By Anna Curran, RN, BSN, PHN — Critical Care ER nurse, 30+ years bedside experience
Last reviewed: July 2026
Imbalanced nutrition: less than body requirements is the NANDA-I diagnosis you use when nutrient intake is not enough to meet metabolic demand. In the 2018–2020 and 2021–2023 taxonomies it sits in Domain 2 (Nutrition), Class 1 (Ingestion), coded 00002, defined as “intake of nutrients insufficient to meet metabolic needs” (NANDA-I 2018–2020).
If you have a care plan due, start with the code and the defining characteristics below, then go straight to the six complete care plans — they are near the top of this page on purpose, formatted the way your instructor expects.
Everything after them is the reference material that makes those care plans defensible: the assessment sequence, the interventions with rationales, the screening cutoffs you are responsible for, the one lab value nearly every nursing website still gets wrong, and the refeeding content that keeps a severely underweight patient from arresting on day two of feeding.
The NANDA-I Label and Code — And Why It Changed
Sort this out first, because your grade depends on which edition your program uses.
| Edition | Label | Code | Status |
|---|---|---|---|
| NANDA-I 2018–2020 (11th ed.) | Imbalanced nutrition: less than body requirements | 00002 | Approved 1975; revised 2000, 2017; Level of Evidence 2.1 |
| NANDA-I 2021–2023 (12th ed.) | Imbalanced nutrition: less than body requirements | 00002 | Retained, revised 2020 |
| NANDA-I 2024–2026 (13th ed.) | Inadequate nutritional intake | Code reassigned | Label replaced; new sibling diagnoses added |
The 13th edition retired the “less than body requirements” wording in favor of Inadequate nutritional intake, defined as “insufficient nutrient consumption to meet metabolic needs” (Open RN / NCBI Bookshelf), and adds Risk for inadequate nutritional intake, Readiness for enhanced nutritional intake, and Inadequate protein energy nutritional intake (Thieme 13th-edition contents).
In practice: if your program uses the 11th or 12th edition — or any care-plan book published before 2024 — write Imbalanced nutrition: less than body requirements (00002). If your program uses the 13th edition, write Inadequate nutritional intake and pull the code from your own copy.
Do not trust codes found on aggregator sites; several circulating numbers for the new labels could not be verified against a primary NANDA-I source. The label changed; the clinical content did not.
Clinical pearl: “Malnutrition” is a medical or dietetic diagnosis made using criteria like GLIM. “Imbalanced nutrition: less than body requirements” is a nursing diagnosis describing the intake deficit you can independently intervene on. Both may appear in one chart. Only one belongs on your care plan.
Defining Characteristics and Related Factors
Subjective — what the patient reports
- Poor appetite, early satiety, altered taste
- Nausea, vomiting, abdominal pain, diarrhea limiting intake
- Painful chewing, ill-fitting dentures, mouth sores
- Coughing or choking with meals
- Fatigue and weakness out of proportion to activity
- Skipping meals, running out of food, inability to afford food
- Body image disturbance or fear of weight gain
Objective — what you assess and measure
- Unintentional weight loss, quantified in kilograms and percentage over a defined interval
- BMI below 18.5 kg/m², or below 20 kg/m² with recent loss
- Documented intake below estimated requirement, recorded as percentage of meals eaten
- Loss of subcutaneous fat at the orbits, triceps, and ribs
- Muscle wasting at the temples, clavicles, deltoids, quadriceps, and interosseous spaces
- Reduced handgrip strength
- Sparse brittle hair, ridged or spoon-shaped nails, dry flaking skin
- Poor wound healing, dehiscence, or a stalled pressure injury
- Edema or ascites that can mask 5–10 kg of true weight loss
- In children: weight-for-height, BMI-for-age, or MUAC z-scores below −1
Related factors
| Category | Examples |
|---|---|
| Inadequate intake | Anorexia from illness, medication, chemotherapy, depression, or pain; dysphagia; prolonged or repeated NPO status; poor dentition, xerostomia, mucositis; food insecurity, isolation, immobility; eating disorders; substance use |
| Impaired absorption or excess loss | Inflammatory bowel disease, celiac disease, short bowel syndrome, pancreatic insufficiency, post-bariatric anatomy, high-output fistula or ostomy, protracted vomiting or diarrhea |
| Increased requirements | Sepsis, burns, major trauma, surgery, cancer and cancer treatment, COPD, heart failure, CKD, HIV, chronic wounds, fever |
How to Write the Diagnostic Statement
Three-part (actual problem):[NANDA-I label] related to [etiology] as evidenced by [defining characteristics with numbers]
Two-part (risk diagnosis):Risk for [NANDA-I label] as evidenced by risk factors of [factors]
A risk diagnosis has no signs and symptoms because the problem has not happened yet. If you can list actual evidence of a deficit, it is no longer a risk diagnosis.
Worked examples
Oncology, chemotherapy-induced anorexia
Imbalanced nutrition: less than body requirements related to decreased oral intake secondary to chemotherapy-induced nausea and mucositis, as evidenced by 6.8 kg (9%) unintentional weight loss over 8 weeks, consumption of 25% or less of meals for 6 consecutive days, BMI 18.2 kg/m², and temporal and interosseous muscle wasting.
Post-stroke dysphagia
Impaired swallowing related to neuromuscular impairment secondary to left middle cerebral artery infarct, as evidenced by failed bedside swallow screen, wet vocal quality and coughing after 3 mL water trials, right-sided buccal pocketing, and 2.3 kg weight loss in 9 days.
Severely underweight patient starting nutrition support
Risk for electrolyte imbalance as evidenced by risk factors of BMI 13.9 kg/m², negligible oral intake for 17 days, baseline serum phosphate 2.4 mg/dL, and initiation of enteral nutrition.
Food insecurity
Ineffective health maintenance related to insufficient financial resources and lack of access to adequate food, as evidenced by a positive Hunger Vital Sign on both items, report of skipping at least one meal daily for 3 months, 5.4 kg weight loss in 4 months, and no current SNAP enrollment.
The three most common mistakes
- Using a medical diagnosis as the related factor. “Related to cancer” is not actionable. “Related to chemotherapy-induced nausea and mucositis” is — you can medicate nausea and treat mucositis.
- Putting albumin in the AEB clause. It is an inflammatory marker (ASPEN position paper).
