evidence & practice / how to series

NUTRITION

How to undertake a nutritional

assessment in adults
Johnstone CC (2018) How to undertake a nutritional assessment in adults. Nursing Standard. 32, 22, 41-45.
Date of submission: 18 September 2017; date of acceptance: 7 November 2017. doi: 10.7748/ns.2018.e11016

Carolyn Catherine Rationale and key points

Johnstone
Lecturer in nursing,
School of Nursing
and Health Sciences,
University of Dundee,
Dundee, Scotland
Correspondence
c.c.johnstone@dundee.
ac.uk
Conflict of interest
None declared
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Nutritional assessment in adults should begin on first contact with the patient, and is
an ongoing process that can take place over several hours or days. A comprehensive
nutritional assessment involves the nurse examining the patient’s physical and
psychological state, as well as considering any social issues that may affect their nutrition.
»» The nurse should use a variety of skills, such as observation, communication and
knowledge of physiology, to inform an adult nutritional assessment. While observation
skills are an essential element of a nutritional assessment, a patient’s nutritional status
is not signified by their appearance alone.
»» The nurse should use a structured approach to assess the patient’s nutritional status.
The use of screening tools can assist the nurse in performing an accurate nutritional
assessment.
»» Unplanned weight loss is an important indicator of nutritional risk; similarly, in some
patients, suboptimal oral health can have a significant effect on their ability to eat.
»» It is important to support adult patients with their nutritional requirements, for example
if they require assistance with functional aspects of nutrition such as using cutlery
and cooking.
Reflective activity
‘How to’ articles can help update your practice and ensure it remains evidence-based.
Apply this article to your practice. Reflect on and write a short account of:
1. How this article might improve your practice when undertaking a nutritional assessment.
2. How you could use this information to educate your patients and colleagues on the
appropriate technique for performing a nutritional assessment.
Keywords
clinical procedures, clinical skills, malnutrition, Malnutrition Universal Screening Tool,
nutrition, nutritional assessment, obesity, screening tools, weight gain, weight loss

Online Preparation and equipment assessment, for example the Malnutrition

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»» The nurse should be aware that
an effective nutritional assessment
begins on first contact with the patient.
A comprehensive nutritional assessment
is likely to take place over a period of
time – potentially over several hours or
days, to enable a thorough assessment
of the patient’s nutritional state and to
provide time for subsequent reviews.
»» Select an appropriate nutritional
screening tool to use during the
Universal Screening Tool (MUST)
(British Association for Parenteral and
Enteral Nutrition (BAPEN) 2011), or the
Mini Assessment Tool (MNA) (Nestle
Nutrition Institute 2009) in older adults.
»» Inform the patient about the procedure
and obtain consent. Ensure that
appropriate communication methods
are used if required, for example when
caring for a patient with learning
disabilities, or who speaks another

