Did you know:
- patients diagnosed with malnutrition stay in the hospital three times longer than other patients?
- surgical patients with malnutrition are four times more likely to develop pressure
- nurses are the healthcare professionals who typically conduct nutrition screening as part of admission assessment?
Today, we know that disease-related malnutrition is prevalent and linked to poor patient outcomes, higher readmission rates, and increased costs. Nurses can and should participate in identifying, preventing, and treating malnutrition. (See Nurse’s role in nutrition care.) This entails a partnership between registered dietitians (RDs) and registered nurses (RNs), with clear interdisciplinary communication throughout the patient’s care trajectory.
To provide optimal nutrition care and ensure each patient is assessed for malnutrition, the multidisciplinary care team (including the RD) should take a logical stepwise approach. The six steps in the American Society for Parenteral and Enteral Nutrition’s (A.S.P.E.N.) Adult Nutrition Care Pathway, described below, require documentation in an electronic health record that’s robust enough to allow efficient assessment, intervention, and communication across the entire healthcare team. (See nutritioncare.org/malnutrition.)
Step 1: Nutrition screening
The Joint Commission requires nutrition screening for all hospital patients within 24 hours of admission to identify those who may be malnourished or at risk for malnutrition. Assessment findings determine if the patient requires a detailed nutrition assessment. In most cases, nurses perform this screening as part of the general admission assessment.
Step 2: At-risk determination
Adults with any of the following may be considered to be at risk for malnutrition:
- involuntary loss of 10% or more of usual body weight within 6 months, or involuntary loss of 5% or more of usual body weight in 1 month
- involuntary loss or gain of 10 lb within 6 months
- body mass index below 18.5 kg/m2 or above 25 kg/m2
- chronic disease
- increased metabolic requirements
- altered diet or diet schedule
- inadequate nutritional in-take, including not receiving food or nutrition products for more than 7 days.
Once you identify an at-risk patient, be sure to communicate this finding to the RD.
Step 3: Nutrition assessment
A comprehensive approach to diagnosing nutrition problems, nutrition assessment relies on a combination of medical, nutrition, and medication histories; physical examination findings; anthropometric measurements; and laboratory data. When conducting a nutrition assessment, check the patient for:
- trouble chewing
- swallowing disorders
- weight history
- height and weight measurement
- skin integrity
- electrolyte abnormalities
- hand-grip strength (have the patient squeeze your hand).
Generally, an RD or a member of the nutrition support service performs a more in-depth nutrition assessment. This assessment delineates the malnutrition diagnosis and serves as the basis for the nutrition plan of care.
Step 4: Malnutrition diagnosis
In 2012, the A.S.P.E.N./Academy of Nutrition and Dietetics Malnutrition workgroup identified six malnutrition characteristics to assess. Two or more of the following findings warrants a malnutrition diagnosis, with severity defined further through specific thresholds or parameters:
- weight loss
- inadequate energy intake
- muscle mass loss
- subcutaneous fat loss
- fluid accumulation
- reduced hand-grip strength.
Step 5: Nutrition care plan
The nutrition care plan is a formal statement of nutritional goals and interventions prescribed for the patient, based on nutrition assessment data. The plan includes statements of nutritional goals and monitoring and evaluation parameters, the most appropriate administration route for nutrition therapy, nutrition access method, anticipated duration of therapy, and training and counseling goals and methods.
Nutrition interventions may include optimizing the patient’s oral intake, providing oral nutrition supplements, and administering enteral and parenteral nutrition. Nurses play a key role in implementing these interventions.
Step 6: Monitoring and transition-of-care planning
The patient’s nutritional status, nutrition goals, and safety and efficacy of interventions need to be monitored on a continual basis, particularly with transition-of-care planning. Be sure to communicate the patient’s nutrition care plan during care transitions. Too often, nutrition interventions stop when a patient is discharged from the hospital; in many cases, the patient needs to be readmitted with worsening malnutrition. Using a transition-of-care plan by nurses (such the A.S.P.E.N. Nutrition Care Pathway) can help prevent readmission of vulnerable patients.
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Peggi Guenter is senior director of Clinical Practice, Quality, and Advocacy at the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) in Silver Spring, Maryland. Ainsley Malone is a clinical practice specialist at A.S.P.E.N. and a member of the nutrition support team at Mt. Carmel West Hospital in Columbus, Ohio. Rose Ann DiMaria-Ghalili is an associate professor of nutrition in the doctor of nursing practice department at Drexel University in Philadelphia, Pennsylvania.