Nutritional screening

Reviewed: June 14, 2019

Introduction

Nutritional screening may identify malnutrition or risk factors associated with malnutrition.1 You can evaluate a
patient's nutritional status by examining information from several sources, such as the patient's medical history,
physical assessment findings, and laboratory results. If nutritional screening determines that the patient is at
risk for a nutritional disorder, you should conduct a comprehensive nutritional assessment to set goals and
determine interventions to correct actual or potential imbalances.2 3

Nutritional screening also provides information about the status of acute and chronic conditions.4 It examines
certain variables to determine the risk of nutritional problems in specific populations, such as pregnant women
and elderly people, and the prevalence of chronic diseases (such as cardiac disorders and diabetes) to detect
nutritional deficiencies or potential imbalances.

If warranted by the patient's needs or condition, complete a nutritional screening within 24 hours of the patient's
admission to an acute care center.2

Equipment

Scale with stadiometer

Nutritional screening tool5
Tape measure
Optional: chair or bed scale, sliding calipers5

Preparation of Equipment

Select the appropriate scale—usually a standing scale for an ambulatory patient or a chair or bed scale for an
acutely ill or debilitated patient. Ensure that the scale is balanced according to the manufacturer's instructions.

Implementation

Perform hand hygiene.6 7 8 9 10 11

Confirm the patient's identity using at least two patient identifiers.12
Provide privacy.13 14 15 16
Explain the purpose of and procedure for the nutritional screening to the patient and family (if appropriate)
according to their individual communication and learning needs to increase their understanding, allay their
fears, and enhance cooperation.5 17
Ask the patient to remove the shoes (if appropriate), and obtain the patient's weight using a standing, chair,
or bed scale, as appropriate. Weight provides a rough estimate of body composition. (See the "Weight
measurement" procedure.)
Ask about unplanned or unintentional weight change. Determine how much weight the patient has lost or
gained and over what period. A weight loss of more than 5% in 30 days or 10% in 180 days or a weight gain
of 10 lb (4.5 kg) or more in 180 days places the patient at nutritional risk.
Measure the patient's height using the measuring bar on the scale while the patient stands erect without
shoes. If the patient can't stand, approximate the height by measuring "wingspan." (See Overcoming height
measurement problems.)

OVERCOMING HEIGHT MEASUREMENT PROBLEMS

A patient confined to a wheelchair or who can't stand straight because of an orthopedic problem, such as
kyphosis or scoliosis, poses a challenge to measuring height accurately. Alternative methods include
measurement of recumbent length, knee height, forearm length, and demi-span.18 However, sliding
calipers is the method of choice because it's closest in accuracy to measuring standing height.19

Calculate or estimate the patient's body mass index (BMI) to evaluate weight in relation to height. (See
Calculating BMI.)20

CALCULATING BMI

Use one of the formulas below to calculate the patient's body mass index (BMI).

OR

Explain BMI to the patient. (See Determining BMI.)

Evaluate the patient's weight distribution by using a tape measure to measure waist circumference around
the abdomen at the level of the iliac crest. Before reading the tape measure, ensure that it's snug without
compressing the skin and that it's parallel to the floor. A measurement of more than 35″ (89 cm) for a
woman or 40″ (102 cm) for a man (with a normal BMI) indicates a greater risk of health problems.2 People
with a high distribution of fat around their waist as opposed to around their hips or thighs are at greater
risk for certain diseases, including type 2 diabetes, dyslipidemia, hypertension, and cardiovascular
disease.20

DETERMINING BMI

Body mass index (BMI) measures weight in relation to height. The BMI ranges shown here are for adults.
Although these ranges don't provide an exact guide for healthy or unhealthy weight, they show that health
risks increase with increasing weight and obesity. To use this graph, find the patient's weight along the
bottom and then go straight up until you come to the line that corresponds to the patient's height. A BMI
of 18.5 to 24.9 (light pink) defines a healthy weight; 25 to 29.9 (medium pink), overweight; and 30 or
more (dark pink), obesity.21

 
 Adapted from U.S. Department of Health and Human Services & U.S. Department of Agriculture. (2015).
2015-2020 Dietary guidelines for Americans (8th ed.). Washington, DC: U.S. Government Printing Office.

Question the patient about eating habits, living environment, and functional status to determine whether the
patient is at risk for nutritional problems. A problem in any of these areas places the patient at risk and
requires further nutritional assessment. (See Risk factors for malnutrition.)

RISK FACTORS FOR MALNUTRITION

Risk factors for malnutrition are varied and multifaceted.22 23 Many processes associated with aging can
promote malnutrition; however, aging itself isn't an independent risk factor for nutritional deficiency. You can
categorize risk factors for malnutrition as medical, lifestyle and social, psychological, and hospitalization-
related.

