★ PSPEN Endorsed · Evidence-Based

PAKISTAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

Nutritional Risk Screening — NRS-2002

Complete 2-phase screening system to identify hospitalized adults at nutritional risk and to guide early nutrition support across Pakistan.

Includes initial screening (4 questions), final scoring, age adjustment, and evidence-based care pathways · For hospitals, clinics & community care

📖 About NRS-2002

The Nutritional Risk Screening 2002 (NRS-2002) is the ESPEN-recommended, validated screening tool for hospitalized adults. It identifies patients who are already malnourished or at risk of nutritional deterioration due to disease, poor intake, or metabolic stress — enabling early nutritional intervention that improves outcomes.

• Two-phase system: Quick initial screening (4 yes/no questions) → Detailed final scoring if at risk
• Three components: Impaired nutritional status + Severity of disease + Age adjustment (≥70 years)
• Score range 0–7: Score ≥3 = At nutritional risk → Start care plan and refer to dietitian/nutrition team
• Fast & practical: 2–4 minutes, usable by nurses, doctors, dietitians across Pakistan's hospital settings

2

Phases

0–7

Total Score

≥3

At-Risk Cut-off

<4m

Time / Patient

Interactive Calculator

⚡ Calculate NRS-2002 Score

Enter patient details — initial screening and final NRS score are calculated automatically.

Weight (kg)

Height (cm)

Age (years)

Weight 3 months ago (kg)

Food intake last week (% of normal) 100% — Normal intake 50–75% — Mild reduction 25–60% — Moderate reduction 0–25% — Severe reduction

Severely ill? (ICU / no intake >5 days) No Yes — severely ill

Nutritional Status Score (auto or override) — Auto from above — 0 — Normal nutritional status 1 — Mild: Wt loss >5% in 3mo OR intake 50–75% 2 — Moderate: >5% in 2mo OR BMI 18.5–20.5 + ill OR intake 25–60% 3 — Severe: >5% in 1mo / >15% in 3mo OR BMI <18.5 + ill OR intake 0–25%

Disease Severity Score (0–3) 0 — Normal nutritional requirements 1 — Mild: hip fracture, chronic disease acute, cirrhosis, COPD, dialysis, diabetes, oncology 2 — Moderate: major abdominal surgery, stroke, severe pneumonia, hematologic malignancy 3 — Severe: head injury, bone marrow transplant, ICU APACHE >10

Manual Initial Screening Override — Use auto calculation — All No — Not at risk on initial screen At least one Yes — Proceed to final

👆 Fill in the fields above — initial screening and final NRS-2002 score will appear here

📋 NRS-2002 — Two-Phase Flowchart

Initial Screening (4 questions) → Final Screening (Nutritional + Disease + Age) → Total Score → Care Plan

I

Initial Screening — 4 Questions

If answer is YES to any question → proceed to final screening

1. Is BMI < 20.5?Low body mass index suggests risk

2. Weight loss in last 3 months?Any unintentional loss

3. Reduced intake last week?Less than normal food

4. Is patient severely ill?e.g., ICU, critical illness

If NO to all 4 →Patient is NOT at risk at present. Re-screen weekly during hospital stay. If scheduled for major surgery, consider preventive nutritional care plan.

If YES to any →Proceed to Final Screening (Phase II) to quantify risk and decide intervention.

If YES to any → Final Screening

II

Final Screening — Full Scoring System

Score Nutritional impairment (0–3) + Disease severity (0–3) + Age ≥70 (+1) = Total 0–7

Impaired Nutritional Status0-3

0 — Normal
Normal nutritional status

0

1 — Mild
Wt loss >5% in 3mo OR intake 50–75% of normal

1

2 — Moderate
Wt loss >5% in 2mo OR BMI 18.5–20.5 + impaired condition OR intake 25–60%

2

3 — Severe
Wt loss >5% in 1mo (>15% in 3mo) OR BMI <18.5 + impaired OR intake 0–25%

3

Severity of Disease0-3

0 — Normal requirements

0

1 — Mild
Hip fracture, chronic disease with acute complications (cirrhosis* , COPD*), hemodialysis, diabetes, oncology

