Hospital Nutrition: Defining Nutrition Risk and Feeding Patients

Hospital Nutrition: Defining Nutrition Risk and Feeding Patients

The primary focus of clinical nutrition is to prevent or treat malnutrition. The first step in the process is to identify patients with, or at risk for, malnutrition via a nutrition screen (see Chapter 1). A nutrition assessment follows along with classification of the degree of malnutrition and implementation of a nutrition care plan. The nurse facilitates the nutrition care process by sharing assessment data; facilitating nutrition therapy interventions; reinforcing nutrition education; monitoring the patient’s intake, weight, and function; and communicating findings so that the plan can be revised as needed. The nurse plays a critical role in combatting malnutrition.

This chapter begins with the etiology and characteristics of malnutrition and leads to options for “feeding” patients, including oral diets, nutritional supplements, enteral nutrition, and parenteral nutrition.


The prevalence of malnutrition among hospitalized adults is estimated at 30% to 50% (Jensen, Compher, Sullivan, & Mullin, 2013); however, only 3.2% of these patients are discharged with the diagnosis of malnutrition (Corkins et al., 2014). This discrepancy may be explained in part by the failure to identify patients with malnutrition and the lack of a universally agreed upon definition of malnutrition. It is well recognized that malnutrition is associated with numerous adverse outcomes, including an increased risk of pressure ulcers, impaired wound healing, immune suppression, increased rate of infection, muscle wasting, prolonged hospital stay, higher readmission rates, higher health-care costs, and increased mortality (Barker, Gout, & Crowe, 2011). The deleterious effect of malnutrition not only affects virtually all organ systems but it can also impair cognitive ability, leaving patients unable to make independent, informed consent when they are in a severely compromised nutritional state (Russo, Gupta, & Merriman, 2016). Timely identification and treatment of malnutrition is critical to improving patient outcomes (Field & Hand, 2015).

Diagnosis of Malnutrition

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) includes diagnosis codes for adult protein calorie malnutrition for billing and research purposes. However, the lack of a universally accepted set of signs and symptoms for defining and classifying the severity of malnutrition results in widespread confusion and potential misdiagnosis (White, Guenter, Jensen, Malone, & Schofield, 2012).

Recognizing the need to standardize how malnutrition is defined and classified, the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition proposed a standardized approach for defining malnutrition in the adult hospitalized patient (White et al., 2012). The etiology-based approach involves assessing the patient for the presence of inflammation, which is a potent contributor to disease related malnutrition (Fig. 14.1) (Malone & Hamilton, 2013). Although there is not one single criteria to confirm the presence of inflammation, a variety of lab values and clinical symptoms may be used, such as low serum albumin, elevated C-reactive protein, high blood glucose, altered white blood
cell count, fever, and infection (Malone & Hamilton, 2013). The etiology-based definitions of malnutrition are

  • Starvation-related, which occurs when food is not available due to environmental or social circumstances. It usually develops slowly and may be caused by abuse, neglect, famine, poverty, or disordered eating (Skipper, 2012).

  • Chronic disease-related, which may occur in patients with diseases such as congestive heart failure or chronic obstructive pulmonary disease. A mild to moderate degree of inflammation impedes appetite, intake, or nutrient utilization.

  • Acute disease or injury-related, which may occur in patients with critical illness, multitrauma, or major infection due to a marked inflammatory response. These patients may be adequately nourished upon admission but are at high risk for malnutrition due to the nature of their illness.

Figure 14.1Etiology-based malnutrition definitions.

Six characteristics have been proposed for diagnosing and classifying the degree of malnutrition (Table 14.1). Malnutrition is diagnosed when a patient demonstrates two or more characteristics and is classified as severe or nonsevere (moderate) based on specific thresholds and/or descriptions for each etiology of malnutrition. Table 14.2 illustrates the interpretation of weight loss.

Nutrition Therapy for Malnutrition

Nutrition intervention is well documented to improve key clinical outcomes (Tappenden et al., 2013). Numerous studies, mostly in patients 65 years of age and older, show specific nutrition interventions have the potential to substantially lower complication rates, length of hospital stay, readmission rates, cost of care, and, in some cases, mortality (Cawood, Elia, & Stratton, 2012; Somanchi, Tao, & Mullin, 2011). Actual nutrient requirements are affected by the underlying etiology of malnutrition. For instance, the nutrition prescription for a patient whose malnutrition is caused by cirrhosis will differ from malnutrition caused by major burns.
Nutrition intervention strategies include oral diets, supplements, enteral nutrition, and/or parenteral nutrition. Often, a combination of nutrition therapies is needed to meet increased nutritional needs (Russo et al., 2016).

