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A Call to Action: Identifying Malnutrition in Patients with Wounds

September 21, 2013

By Mary Ellen Posthauer RDN, CD, LD, FAND

In last month's blog, I discussed recent research and publication of the consensus statement of the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.): Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).

The first step in the process is to define nutritional risk by identification of two or more of these characteristics:

  • Insufficient energy intake (acute illness < 75% of estimated energy requirement for > 7 days)
  • Weight loss (acute = 1-2% in week)
  • Loss of muscle mass (acute = mild loss)
  • Loss of subcutaneous fat (mild-moderate loss)
  • Localized or generalized fluid accumulation, which masks weight loss (acute= mild to moderate)
  • Diminished functional status as measured by hand grip strength (acute= NA)
  • Assume you are making wound care rounds in the acute care setting and review the medical record for a patient with a new stage IV pressure ulcer. Prior to hospitalization for major surgery ten days ago, the patient had no history of weight loss or appetite decline. Following surgery, he remained NPO for seven days with only an IV for hydration and lost 10 pounds. For the past three days he has eaten less than 1000 calories. Due to his inactivity, he has mild depletion of both muscle mass and subcutaneous fat. His malnutrition would be defined as acute injury malnutrition.

    This scenario is not uncommon since I have had wound care nurses approach me during seminars and relate similar stories. One of the major concerns in this scenario is the patient being NPO for seven days without consideration of either enteral or parenteral nutrition that would have provided the patient with the appropriate calories and protein to prevent malnutrition and pressure ulcers. In situations such as this one, neither the wound care nurse nor the registered dietitian is contacted until the patient critically requires wound care treatment and nourishment. One recent study estimated that among patients admitted to the hospital who are not malnourished, approximately one third might become malnourished while in the hospital. Because there is a strong correlation between nutrition and wound healing, impaired wound healing can increase the length of stay thus increasing costs and decreasing quality of life for the patient.

    Since the current focus of the health care delivery system is on controlling cost and improving quality and care, collaboration among all disciplines is a priority. Communication between departments is key and we must all assume a role in addressing the importance of nutrition care in improving patient outcomes.

    The Interdisciplinary Alliance to Advance Patient Nutrition published a call to action highlighting the critical role of nutrition intervention in clinical care. The Alliance includes members from the Academy of Nutrition and Dietetics, A.S.P.E.N, The Academy of Medical and Surgical Nurses and Abbott Nutrition. The article referenced below describes practical methods to quickly diagnose and treat both malnourished individuals and those at risk for malnutrition.

    Join me next month as we follow a malnourished patient from admission to discharge implementing the strategies suggested by the Alliance.


    1. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Thomas R, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013;113(9):1219-1237.
    2. Branschweig C, Gomez S, Sheean PM, Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000; 100(11):1316-1322.

    About The Author
    Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.

    The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

    The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.