Medical factors

Poor appetite
Poor dentition, other oral problems, and dysphagia
Loss of taste and smell
Respiratory disorders
Gastrointestinal disorders
Endocrine disorders
Neurologic disorders
Infections
Physical disability and poor mobility
Drug interactions
Other disease states, such as cancer

Lifestyle and social factors

Lack of knowledge about food, cooking, and nutrition

Isolation and loneliness
Poverty
Inability to shop or prepare food
Substance abuse
 Polypharmacy

Psychological factors

Confusion
Dementia
Depression
Bereavement
Anxiety

Hospitalization-related factors

Food service issues (when the patient's sole nutritional supply is hospital food, choice is limited or
presentation is poor)
Slow eating and limited time for meals
Missing dentures
Need for assisted or supervised feeding
Inability to reach food, use cutlery, or open packages
Unpleasant sights, sounds, and smells
Increased nutrient requirement (as needed because of infection, catabolic state, or wound healing)
Limited provision for religious or cultural dietary needs
Nothing-by-mouth status or missed meals while undergoing tests or surgery

Review the patient's medical record and conduct an interview to determine whether the current illness or
medical history places the patient at nutritional risk. Use a nutritional screening tool if available.
Review physical assessment findings for signs of poor nutrition. (See Evaluating nutritional disorders.)

EVALUATING NUTRITIONAL DISORDERS

Body system or Sign or symptom Implications
region
General
Weakness and fatigue Anemia or electrolyte imbalance

Weight loss Decreased calorie intake,

increased calorie use, or
inadequate nutrient intake or
absorption

Skin, hair, and

nails Dry, flaky skin Vitamin A, vitamin B-complex, or
linoleic acid deficiency

Dry skin with poor turgor Dehydration

Rough, scaly skin with bumps Vitamin A deficiency

Petechiae or ecchymoses Vitamin C or K deficiency

 Sore that won't heal Protein, vitamin C, or zinc
deficiency

Thinning, dry hair Protein deficiency

Spoon-shaped, brittle, or ridged nails Iron deficiency

Eyes
Night blindness; corneal swelling, Vitamin A deficiency
softening, or dryness; Bitot spots (gray
triangular patches on the conjunctiva)

Red conjunctiva Riboflavin deficiency

Throat and
mouth Cracks at the corner of the mouth Riboflavin or niacin deficiency

Magenta tongue Riboflavin deficiency

Beefy red tongue Vitamin B12 deficiency

Soft, spongy, bleeding gums Vitamin C deficiency

Poor dentition Overconsumption of refined

sugars or acidic carbonated
beverages; illicit drug use24

Swollen neck (goiter) Iodine deficiency

Cardiovascular
Edema, shortness of breath, cough, third Protein deficiency, thiamine
and fourth heart sounds, murmur deficiency

Tachycardia, irregular rhythm Fluid volume deficit, electrolyte

imbalance, anemia

GI
Ascites Protein deficiency

Musculoskeletal
Bone pain and bowleg Vitamin D or calcium deficiency
 Muscle wasting Protein, carbohydrate, and fat
deficiency

Neurologic
Altered mental status, ataxia Dehydration and thiamine or
vitamin B12 deficiency

Paresthesia, neuropathies Vitamin B12, pyridoxine,

thiamine, or niacin deficiency;
electrolyte imbalance

Refer the patient to a registered dietitian if the nutritional screening suggests a risk of nutritional problems.
2 The dietitian will then perform a comprehensive nutritional assessment.

Perform hand hygiene. 6 7 8 9 10 11

Document the procedure. 25 26 27 28

Special Considerations
You'll typically perform the nutritional screening during the initial nursing history and physical assessment,
but should complete it within 24 hours of admission. 2 29 30
When measuring height, note growth of children as well as diminishing height of older adults. You can note
growth of children on standardized charts to assess growth patterns for possible abnormalities. You
should investigate diminishing height of older adults, which may be related to osteoporotic changes. 5

Documentation

Record the date and time of the nutritional screening. Record the patient's height and weight on the screening
form as well as on the graphic sheet or patient care flow sheet. Note the type of scale you used. Complete the
screening tool, as recommended. Calculate and record the patient's BMI. Use a progress note to record
information that doesn't have a space on the screening tool. Record whether the patient has experienced weight
loss, the time over which the loss occurred, and how much weight the patient lost.