- Writing the actual diagnosis when only risk factors exist. A patient with a normal BMI, stable weight, and an NPO order for tomorrow’s procedure gets the risk version.
Six Nursing Care Plans for Imbalanced Nutrition
Care Plan 1 — Imbalanced Nutrition: Less Than Body Requirements (Oncology)
Nursing diagnosis: Imbalanced nutrition: less than body requirements (NANDA-I 00002)
Diagnostic statement: Imbalanced nutrition: less than body requirements related to decreased oral intake secondary to chemotherapy-induced nausea, mucositis, and taste alteration, as evidenced by 6.8 kg (9%) unintentional weight loss over 8 weeks, intake of 25% or less of meals for 6 consecutive days, BMI 18.2 kg/m², and temporal and interosseous muscle wasting.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| MST score 4; 9% weight loss in 8 weeks | Place RDN consult within 24 hours of the positive screen | An MST of 2 or more indicates nutritional risk requiring formal assessment | RDN assessment completed within 24 hours |
| Weight 51.4 kg, BMI 18.2 kg/m² | Weigh daily, same scale and time; calculate percentage change weekly | Weight change over time is the most sensitive index of energy balance | Weight stable or up 0.5 kg/week for 4 weeks |
| Intake 25% or less for 6 days | Record percentage of every meal; run a 3-day calorie count | GLIM’s etiologic criterion is intake ≤50% of requirement for >1 week | Intake reaches 75% of meals within 7 days |
| Target 25–30 kcal/kg and >1.0–1.5 g protein/kg | Deliver ~1,300–1,550 kcal and 51–77 g protein daily at 51.4 kg; add 2 supplements between meals | ESPEN recommends 25–30 kcal/kg/day and protein above 1 g/kg/day, up to 1.5 g/kg/day, in cancer | Intake meets 80% of calorie and protein target within 5 days |
| Nausea 6/10 before meals | Give prescribed antiemetic 30–60 minutes before each meal; reassess 30 minutes post-dose | Symptom control must precede any feeding intervention | Nausea 2/10 or lower at mealtimes within 72 hours |
| Grade 2 mucositis; metallic taste | Oral care with alcohol-free rinse before and after meals; offer cold, soft, non-acidic foods and plastic utensils | Reduces mucosal pain and taste aversion, both of which suppress intake | Mealtime oral pain 3/10 or lower; tolerates soft diet |
| Albumin 2.6 g/dL in chart | Document intake, weight trend, and physical wasting as the evidence; do not chart albumin as a nutrition marker | ASPEN states albumin and prealbumin characterize inflammation and should not be used as nutrition markers | Care plan evidence rests on intake, weight, and exam findings only |
Care Plan 2 — Impaired Swallowing (Post-Stroke Dysphagia)
Nursing diagnosis: Impaired swallowing (NANDA-I 00103)
Diagnostic statement: Impaired swallowing related to neuromuscular impairment secondary to left middle cerebral artery infarct, as evidenced by failed bedside swallow screen, wet vocal quality and coughing after 3 mL water trials, right-sided buccal pocketing, and 2.3 kg weight loss over 9 days.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| Day 1 post-stroke, no swallow screen documented | Keep NPO — including oral medications — until a validated dysphagia screen is complete | AHA/ASA gives dysphagia screening before any oral intake a Class I recommendation | Screen completed before first oral intake; no aspiration event |
| Wet voice and cough after 3 mL water | Notify provider; obtain speech-language pathology consult within 24 hours | SLP determines safe consistency and compensatory strategies | SLP evaluation completed within 24 hours; texture prescribed |
| Buccal pocketing on the right | Position upright at 90° for intake and 30 minutes afterward; check the oral cavity after every meal | Upright positioning and oral clearance directly reduce aspiration risk | No pocketing on post-meal checks for 5 consecutive days |
| Consuming 40% of texture-modified tray | Give small single-consistency bites with the SLP-directed maneuver; allow at least 30 uninterrupted minutes per meal | Rushed, mixed-consistency meals are a leading cause of aspiration | Consumes at least 75% of each meal within 7 days |
| Temperature 99.2°F, lungs clear | Auscultate lungs and check temperature and SpO2 every 4 hours; report new crackles, fever, or SpO2 drop | Aspiration pneumonia typically presents within 24–72 hours of a silent event | Remains afebrile, lungs clear, SpO2 above 94% |
| No oral hygiene protocol in place | Perform oral care with a suction toothbrush at least twice daily and after every meal | AHA/ASA notes oral hygiene protocols to reduce post-stroke pneumonia may be reasonable | Oral care documented twice daily; no pneumonia develops |
| 2.3 kg weight loss in 9 days | Weigh daily; escalate to provider and RDN for enteral access if intake stays below 50% of goal for 72 hours | Prolonged inadequate intake meets GLIM’s etiologic criterion and mandates a route change | Weight stabilizes; alternative route initiated if intake remains inadequate |
Care Plan 3 — Risk for Electrolyte Imbalance (Refeeding Syndrome)
Nursing diagnosis: Risk for electrolyte imbalance (NANDA-I 00195)
Diagnostic statement: Risk for electrolyte imbalance as evidenced by risk factors of BMI 13.9 kg/m², negligible nutritional intake for 17 days, baseline serum phosphate 2.4 mg/dL and potassium 3.2 mEq/L, and planned initiation of enteral nutrition.