nursingstandard.com volume 32 number 22 / 24 January 2018 / 41

evidence & practice / how to series
Disclaimer language, methods such as Makaton,
Please note that easy to read symbols or the use of an
information provided interpreter may be considered.
by Nursing Standard is »» Ensure the patient is in a comfortable
not sufficient to make position for the assessment, for example
the reader competent sitting in a chair or on a bed.
to perform the task. All »» Ensure all necessary equipment is
clinical skills should be available and in effective working order,
formally assessed at including:
the bedside by a nurse –– Accurately calibrated weighing scales.
educator or mentor. It is –– Height measure.
the nurse’s responsibility –– Tape measure.
to ensure their practice It should be noted that some types of scale
remains up to date may be able to provide height and weight
and reflects the latest measurements simultaneously.
evidence
Procedure
1. During the initial nutritional
assessment, obtain the patient’s height
and weight measurements using
calibrated weighing scales and a height
measure; this information will enable
the selected nutritional screening
tool to be completed. Where this is not
possible, calculate the patient’s mid-
upper arm circumference by measuring
the ulna length and upper arm
circumference with a tape measure, as
detailed in the MUST (BAPEN 2011).
2. Use your observational skills to
examine the patient for the following
common signs of malnutrition:
–– Clothing – loose-fitting clothing may
be an indication that there has been
significant unintentional weight loss.
–– Muscle-wasting – severe malnutrition
results in muscle breakdown (muscle
tissue is used as an energy source),
resulting in a skeletal appearance.
This is often particularly evident in
the arms and face, with prominent
cheekbones and sunken eyes.
–– Reduced skin elasticity – this is caused
by a reduction of collagen in the
skin. A simple test involves pinching
the skin gently and observing for its
natural recoil. It is important to note
that any recoil of the skin will be
reduced in older adults because of the
natural thinning of the skin with age.
–– Hair loss – thinning hair is common
in people with malnutrition, although
this can be challenging to assess when
42 / 24 January 2018 / volume 32 number 22
meeting a patient for the first time.
–– Brittle nails – a diet lacking in the main
food groups, particularly protein, will
slow and damage nail growth.
3. Assess the patient’s normal dietary
intake, including portion size,
frequency of intake and range of foods
consumed. One method for finding out
this information is to ask the patient
what they ate during the previous day.
4. Assess the patient’s oral health. This
can be undertaken by observing the
fit of any dentures and whether the
patient’s mouth is dry. In patients with
severe malnutrition, the tongue can be
dry, redder than normal and swollen,
which interferes with their ability
to swallow.
5. Ask the patient if they have weighed
themselves recently and/or if they think
their weight has changed recently. Also,
ask if they know what their normal
weight is, and if they have experienced
any unplanned weight loss in the past
few months.
6. Ask the patient if they have experienced
changes to their appetite, and/or sense
of taste, smell or sight. Sensory changes
can have a significant effect on patients’
enjoyment of food, their desire to eat
and their appetite.
7. Ask the patient about their energy
levels, mood – in particular, how they
feel about eating – and concentration.
Lack of energy, low mood, loss of
interest in food and increased irritability
are features of several illnesses, for
example chronic fatigue, and can affect
nutritional intake, as well as being
a consequence of malnutrition.
8. Ask the patient about their access to
food, including whether they are able
to shop for groceries, and whether they
have the ability to store food and cook.
9. Observe the patient for any motor skills
deficits, which may have resulted from
a stroke, Parkinson’s disease, multiple
sclerosis or motor neurone disease, for
example, and which may have affected
their ability to eat – such as difficulty
holding cutlery. Ask the patient if
there is anything that is affecting
their ability to eat.
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10. Ask the patient about their ability
to swallow, using questions such as,
‘Do you ever choke when drinking?’
and ‘Does food or drink ever go
down “the wrong way”?’ Also, ask
if food ever gets ‘stuck’ when they
are eating.
11. Observe the patient’s ability to swallow
saliva. For example, ‘drooling’ may
indicate that they find this challenging.
12. Assess the patient using a nutritional
screening tool such as the MUST
(BAPEN 2011) (Box 1), or the MNA
(Nestle Nutrition Institute 2009), which
is used to identify older patients at
risk of malnutrition (Box 2). Devise an
action plan based on the patient’s score
and the recommended interventions of
the screening tool used, for example the
use of dietary supplements or referral
to a dietician.
13. If necessary, based on what has been
observed in step 10, undertake a
bedside swallow assessment (Scottish
Intercollegiate Guidelines Network
2010). If any issues with the patient’s
swallowing ability are identified,
implement an action plan to reduce the
risk of aspiration, while ensuring that
the patient’s fluid and nutritional intake
is optimised.
As part of an ongoing nutritional
assessment or review, the following steps
can be performed:
»» While the patient is eating and drinking,
assess their ability to use cutlery, plates,
bowls and cups, as well as their ability
to take food from their plate and place
it in their mouth. This assessment can
indicate whether the patient requires
equipment such as adapted cutlery,
non-slip mats or plate guards.
»» Reassess the patient’s nutritional
status as per the nutritional screening
tool used. This will usually be
undertaken on a weekly basis. More
frequent assessment may be required
if the patient’s condition changes,
or if indicated by the nurse’s clinical
judgement, for example if the nurse
notices that the patient is leaving large
amounts of food, or finds evidence in the
home that food is not being eaten.
nursingstandard.com
Evidence base
Supporting patients’ nutritional
requirements is a fundamental aspect
of nursing care. However, this is not
always considered a high priority, despite
malnutrition affecting more than three
million people in the UK (NHS England
2015). It has been estimated that 29% of
adults admitted to acute care between 2007
and 2011 were malnourished; in 2011,
41% of these individuals were admitted
from care homes and 23% of adults were
admitted from their homes (Russell and
Elia 2014). This suggests that malnutrition
is a significant issue for those living in
long-term care settings, and nurses should
be aware of this when managing the care
of older adults.
BOX 1. Five steps of the Malnutrition
Universal Screening Tool
1. Measure the patient’s height and weight. Use this
information to calculate the patient’s body mass
index score using the graph provided in the
screening tool
2. Note the percentage of unplanned weight loss and
score the patient using the tables provided in the
screening tool
3. Establish acute disease effect and score using the