Table 14.1 Characteristics to Assess for Malnutrition

Malnutrition Characteristics

How Obtained

Potential Problems

Weight loss over time

Actual or stated measurement upon admission

Weight history

Fluid overload or dehydration will skew admission weights.

Usual weight may be unknown or difficult for the patient or caregiver to recall.

Inadequate food and nutrition intake compared with requirements

History obtained from the patient or caregiver

Meal consumption documentation

If indirect calorimetry is not available, calorie needs are estimated by using predictive equations which are less valid.

Loss of muscle mass

Physical assessment of various muscles, such as quadriceps, trapezius, deltoid

Requires experience and training

Loss of fat mass

Physical assessment of subcutaneous fat, such as the orbital region, upper arm, and thoracic regions

Requires experience and training

Fluid accumulation

Physical exam for the presence of local or generalized fluid retention, such as in the lower and upper extremities, face and eyes, and scrotal area

Fluid accumulation may be caused by other conditions such as congestive heart failure or chronic kidney disease.

Measurably diminished hand grip strength

Measured by a dynamometer

Requires experience and training

Diseases such as rheumatoid arthritis, dementia, and neuromuscular diseases may limit validity of measure.

Source: Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in practice. Nutrition in Clinical Practice, 28, 639-650.

Although timely implementation of a nutrition care plan is clinically important, it is often delayed (Russo et al., 2016). For instance, patients may be nothing by mouth (NPO) for extended periods of time due to medical diagnostic tests or procedures. Patients with poor intake due to changes in mental status may be candidates for enteral nutrition, but it may not be implemented in the hope of quick improvement in mentation. These and other scenarios leave a gap between what is recommended and what is actually implemented. Efforts should be made to monitor “holds” on oral diets or enteral nutrition for procedures and to ensure that enteral or parenteral formulas are infused at the prescribed rate to maximize benefits (Tappenden et al., 2013).

Table 14.2 Interpretation of Weight Loss by Malnutrition Etiology

Etiology of Malnutrition

Moderate Malnutrition

Severe Malnutrition

Starvation or chronic disease

5%/1 month

7.5%/3 months

10%/6 months

20%/1 year

>5%/1 month

>7.5%/3 months

>10%/6 months

>20%/1 year

Acute disease or injury

1-2%/1 week

5%/1 month

7.5%/3 months

>2%/1 week

>5%/1 month

>7.5%/3 months

Source: Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in practice. Nutrition in Clinical Practice, 28, 639-650.


The goal of nutrition intervention for all hospitalized patients, whether or not they have been diagnosed with malnutrition, is to provide sufficient calories and nutrients to meet the patient’s estimated needs in a form the patient can tolerate and utilize. Feeding strategies are presented in the following text.

Oral Diets

Oral diets are the easiest and most preferred method of providing nutrition. In most facilities, patients choose what they want to eat from a menu representing the diet ordered by the physician. Oral diets may be categorized as “regular,” modified consistency, or therapeutic. Often, combination diets are ordered, such as a pureed low-sodium diet or a high-protein, soft diet. The actual foods allowed on a diet vary among institutions and the diet manual used.

Private and government regulatory agencies stipulate meal timing, frequency, and nutritional content and require that hospital menus be supervised by a qualified dietitian. Many hospital food service departments offer a room service, cook-to-order menu. Compared to more traditional food service menus, a restaurant-style service gives patients greater control over what and when they eat, provides more menu choices, improves food quality and service temperatures, reduces food waste, and improves patient satisfaction (Fitzpatrick, 2010).

A study by van Bokhorst-de van der Schueren, Roosemalen, Weijs, and Languis (2012) found that although meals provided adequate amounts of calories and protein, most patients do not consume complete meals: 61% of patients consumed <90% of their calorie requirement and 75% consumed <90% of their protein requirement. Appetite may be impaired by fear, pain, or anxiety. Hospital food may be refused because it is unfamiliar, tasteless (e.g., cooked without salt), inappropriate in texture (e.g., pureed meat), religiously or culturally unacceptable, or served at times when the patient is unaccustomed to eating. Inadequate liquid diets may not be advanced to a solid food diet in a timely manner. Patients may underestimate the importance of nutrition in their recovery process. Giving the right food to the patient is one thing; getting the patient to eat (most of it) is another. See Box 14.1 for suggestions on how to promote an adequate intake.