Document laboratory results, including the time and name of anyone you notified of abnormal results and
whether you received orders. Note any nutritional problems you detected during the physical assessment and
review of the patient's medical record. For patients at nutritional risk, record the date and time as well as the
names of people you notified and whether they came to see the patient. Also document any orders you received,
nursing interventions you performed, and the patient's response. Document teaching you provided to the patient
and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References

1. Omidvari, A. H., et al. (2013). Nutritional screening for improving professional practice for patient
outcomes in hospital and primary care settings. Cochrane Database of Systematic Reviews, 2013(6),
CD005539. (Level I)
2. Mueller, C., et al. (2011). A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in
adults. Journal of Parenteral and Enteral Nutrition, 35, 16–24. Accessed April 2019 via the Web at
 https://onlinelibrary.wiley.com/doi/pdf/10.1177/0148607110389335 (Level I)
3. Kirkland, L., et al. (2013). Nutrition in the hospitalized patient. Journal of Hospital Medicine, 8, 52–58. (Level
VII)
4. Lilamand, M., et al. (2015). The mini nutritional assessment short form and mortality in nursing home
residents: Results from the INCUR study. Journal of Nutrition, Health and Aging, 19, 383–388. (Level IV)
5. Potter, P., et al. (2016). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.
6. The Joint Commission. (2019). Standard NPSG.07.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
7. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16),
1–45. Accessed April 2019 via the Web at https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
8. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient
safety challenge, clean care is safer care" [Online]. Accessed April 2019 via the Web at
http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf (Level IV)
9. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.21. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
10. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Infection control. 42 C.F.R. § 482.42.
11. DNV GL-Healthcare USA, Inc. (2019). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.2. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
12. The Joint Commission. (2019). Standard NPSG.01.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
13. Accreditation Association for Hospitals and Health Systems. (2018). Standard 15.01.16. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
14. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Patient's rights. 42 C.F.R. § 482.13 (c)(1).
15. DNV GL-Healthcare USA, Inc. (2019). PR.2.SR.5. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.2. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
16. The Joint Commission. (2019). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
17. The Joint Commission. (2019). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
18. Froehlich-Grobe, K., et al. (2011). Measuring height without a stadiometer. American Journal of Physical
Medicine and Rehabilitation, 90, 658–666. Accessed April 2019 via the Web at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148840 (Level IV)
19. Frid, H., et al. (2013). Agreement between different methods of measuring height in elderly patients.
Journal of Human Nutrition and Dietetics, 26(5), 504–511. (Level IV)
20. U.S. Department of Health and Human Services, National Heart, Lung, and Blood Institute. (2013).
"Integrated guidelines for cardiovascular health and risk reduction in children and adolescents" [Online].
Accessed April 2019 via the Web at https://www.nhlbi.nih.gov/health-
pro/guidelines/current/cardiovascular-health-pediatric-guidelines (Level I)
21. U.S. Department of Health and Human Services & U.S. Department of Agriculture. (2015). "Dietary
guidelines for Americans: 2015-2020 (8th ed.)" [Online]. Accessed April 2019 via the Web at
https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf (Level VII)
22. De Morais, C., et al. (2013). Nutritional risk of European elderly. European Journal of Clinical Nutrition, 67,
1215–1219. (Level IV)
23. Roy, R., et al. (2015). Food environment interventions to improve the dietary behavior of young adults in
tertiary education settings: A systematic literature review. Journal of the Academy of Nutrition and Dietetics,
115(1), 1647–1681. (Level V)
24. Bassiouny, M. A. (2013). Dental erosion due to abuse of illicit drugs and acidic carbonated beverages.
General Dentistry, 61, 38–44. (Level VI)
25. The Joint Commission. (2019). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
26. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
27. Accreditation Association for Hospitals and Health Systems. (2018). Standard 10.00.03. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
28. DNV GL-Healthcare USA, Inc. (2019). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.2. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
29. The Joint Commission. (2019). Standard PC.01.02.03. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
30. Accreditation Association for Hospitals and Health Systems. (2018). Standard 10.01.24. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)

Additional References
Becker, P., et al. (2015). Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and
Enteral Nutrition: Indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition).
Nutrition of Clinical Practice, 30, 147–161. (Level VII)
Boaz, M., et al. (2013). Nurses and nutrition: A survey of knowledge and attitudes regarding nutrition assessment and care of
hospitalized elderly patients. Journal of Continuing Education in Nursing, 44, 357–364. (Level IV)
Caccialanza, R., et al. (2013). Serum prealbumin: An independent marker of short-term energy intake in the presence of multiple-
organ disease involvement. Nutrition, 29, 580–582. (Level IV)
Jensen, G. L., et al. (2013). Recognizing malnutrition in adults: Definitions and characteristics, screening, assessment, and team
approach. Journal of Parenteral and Enteral Nutrition, 37, 802–807. (Level VII)
Leistra, E., et al. (2014). Systematic screening for undernutrition in hospitals: Predictive factors for success. Clinical Nutrition, 33,
495–501. (Level IV)