Formatting note for students: A risk diagnosis is a two-part statement — the label plus its risk factors. There is no “as evidenced by” clause containing defining characteristics, because the problem has not occurred yet. If your instructor requires three-part form, list the risk factors after “as evidenced by” — never signs and symptoms of a problem the patient does not yet have.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| BMI 13.9 kg/m², negligible intake 17 days | Flag as extreme refeeding risk before any feeding, including dextrose-containing IV fluids | NICE identifies BMI under 14 kg/m² or negligible intake beyond 15 days as extreme risk | Risk documented and communicated before the first calorie |
| Thiamine not yet given | Give thiamine 200–300 mg PO daily plus vitamin B co strong 1–2 tablets three times daily (or full-dose IV B preparation) immediately before and during the first 10 days of feeding | Carbohydrate metabolism consumes thiamine; deficiency precipitates Wernicke encephalopathy | Thiamine given before feeding; no ophthalmoplegia, ataxia, or new confusion |
| Feeding order written for goal rate | Confirm initiation at 5 kcal/kg/day with continuous cardiac rhythm monitoring, advancing to full needs no faster than 4–7 days | NICE directs 5 kcal/kg/day in extreme cases and a maximum of 10 kcal/kg/day in high risk | Feeding advanced per protocol without arrhythmia or decompensation |
| Phosphate 2.4 mg/dL, potassium 3.2 mEq/L | Give prescribed potassium 2–4 mmol/kg/day, phosphate 0.3–0.6 mmol/kg/day, magnesium 0.2 mmol/kg/day IV (or 0.4 mmol/kg/day PO) from the start of feeding | NICE supplements concurrently and states pre-feeding correction is unnecessary | Phosphate, potassium, magnesium within reference range through day 7 |
| Labs drawn once daily | Draw phosphate, potassium, magnesium, and glucose at baseline and at least daily for 5 days; escalate any drop of 10% or more | ASPEN defines refeeding syndrome as a 10–20% (mild) to over 30% (severe) fall within 5 days of feeding | Any 10% decrement reported to the provider within 1 hour of resulting |
| Weight 34 kg; no baseline fluid record | Record strict intake and output every shift, weigh daily, assess for edema, crackles, JVD, and dyspnea each shift | Insulin-driven sodium and water retention can precipitate fluid overload and cardiac failure | Fluid balance within 500 mL of even; no crackles, edema, or dyspnea |
| On continuous telemetry | Monitor ECG continuously; report new PVCs, QT prolongation, or ventricular ectopy immediately | Hypokalemia and hypomagnesemia during refeeding cause potentially fatal arrhythmias | Sinus rhythm without ectopy through the first 7 days of feeding |
Your role as the nurse: You do not write the thiamine order, the starting calorie rate, or the electrolyte doses in this plan — you confirm they exist before the first calorie goes in, give them on time, and call the provider if a feeding order starts a patient like this at goal rate.
Care Plan 4 — Deficient Knowledge (Nutrition Self-Management)
Nursing diagnosis: Deficient knowledge (NANDA-I 00126)
Diagnostic statement: Deficient knowledge related to lack of exposure to nutrition self-management information, as evidenced by the patient stating that “soup and crackers” is an adequate daily diet, inability to name a single high-protein food, and no knowledge of a target weight or when to call the clinic.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| Cannot name any high-protein food | Teach 5 affordable protein sources with gram amounts (3 oz chicken ≈ 21 g, 1 cup Greek yogurt ≈ 17 g, 2 eggs ≈ 12 g) | Concrete grams turn an abstract target into food the patient can buy and eat | Names 5 protein sources with portions before discharge |
| No knowledge of a daily target | Give the RDN target in plain terms — “about 1,500 calories and 65 grams of protein a day” | Measurable goals outperform “eat more” | Restates the daily calorie and protein target in own words |
| Believes three meals is the only pattern | Teach 6 eating occasions: 3 small meals plus 3 energy-dense snacks every 2–3 hours | Small frequent intake is better tolerated with anorexia and early satiety | Describes a 24-hour schedule with 6 eating occasions |
| Has supplements at home but does not use them | Demonstrate fortification (powdered milk, oil, nut butter, cheese); instruct to take supplements between meals | Supplements taken with meals displace food rather than adding to intake | Verbalizes between-meal timing; demonstrates one fortification method |
| No scale at home; does not track weight | Teach weighing weekly, same day, same time, same clothing, and recording it | Weekly home weights detect ongoing loss before the next appointment | Records 4 consecutive weekly weights |
| Cannot name a reason to call the clinic | Provide a written red-flag list: 5% or more weight loss in a month, no intake for over 24 hours, new swallowing difficulty, vomiting beyond 24 hours, new confusion | Written material supports recall after discharge, when anxiety impairs retention | Names at least four red flags requiring a call |
| Teaching not yet validated | Use teach-back on every item; document the patient’s own wording | Teach-back confirms comprehension rather than assumed understanding | Correctly teaches back all key points before discharge |
Care Plan 5 — Risk for Impaired Skin Integrity (Malnutrition and Delayed Wound Healing)
Nursing diagnosis: Risk for impaired skin integrity (NANDA-I 00047)
Diagnostic statement: Risk for impaired skin integrity as evidenced by risk factors of BMI 17.4 kg/m², 12% unintentional weight loss over 5 months, Braden score of 13, bed rest with limited mobility, and intake below 50% of estimated energy needs for 10 days.
Formatting note for students: Again, no signs and symptoms — the skin is still intact. If a pressure injury has already developed, use Impaired skin integrity or Impaired tissue integrity in full three-part form, with stage, location, and measurements in the AEB clause.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| Braden score 13 (moderate risk) | Reassess Braden at least daily and with any change in condition; document subscale scores | Subscale scores direct which specific interventions are needed | Braden stable or improved; no new pressure injury |
| Weight 46 kg, BMI 17.4 kg/m² | Deliver 30–35 kcal/kg/day — about 1,380–1,610 kcal/day at 46 kg — with the RDN | The 2019 international guideline recommends 30–35 kcal/kg/day for adults with or at risk of pressure injury who are malnourished | Intake meets 80% or more of the calorie target within 5 days |
| Protein intake estimated at 32 g/day | Target 1.25–1.5 g protein/kg/day — about 58–69 g/day at 46 kg — with fortified foods and high-protein supplements | The same guideline recommends 1.25–1.5 g protein/kg/day in this population | Protein intake reaches at least 58 g/day within 5 days |
| Bony prominences visible; sacrum blanchable | Reposition at least every 2 hours in bed and every hour in a chair; use a pressure-redistributing surface | Loss of subcutaneous fat removes natural cushioning over bony prominences | Skin over bony prominences intact; no non-blanchable erythema |
| Skin dry and flaking; 2 incontinence episodes | Inspect skin head-to-toe every shift; apply a barrier product and cleanse promptly after each episode | Moisture-associated skin damage compounds pressure injury risk | No moisture-associated damage or new breakdown |
| Supplement ordered but not consumed | Offer high-calorie, high-protein fortified foods and supplements in addition to the usual diet; record amounts taken | The guideline recommends fortified foods and supplements when requirements cannot be met by normal intake | Consumes 2 supplements daily for 7 consecutive days |
| Does not reposition independently | Teach and cue weight shifts every 15 minutes while sitting; involve family in repositioning | Self-initiated micro-shifts extend the interval between nurse-driven turns | Demonstrates independent weight shifts every 15 minutes while up |
Care Plan 6 — Ineffective Health Maintenance (Food Insecurity)
Nursing diagnosis: Ineffective health maintenance (NANDA-I 00099) — revised to “Ineffective health maintenance behaviors” in more recent NANDA-I editions (Thieme 13th-edition contents). Use your program’s edition.
