Burns Nutrition Assessment Format

Burn Injury, Energy Estimates & Recovery

Used by dietitians, nutrition students, hospitals and health workers across India.

Fill online | Download blank PDF (free sign-up)

What the format covers

Patient Profile

  • Registration / OPD No.
  • Date of Assessment
  • Patient Name
  • Age (years)
  • Gender
  • Contact No.
  • Address
  • Referred By
  • Ward / Bed No.
  • Occupation
  • Education
  • Modified Kuppuswamy scale class
  • Medical diagnosis / chief complaint
  • Past medical & surgical history
  • Family history
  • Physical activity level (ICMR-NIN 2020)

Anthropometric Measurements

  • Height (cm)
  • Weight (kg)
  • BMI (kg/m²)
  • MUAC (Mid-Upper Arm Circumference) (cm)
  • Waist Circumference (cm)
  • Hip Circumference (cm)
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • Usual body weight (kg)
  • % weight change (%)
  • Body Fat % (%)
  • Ideal Body Weight (kg)
  • BMI Category (Asia-Pacific)

Burn Injury & Energy Assessment

  • Total body surface area burned (% TBSA)
  • Burn depth
  • Date of injury
  • Inhalation injury
  • Days post-burn (days)
  • Temperature (°C)
  • Calorie intake previous 24 h (kcal)
  • Harris–Benedict BEE (adult, no stress/activity factors)
  • Reference (guideline) — dietitian to prescribe: Toronto energy formula (adult estimate, kcal/day)
  • Reference (guideline) — dietitian to prescribe: Curreri adult reference (kcal/day; tends to overestimate)
  • Reference (guideline) — dietitian to prescribe: Burns protein target

Burns Supplements & Weekly Monitoring

  • Micronutrients given
  • Glutamine — treating-team decision / indication
  • Weekly weight — table: Date, Week, Weight (kg), Notes / fluid status

Dietary Assessment

  • Diet Type
  • No. of Meals/Day
  • Appetite
  • Food Allergy / Intolerance
  • Food Aversions
  • Food Preferences
  • Water Intake (litres/day)
  • Alcohol Consumption
  • Tobacco Use
  • 24-hour dietary recall — table: Time, Meal, Food / dish, Ingredients, Household measure, Approx. quantity (g/mL)
  • Food frequency — table: Frequency, Usual portion
  • Nutritional Supplements

Nutrition-Focused Physical Examination (NFPE)

  • Muscle wasting
  • Subcutaneous fat loss
  • Oedema
  • Hair
  • Eyes
  • Mouth
  • Skin
  • Nails
  • Goitre
  • Handgrip strength (optional) (kg)

Nutrition Diagnosis & Risk Stratification

  • GLIM 2019 — phenotypic criteria
  • GLIM 2019 — etiologic criteria
  • GLIM malnutrition
  • GLIM severity (assessor confirmed)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically) (g/day)
  • Protein Requirement (g/day)
  • Special Nutrient Focus
  • Dietary Advice / Modifications
  • Sample Meal Plan Given?
  • Next Follow-Up Date
  • Counselling Notes
  • Monitoring & Evaluation — table: Indicator, Baseline, Target, Review date, Outcome

Diet Prescription (filled by dietitian)

  • Prescribed energy (kcal/day)
  • Prescribed protein (g/day)
  • Prescribed fluid (mL/day)
  • Diet type / consistency
  • Restrictions
  • Meal plan — table: Time, Food / dish, Quantity (household measure)
  • Foods to include
  • Foods to avoid
  • Prescribed by (name, reg. no.)

Signature

  • Dietitian Name & Signature

Automatic scores in this form

  • BMI
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • % weight change
  • BMI Category (Asia-Pacific)
  • Harris–Benedict BEE (adult, no stress/activity factors)
  • Reference (guideline) — dietitian to prescribe: Toronto energy formula (adult estimate, kcal/day)
  • Reference (guideline) — dietitian to prescribe: Curreri adult reference (kcal/day; tends to overestimate)
  • Reference (guideline) — dietitian to prescribe: Burns protein target
  • GLIM malnutrition
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically)

All calculated values are indicative — clinical judgement required.

Standards & references

  • ESPEN burns 2013
  • ISBI practice guidelines 2016
  • Toronto formula
  • Original Harris–Benedict BEE
  • Curreri formula (adult reference)
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Burns Nutrition Assessment format?

The format has 10 sections: Patient Profile; Anthropometric Measurements; Burn Injury & Energy Assessment; Burns Supplements & Weekly Monitoring; Dietary Assessment; Nutrition-Focused Physical Examination (NFPE); Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 13 values automatically, such as BMI, Waist-Hip Ratio (WHR), Waist risk (Asian cut-off).

Which guidelines does the Burns Nutrition Assessment follow?

It follows ESPEN burns 2013, ISBI practice guidelines 2016, Toronto formula, Original Harris–Benedict BEE, Curreri formula (adult reference), GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Burns Nutrition Assessment as a PDF?

Yes. After a free sign-up you can fill the form online and download both blank and filled A4 PDFs, and save private case sheets for your patients.

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