Introduction

Approximately 45% of people admitted to care settings are at risk of malnutrition (Stratton et al, 2022). Many inpatients may not feel like eating or drinking as a result of acute illness or a long-term health condition (Rollins, 2002). In a busy clinical environment, it can be challenging for healthcare professionals to provide sufficient nutrition and hydration to meet patients’ requirements.

Malnutrition is a complex condition and does not occur solely as a result of poor hospital catering. Although the quality of food is important, it is just one factor to consider when providing nutritional care.
Malnutrition is defined as a:

The Nursing and Midwifery Council (2018) state that nutrition and hydration are fundamental aspects of care, where nurses must ensure that:

It is the nurse’s responsibility to ensure that people in their care receive optimum nutrition and hydration in order to promote effective and uncomplicated recovery.

Consequences of poor nutrition

Poor nutrition can cause avoidable harm to patients. Some examples of the negative consequences of poor nutrition include:

• General infection – loss of immune tissue and function, reducing the body’s ability to fight infections
• Pressure ulcers – reduced activity and immobility as well as loss of skin and subcutaneous fat resulting in greater pressure over bony protuberances
• Deep vein thrombosis and venous thromboembolism – caused by inactivity and immobility, partly as a result of loss of muscle mass and function as well as behavioural effects (loss of energy)
• Falls – muscle weakness and poor coordination, low blood pressure as a result of dehydration
• Respiratory failure (and delayed weaning from ventilators) – loss of respiratory muscle strength and early fatigue (Elias, 2015)

All of the above will lead to an increased length of stay, poorer outcomes and decreased patient satisfaction (Stratton et al, 2018).

Detecting and treating malnutrition

It can be challenging to detect malnutrition, so patients admitted to hospital should be screened using a validated tool such as the British Association for Parenteral and Enteral Nutrition’s Malnutrition Universal Screening Tool (MUST) (Elia, 2003). Screening should be conducted within 24 hours of admission, then an appropriate nutritional care plan tailored to the patient’s requirements can be started (National Institute for Health and Care Excellence, 2017).

As well as the screening tool, nurses are ideally placed to use their clinical skills holistically to determine if a patient is malnourished or at risk of being so. The LEARN mnemonic can be helpful in assessing whether a patient is at risk of malnutrition:

• Look at your patient – do they look thin? Are their clothes loose fitting?
• Engage with them – are they talkative? How do they manage their food budget? Are they independent? Do they need help with managing their diet?
• Ask your patient – How is your appetite? Is there any food you do not like? Is cooking a chore?
• Relatives/carers – Do they have any concerns about the patient’s eating and/or drinking habits?
• Needs – do they have any nutritional needs? Are they on a special diet? Do they experience challenges eating as a result of poor dentition? Do they struggle to cook or cut food? (Anderson, 2019)

Some patient groups who are at a greater risk of malnutrition and dehydration in the acute care setting include people:

• with chronic disease or long-term health conditions, such as chronic obstructive pulmonary disease, cancer, rheumatoid arthritis or osteoarthritis
• who are socially isolated and find it difficult to access food
• with progressive neurological disorders, such as Parkinson’s disease, stroke and motor neurone disease
• living with dementia
• with learning disabilities
• with any acute condition that may affect their ability to eat and/or drink (eg those with an acute respiratory condition or with an impaired ability to swallow) (Holdaway, 2021)

Strategies for managing patients who are at risk of malnutrition

• Food charts – these need to be completed accurately, containing what the patient has eaten and drunk at each meal and the quantities. These are critical when it comes to informing other healthcare professionals, such as dietitians, how much an individual has consumed in a day and whether any specialist nutritional support is required
• Protected mealtimes – periods in a hospital ward when all non-urgent clinical activity stops. During these times, patients can eat without being interrupted and staff can offer assistance if needed. Research suggests that patients who are not interrupted and receive appropriate services and support during mealtimes are happier, more relaxed and eat more (Palmer and Huxtable, 2015). The better nutritional support a patient receives, the higher their chances are of recovering from illness and reducing length of hospital stay (Elias, 2015). It is also good practice to encourage loved ones to visit and help the patient to eat and drink – especially in the case of people with learning disabilities or dementia
• Talk to families – find out what food the patient likes or dislikes. If a patient is unable to express what they like to eat and drink, consult family members and carers. Providing the patient with food and drinks that they enjoy will encourage them to consume more, enabling their nutritional needs to be met
• Be aware that patients may need help cutting up food or opening packets because of poor dexterity

Conclusions

Nutritional care is a concern of the entire multidisciplinary team. However, ward staff are the only healthcare professionals who are in contact with patients throughout the day and who can provide good continuity of care. Other team members rely on accurate reporting, observations and good communication to ensure that patients receive high-quality nutritional care while in hospital.