NHS
                                       National Institute for 
                              Health and Clinical Excellence
           Quick reference guide
           Issue date: February 2006
           Nutrition support in adults 
           Oral nutrition support, enteral tube feeding 
           and parenteral nutrition 
           Clinical Guideline 32
           Developed by the National Collaborating Centre for Acute Care
          Nutrition support in adults           Grading of recommendations
         Grading of recommendations
         This quick reference guide summarises the recommendations in the NICE clinical guideline ‘Nutrition
         support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’. The
                                                   A B C D
         recommendations are based on the best available evidence and are graded     ,    ,    ,    , good
         practice point D(GPP) , depending on the type of evidence. For more information on the grading
         system, see the NICE guideline (www.nice.org.uk/CG032NICEguideline). 
         Contents
         Grading of recommendations                             2
         Outline care pathway                                   3
         Patient-centred care                                   4
         Key priorities for implementation                      5
         Organisation of nutrition support                      6
         Step 1. Screen                                         7
         Step 2. Recognise                                      9
         Step 3. Treat: oral                                    10
         Step 3. Treat: enteral                                 13
         Step 3. Treat: parenteral                              15
         Step 3. Treat: prescription                            18
         Step 4. Monitoring                                     20
         Implementation                                         25
         Further information                                    25
          This guidance is written in the following context
          This guidance represents the view of the Institute, which was arrived at after careful consideration
          of the evidence available. Health professionals are expected to take it fully into account when
          exercising their clinical judgment. The guidance does not, however, override the individual
          responsibility of health professionals to make decisions appropriate to the circumstances of the
          individual patient, in consultation with the patient and/or guardian or carer.
         National Institute for                © National Institute for Health and Clinical
         Health and Clinical Excellence        Excellence, February 2006. All rights
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         www.nice.org.uk                       express written permission of the National
         ISBN 1-84629-150-X                    Institute for Health and Clinical Excellence.
       2 National Institute for Health and Clinical Excellence
            Nutrition support in adults                                            Outline care pathway
          Outline care pathway
                                                  Organisation
                                                      Screen
                                                    Recognise
                                                     Consider
                      Oral           And/             Enteral           And/           Parenteral
                                       or                                 or
                                                  Prescription
                                                    Monitor
                                                      Review
                                                                  National Institute for Health and Clinical Excellence   3
          Nutrition support in adults            Patient-centred care
         Patient-centred care
         This guideline offers best practice advice on the care of adults who are malnourished or at risk of
         malnutrition. 
         Treatment and care should take into account patients’ needs and preferences. People with malnutrition
         should have the opportunity to make informed decisions about their care and treatment, in partnership
         with their healthcare professionals. 
         Good communication between healthcare professionals and patients is essential. It should be supported
         by evidence-based written information tailored to the patient’s needs. Treatment and care, and the
         information patients are given about it, should be culturally appropriate. It should also be accessible to
         people with additional needs such as physical, sensory or learning disabilities, and to people who do not
         speak or read English.
         Patients having nutrition support, and their carers, should be:
         • fully informed about their treatment
         • given tailored information 
         • given the opportunity to discuss diagnosis, treatment options and relevant physical, psychological
           and social issues 
         • given contact details for relevant support groups, charities and voluntary organisations. D(GPP)
          Recommendations in this guideline apply to all patients with malnutrition or at risk of malnutrition,
          whether they are in hospital or at home. Good coordination between the hospital and the home or
          community setting is needed when patients are transferred between settings.
       4 National Institute for Health and Clinical Excellence