Nutrition is the process by which an organism uses food to support its life. Nutrients acquired from foods and fluids are used for the body’s cellular metabolism. Optimal nutrition means having adequate vitamins and nutrients to support the body’s processes.
Malnutrition occurs due to inadequate, excessive, or imbalanced nutritional intake. This includes being underweight or overweight, or lacking specific nutrients.
In this article:
- Risk Factors
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Disturbed Body Image
- Fatigue
- Imbalanced Nutrition Less Than Body Requirements
- Overweight
Risk Factors
Common risk factors for malnutrition include:
- Genetics
- Stress
- Depression
- Obesity
- Imbalanced diet consumption
- Poverty
- Malabsorption or digestive disorders
- Eating disorders
- Cancer
Nursing Process
Management of malnutrition will vary depending on the type of malnutrition and the existing health conditions that caused the malnutrition.
Nurses play an important role in the nutritional screening of all patients, successfully identifying those who are malnourished or those who are at risk of developing malnutrition. Patient education is also an essential part of preventing malnutrition as the nurse reinforces healthy dietary habits and offers resources to support adequate nutrition.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to malnutrition.
Review of Health History
1. Note the patient’s general symptoms.
Clinical manifestations of malnutrition can vary. The most obvious signs include the following:
- Dry and scaly skin
- Hair loss
- Brittle nails
- Mouth ulcers
- Poor weight gain
- Electrolyte imbalances
- Decreased muscle mass and weakness
- Stunted growth
- Delayed development
- Mental changes
- Irritability
- Confusion
2. Identify specific nutrient deficiencies.
The most common micronutrient deficiencies are related to the following symptoms and conditions:
- Iron: Fatigue, anemia, skin pallor, shortness of breath, impaired cognition, headache, inflammation of the tongue (glossitis), and brittle nails
- Iodine: Goiter, delayed growth and development, and mental retardation
- Vitamin D: Hypocalcemia, rickets, and poor growth
- Vitamin A: Night blindness, dryness of the eye (xerophthalmia), slow growth, frequent infections, infertility
- Folate: Glossitis, fatigue, muscle weakness, vision abnormalities, megaloblastic anemia, and neural tube defects in babies of women not taking folate supplements
- Zinc: Anemia, dwarfism, liver and spleen enlargement (hepatosplenomegaly), hyperpigmentation, hypogonadism, acrodermatitis enteropathica (dermatitis, alopecia, and watery stools), and lowered immune response
3. Monitor for weight changes.
Unintentional weight loss is the most common sign of malnutrition (undernutrition). Being overweight can also be related to malnourishment. Malnourishment may manifest as an unintended loss of 5–10% of body weight in 3–6 months.
4. Identify the patient’s risk factors:
These risk factors are associated with malnutrition:
Undernutrition:
- Eating difficulties: nausea and impaired swallowing
- Depleted calories: chronic diarrhea and cancer
- The need for extra calories: pregnancy, breastfeeding, or puberty
- Eating disorders: anorexia and bulimia
- Malabsorption: pancreatic insufficiency and inflammatory bowel disease
- Mental conditions: depression, dementia
- Requiring chronic enteral/parenteral feeding
- Disinterest in eating: restricted diet
- Financial constraints
- Limited access to healthy food
Overnutrition:
- Eating disorders: binge eating disorder
- Mental conditions: chronic stress, anxiety, depression
- Slowing down of metabolism: hypothyroidism
- Hindrance to the feeling of hunger and fullness: hormonal imbalances
- Processed food options
- Sedentary lifestyle
5. Review the patient’s supplement list.
Identify the patient’s current use of vitamins and supplements. Malnutrition is related to both deficits and excesses in the dietary intake of energy and nutrients. For example, too much vitamin C can cause diarrhea, and overuse of iron causes nausea, vomiting, and liver damage.
6. Assess the patient’s eating habits.
Malnutrition occurs due to poor food choices or limited access to healthy food leading to inadequate, excessive, or imbalanced nutritional intake. The nurse should closely assess the patient’s food choices, eating patterns, and relationship with food.
7. Obtain a thorough medical history.
A standard thorough medical history will provide important information about the risk or potential causes of malnutrition.
Physical Assessment
1. Perform a physical assessment.
The following physical symptoms are connected to protein-energy malnutrition (PEM), the most common form of nutrition deficiency in hospitalized patients in the U.S.:
- CNS: Irritable, decreased concentration, lack of emotion (apathy)
- HEENT: Papillary atrophy (smooth, shiny tongues with a red or pink background), angular cheilitis (fissured and chapped lips), and stomatitis (inflammation of oral mucosa).