1

2 — Moderate
Major abdominal surgery*, stroke*, severe pneumonia, hematologic malignancy

2

3 — Severe
Head injury*, bone marrow transplant*, ICU patients (APACHE >10)

3

Age Adjustment+1

Age <70 years
No extra points

0

Age ≥70 years
Add 1 point to total score (elderly at higher risk)

+1

Formula:
Total = Nutritional (0–3) + Disease (0–3) + Age (0–1)
Range: 0–7

* Examples: Severity grading depends on disease stage, complications and tolerance. The examples are guides — use clinical judgement for other diagnoses (* = based on protein requirements).

Add scores → Total NRS-2002 Score 0–7

∑

Total Score & Risk Category

NRS-2002 final interpretation

<3

NOT AT NUTRITIONAL RISKTotal score 0–2 · No nutritional intervention required at presentRe-screen weekly if hospitalized. If major surgery planned, consider preventive plan.

≥3

AT NUTRITIONAL RISKTotal score 3–7 · At risk — Start nutritional care planRefer to dietitian, monitor, improve intake, consider supplements/support.

<3 · Not at Risk Routine Monitoring

• Continue routine clinical care
• Re-screen weekly for inpatients; for outpatients at next visit
• If major operation planned — consider preventive nutrition support
• No dietetic referral needed unless intake deteriorates

≥3 · At Risk Treat & Refer

• Start nutritional care plan immediately
• Refer to dietitian / clinical nutrition team
• Consider ONS / enteral / parenteral per indication & GI function
• Monitor: weekly in hospital, monthly in community, and after any clinical change

⚠️ Clinical Notes: NRS-2002 is validated for hospitalized adults (≥18 years). For ICU patients, combine with clinical judgement, biochemistry, and functional assessment. If weight/height cannot be measured, use MUAC, ulna length, knee height or SGA. * Protein requirements increase with disease severity — marked * conditions indicate higher protein needs per ESPEN guidance.

★ PAKISTAN SOCIETY FOR PARENTERAL & ENTERAL NUTRITION ★

Developed & endorsed for clinical use by PSPEN Pakistan — Adapted from ESPEN NRS-2002 for local practice
For educational & clinical use by qualified healthcare professionals. © PSPEN · 2025

Reference Tables

📊 Detailed NRS-2002 Scoring Definitions

Official scoring criteria used in Phase II of NRS-2002 — keep this chart at nursing stations.

← Swipe table on mobile →

Score	Impaired Nutritional Status	Severity of Disease
0	Normal nutritional status	Normal nutritional requirements
1 (Mild)	Wt loss >5% in 3 months OR Food intake below 50–75% of normal requirement in preceding week	Hip fracture* · Chronic patients with acute complications: cirrhosis*, COPD* · Chronic hemodialysis, diabetes, oncology
2 (Moderate)	Wt loss >5% in 2 months OR BMI 18.5–20.5 + impaired general condition OR Food intake 25–60% of normal requirement	Major abdominal surgery* · Stroke* · Severe pneumonia, hematologic malignancy
3 (Severe)	Wt loss >5% in 1 month (>15% in 3 months) OR BMI <18.5 + impaired general condition OR Food intake 0–25% of normal requirement	Head injury* · Bone marrow transplantation* · Intensive care (APACHE score >10)

* Marked conditions indicate prototype diagnoses where protein needs are increased and can be used as reference for other conditions. Scoring must incorporate clinical judgement for comorbidities and complications.

Support Charts

📊 BMI Classification & Re-screening Schedule

Use together with NRS-2002 initial screening — especially Question 1 (BMI <20.5).

WHO BMI Classification (Adults)

← Swipe →

BMI	Category	MUST-like
<16	Severe Underweight	High Risk
16–18.4	Underweight	Risk
18.5–20.5	Low Normal	NRS Yes
20.5–24.9	Normal	Normal
≥25	Overweight/Obese	Not NRS risk*

Re-screening Schedule (PSPEN)

← Swipe →

Setting	<3 Not at risk	≥3 At risk
Hospital inpatient	Weekly	Weekly — monitor care plan
Outpatient / GP	Each visit / monthly	2–4 weekly
Care home	Monthly	Monthly
Community	Monthly–3 monthly if elderly	Monthly

* Obesity does not exclude simultaneous risk of undernutrition due to poor intake/severe disease — use clinical judgement.