Regular Diet

Regular diets are used to achieve or maintain optimal nutritional status in patients who do not have altered nutritional needs. No foods are excluded, and portion sizes are not limited on a normal diet. The nutritional value of the diet varies significantly with the actual foods chosen by the patient.

Regular diets are adjusted to meet age-specific needs throughout the life cycle. For instance, a regular diet for a child differs from that of an adult. Regular diets are also altered to meet specifications for vegetarian or kosher eating.

Sometimes, physicians order a diet as tolerated (DAT) on admission or after surgery. This order is interpreted according to the patient’s appetite and ability to eat and tolerate food. The nurse has the authority to advance the DAT.

Modified Consistency Diets

Modified consistency diets include clear liquid and mechanically altered diets (Table 14.3). A clear liquid diet is the most frequently ordered postoperative meal, based on the rationale that a gradual progression from a clear liquid diet to a regular diet is important for maximizing tolerance when
eating resumes. However, there is little scientific evidence to support this practice. In a randomized controlled trial of patients undergoing major gastrointestinal (GI) surgery, giving “normal food” on the first postoperative day did not increase morbidity or mortality; postop nausea occurs in approximately 20% of patients whether they are advanced first to clear liquids or to solid food (Lassen et al., 2008). A regular diet as the first meal has been shown to be well tolerated and provides more nutrition and greater patient satisfaction than a clear liquid diet (Warren, Bhalla, & Cresci, 2011).

Table 14.3 Characteristics of Modified Consistency Diets

Diet Characteristics

Foods Allowed


Clear liquid

A short-term, highly restrictive diet composed only of fluids or foods that are transparent and liquid at body temperature (e.g., gelatin). It requires minimal digestion and leaves a minimum of residue. Inadequate in calories and all nutrients except vitamin C if vitamin C-fortified juices are used.

Clear broth or bouillon

Coffee, tea, and carbonated beverages, as allowed and as tolerated

Fruit juices; clear (apple, cranberry, grape) and strained (orange, lemonade, grapefruit)

Fruit ice made from clear fruit juice



Sugar, honey, hard candy

Commercially prepared clear liquid supplements

In preparation for bowel surgery or colonoscopy; acute gastrointestinal disorders; transitional feeding after parenteral nutrition

Practice of using clear liquids as initial feeding after surgery may not be warranted.

Pureed diet

A diet composed of foods that are blended, whipped, or mashed to pudding-like consistency

All foods should be smooth and free of lumps.

Most foods can be liquefied by combining equal parts of solids and liquids; fruits and vegetables need less liquid.

Broth, gravy, cream soups, cheese, tomato sauce, milk, and fruit juice are preferable to water for blenderizing due to their higher calorie and nutritional value.

Liquids may be thickened to improve ease of swallowing.

All foods are allowed, but consistency is changed to liquid.

Used after oral or facial surgery; for wired jaws; chewing and swallowing problems

Mechanically altered diet

A regular diet modified in texture only; excludes most raw fruits and vegetables and foods containing seeds, nuts, and dried fruit

Gravies, sauces, milk, and water are used to soften foods that are chopped, ground, mashed, or cooked soft.

Sticky foods such as peanut butter are avoided.

Chopped or ground diet: milk; yogurt; pudding; cottage cheese; mashed, soft ripened fruit (peaches, pears, bananas); cooked, mashed soft vegetables (peas, carrots, yams); ground meats; soft casseroles; smooth cooked cereals; soft bitesized pasta; bread products made into a slurry with the addition of gravy or syrup

Used for patients who have limited chewing ability, such as patients who are edentulous, have ill-fitting dentures, or have undergone surgery to the head, neck, or mouth

Soft diet

A regular diet that features soft-textured foods that are easy to chew and swallow. Hard, sticky, dry, or crunchy foods are excluded.

Soft cooked vegetables; shredded lettuce; canned fruit; soft, peeled fresh fruit; well-moistened, thin sliced, tender, or ground meats, poultry, or fish; eggs; milk; yogurt; mashed potatoes; white rice; well-cooked pasta; well-moistened cereals without dried fruits or nuts

Used to limit gastrointestinal irritation and minimize gut activity for healing purposes

Not intended for long-term use because it can cause constipation

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Nov 8, 2018 | Posted by in NURSING | Comments Off on Hospital Nutrition: Defining Nutrition Risk and Feeding Patients

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