Diagnostic statement: Ineffective health maintenance related to insufficient financial resources and inadequate access to food, as evidenced by a positive Hunger Vital Sign on both items, report of skipping at least one meal daily for 3 months, 5.4 kg (8%) unintentional weight loss over 4 months, and no current SNAP enrollment.
| Assessment | Nursing Intervention | Rationale | Desired Outcome |
|---|---|---|---|
| Food insecurity never screened | Administer the 2-item Hunger Vital Sign on admission; “often true” or “sometimes true” to either item is positive | The Hunger Vital Sign is a validated 2-item screen, 94–98% sensitive against longer USDA modules | Screen completed and documented within 24 hours of admission |
| Positive on both HVS items | Place a social work referral within 24 hours | A positive screen only helps if it triggers a resource connection | Social work consult completed before discharge |
| Not enrolled in SNAP; no pantry access | Provide written information for SNAP, local pantries, WIC if eligible, and home-delivered meals; confirm eligibility with social work | Removing logistical barriers is the strongest predictor of follow-through | Application submitted or pantry appointment scheduled before discharge |
| 8% weight loss over 4 months | Weigh at every visit; calculate percentage change against the 5%-in-6-months threshold | GLIM’s phenotypic criterion is >5% weight loss within 6 months | No further loss; weight stable or rising at 4-week follow-up |
| Eating one meal on most days | Teach low-cost energy-dense options: eggs, dried beans, peanut butter, canned fish, oats, frozen vegetables, powdered milk | Nutrition teaching must match the patient’s actual budget to be actionable | Names at least 5 affordable high-protein foods available locally |
| Single room, no stove or refrigerator | Adapt the plan to shelf-stable, no-cook foods; involve social work on housing and equipment | A plan requiring a stove fails in a room without one | Plan uses only foods the patient can actually prepare |
| No transportation to store or clinic | Arrange transportation resources and confirm a follow-up appointment before discharge | Transportation is among the most common unaddressed barriers to food and follow-up | Follow-up appointment confirmed with transportation arranged |
Nursing Assessment for Imbalanced Nutrition
1. Complete a validated screen within 24 hours of admission and rescreen weekly.
Use MST, MUST, or MNA-SF in older adults, and document the numeric score. BAPEN specifies weekly rescreening for inpatients (BAPEN).
2. Weigh daily — same scale, same time, same clothing.
Weight is your most sensitive nutrition measure and your most abused one. A bed scale at 0600 and a standing scale at 1400 are not comparable data.
3. Calculate percentage weight change, not just pounds.
(Usual weight − current weight) ÷ usual weight × 100. Ten pounds means something different at 250 lb than at 105 lb. GLIM’s thresholds are >5% in 6 months and >10% beyond 6 months.
4. Calculate BMI and interpret it against age.
GLIM uses <20 kg/m² under 70 and <22 kg/m² at 70 and above. Older adults need a higher floor.
5. Quantify intake as a percentage of every meal.
“Poor appetite” is not data. “25% of breakfast, 10% of lunch, 0% of dinner” is. GLIM’s etiologic criterion is ≤50% of requirement for more than one week.
6. Perform a nutrition-focused physical exam and measure handgrip strength if a dynamometer is available.
Check the temples, clavicles, deltoids, interosseous spaces, and quadriceps for muscle loss; the orbits, triceps, and ribs for fat loss; then hair, nails, skin, oral mucosa, and edema. Diminished handgrip is one of the six Academy/ASPEN characteristics.
7. Screen for dysphagia before the patient eats, drinks, or takes oral medication.
In acute ischemic stroke this is a Class I AHA/ASA recommendation for identifying aspiration risk (Powers WJ et al., 2019 AHA/ASA guideline).
8. Screen for food insecurity with the Hunger Vital Sign.
Two items: in the past 12 months, did the household worry food would run out before there was money for more, and did the food bought not last. “Often true” or “sometimes true” to either item is positive (Children’s HealthWatch). It has tested 94–98% sensitive against longer USDA modules (Am J Public Health).
9. Reconcile medications and review the labs that matter.
Chemotherapy, opioids, metformin, SSRIs, digoxin, anticholinergics, and diuretics all suppress appetite, alter taste, or drive electrolyte loss. Check potassium, phosphate, magnesium, glucose, and CBC — not albumin.
10. Identify refeeding risk before anyone orders a tray.
Apply the NICE criteria below before feeding starts, not after.
Nursing Interventions and Rationales
Monitoring
Weigh daily on the same scale, same time, same clothing, and calculate percentage change weekly.
Rationale: The most sensitive available measure of energy balance. A 1 kg change equals roughly 1 L of fluid, so interpret alongside intake and output.
Record the percentage of every meal consumed, and run a 3-day calorie count when intake is questionable.
Rationale: GLIM’s etiologic criterion requires quantified intake. “Ate poorly” cannot support a diagnosis or a referral.
Check potassium, phosphate, magnesium, and glucose daily during the first days of nutrition support in at-risk patients.
Rationale: A 10–20% drop within 5 days of starting feeds meets ASPEN’s threshold for mild refeeding syndrome (ASPEN 2020).
Increasing Oral Intake
Offer small, energy-dense meals and snacks every 2–3 hours instead of three large meals.
Rationale: Early satiety and anorexia make large volumes aversive; small frequent portions deliver more total calories.
Fortify food before adding supplements — butter, oil, cream, cheese, nut butter, powdered milk, protein powder into foods the patient already eats.
Rationale: The 2019 international pressure injury guideline recommends high-calorie, high-protein fortified foods and supplements when requirements cannot be met by normal intake (EPUAP/NPIAP/PPPIA).
Give oral nutrition supplements between meals, not with them, and record how much is actually consumed.
Rationale: Supplements served with meals displace food rather than adding to it. An untouched carton at the bedside is not nutrition.
Protect mealtimes — cluster care, defer non-urgent procedures, do not draw labs or change dressings during meals, and provide feeding assistance.
Rationale: Interrupted meals and trays removed untouched are leading modifiable causes of inpatient undernutrition.
Provide oral care before every meal and treat nausea and pain proactively, giving antiemetics 30–60 minutes before meals when ordered.