- GI: Hepatomegaly (enlarged liver), fatty infiltration (steatosis or fatty liver), abdominal distention, and weak abdominal muscles
- Integumentary: reduced subcutaneous tissue, hyperpigmented skin plaques, dry skin, fissured or ridged nails, thin and brittle hair, hair loss, poor wound healing
- Lymphatics: edema to the extremities and anasarca (generalized edema)
2. Measure the vital signs.
Undernutrition can manifest through:
- Low body temperature (hypothermia)
- Low heart rate (bradycardia)
- Low blood pressure (hypotension)
Overnutrition can reveal high blood pressure (hypertension).
3. Calculate the BMI.
Calculate the patient’s body mass index (BMI). Malnourished patients may display a BMI below 18.5. Recent updates in the medical community recognize that BMI does not accurately capture weight as it does not distinguish between fat, bone density, or muscle mass. BMI should not be the only predictor of malnutrition.
4. Initiate screenings for malnutrition.
The primary purpose of nutritional status screening is to identify patients with nutritional inadequacies needing additional evaluation and treatment.
- >2 years old: Determine the body mass index (BMI).
- <5 years old: The child’s height and weight should be compared with the following:
- Reference curves of height-for-age
- Weight-for-age
- Weight-for-height
Note: Use the WHO (World Health Organization) growth guidelines to interpret anthropometric data among children.
5. Determine the patient’s arm circumference.
Mid-upper arm circumference (MUAC) can be used to detect whether a patient is severely undernourished. The arm circumference of a patient is measured at the point halfway between the patient’s shoulder and elbow. The World Health Organization classifies acute malnutrition as having a mid-upper-arm circumference (MUAC) <11.5 cm or a weight-for-height Z-score (WHZ) <-3.
6. Assess the child’s growth and development.
A child’s growth, development, and general well-being can be permanently and severely harmed by malnutrition. Poor nutrition during the first 1,000 days of life can also negatively affect a child’s mental capacity.
7. Assess for the presence of dehydration and acidosis.
Protein-energy malnutrition is associated with dehydration and metabolic acidosis. Look for signs of dehydration (such as dry skin and poor skin turgor) and metabolic acidosis (such as headache, confusion, and tachycardia).
Diagnostic Procedures
1. Take blood samples for specific nutrient imbalances.
Blood should be drawn to check for specific nutrient imbalances like anemia or iron deficiency.
2. Assess for protein malnutrition.
Levels of the following parameters are used as indicators of protein nutritional status:
- Serum albumin
- Retinol-binding protein
- Prealbumin
- Transferrin
- Creatinine
- Blood urea nitrogen
3. Assess hormone levels.
Excess or inadequate hormone levels also influence nutrition. The following hormones can be checked for abnormalities:
- Human growth hormone
- Insulin
- Thyroxine
- Somatostatin
- Cortisol
- Estrogen
4. Assess electrolytes and enzymes.
Imbalances in electrolytes and organ function can also provide crucial information. Consider the following lab tests:
- Calcium
- Potassium
- Magnesium
- Chloride
- Lipase
- Amylase
5. Check the peak height velocity.
Velocity curves show the period when a child experiences their fastest growth rate, also known as a “growth spurt.” If the height velocity is abnormal, other examinations might concentrate on thyroid function or sweat chloride testing (to diagnose cystic fibrosis).
6. Obtain stool specimens.
Stool samples should be collected if the patient has a history of unusual stools, bowel pattern changes, or suspected inflammatory bowel disease.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with malnutrition.
Reverse Malnutrition
1. Treat the underlying cause.
The underlying cause and the severity of malnutrition affect the course of treatment. Interventions may include medications for chronic diseases, mental health treatment, financial resources, multidisciplinary consultations, and nutritional support.
2. Provide the recommended caloric intake.
Most children who suffer from mild malnutrition respond well to increased oral calorie intake. Refeeding with a customized, high-calorie nutritional formula with vitamin supplementation will resolve nutrient deficits and improve weight.
3. Increase protein in the diet.
Protein intake can be increased no matter the client’s preferred diet or food preferences:
- Meat: pork and beef
- Poultry: chicken and turkey
- Fish and seafood: tuna, salmon, shrimp
- Eggs
- Dairy products: milk and cheese
- Nuts: almonds and cashews
- Legumes and beans: beans and lentils
4. Increase calories.
Patients who are averse to eating due to nausea, vomiting, pregnancy, pain, or eating disorders may not be able to eat full meals and can eat smaller portions of high-calorie foods instead, like smoothies, nut butters, potatoes, cheese, and whole milk.
