Nurses Role in Malnutrition

Malnutrition in Hospitalized Patients
The prevalence of malnutrition ranges up to 50% among patients in hospitals (Correia et al., 2014).  Malnutrition is also common in long-term and other health care settings.  Unfortunately, the incidence of malnutrition among patients has not improved over the past decade.  The consequences of malnutrition are serious.  Malnutrition affects a patient’s health and therefore affects health care facilities.  Malnutrition, a clinical disease, has been identified as the most costly comorbidity associated with certain diseases, such as a hip fracture  (Bell, Bauer, Capra, & Pulle, 2013).  There is a need for a call to action worldwide to increase attention to the importance of nutrition (Correia et al., 2014).

What is malnutrition?  Malnutrition is a broad term that can define any disproportion in nutrition  (Barker et al., 2011).  Nutrition disproportion can be either over-nutrition, which is often seen in the developed world, or under-nutrition.  Under-nutrition is seen in developing countries and also in hospitalized patients around the globe.  Malnutrition is a complex interplay between underlying disease, disease-related metabolic alterations, and the reduced availability of nutrients.  The reduced availability of nutrients can be either due to reduced intake, impaired absorption, increased losses, or a combination of those factors (Barker et al., 2011).

Malnutrition’s effect on patients.  Malnutrition among hospitalized patients is normally associated with (a) depleted body mass, (b) poor wound healing, (c) impaired immune function, and (d) weakened ventilator drive and respiratory muscles (Barker et al., 2011).   Studies reported that malnourished patients have (a) three days longer length of stay, (b) higher rates of medical prescriptions, and (c) higher rates of infections (Barker et al., 2011).

Malnutrition’s effect on facilities.  Malnutrition affects overall health status and can increase (a) hospital stay, (b) infection, (c) morbidity, and (d) mortality (Barker et al., 2011).  A German study reported that malnourished patients have a length of stay that is 43% longer compared to well-nourished patients.  Unrecognized malnutrition causes financial losses to hospitals.  One American study stated that malnourished patients had six days longer length of stay resulting in increased spending of  $1,633 per patient per stay (Barker et al., 2011).