Rationale: Xerostomia, mucositis, taste change, nausea, and pain all blunt intake and make every other intervention ineffective.
Honor food preferences and cultural requirements, and advocate for liberalizing restrictive therapeutic diets when undernutrition risk outweighs the benefit.
Rationale: A sodium-restricted, carbohydrate-controlled, low-fat diet the patient will not eat delivers zero calories. Liberalization is often the highest-yield intervention in frail older adults.
Safety, Swallowing, and Collaboration
Keep the patient NPO — including oral medications — until a dysphagia screen is complete after any stroke, position upright at 90° for all intake and 30 minutes afterward, and perform oral hygiene at least twice daily.
Rationale: AHA/ASA gives pre-intake dysphagia screening a Class I recommendation and notes that oral hygiene protocols to reduce post-stroke pneumonia may be reasonable (AHA/ASA 2019).
Refer every positive screen to the RDN, and involve speech-language pathology, pharmacy, social work, and the provider as indicated.
Rationale: Nutrition is a team diagnosis. The RDN sets targets; the nurse delivers, monitors, and escalates.
Screen for food insecurity before discharge and connect positive screens to SNAP, WIC, food pantries, or home-delivered meals.
Rationale: A perfect discharge diet plan fails if there is no food in the house.
Nutrition Screening — The Tools You Administer
These are the screens you perform, not the dietitian. Most facilities require one within 24 hours of admission, long before an RDN has seen the patient, and your score is what triggers the referral. Learn the numbers, not just the acronyms.
| Tool | Population | Components | Scoring | Action threshold |
|---|---|---|---|---|
| MST | Adult acute care, ambulatory | 2 questions: reduced intake from poor appetite; amount of recent unintentional weight loss | 0–5 points | ≥2 = at risk — refer to RDN |
| MUST | Adults, all settings | BMI + unplanned weight loss + acute disease effect | 0, 1, or ≥2 | 0 low risk, 1 medium, ≥2 high risk |
| MNA-SF | Adults ≥65 | 6 items: intake decline, weight loss, mobility, acute stress, neuropsych problems, BMI or calf circumference | 0–14 points | 12–14 normal, 8–11 at risk, 0–7 malnourished |
ASPEN and the Academy of Nutrition and Dietetics identify MST as the tool with the strongest validity and reliability evidence in adult acute and ambulatory care; a score of 2 or more indicates nutritional risk (Academy of Nutrition and Dietetics Evidence Analysis Library).
MUST is scored in five steps (BAPEN): BMI >20 = 0, 18.5–20 = 1, <18.5 = 2; unplanned weight loss in 3–6 months <5% = 0, 5–10% = 1, >10% = 2; acutely ill with no or likely no intake for >5 days = 2; add for the total; then rescreen — hospital inpatients weekly, care homes monthly, community annually for high-risk groups such as adults over 75. If the patient cannot be weighed or measured, a MUAC under 23.5 cm suggests BMI is likely below 20 kg/m².
MNA-SF is the geriatric standard: maximum 14 points, with 12–14 normal, 8–11 at risk, 0–7 malnourished (Nestlé Nutrition Institute MNA user guide). If abnormal, the full 30-point MNA can follow: 24–30 well-nourished, 17–23.5 at risk, below 17 malnourished.
You will also see SGA in the chart, but it is performed by the dietitian, not by you; it produces a letter rating of A (well-nourished), B (mild/moderate), or C (severe) (SGA form).
Your role as the nurse: Administer the screen, document the numeric score, and place the RDN referral the moment it crosses the threshold — do not wait for someone else to notice the number.
Clinical pearl: Screening is not assessment. A positive screen diagnoses nothing — it triggers a referral. Chart “MST score 3, RDN consult placed,” not “patient is malnourished.”
The Albumin Correction — Stop Charting Low Albumin as Proof of Malnutrition
This is the most common error on competing nursing sites, in student care plans, and in a fair number of hospital charts.
ASPEN’s position paper is unambiguous: serum albumin and prealbumin “characterize inflammation rather than describe nutrition status or protein-energy malnutrition,” and they “should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers” (Evans DC, Corkins MR, Malone A, et al. Nutr Clin Pract. 2021;36(1):22–28, doi:10.1002/ncp.10588).
Why the levels fall: during inflammation the liver reprioritizes protein synthesis toward acute-phase reactants, and increased capillary permeability redistributes serum proteins out of the intravascular space. The low number reflects the inflammatory state, not nutrient stores. As the position paper puts it, there is an association between inflammation and malnutrition, but not between malnutrition and visceral-protein levels.
Three more points worth knowing:
- Albumin’s half-life is roughly 14–20 days and it reflects only the intravascular compartment, so it cannot track short-term nutritional change even in theory.
- SCCM/ASPEN critical care guidelines state that albumin, prealbumin, transferrin, and CRP should not be used as indicators of protein status in the ICU (McClave et al., Crit Care Med. 2016;44(2):390–438).
- A rising prealbumin during nutrition support usually signals resolving inflammation and a shift to anabolism, not that your feeding plan is working (ASPEN visceral protein fact sheet).Clinical pearl: If you write “as evidenced by albumin 2.4 g/dL,” you have documented inflammation, not nutrition. Replace it with something defensible: percentage of meals consumed, quantified weight loss, muscle and fat wasting on exam, or handgrip strength.
Refeeding Syndrome — The Complication That Kills Patients You Just Started Feeding
The mechanism
In starvation the body shifts to fat and protein catabolism, insulin secretion falls, and intracellular phosphate, potassium, and magnesium are depleted even when serum levels look normal. Reintroduce carbohydrate and insulin surges, driving glucose — and with it phosphate, potassium, and magnesium — rapidly into cells. Serum levels crash. Thiamine is consumed as a cofactor in carbohydrate metabolism, and sodium and water retention increases.
The consequences: hypophosphatemia (impaired ATP production, respiratory muscle failure, rhabdomyolysis), hypokalemia and hypomagnesemia (arrhythmias, including fatal ones), fluid overload and cardiac failure, and Wernicke encephalopathy from acute thiamine deficiency.