5. Correct the deficiencies.
Recommend taking supplements of necessary nutrients (such as vitamins, iron, and folate) as prescribed.
6. Refeed the patient.
The body adapts to undernutrition by slowing metabolism. Refeeding must be done with caution as refeeding syndrome can occur, which causes serious shifts in fluids and electrolytes as the body learns to metabolize nutrients again.
7. Instruct on weight loss.
Obesity is a sign of overnutrition. The likelihood of developing secondary illnesses (like diabetes and heart disease) can be decreased by losing excess weight. Diet and exercise regimens, medications, and medical procedures are all possible forms of weight loss treatment.
8. Encourage patient adherence.
Long-term support systems like counseling, behavioral therapy, support groups, and nutrition instruction may be needed to promote adherence to the plan of care.
9. Explain the need for tube feedings.
Enteral supplementation may be required in cases of moderate to severe malnutrition. Patients who cannot eat, refuse to eat, or have problems absorbing nutrients from food can be fed intravenously (parenteral nutrition) or through a tube placed in the stomach (enteral nutrition). Short-term tube feeding can be accomplished by inserting a nasogastric tube.
10. Monitor progress.
Progress must be periodically monitored to ensure that treatment is effective. The patient will have their weight and height measured along with other data like meal or calorie tracking.
11. Seek guidance from a dietitian.
Patients may receive advice from a dietitian regarding dietary adjustments. Registered dieticians can suggest necessary supplements and review lab results to monitor ongoing nutrient deficiencies.
12. Closely monitor for the development of complications.
A patient with malnutrition may need to be hospitalized, depending on the severity. Children, older adults, and patients with impaired cognition or decision-making abilities who present with dehydration or symptoms of malnutrition need assessment for neglect or abuse.
13. Administer appetite stimulants.
Megestrol treats anorexia, cachexia, and malnutrition in patients with cancer and AIDS.
Prevent Malnutrition
1. Offer financial or community resources.
Families at risk for malnutrition due to poverty or lack of access will require referrals to programs that assist with obtaining healthy food. This can include WIC (Women, Infants, and Children), food pantries, and other government assistance programs.
2. Allow the patient to create their meal plan.
Involving the patient in creating a healthy meal plan promotes adherence and commitment by choosing the foods they prefer. The nurse will also be able to evaluate effective teaching.
3. Prevent malnutrition in pregnancy.
Pregnant patients require extra calories to support the growth of the fetus. Ensure pregnant patients are gaining adequate weight and are taking folic acid to prevent birth defects.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for malnutrition, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for malnutrition.
Deficient Knowledge
Nutrition education is an essential part of the management of malnutrition as patients are encouraged to learn new ways to supplement diets, prevent nutrient deficiencies, and make better food choices.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Incomplete or unreliable information about nutrition
- Inadequate access to resources
- Inadequate awareness of resources
- Inadequate knowledge surrounding nutrition
- Lack of interest or motivation
- Misinformation about diets
As evidenced by:
- Inadequate follow-through of instructions
- Insufficient adherence to dietary recommendations
- Frequent requests for information about new diets
- Development of preventable disorders
Expected outcomes:
- Patient will verbalize two dietary changes to support proper nutrition.
- Patient will set a personal dietary goal and effectively formulate a plan to achieve it.
Assessment:
1. Assess the patient’s understanding and perception of nutritional needs.
Understanding how the patient perceives their own nutritional needs will enable the healthcare team to plan the best approach to delivering accurate information and care.
2. Assess for poor health literacy.
Patients with a poor understanding of diet and how certain foods affect their health may not be making appropriate food choices. Do not assume patients are aware of what is healthy or not.
Interventions:
1. Provide information about vitamins and minerals.
Patients often do not possess accurate knowledge surrounding the importance of vitamins and minerals. Most Western diets lack sufficient nutrients. Provide information on foods that contain necessary nutrients.
2. Develop a plan to prevent overeating.
Holidays, travel, and social events can lead to overconsumption. Help the patient recognize scenarios that lead to poor decision-making and plan ahead to prevent diet fluctuations.
3. Promote community resources.
Cooking classes, exercise groups, eating disorder support groups, and health departments and clinics can support the patient in learning ways to improve nutrition.
