This document discusses malnutrition screening in acute care settings. It defines malnutrition and identifies risk factors such as acute or chronic illness. Causes of malnutrition include inadequate intake, impaired absorption, and social factors. The document reviews types of malnutrition and recommends screening tools to identify patients at risk. Signs of malnutrition include loss of muscle mass and subcutaneous fat. A nutrition-focused physical assessment is described to evaluate six body sites for muscle and fat loss. Complications of untreated malnutrition include increased mortality, longer hospital stays, and higher healthcare costs. Standardized screening tools are needed to properly identify and treat malnutrition.

1. Malnutrition Screening in Acute
Care: Who’s at Risk?
By Katherin Rehn

2. Learning Objectives
• Upon completion of this program, attendees
will…
▫ Learn why it is important to diagnose
malnutrition
▫ Be able to identify causes of malnutrition
▫ Recognize six symptoms of malnutrition
▫ Be able to identify protocol for a nutrition-focused
physical assessment
▫ Be able to identify muscle and subcutaneous fat
sites on the body
▫ Recognize complications of malnutrition

3. What is Malnutrition?
• Decline in lean body mass with the potential for
functional impairment
• Synonymous with undernutrition
• Overweight/obese individuals are at risk for
malnutrition
• RDNs are looking at this issue due to the ability
to code and gain reimbursement for MNT
services
White et al, 2012
Phillips, 2014

4. Causes
• Inadequate intake and/or increased
requirements, impaired absorption, altered
transport, and altered nutrient utilization
• Acute illness/condition: broken hip, infection,
burns, trauma, major surgery
• Chronic illness: renal disease, cancer, HIV/AIDS
• Social factors: old age, unable to afford food,
poor mobility
Hamiruden, 2015

5. Types of Malnutrition
• Starvation Related Malnutrition
• Chronic-disease related malnutrition
• Acute Disease or injury related malnutrition
ASPEN, 2016

6. Screening for Malnutrition
• Traditional protocol set forth by Joint
Commission in 1996
▫ Not definitive
▫ Poor specificity
▫ Does not look at role of inflammatory proteins on
nutrition status
▫ Lack of national standardization
White et al, 2012
ASPEN, 2016

7. Examples of Validated Nutrition
Assessments
Mini Nutrition Assessment Malnutrition Screening Tool Malnutrition Universal
Screening ToolNestle Nutrition Institute
Abbott Nutrition, 2013
British Association of Parenteral and Enteral Nutrition, 2003

8. ACEND and ASPEN Standards
• Identification of 2 or more of the following must
be present to diagnose malnutrition
▫ Insufficient energy intake
▫ Weight loss
▫ Loss of muscle mass
▫ Loss of subcutaneous fat
▫ Localized or generalized fluid accumulation that
may sometimes mask weight loss
▫ Diminished functional status as measured by grip
strength
White et al, 2012
ASPEN, 2016

9. Litchford, 2013

10. Nutrition Focused Physical Assessment
• Important in order to
assess nourishment and
degree of malnutrition
• Gives evidence for
malnutrition diagnosis
Phillips, 2015

11. Before Performing an Assessment
• Make sure to introduce self to
family and patient, explain
rationale for examination
• Ask pt permission for exam
• Wash/dry hands thoroughly
and use gloves
• Use standard precautions to
prevent disease transmission
Scollard, 2015

12. Subcutaneous Fat Loss Sites
Scollard, 2015

13. Subcutaneous Fat Loss
Exam Areas Severe
Malnutrition
Mild-Moderate
Malnutrition
Well Nourished
Orbital region
(surrounding eye)
Hollow look,
depressions, dark
circles, loose skin
Slightly dark
circles, somewhat
hollow look
Slightly bulged fat
pads, Fluid
retention may
mask loss
Upper Arm region
(triceps/biceps)
Very little space
between folds
Some depth
pinch, but not
ample
Ample fat tissue
obvious between
folds of skin
Thoracic and
lumbar region
(ribs, lower back,
midaxillary line)
Depression
between ribs very
easy to see, Iliac
crest very
prominent
Ribs apparent,
but depressions
between them are
less pronounced,
Iliac crest
somewhat
prominent
Chest is full, ribs
don’t show
Slight to no
protrusion of the
iliac crest
Scollard, 2015