Who is at risk — NICE criteria
High risk if the patient has ONE OR MORE of (NICE CG32):
- BMI under 16 kg/m²
- Unintentional weight loss over 15% in the last 3–6 months
- Little or no nutritional intake for more than 10 days
- Low potassium, phosphate, or magnesium before feeding
Or TWO OR MORE of:
- BMI under 18.5 kg/m²
- Unintentional weight loss over 10% in the last 3–6 months
- Little or no nutritional intake for more than 5 days
- History of alcohol misuse, or drugs including insulin, chemotherapy, antacids, or diuretics
NICE also treats any patient with little or no intake for more than 5 days as at risk, and flags BMI under 14 kg/m² or negligible intake beyond 15 days as extreme risk.
Once it occurs, ASPEN defines refeeding syndrome as a fall in serum phosphorus, potassium, and/or magnesium of 10–20% (mild), 20–30% (moderate), or over 30% (severe) — and/or organ dysfunction from those decreases or from thiamine deficiency — within 5 days of reinitiating or substantially increasing energy provision (da Silva JSV et al., Nutr Clin Pract. 2020;35(2):178–195).
What the nurse does
Recognizing the at-risk patient and monitoring what happens after the first feed is nursing work. The prescribing detail — thiamine dose, starting calorie rates, electrolyte doses — sits further down in the background section; here is your part:
- Identify refeeding risk before the first feed. Apply the NICE criteria above before the first tray, can of formula, or bag of TPN is ordered, and document the risk level.
- Make sure thiamine is given before feeding starts, and continue it as ordered through the early days of feeding — carbohydrate metabolism consumes thiamine, and deficiency precipitates Wernicke encephalopathy.
- Expect a slow calorie start. A high-risk patient advances to full needs over days, not hours. An order that starts a severely underweight patient at goal rate gets questioned before it gets hung.
- Monitor phosphate, potassium, magnesium, and glucose at baseline and at least daily for the first several days — many protocols check every 12 hours for the first 72 hours. Report any drop of 10% or more.
- Watch for cardiac and respiratory decompensation. New arrhythmia or ectopy, crackles, JVD, edema, dyspnea, or new weakness and shortness of breath in a patient started on feeds two days ago all get escalated.
- Keep strict intake and output and daily weights, and restore circulating volume as ordered — insulin-driven sodium and water retention can precipitate fluid overload and cardiac failure.
Your role as the nurse: You are the person who flags the risk before the first calorie and the person who catches the falling phosphate on day two — neither of which requires writing a single order.
Clinical pearl: The refeeding-risk assessment happens before the first tray, the first can of formula, or the first bag of TPN — including the D5 in a maintenance IV. Carbohydrate is carbohydrate.
Enteral vs. Parenteral Nutrition — And Your Responsibilities for Each
If the gut works, use it. Enteral nutrition preserves gut mucosal integrity, costs less, and avoids central line complications. Parenteral nutrition is for patients whose GI tract cannot be used or cannot absorb enough — not for patients who simply will not eat.
| Enteral nutrition (EN) | Parenteral nutrition (PN) | |
|---|---|---|
| Use when | GI tract functional but oral intake inadequate or unsafe — dysphagia, altered mentation, mechanical ventilation, head and neck cancer | Non-functional or inaccessible GI tract — obstruction, high-output fistula, short bowel, severe malabsorption, prolonged ileus |
| Timing in critical illness | Start early, within 24–48 hours of ICU admission | Withhold in low-risk patients if EN is not feasible; start promptly in high-risk or severely malnourished patients when EN is not an option |
| Escalation | Aim for >80% of goal energy and protein within 48–72 hours in high-risk patients | Add supplemental PN after 7–10 days if EN delivers under 60% of goal |
| Main risks | Aspiration, tube misplacement, diarrhea, occlusion | Catheter-related bloodstream infection, hyperglycemia, hepatobiliary complications, refeeding |
Timing, escalation, and supplemental PN recommendations are from SCCM/ASPEN 2016.
Your role as the nurse: The route and the timing are the provider’s and RDN’s call, but you are the one who reports that the patient has been getting well under goal for days — that report is what triggers the change.
Enteral nursing responsibilities
- Verify tube position after placement and before every use. NICE specifies confirming all nasogastric tube positions by aspiration and pH-graded paper, with X-ray if necessary (NICE CG32). A gastric aspirate pH of 1–5.5 is consistent with gastric placement; pH above 5.5 or no obtainable aspirate requires radiographic confirmation (ASPEN NOVEL guidance card; NG tube safety review). Never use auscultation — the “whoosh test” is not valid. Any blindly placed tube needs radiographic confirmation before first use in adults, and post-pyloric placement is confirmed by abdominal X-ray unless placed radiologically.
- Keep the head of bed at least 30°, preferably 30–45°, during feeding and afterward unless contraindicated, and verify positioning at least every 4 hours (ASPEN enteral nutrition practice recommendations).
- Know the residuals debate. SCCM/ASPEN recommend that gastric residual volumes not be used as part of routine care in ICU patients on EN, because holding feeds for arbitrary volumes causes underfeeding without reducing aspiration or pneumonia. Where GRV monitoring remains policy, feeding should not automatically be held for a residual under 500 mL absent other signs of intolerance (SCCM/ASPEN 2016). Assess distension, pain, vomiting, and bowel sounds — not just the syringe.
- Flush with a minimum of 30 mL of water before and after feeds and medications and every 4 hours during continuous feeding. Give medications separately, never mixed into formula. In intensive care, NG feeding is usually delivered continuously over 16–24 hours daily (NICE CG32).
Parenteral nursing responsibilities — CLABSI prevention
- Maximal sterile barrier precautions at insertion, skin prep with >0.5% chlorhexidine with alcohol, and the subclavian site preferred over jugular or femoral in adults for non-tunneled central catheters; avoid the femoral vein in adults (CDC catheter infection prevention strategies).
- Use the minimum number of ports or lumens necessary and dedicate one lumen to PN.
- Assess the site daily by palpation through the dressing and by inspection when a transparent dressing is used.
- For adults 18 and older, chlorhexidine-impregnated dressings with an FDA-cleared CRBSI indication are recommended (Category IA) for short-term non-tunneled central venous catheters (CDC dressing recommendations).
- Hang time: PN solutions and administration sets are replaced every 24 hours; separately infused lipid emulsion is limited to a 12-hour maximum (Infusion Nurses Society / ASPEN guidance).
- Monitor capillary glucose per protocol — hyperglycemia is the most common metabolic complication of PN — and never stop PN abruptly; taper or hang dextrose per order to prevent rebound hypoglycemia.