4. Encourage the patient to continue follow-up care.
Nutrition needs change throughout life. Toddlers, adolescents, pregnant or breastfeeding women, and elderly patients all have different nutritional needs. Encourage patients to discuss concerns with their primary care providers or a registered dietician.
Disturbed Body Image
A patient who does not view themselves as they are is at risk for malnutrition.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Change in appearance
- Cultural influences
- Social media influences
- Eating disorders
As evidenced by:
- Verbal or nonverbal negative responses about the body (e.g., shame, embarrassment, guilt)
- Hiding the body
- Preoccupation with appearance
- Negative feelings about the body (i.e., feelings of helplessness, hopelessness, powerlessness, vulnerability)
- Avoids social situations
Expected outcomes:
- Patient will implement two strategies to maintain a healthy weight.
- Patient will identify irrational beliefs and expectations regarding body appearance and weight.
- Patient will demonstrate social involvement in situations that may cause discomfort related to appearance (swimming, sports, etc.).
Assessment:
1. Assess for a history of eating disorders.
Anorexia nervosa, body dysmorphic disorder, and bulimia nervosa are mental illnesses that cause patients to become obsessed with their weight and appearance, leading to extreme measures to control weight gain. These practices frequently cause imbalances in nutrition.
2. Assess the patient’s verbal remarks about their weight.
Remain alert for verbalizations about dissatisfaction with the patient’s weight or appearance. Nonverbal observations such as covering the body or wearing loose clothing can reflect a disturbed body image.
Interventions:
1. Refer to a mental health professional.
In cases of eating disorders, counseling is necessary to cope with shame, guilt, and the perception of an overweight appearance.
2. Demonstrate positive self-talk.
Positive comments or acknowledgments can help boost the patient’s self-esteem.
3. Promote social interaction by:
- Encourage contact with friends and family
- Encourage involvement in group activities
- Provide an opportunity to share with people going through similar experiences
As the patient participates in activities and interacts with others, it will become easier, and the patient will become less transfixed on their weight.
4. Assist with healthy weight gain.
Patients with eating disorders are fearful of weight gain. The patient must unlearn toxic coping behaviors and may require inpatient treatment to ensure adequate nutrition.
Fatigue
Inadequate intake can cause the muscles to become wasted and weak, which ultimately causes exhaustion, fatigue, and decreased capacity for physical and mental activities.
Nursing Diagnosis: Fatigue
Related to:
- Reduced metabolic energy production
- Malnutrition
- Physical deconditioning
As evidenced by:
- Expresses extreme lack of energy
- Difficulty maintaining usual physical activity
- Expresses tiredness or weakness
- Reduced concentration level
- Lethargy or sluggishness
- Increased need to rest
- Inability to perform desired activities
Expected outcomes:
- Patient will be able to identify the source of exhaustion and the control aspects that affect it.
- Patient will verbalize an improved sense of energy.
- Patient will be able to complete tasks and participate in hobbies.
Assessment:
1. Assess the patient’s description of the fatigue.
Have the patient rate on a 1 to 10 scale to help determine the patient’s level of fatigue or exhaustion. Proper evaluation of fatigue and its impact can help formulate an appropriate treatment regimen.
2. Assess compounding causes of fatigue.
Malnutrition causes fatigue. Additional factors that may be causing or caused by malnutrition should also be considered such as pregnancy, depression, anemia, and cancer.
Interventions:
1. Determine the patient’s nutritional intake.
One of the most dominant symptoms of malnutrition is persistent fatigue. Have the patient keep a food diary and track their intake. They may not be taking in enough calories to meet their energy requirements.
2. Establish realistic goals.
Patients who experience fatigue due to a chronic condition and malnutrition may not be able to partake in strenuous activity. Increased rest periods and sleep may be required. Activity can be increased as tolerated.
3. Include the patient’s family members in patient care.
The patient’s social support is important to help the patient implement lifestyle modifications intended to reduce exhaustion.
4. Encourage easy-to-prepare, nutritionally dense foods.
Large meals or difficult-to-prepare foods may worsen fatigue. Provide plenty of healthy, easy grab-and-go foods such as nut butters, fruit, cheese, and yogurt.