Alternative Methods

📏 When Weight or Height Cannot Be Measured

🦴 Ulna Length

Olecranon to styloid process → convert to height using validated tables. Best for bedridden patients.

🦵 Knee Height

Heel to anterior thigh, knee 90°. Use age/gender equations. Best for elderly.

📐 MUAC

Mid-upper arm circumference. <23 cm = undernutrition risk; <19 cm = severe. Rapid screening tool.

📋 SGA

Subjective Global Assessment — comprehensive bedside nutritional assessment when NRS is not applicable.

Clinical Pathways

🏥 When to Refer to Nutrition Team

🚨 Immediate (24–48h)

• NRS ≥3 with inadequate intake
• BMI <18.5 or Wt loss >10% with acute disease
• ICU, head injury, bone marrow transplant, major surgery with poor intake
• No oral intake >5 days, severe dysphagia, aspiration

📅 Routine (1–2 weeks)

• NRS = 1–2 but intake declining or chronic disease worsening
• Elderly ≥70 with BMI 18.5–20.5
• Post-surgical, oncology, COPD, CKD patients needing review
• Community elderly with reduced appetite/mobility

Best Practice

💡 PSPEN Implementation Tips for Pakistan

🏥

For Hospitals

• Screen all admissions within 24h
• Add NRS score to nursing admission sheet
• Flag ≥3 patients for dietitian automatically
• Re-screen weekly and at discharge

👨‍⚕️

For GPs

• Screen elderly and chronic disease at each visit
• Combine with weight & medication review
• Educate in local language on food-first

🏡

For Community

• Train LHWs/nurses in NRS initial 4 questions
• Screen home-bound elderly first visit
• Family counseling on high-protein local foods: daal, eggs, milk, nuts

🍽️

Intervention

• Food first: small frequent meals 5–6/day
• ONS if diet insufficient
• Manage nausea, pain, dental, depression
• Enteral/parenteral if GI failure per PSPEN guidance

FAQ

❓ Frequently Asked Questions — NRS-2002

Q1. What is the difference between MUST and NRS-2002?

MUST focuses mainly on BMI, weight loss and acute disease effect (score 0–6). NRS-2002 adds detailed disease severity grading (0–3) and age adjustment ≥70 years, giving a total 0–7. ESPEN recommends NRS-2002 specifically for hospitalized patients, while MUST is more versatile across community, care homes and hospitals. PSPEN endorses both — NRS-2002 for inpatients.

Q2. Can NRS-2002 be used in children or pregnant women?

No. NRS-2002 is validated for adults ≥18 years in hospitals. Use paediatric tools (e.g., STAMP, STRONGkids) for children, and specialist antenatal assessment for pregnant women.

Q3. If initial screening is all NO, do I need final screening?

No. If all 4 initial questions are NO, the patient is not at risk at that time. Document, provide routine care, and re-screen weekly if still hospitalized.

Q4. How accurate is BMI <20.5 cut-off for Pakistanis?

BMI <20.5 is part of NRS initial screening and is deliberately higher than WHO underweight cut-off (18.5) to be sensitive. South Asian populations have higher fat at lower BMI, so this cut-off is appropriate, even protective, for early detection in Pakistani patients.

Q5. What if I cannot measure weight or height?

Use MUAC, ulna length or knee height to estimate height and assess nutritional status. If still impossible, rely on SGA and clinical judgement for nutritional risk.

Q6. Score ≥3 but patient is obese — should I intervene?

Yes. Sarcopenic obesity or obese patients with severe disease and very poor intake can be at nutritional risk despite high BMI. Ensure protein intake and consider dietitian referral even if BMI is high.

Q7. Is training required?

PSPEN recommends a 2–3 hour training covering initial 4 questions, scoring of nutritional status and disease severity, age adjustment and documentation. Training materials are available for hospital teams.