Your role as the nurse: You do not compound the PN, but you own the line and the glucose — sterile handling, daily site assessment, hang times, glucose checks, and never letting a bag run dry without a dextrose order in place.
Age-Specific Considerations
| Infants and children | Adults | Older adults (65+) | |
|---|---|---|---|
| Screening tool | Growth charts and z-scores | MST or MUST | MNA-SF — 12–14 normal, 8–11 at risk, 0–7 malnourished |
| Key measurement | Weight-for-height, BMI-for-age, length/height-for-age, MUAC z-scores | Weight, BMI, percentage weight change | Weight, BMI, MUAC; calf circumference when height cannot be measured |
| Severity thresholds | z-score −1 to −1.9 mild; −2 to −2.9 moderate; −3 or below severe | GLIM: BMI <20 kg/m² moderate, <18.5 kg/m² severe | GLIM raises the floor: <22 kg/m² moderate, <20 kg/m² severe |
| With serial measures | Weight gain velocity <75%/<50%/<25% of expected under 2 years; weight loss of 5%/7.5%/10% of usual body weight ages 2–20 | >5% loss in 6 months is significant | Any deficit accelerates sarcopenia |
| Chronicity | Acute = under 3 months; chronic = 3 months or longer | Same framing | Usually chronic and multifactorial |
| Main drivers | Illness-related feeding difficulty, food insecurity, feeding disorders | Cancer, GI disease, critical illness, substance use, food insecurity | Dysphagia, dentition, polypharmacy, depression, isolation, dementia, immobility |
| Practical priority | Plot every measurement; a falling channel is the earliest sign | Quantify intake and weight change | Liberalize restrictive diets; protect mealtimes; provide feeding assistance |
Pediatric z-score and serial-measurement thresholds are from the Academy of Nutrition and Dietetics / ASPEN pediatric malnutrition consensus statement.
Clinical pearl: In older adults the therapeutic diet is often the problem. A frail 82-year-old on a 2-gram sodium, carbohydrate-controlled, low-cholesterol diet who eats 20% of every tray is being harmed by the diet order. The mortality risk of undernutrition exceeds the risk of slightly higher sodium.
Red Flags Requiring Immediate Escalation
| Finding | Concern | Action |
|---|---|---|
| BMI <16 kg/m², weight loss >15% in 3–6 months, or no intake >10 days | High refeeding risk | Document before feeding; thiamine first; start at 10 kcal/kg/day or less |
| BMI <14 kg/m² or negligible intake >15 days | Extreme refeeding risk | Start at 5 kcal/kg/day with continuous cardiac rhythm monitoring |
| Phosphate, potassium, or magnesium falls 10% or more within 5 days of starting feeds | Refeeding syndrome | Notify provider immediately; replace electrolytes; consider slowing advancement |
| Confusion, ataxia, or ophthalmoplegia in a starved or alcohol-using patient | Wernicke encephalopathy | Urgent provider notification; thiamine before any glucose |
| New cough, wet voice, or fever after oral intake in a dysphagia patient | Aspiration / aspiration pneumonia | Stop oral intake, suction, assess airway and oxygenation, notify provider |
| Gastric aspirate pH above 5.5 or no aspirate obtainable | Unconfirmed tube position | Do not feed or medicate; obtain radiographic confirmation |
| Fever, chills, or rigors during or after a PN infusion | Catheter-related bloodstream infection | Stop infusion, obtain cultures per policy, notify provider immediately |
| Glucose above 180 mg/dL or below 70 mg/dL on nutrition support | Metabolic complication of feeding | Notify provider; never abruptly stop PN — taper or hang dextrose per order |
| Weight loss of 5% or more in 1 month despite an active plan | Plan failure | Escalate to RDN and provider; reassess the feeding route |
| New or worsening pressure injury with BMI under 18.5 | Malnutrition-driven impaired healing | Escalate to RDN and wound care; target 30–35 kcal/kg and 1.25–1.5 g protein/kg |
What the Dietitian and Provider Decide — And What You Need to Catch an Error
Everything in this section is somebody else’s order to write. You are not calculating calorie targets, staging malnutrition, or dosing electrolytes. You are learning these numbers well enough to recognize an order that looks wrong and question it before you hang it.
The targets they set
| Clinical situation | Energy | Protein | Source |
|---|---|---|---|
| Adult, not severely ill, not at refeeding risk | 25–35 kcal/kg/day (lower end if BMI >25); fluid 30–35 mL/kg/day | 0.8–1.5 g/kg/day | NICE CG32 rec 1.4.2 |
| High refeeding risk | Maximum 10 kcal/kg/day, advancing to full needs over 4–7 days | Per RDN; electrolytes supplemented from the start | NICE CG32 rec 1.4.8 |
Your role as the nurse: Do the rough arithmetic in your head — kilograms times the range — and if the ordered volume of formula or the tray plan is nowhere near it, or if a high-risk patient is ordered at full goal, call it out.
How malnutrition is formally diagnosed — GLIM
The Global Leadership Initiative on Malnutrition (GLIM) 2019 consensus unified how adult malnutrition is diagnosed worldwide (Cederholm et al., doi:10.1002/jcsm.12383). The RDN uses it after a positive screen to make and stage the malnutrition diagnosis: at least one phenotypic plus at least one etiologic criterion is required, and severity — Stage 1 moderate versus Stage 2 severe — is graded on phenotypic criteria only (ESPEN GLIM fact sheet; ASPEN GLIM framework). Your screening score is what starts that process.
| Type | Criteria |
|---|---|
| Phenotypic | Non-volitional weight loss; low BMI; reduced muscle mass |
| Etiologic | Reduced food intake or assimilation; inflammation or disease burden |
The thresholds attached to the first two phenotypic criteria are the same ones you already use at the bedside: >5% weight loss within 6 months or >10% beyond 6 months, and BMI <20 kg/m² under 70 years or <22 kg/m² at 70 and older. The etiologic intake criterion is ≤50% of energy requirement for >1 week or any reduction for >2 weeks. The GLIM Consortium explicitly advises against using hypoalbuminemia as an indicator of malnutrition (2025 GLIM update, JPEN).
In the US you will also see the 2012 Academy/ASPEN consensus, which requires 2 or more of 6 characteristics: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that may mask weight loss, and diminished functional status by handgrip strength (Academy/ASPEN consensus statement). Note what is absent from that list: albumin, prealbumin, transferrin.