Imbalanced Nutrition Less Than Body Requirements
A lack of nutrients can increase the risk of other health complications like a weakened immune system, osteoporosis, and poor wound healing.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Disease processes
- Altered taste perception
- Food aversion
- Inadequate food supply
- Inaccurate information on nutrient requirements
- Difficulty swallowing or chewing
- Depression
- Inability to absorb nutrients
As evidenced by:
- Electrolyte imbalances
- Ineffective wound healing
- Decreased levels of transferrin, protein, and serum albumin
- Loss of muscle tone
- Hypoglycemia
- Pale mucous membranes
- Dry skin
- Excessive hair loss
- Diarrhea or constipation
- Food intake less than the recommended daily allowance
- Body weight below the ideal weight range appropriate for age and gender
Expected outcomes:
- Patient will maintain a healthy weight for their age and gender.
- Patient will display adequate nutrition as evidenced by acceptable electrolyte and iron levels.
Assessment:
1. Assess BMI.
Nutrition needs will vary depending on age and gender. Body mass index measures weight in relation to height. BMI can quickly determine an underweight patient but still requires further assessment as a BMI does not always accurately portray nutrition requirements.
2. Assess and monitor laboratory results.
Laboratory results are vital in establishing the patient’s nutritional status. Serum laboratory tests like electrolytes, total protein, prealbumin, and albumin tests can help determine which nutrients are inadequate.
3. Assess for physical signs of malnutrition.
Nutritional insufficiency can make the patient appear exhausted and lethargic. Pallor, dry skin, loss of subcutaneous tissue, dull and brittle hair, and mouth fissures can also signal poor nutrition.
4. Assess the patient’s nutritional history.
Patients may experience malnutrition for several reasons. The nurse can assess for opportunities for intervention by first obtaining a history of the patient’s usual dietary intake and habits.
Interventions:
1. Treat underlying conditions.
Health conditions such as cystic fibrosis, irritable bowel syndrome, eating disorders, and more can affect nutritional intake. Underlying conditions must be stabilized in order to improve nutrition.
2. Administer parenteral nutrition.
Patients with chronic conditions or illnesses may require parenteral nutrition infusions or tube feedings.
3. Determine the availability of food.
Lack of access to nutritional food due to finances or food deserts is a common barrier. The nurse can direct the patient and family to community resources.
4. Consult with a dietician.
Dieticians can recommend diet modifications to increase calories and other nutrients and create meal plans to improve fat, carbohydrate, and protein intake.
5. Supplement diets.
Patients who have difficulty gaining weight or absorbing nutrients may require meal replacement or protein shakes. Children can be provided with high-calorie snacks and frequent small meals may be better utilized than large ones.
Overweight
Malnutrition can also result from overeating, causing weight gain.
Nursing Diagnosis: Overweight
Related to:
- Excessive consumption of sugary foods and beverages
- Excessive food intake more than recommended
- Disturbed eating patterns
- Sedentary lifestyle
As evidenced by:
- Weight 10% over ideal for height and frame
- BMI 25 kg/m2 to 29.9 kg/m2
- Triceps skinfold >15mm in men, >25mm in women
Expected outcomes:
- Patient will manifest a BMI of 18.5 to 24.9.
- Patient will demonstrate choosing healthy food choices and portions.
- Patient will demonstrate increased physical activity.
Assessment:
1. Assess body mass index (BMI).
A BMI greater than 25 is considered overweight. Note: recent guidelines recognize that BMI does not account for a patient’s muscle mass or bone density and should not be the only measurement for monitoring weight status.
2. Assess the patient’s history of weight gain or loss.
Inquire about any past difficulties with weight in childhood and adolescence, including any diagnosed eating disorders.
3. Inquire about food choices.
The nurse must assess what foods the patient is choosing and their understanding of healthy diet choices in order to instruct on modifications.
Interventions:
1. Teach the patient to keep a daily food log and caloric intake.
A food diary allows for the identification of food choices and eating patterns. The patient can use apps to easily log food that automatically calculates calories, fat, carbohydrates, protein, and sugar. This can help patients adhere to a particular diet or caloric intake.
2. Encourage the patient to engage in physical activity.
Increased physical activity of at least 150 minutes/week is crucial for weight loss. Help the patient choose activities they feel motivated to participate in.
3. Instruct on reading food labels and adhering to portion control.
Many processed, frozen, and packaged foods contain excessive amounts of sodium, fat, and sugar. Help the patient understand how to read these labels to make healthier choices. Large portions are another contributor to weight gain. Help patients keep portions smaller by measuring food, using smaller plates, and eating slowly.
4. Utilize motivational interviewing for change behavior.
Motivational interviewing techniques help patients recognize how their choices affect their weight, what is most important to them regarding weight loss, and which strategies they feel will be most effective in losing weight.
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