description provided in the screening tool
4. Add the scores from steps 1, 2 and 3 together to
determine the patient’s overall risk of malnutrition.
The overall score will be used to determine if the
patient is at low, medium or high risk of malnutrition
5. Use guidelines and local policy to develop a care plan
for the patient
(Adapted from British Association for Parenteral and Enteral
Nutrition 2011)
BOX 2. Scoring criteria in the Mini
Assessment Tool used to screen for
malnutrition in older adults
»» Has the patient’s food intake declined over the past
three months because of loss of appetite, digestive
issues, or issues with chewing or swallowing?
»» Weight loss during the past three months
»» Mobility – for example, is the patient bed-bound or
able to go out?
»» Has the patient experienced psychological stress or
acute disease in the past three months?
»» Does the patient have any neuropsychological
conditions, such as dementia or depression?
»» Body mass index score
(Adapted from Nestle Nutrition Institute 2009)
volume 32 number 22 / 24 January 2018 / 43
evidence & practice / how to series
It is important for nurses to remember
that patients who are overweight or
underweight can be malnourished.
However, malnutrition in patients who
are obese is more likely to be related to
a diet deficient in essential nutrients, such
as vitamins and minerals, rather than
protein energy undernutrition. Protein
energy undernutrition develops when
nutritional intake is not sufficient to
meet demand; for example, when there is
reduced ability to access food. In addition,
the condition can develop during acute
or critical illness because of increased
metabolic demand (Price 2008).
Assessment of nutritional status is
important in healthcare and should be
undertaken when a person is admitted
to hospital or to a community caseload
(Health Improvement Scotland 2014);
this extends to the requirement for regular
screening of nutritional risk and the
development of a nutritional care plan.
The Council of Europe (2003) developed a
resolution on food and nutritional care in
hospitals, which identified ten characteristics
of optimal nutritional care in hospital,
including the requirement for screening
for malnutrition on admission and weekly
thereafter, and the development of a care
plan that identifies the patient’s nutritional
requirements and how to meet them.
The range of people at risk of developing
malnutrition extends beyond those with
chronic, progressive and acute conditions
to those who are frail, have reduced
mobility, are depressed, have limited social
support, are housebound, or who are living
in poverty (Brotherton et al 2012). Any
nutritional assessment should take account
of this range of issues to ensure that any
care plan is holistic and will be able to
support the patient’s requirements.
The risk of developing malnutrition can
be quantified with the use of a tool such
as the MUST (BAPEN 2011) or the MNA
(Nestle Nutrition Institute 2009), which
can indicate the necessity for referral to
other healthcare practitioners and the
implementation of an individualised care
plan. The MUST (BAPEN 2011) is the
most commonly used tool in the UK,
although the MNA (Nestle Nutrition
44 / 24 January 2018 / volume 32 number 22
Institute 2009) is specifically designed for
use in older people.
Observation is an essential element of
any assessment, and Willis (2017) noted
that the nurse’s ability to identify the signs
of malnutrition will develop with increased
interaction with the patient. The MUST
(BAPEN 2011) identifies unintentional
weight loss as an important indicator of
risk; however, not all of the issues that can
affect a person’s ability to maintain their
nutritional health will be identified using
a screening tool. Identifying risk accurately
can also rely on previous knowledge of the
patient and information gained from the
patient or their carer, as well as subjective
measures such as whether the patient’s
clothes are loose-fitting.
Booker et al (2011) discussed the
importance of undertaking an initial nursing
assessment to identify the patient’s dietary
history and any changes in appetite, as well
as considering individual lifestyle issues such
as the patient’s ability to carry shopping, the
distance they have to travel to the nearest
shops, and the effect of limited budgets
on nutrition (Willis 2017). Willis (2017)
added that frailty in older people and social
isolation must also be considered because
they can affect nutritional intake. However,
it is important to remember that frailty is
not an inevitable consequence of ageing and
a comprehensive assessment of nutritional
risk can improve health outcomes since
it enables the nurse to implement dietary
interventions that can increase nutritional
intake (Wallington 2016).
Unintentional weight loss in older
people is associated with increased rates
of mortality and morbidity; however, it
is not always possible to identify a clear
pathophysiological cause (Gaddey and
Holder 2014). Alterations in the body’s
physiology associated with ageing, such as
the gradual loss of muscle mass, declining
digestive function because of decreased
gut motility, reduced muscle strength and
tone, and reduced sensory feedback, do not
account for significant or rapid weight loss
in older adults (Tortora and Derrickson
2013). In the author’s clinical opinion,
other issues such as the patient’s physical
ability and lifestyle have a role in the
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development of malnutrition and should be
included in assessments of their nutritional
requirements.
Gomes et al (2016) found a statistically
significant link between suboptimal outcomes
and malnutrition, identified using the MUST
tool, in patients who had experienced a
stroke. For example, individuals who were
malnourished and had a stroke had increased
mortality rates and prolonged hospital
stays. Gomes et al (2016) stated that these
findings reflect those of other studies where,
for example, Stratton et al (2006) found
that older people who were malnourished
had suboptimal outcomes and Lim et al
(2012) identified that people who were
malnourished had prolonged hospital stays.
Overall, evidence supports the use
of a screening tool when undertaking
a nutritional assessment (Young et al
2013). However, Young et al (2013) also
found little significant variation between
nutritional screening tools, noting that
no single tool has been found to produce
improved outcomes compared to another.
This suggests that the action of screening,
rather than the tool used, is more
important to enable accurate assessment of
a patient’s nutritional status. Therefore, the
continued use of the MUST (BAPEN 2011)
in the UK can be recommended, although
the use of an alternative such as the MNA
(Nestle Nutrition Institute 2009) can also
accurately identify nutritional risk.

References

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Nutrition (2011) Malnutrition Universal
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must/must_full.pdf (Last accessed:
11 January 2018.)
Brotherton A, Holdoway A, Mason P et al
(2012) Managing Adult Malnutrition in the
Community. www.malnutritionpathway.co.uk
(Last accessed: 11 January 2018.)
Council of Europe (2003) Council of Europe
Resolution: Food and Nutritional Care in
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