The Role of Nurses in Patient Nutrition
Nurses not only provide but also oversee patient care (Tappenden et al., 2013). Nurses also observe nutrition intake and tolerance, interact with the patient, and interact with family or caregivers (Tappenden et al., 2013).  Information like (a) anthropometric, (b) appetite, (c) intake, and (d) tolerance of alternative nutrition are critical in patient care.  Nutrition concerns should not be treated as a one-off observation on admission; rather it is an essential part of continuous patient care.  It is important to acknowledge nursing nutrition assessment as an essential tool for ongoing assessment during the patient’s admission and should be carried out by staff with appropriate education and training (Tappenden et al., 2013).
Identification of malnutrition.  Fifteen published studies reviewed the contributing factors to malnutrition; these factors include (a) failure to recognize malnutrition, (b) lack of nutritional screening assessment, (c) lack of nutritional training, (d) confusion regarding nutrition responsibility, (e) failure to record height and weight, (f) failure to record patient intake, (j) lack of adequate intake, (h) lack of staff to assist in feeding, (i) importance of nutrition being unrecognized.  American, Australian, and European data report similar malnutrition rates (Barker et al., 2011).
Parameters to identify malnutrition.  The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) specified criteria for the purposes of diagnosing malnutrition (Bell et al., 2013).  The former criteria include a body mass index (BMI) of less than18.5 kg·m–2 while the new criteria include a combination of factors.  The factors used to identify malnutrition include a mixture of intake, anthropometric, fluid status, and functional measures (Bell et al., 2013).
Weight history.  Weight history is one of the important parameters to identify malnutrition (Roberts, Chaboyer, & Desbrow, 2014).  Unrecognized unintentional weight loss among hospitalized patients is one of the main contributors to hospitalized patients’ malnutrition (Roberts, et al., 2014).  A hospital survey showed that more than 40% of patients lost weight in the three months before entering the hospital (Correia et al., 2014).  Unfortunately, studies revealed that documentation of weight loss by nurses was found to be poor at just 19%.  Moreover, only 7% of these patients were referred to a dietitian (Barker et al., 2011).
Diet history of poor oral intake.  Decreased intake and poor appetite upon admission are prompts to additional intervention by dietitians (Barker et al., 2011).  One survey indicated that more than 50% had reduced food intake the week before admission (Correia et al., 2014).  Non-nutrition trained staff utilizes poor appetite as a tool to identify malnutrition.  Documentation of appetite loss by nursing staff was found to be at just 53%.  Moreover, only 9% of these patients were referred to a dietitian (Barker et al., 2011).
Oral intake during hospitalization.  Inadequate food intake during hospitalization may be a result of medical, psychosocial, and environmental barriers (Bell et al., 2013).    Moreover, poor intakes have been demonstrated to result in an ongoing deterioration of nutritional status after discharge.  Some of the contributing factors to decreased oral intake are decreased appetite, dislike of textures, swallowing problems, and pain.  The main reported factor to limited intake during hospitalization is mealtime interruption (Bell et al., 2013).  Intake of less than 50% of meals is a sign to consult a dietitian.  Studies showed that patients who were referred to a dietitian due to poor intake had an improved energy intake either by adding nutritional supplements, prescribing enteral nutrition or by adjusting a therapeutic diet (Roberts, et al., 2014).
Enteral or parenteral nutrition. Nurses perceive nutrition as the least important in a patient’s care (Bell et al., 2013).  Placing a gastric tube is considered important when the patient is unable to receive the medications orally.  Enteral and parenteral nutrition contribute to patients’ overall health and prognosis.  Dietitians complete nutrition assessments to recommend the most appropriate type of feeding (Bell et al., 2013).
Specific diagnosis associated with malnutrition.  Disease-related malnutrition is malnutrition triggered by illness or disease (Correia et al., 2014).  Malnutrition can complicate the disease itself, leading to a vicious cycle of complications.  Diseases frequently implicated in disease-related malnutrition include kidney disease, cancer, heart failure, Chronic Obstructive Pulmonary Disease, or rheumatoid arthritis.  Such diseases have inflammation as a disease component; therefore it increases the risk of malnutrition.  The risk of malnutrition affects overweight or obese patients.  Moreover, acute illnesses such as severe infection, surgery, burn injury, or sepsis have marked inflammation, which adds to and perpetuates the risk of malnutrition (Correia et al., 2014).
Diet order.  Delayed diet order affects nutrition status (Tappenden et al., 2013). Accurate and timely diet orders contribute to the patient’s nutritional status.  A delayed inaccurate diet order may cause complications.  One of the nurse’s nutrition interventions is to initiate nutrition within 24 hours of admission (Tappenden et al., 2013).
Chewing or swallowing issues.  Unrecognized chewing and swallowing issues may interfere with food intake and patient safety (Bell et al., 2013).   Swallowing and chewing issues contribute to 20% of the reported or observed barriers to volitional intake (Bell et al., 2013).
Physical exam. The nurse’s role includes consulting, or at least reporting, the possible concerns based on the patient’s appearance (Roberts et al., 2014).  Nausea and vomiting, malnourished appearance, and skin issues including pressure ulcers are some examples that should be reported (Roberts et al., 2014).
Functional assessment.  A functional assessment includes a patient’s ability to feed themselves and to communicate needs (Tappenden et al., 2013).  Many patients are unable to feed themselves or may require some assistance.  Reduced functional ability such as vision impairment and reduced strength may affect a patient’s ability to consume meals (Tappenden et al., 2013).

Current Recommendations
How malnutrition is identified.  There is a lack of clarity between malnutrition risk and the diagnosis of malnutrition (Bell et al., 2013).  Nutrition screening by nurses is the first step in nutrition care; if nutrition risk factors are unidentified, appropriate intervention cannot be applied (Roberts et al., 2014).  Validated nutrition screening tools are available, however, there is a lack of a universal nutrition-screening tool.  The Academy of Nutrition and Dietetics and ASPEN malnutrition consensus criteria to diagnose malnutrition are unintentional weight loss, evidence of inadequate intake, loss of muscle mass, loss of subcutaneous fat, fluid accumulation, and reduce and grip strength (Tappenden et al., 2013).
Improving nutrition care is a multidisciplinary task (Tappenden et al., 2013).  Six principles are deemed essential elements to achieve optimal patient nutrition. The six principles are: create an institutional culture; redefine clinicians’ roles to include nutrition; recognize and diagnose all patients at risk; rapidly implement interventions and continued monitoring; communicate nutrition care plans; and develop discharge nutrition care and education plans (Tappenden et al., 2013).

