Critical Care / ICU Nutrition Assessment Format

Critical Illness, Feeding & Daily Monitoring

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

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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)

ICU Admission & Nutritional Risk

ICU day
ICU diagnosis
Ventilated
Vasopressors / dose
APACHE II
SOFA
Comorbidity count
Days hospital admission → ICU (days)
Modified NUTRIC (0–9)

Feeding Delivery & Targets

Feeding route
Feeding started within 48 hours
Formula name
Actual infused rate (mL/h)
Hours infused (hours/day)
Formula energy density (kcal/mL)
Formula protein density (g/L)
Propofol volume in 24 hours (1.1 kcal/mL) (mL/day)
Delivered energy (feed + propofol)
Delivered protein
Reference (guideline) — dietitian to prescribe: ICU energy target hint (kcal/day)
Reference (guideline) — dietitian to prescribe: ICU protein target hint
% prescribed energy target achieved (care-plan energy)
% prescribed protein target achieved (care-plan protein)

GI Tolerance & Refeeding Risk

Gastric residual volume (mL)
Vomiting
Abdominal distension
Diarrhoea
Bowel sounds
NICE refeeding — major criteria (one sufficient)
NICE refeeding — minor criteria (two required)
High refeeding risk
Phosphate (mmol/L)
Potassium (mmol/L)
Magnesium (mmol/L)
Glucose (mg/dL)
Triglycerides (propofol / lipid infusion) (mg/dL)

Daily ICU Monitoring

Daily ICU monitoring — table: Date, ICU day, Route, kcal delivered, Protein (g), % target, GRV (mL), Glucose, PO4, Notes

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)
Modified NUTRIC (0–9)
Delivered energy (feed + propofol)
Delivered protein
Reference (guideline) — dietitian to prescribe: ICU energy target hint (kcal/day)
Reference (guideline) — dietitian to prescribe: ICU protein target hint
% prescribed energy target achieved (care-plan energy)
% prescribed protein target achieved (care-plan protein)
High refeeding risk
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 ICU 2023
ASPEN/SCCM 2016 & 2022
Modified NUTRIC score (Heyland; without IL-6)
ISPEN
NICE CG32
GLIM 2019
Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Critical Care / ICU Nutrition Assessment format?

The format has 12 sections: Patient Profile; Anthropometric Measurements; ICU Admission & Nutritional Risk; Feeding Delivery & Targets; GI Tolerance & Refeeding Risk; Daily ICU 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 17 values automatically, such as BMI, Waist-Hip Ratio (WHR), Waist risk (Asian cut-off).

Which guidelines does the Critical Care / ICU Nutrition Assessment follow?

It follows ESPEN ICU 2023, ASPEN/SCCM 2016 & 2022, Modified NUTRIC score (Heyland; without IL-6), ISPEN, NICE CG32, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Critical Care / ICU 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.