I. Pathophysiology: Malnutrition is a disorder of body composition
in which nutritional intake is less than required and
results in reduced organ function, abnormalities in blood
chemistry, reduced body mass, and worsened clinical outcomes.
a. Nutritional status is affected by multiple factors, including
eating behaviors, disease states, economics, and environment.
b. In the acutely or chronically ill client, the impact of malnutrition
includes muscle mass loss, progressive weakness,
potential for infection, poor healing, and a higher rate of
c. When oral intake is inadequate or not possible, specifically
designed nutritional therapy can be administered via an
enteral or parenteral route to prevent or correct proteincalorie
II. Clinical Indication for Feeding
a. Preexisting nutritional deprivation; unplanned or unexplained
loss of 10% in body weight
b. Anticipated or actual inadequate energy intake by mouth,
such as inability to consume food or drink orally for 7 days
or more, based on individual nutritional status
c. Critically ill individuals, because of their increased metabolic
demands and limited nutritional reserve, commonly
require nutritional support.
d. The Joint Commission for Accreditation of Healthcare
Organizations (JCAHO) recognizes the negative impact of
malnutrition in hospitals and long-term care institutions and
has, in turn, made nutritional assessment, support, and
ongoing reassessment an essential part of accreditation
requirements (JCAHO, 1997).
III. Etiology of Malnutrition
a. Can exist in persons who are underfed or overfed, occurring
in both extremely thin and obese individuals
b. May result from an inadequate or unbalanced diet,
digestive difficulties, absorption problems, or other medical
i. Acute conditions, such as surgery, severe burns, infections,
and trauma, that drastically increase short-term
ii. Chronic diseases associated with nutrient loss, nutrient
demand, and with malabsorption, such as celiac disease,
cystic fibrosis, pancreatic insufficiency, pernicious
iii. Conditions and treatments associated with malnutrition
through decreased intake, such as depressed appetite, difficulty
swallowing, and nausea associated with both cancer
and chemotherapy, as well as with HIV/AIDS and its drug
c. Certain age groups, such as elderly clients, require fewer
calories but continue to require adequate nutritional support
because they are often less able to absorb nutrients, due in
part to decreased stomach acid production, and are more
likely to have one or more chronic ailments that may affect
their nutritional status.
IV. Routes for Feeding
a. Enteral nutrition
i. Gastrointestinal (GI) intubation is preferred for clients
with functional GI tract, but who are unable to consume
an adequate nutritional intake or for whom oral intake is
contraindicated or impossible.
ii. Feeding may be done via flexible catheter (such as
nasogastric [NG], orogastric tube) or enterostomy (such
as gastrostomy, duodenostomy, or jejunostomy tube).
iii. Feeding may be short-term for supplementation of oral
intake or long-term to provide for all of client’s nutrition.
b. Parenteral nutrition
i. May be chosen because of altered metabolic states or
when mechanical or functional abnormalities of the GI
tract prevent enteral feeding
ii. Goals are to improve the client’s nutritional status;
establish and maintain a positive nitrogen balance;
improve or maintain muscle strength and mass; promote
weight gain; and encourage the healing process through
infusion of amino acids, fat, carbohydrates, trace
elements, vitamins, and electrolytes, as indicated.
iii. The average adult requires approximately 1,500 calories
per day in order to maintain energy stores.
iv. Nutritional support is provided via an intravenous (IV)
route, either centrally or peripherally.
1. Central: Formula is concentrated hyperosmolar and
must be infused via a central vein (subclavian or
jugular) into the superior vena cava or peripherally
inserted central catheter (PICC), inserted into the arm
and passed into a major blood vessel.
2. Peripheral: Formula is similar, but less concentrated than
central formula and is infused via a peripheral vein.
Client may be treated in any setting, including community
or home care.
Acquired immunodeficiency syndrome (AIDS),
Burns: thermal, chemical, and electrical—acute and convalescent
Cirrhosis of the liver,
Chronic obstructive pulmonary disease (COPD) and asthma,
Diabetes mellitus/diabetic ketoacidosis,
Eating disorders: anorexia nervosa/bulimia nervosa,
Eating disorders: obesity,
Fluid and electrolyte imbalances,
Inflammatory bowel disease (IBD): ulcerative colitis,
Obesity: bariatric surgery—gastric partitioning/gastroplasty,
Psychosocial aspects of care,
Renal failure: chronic,
1. Promote consistent intake of adequate calorie and protein
2. Prevent complications.
3. Minimize energy losses and needs.
4. Provide information about condition, prognosis, and
1. Nutritional intake adequate for individual needs.
2. Complications prevented or minimized.
3. Fatigue alleviated.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.