Who conducts malnutrition screening and assessment?
According to the American Dietetic Association, nutrition risk screening is “the process of identifying patients with characteristics commonly associated with nutritional problems who may require comprehensive nutrition assessment” (Barker et al., 2011).  Nurses perform and complete the nutrition screening and detect the at-risk patients.  Subsequently, at-risk patients are referred to clinical dietitians for additional assessment.  The American Dietetic Association defines nutrition assessment as “a comprehensive approach to defining nutritional status using medical, nutritional, and medication histories; physical examination, anthropometric measurements, and laboratory data” (Barker et al., 2011).  A Danish study utilized the nutrition risk screening and found that 40% of the patients are at risk of malnutrition, only eight percent were documented as malnourished.  Another Australian study screened 275 patients for malnutrition and identified 23% of those patients are at malnutrition risk.  Only 36% of the identified patients were referred to a dietitian for further assessment.  In another similar study, 42% of screened patients were at risk of malnutrition and only 15% were referred to a dietitian.  Despite the availability of nutrition assessment and screening tools, malnutrition prevalence remains high due to recognition issues.  As a result, appropriate treatment is not always being delivered.

Tools:
There are a number of validated nutritional tools (Tappenden et al., 2013).  Nutrition screening tools vary by facilities. The Malnutrition Screening Tool (MST) is a simple tool with three questions that assess recent weight and appetite loss in patients.  Another tool is the Malnutrition Universal Screening Tool (MUST), which is based on BMI, unintentional weight loss, and the presence or absence of serious disease which permits a score to be originated to determine the need for nutrition intervention.  The Mini Nutrition Assessment (MNA) is another tool that was developed specifically to be used for patients that are over 65 years old.  The tool is an 18-item assessment including data on anthropometrics, medical, lifestyle, dietary, and psychosocial factors.  The tool is based on point-based scoring to determine a malnourished patient and patients who are at risk of malnutrition.  Most screening tools address the basic questions regarding weight loss, food intake and appetite, BMI, and disease severity.  Nutrition screening should be a simple and rapid process that can be carried out by busy admitting staff, mainly nurses (Barker et al., 2011).  Studies revealed that nurses’ utilization of the nutrition screening tools improves malnutrition identification.  Consequently, the use of screening tools increased intervention and therefore improved nutrition care (Omidvari, 2013).

Challenges and Barriers
Nurses’ training in nutritional screening is essential because they are the first to meet the patient, they check on the patient more regularly, and therefore, they can afterward monitor the patient’s diet and indicators of the nutritional screening (Duerksen et al., 2014).  Challenges and barriers include nurses’ nutrition competencies and education.  Moreover, lack of time and communication concerns contributes to overlooking quality nutritional care (Duerksen et al., 2014).

Nurses nutrition competence:
Medical professionals often emphasize the importance of nutritional screening; however, it can be sometimes overlooked in daily practice (Green & James, 2013).  Challenges impeding nurses in conducting regular nutritional screening include lack of time and insufficient training.  According to Green and James (2013), at some hospitals, nurses overlooked routine screening for malnutrition.  There can be a number of reasons for neglecting patients’ nutrition screening, including both the lack of education and training in nurses leading to them underestimating the issue of malnutrition.  The other barrier, however, is that guidelines prescribed for nurses to conduct the nutritional screening for each patient admitted to their care on daily basis can be quite challenging on a par with the other tasks (Green & James, 2013).
Nutritional screening appears to be a time-consuming procedure (Green & James, 2013). Nurses’ insufficient training in nutrition is one of the contributing factors in underestimating malnutrition (Duerksen et al., 2014).  Nurses who are not competent about all the dangers of malnutrition and who do not have the skills to perform the screening faster, sometimes prefer to neglect it (Green & James, 2013).  Moreover, different health professional program directors agree on the need for increasing nutrition competency in their programs (Touger-Decker, Barracato, & O’sullivan-Maillet, 2001).