14. Muscle Loss
Exam Area Severe
Malnutrition
Mild-Moderate
Malnutrition
Well Nourished
Temple
Region
Hollowing, scooping,
depression
Slight Depression Can see/feel well-
defined muscle
Clavicle Bone
Region
Protruding,
prominent bone
Visible in male,
some protrusion in
female
Not visible in male,
visible but not
prominent in female
Clavicle and
Acromion
Region
Shoulder to arm joint
looks square,
bones/protrusion
prominent
Acromion process
may slightly
protrude
Rounded, curves at
arms, shoulder, neck
Scapular
Bone Region
Prominent, visible
bones, depressions
between ribs/scapula
or shoulder/spine
Mild depression,
bone may show
slightly
Bones not
prominent, no
significant
depressions
Dorsal Hand Depressed area
between thumb and
forefinger
Slightly depressed Muscle bulges, could
be flat
Scollard, 2015

15. Lower Body
Exam Areas Severe
Malnutrition
Mild-Moderate
Malnutrition
Well Nourished
Patellar Region Bones prominent,
little sign of
muscle around
knee
Knee cap less
prominent, more
rounded
Muscles protrude,
bones not
prominent
Anterior Thigh
Region
Depression/line
on thigh, thin
Mild depression
on inner thigh
Well rounded,
well developed
Posterior Calf
Region
Thin, minimal to
no muscle
definition
Not well
developed
Well developed
bulb of muscle
Lower body is less sensitive to change
Scollard, 2015

16. Rule Out Edema
• Make sure patient is at
dry weight so excess fluid
does not cause you to
miss malnutrition
• Can check ankles and
look for pitting after
touching ankles
Scollard, 2015

17. Complications of Malnutrition
• Increased morbidity and mortality
• Decreased function and quality of life
• Increased frequency and length of hospital stay
• Higher healthcare costs
Hamiruden, 2015

18. Conclusions
• Need to have standardized, universal assessment
tools for malnutrition to identify patients and
help prevent negative outcomes
• Healthcare team needs to work together in order
to create these standards
• Need to also work together for better treatment
and discharge plans
White et al, 2012

19. References
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for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult
malnutrition (undernutrition). J Parenter Enteral Nutr. 2012; 36: 275-283.
2. Feed your patient: ASPEN’s malnutrition solution center. ASPEN website. http://www.nutritioncare.org/Malnutrition/.
Updated 2016. Accessed March 17, 2016.
3. Litchford M. Putting the nutrition-focused physical assessment into practice in long-term care. Annals of Long-Term
Care Website. http://www.annalsoflongtermcare.com/content/putting-nutrition-focused-physical-
assessment-practice. Published November 14, 2013. Accessed March 17, 2016.
4. Scolard T. Nutrition-focused physical assessment: Practical methods to start and move your clinical practice forward.
Utah Academy of Nutrition and Dietetics. March 27, 2015. http://www.eatrightutah.org/docs/AM15-Speaker2-04b.pdf
Accessed March 17, 2016
5. Hamiruden HR, Charleton K, Walten K. Outcomes related to nutrition screening in community living older adults: A
systematic literature review. Arch Gerontol Geriatr. 2016; 62: 9- 25.
6. Phillips W. Coding for malnutrition in adult patients: What the physician needs to know. Nutrition Issues in
Gastroenterology. September, 2014.https://med.virginia.edu/ginutrition/wp-
content/uploads/sites/199/2014/06/Parrish-Sept- 14.pdf. Accessed May 5, 2016.
7. Mini Nutrition Assessment. Nestle Nutrition Institute Website. http://www.mna-elderly.com. Accessed May 16, 2016.
8. Malnutrition Screening Tool. Abbott Nutrition Website. http://static.abbottnutrition.com/cms-
prod/abbottnutrition.com/img/Malnutrition%20Screening%20Tool_FINAL%20_Professional.pdf. Updated 2013.
Accessed May 16, 2016.
9. Malnutrition Universal Screening Tool. British Association of Parenteral and Enteral Nutrition Website. Published
2003. Accessed May 16, 2016.
10. Skipper A, Ferguson M, Thompson K, Castellanos V, Porcari J. Nutrition screening tools: An analysis for evidence. J
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