thenar eminence, interosseous muscles) |
| Hair | Thin, brittle, losing colour |
| Skin | Dry, flaking, poor wound healing, pressure ulcers |
| Eyes | Conjunctival pallor (anaemia), Bitot's spots (vitamin A deficiency) |
| Mouth | Angular cheilitis (B2/iron), glossitis (B12/folate/iron), bleeding gums (vitamin C) |
| Nails | Koilonychia (iron), leukonychia (zinc/protein) |
| Neurology | Peripheral neuropathy (B1, B6, B12) |
| Oedema | Bilateral lower limb or periorbital (hypoalbuminaemia) |
Nutritional Support — Escalating Approach
Step 1: Food First
- Nutritional fortification of normal food (full-fat milk, butter, cream, fortified foods)
- Small frequent meals
- Assisted eating if needed
- Remove barriers: denture repair, pain management
Step 2: Oral Nutritional Supplements
- High-calorie, high-protein drinks (e.g., Ensure Plus, Fortisip)
- Prescribable on FP10 for specific indications
- Generally used when dietary modification alone is insufficient
Step 3: Enteral Feeding (Tube Feeding)
- Nasogastric (NG) tube: short-term (under 4-6 weeks), functioning gut, unable to swallow safely or insufficient oral intake
- Percutaneous endoscopic gastrostomy (PEG): longer-term, for patients with persistent dysphagia (stroke, neurological disease, head and neck cancer)
NG tube use:
- Confirm position with pH testing (aspirate pH below 5.5 before each feed) or CXR if pH equivocal
- Never use a tube if position is uncertain
⚠️ Red Flag
Refeeding syndrome: A dangerous complication of reintroducing nutrition to severely malnourished or chronically starved patients. Rapid insulin release drives phosphate, potassium, and magnesium into cells — causing hypophosphataemia, arrhythmias, cardiac failure, and seizures. High-risk patients (BMI below 16, over 10% weight loss, minimal intake over 5 days): start feeding at 10 kcal/kg/day, supplement thiamine (Pabrinex) before and during refeeding, and monitor electrolytes daily for first week.
Step 4: Parenteral Nutrition (PN)
- Intravenous nutrition via central line — reserved for patients with non-functioning gut (prolonged ileus, high-output fistula, short bowel syndrome)
- Significant risks: line sepsis, electrolyte disturbances, hepatic complications
- Managed in collaboration with nutrition support team
Frequently Asked Questions
"What is refeeding syndrome and how do you prevent it?"
Refeeding syndrome is a potentially fatal metabolic complication of reintroducing nutrition after prolonged starvation or severe malnutrition. The sudden insulin surge when carbohydrate is introduced drives phosphate, potassium, and magnesium into cells, causing dangerous drops in serum levels. Prevention: identify high-risk patients using NICE criteria (BMI below 16, over 10% weight loss, negligible intake for over 5 days, history of alcohol excess or malabsorption). Start at 10 kcal/kg/day, give IV Pabrinex (thiamine) before refeeding, and monitor electrolytes and ECG daily for 1 week.
"What blood tests are relevant in malnutrition?"
Full blood count (anaemia — iron/B12/folate deficiency), ferritin, B12, folate, albumin (marker of chronic malnutrition, also affected by inflammation), prealbumin (more sensitive short-term marker), zinc, magnesium, phosphate (especially if at risk of refeeding), vitamin D, LFTs, and TFTs (weight loss can be driven by hyperthyroidism).
"When is a PEG tube indicated over an NG tube?"
NG tubes are used for short-term feeding (under 4-6 weeks) or as a diagnostic trial before a longer-term decision. PEG tubes are appropriate when long-term enteral feeding is anticipated and the patient has a functional gastrointestinal tract but cannot swallow safely (e.g., post-stroke dysphagia, MND, head and neck cancer). The decision requires multidisciplinary discussion and, importantly, patient and family agreement — PEG insertion should never be done without proper consent and goals-of-care discussion.
"How does dysphagia affect nutrition and how is it assessed?"
Dysphagia causes inadequate oral intake, aspiration risk, and dehydration. Assessment begins with a trained nurse or speech and language therapist (SALT) performing a bedside swallow assessment. Modified diet textures (IDDSI framework) and thickened fluids may be required. Formal videofluoroscopy or FEES (fibreoptic endoscopic evaluation of swallowing) can identify the precise level and type of dysphagia.
"How do you counsel a patient about starting oral nutritional supplements?"
"Your MUST score shows you are at high risk of malnutrition, which can slow your recovery and make you more susceptible to complications. I'd like to start you on a nutritional supplement drink alongside your normal meals — not to replace food, but to top up your calories and protein. They come in different flavours, so we can find one you enjoy. Taking one or two a day, sipping slowly, works best. We will also refer you to our dietitian who can give you detailed advice."
Related Posts
- Frailty Assessment OSCE — weight loss and nutritional deficit as core frailty domains
- Drug History OSCE — medications that suppress appetite or impair absorption
- Discharge Planning OSCE — ensuring nutritional support continues after hospital discharge