Education and training:
Education and profound training in nutrition can improve the routine of nutritional screening (Barker et al., 2011).  Additionally, nurses become more confident in using the screening tools.  Essentially, the willingness among nurses to perform the nutritional screening in each patient will increase with the enhanced awareness of the issue of malnutrition in hospitalized patients.  Therefore, hospitals and other medical establishments should develop a culture of awareness and training (Duerksen et al., 2014).
Whether the nurses’ nutrition competence is impeded or encouraged depends on the culture of an organization (Green & James, 2013).  In other words, there has to be a manager to address all the issues that nurses can have with conducting the nutritional screening to facilitate their work (Green & James, 2013).  Therefore, it is important to address malnutrition at a higher level rather than simply introducing extra duties that could be time-consuming for nurses that will fall off over time (Tangvik, Guttormsen, Tell, & Ranhoff, 2012).
In order to enhance the awareness and affirm the knowledge of nutritional screening techniques among qualified medical professionals, there are a number of studies and initiatives trying to implement the guidelines for nutritional screening at the hospitals and in university training courses for nurses (Tangvik et al., 2012).  Nutrition education for nurses is limited, which impacts the level of nutrition management of hospitalized patients (Duerksen et al., 2014).  Several studies have shown that nurses desire more education in nutrition, mainly after practicing.  Nurses desire further education and training in nutrition screening and understanding the risk window (Duerksen et al., 2014).

Malnutrition triggers identification:
Malnutrition often remains untreated because it was not recognized in time (Barker et al., 2011).  Nevertheless, there are factors triggering identification.  The primary task of the nurse is to estimate the nutrition risks of the patient rather than complete a thorough nutritional assessment.  Estimating nutrition risks is a simplified procedure that requires asking a patient questions to conclude whether a detailed nutritional screening is needed.  Given the fact that nurses have contact with the admitted patients on a daily basis, they would be more effective using such a protocol (Duerksen et al., 2014).
Weakened immune response, slow healing of wounds, possible injuries, and problems with body thermoregulation are some symptoms of malnutrition (Barker et al., 2011).  General weakness, caused by insufficient nutrition, results in muscle and fat mass loss and reduced functioning of the respiratory and cardiac organs.  Additionally, there are psychological aspects of malnutrition that involve fatigue that could result in depression. The development of malnutrition in patients is commonly linked to prolonged hospitalization.  Therefore, patients receiving longer treatment should be regularly screened for the nutrition risks (Duerksen et al., 2014).
Nevertheless, the identification of malnutrition is quite essential for its treatment. According to Barker et al. (2011), the prevalence of malnutrition in Western countries is between 20% and 50%.  The increased prevalence leads to the increase in production of new tools and equipment for nutrition risk screening, allowing identifying more accurately malnutrition in hospitalized patients (Barker et al., 2011).
However, Tangvik et al. (2012) concluded that even with an improved competence in nutritional screening, the percentage of patients receiving nutritional care did not increase.  Screening procedures and nutritional care usually belong to the set of responsibilities of nurses and physicians (Tangvik et al., 2012).  When speaking of screening tools, it is hard to address the issue on the generalized level.  Different tools are used in different hospitals, which is why the hospitals’ management needs a consistent policy of regulating the issue at the local level. Nevertheless, nurses appear to be more responsive to the importance of nutritional screening when there is an opportunity for training and support (Green & James, 2013).

Malnutrition triggers communication:
Malnutrition triggers identification, and then communication can be confusing for nurses (Barker et al., 2011).  Nursing staff members identify patients with poor intake.  The problem is the lack of communication of the malnutrition trigger.  Nurses related patients’ neglected nutritional status could be adding to the confusion regarding nutrition responsibility arker et al., 2011).  Lack of defined role and responsibility toward nutrition care and intervention are other factors that lead to confusion among nursing staff members (Duerksen et al., 2014).

Conclusion:
Nurses are the first healthcare professional to assess the patient upon admission to the hospital, which allows them to identify patients at risk early. Additionally, nurses spend the majority of their time with the patients. The role of the nurses are very crucial in malnutrition and particularly the early identification of malnutrition or malnutrition risk. The current practices and tools offer great assistance to nursing staff however the lack of time, training, nutrition education can be a barrier to achieving the optimum practice.

References:
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