Your role as the nurse: You supply the data these criteria run on — quantified intake, percentage weight change, BMI, and the wasting you found on exam — and you never chart the malnutrition diagnosis yourself.
The refeeding orders — the prescribing detail
This is the dosing side of the refeeding content above, all from NICE CG32 recommendation 1.4.8:
- Thiamine and vitamins first: oral thiamine 200–300 mg daily, plus vitamin B co strong 1–2 tablets three times daily (or a full-dose daily IV vitamin B preparation) and a balanced multivitamin/trace element supplement once daily — immediately before and during the first 10 days of feeding.
- Start low: maximum 10 kcal/kg/day, increasing slowly to meet or exceed full needs by 4–7 days; 5 kcal/kg/day in extreme cases, with continuous cardiac rhythm monitoring.
- Supplement electrolytes from the start: potassium 2–4 mmol/kg/day; phosphate 0.3–0.6 mmol/kg/day; magnesium 0.2 mmol/kg/day IV or 0.4 mmol/kg/day oral — unless pre-feeding plasma levels are already high.
- Do not delay feeding to correct levels first: NICE states pre-feeding correction of low plasma levels is unnecessary; correct concurrently with feeding.
Your role as the nurse: Verify thiamine is on the MAR and given before the feed starts, confirm the starting rate matches the risk level, give the ordered electrolytes on schedule, and question any order that withholds feeding until electrolytes normalize.
NCLEX Tips for Imbalanced Nutrition Questions
- Low albumin is not evidence of malnutrition. If an answer offers albumin as the best indicator of nutritional status, eliminate it. Weight change, quantified intake, and physical wasting are the defensible answers.
- Weight is the best single nursing measure. Daily, same scale, same time, same clothing.
- Thiamine comes before glucose. In a starved or alcohol-using patient, dextrose before thiamine can precipitate Wernicke encephalopathy.
- Start low and go slow in refeeding. Any answer starting a severely underweight patient at full caloric goal is wrong.
- Phosphorus is the refeeding electrolyte. A patient started on feeds two days ago who is now weak and short of breath — think hypophosphatemia.
- If the gut works, use it. Choosing TPN for a patient with a functional GI tract is wrong.
- Never verify tube placement by auscultation. pH testing and X-ray only.
- Head of bed at least 30°, preferably 30–45°, for enteral feeding.
- NPO until the swallow screen after a stroke — including oral medications.
- A risk diagnosis has no signs and symptoms, only risk factors.
Frequently Asked Questions
What is the nursing diagnosis for poor nutrition?
The standard NANDA-I diagnosis is Imbalanced nutrition: less than body requirements (00002), defined as intake of nutrients insufficient to meet metabolic needs (NANDA-I 2018–2020). In the 2024–2026 (13th) edition this label was replaced by Inadequate nutritional intake (Open RN / NCBI). Use whichever edition your program uses — the clinical content is identical.
What is the NANDA code for imbalanced nutrition less than body requirements?
00002. It sits in Domain 2 (Nutrition), Class 1 (Ingestion), was approved in 1975, and was revised in 2000, 2017, and 2020, with a Level of Evidence of 2.1.
How do you write a care plan for imbalanced nutrition?
Write the three-part statement — label, related to an etiology you can actually intervene on, as evidenced by quantified findings — then build assessment, interventions, rationales, and measurable outcomes around it. Every row of your table should contain a number. “Encourage adequate intake” is not an intervention; “deliver 1,380–1,610 kcal/day as 3 meals plus 3 energy-dense snacks and record percentage consumed” is.
Is low albumin a sign of malnutrition?
No. ASPEN states that albumin and prealbumin “characterize inflammation rather than describe nutrition status or protein-energy malnutrition” and should not be used as nutrition markers (Evans et al., 2021). The GLIM Consortium likewise advises against hypoalbuminemia as an indicator of malnutrition (2025 GLIM update). Low albumin signals inflammation, not undernutrition — though the two often coexist.
What is refeeding syndrome and who is at risk?
Refeeding syndrome is the dangerous electrolyte and fluid shift that follows reintroducing nutrition to a starved patient: insulin surges and drives phosphate, potassium, and magnesium into cells, causing arrhythmias, respiratory failure, and cardiac decompensation. NICE defines high risk as any one of BMI under 16 kg/m², weight loss over 15% in 3–6 months, negligible intake for more than 10 days, or low pre-feeding potassium, phosphate, or magnesium — or any two of BMI under 18.5 kg/m², weight loss over 10%, negligible intake for more than 5 days, or a history of alcohol misuse or use of insulin, chemotherapy, antacids, or diuretics (NICE CG32).
How many calories does a malnourished patient need?
For adults who are not severely ill and not at refeeding risk, NICE recommends 25–35 kcal/kg/day and 0.8–1.5 g protein/kg/day, with 30–35 mL fluid per kg (NICE CG32). Critically ill adults are generally targeted at 25–30 kcal/kg/day with 1.2–2.0 g protein/kg actual body weight when indirect calorimetry is unavailable (SCCM/ASPEN 2016). Patients at high refeeding risk start at a maximum of 10 kcal/kg/day.
What is the difference between imbalanced nutrition and malnutrition?
“Imbalanced nutrition: less than body requirements” is a nursing diagnosis describing the patient’s response to inadequate intake and the interventions the nurse performs independently. “Malnutrition” is a medical or dietetic diagnosis made against formal criteria such as GLIM or the Academy/ASPEN characteristics. A patient can carry both; only the nursing diagnosis belongs at the top of your care plan.
How do you verify nasogastric tube placement before feeding?
Aspirate gastric contents and test with pH-graded paper — a pH of 1–5.5 is consistent with gastric placement. If pH is above 5.5 or no aspirate can be obtained, get radiographic confirmation before using the tube (NICE CG32; ASPEN NOVEL guidance). Any blindly placed tube requires an X-ray before first use in adults, and auscultation of insufflated air is not acceptable.
Related Nursing Care Plans
- Malnutrition Nursing Diagnosis and Care Plan
- Imbalanced Nutrition: More Than Body Requirements Nursing Diagnosis and Care Plan
- Dehydration Nursing Diagnosis and Care Plan
- Impaired Skin Integrity Nursing Diagnosis and Care Plan
- Deficient Knowledge Nursing Diagnosis and Care Plan
- Nausea and Vomiting Nursing Diagnosis and Care Plan
- Nursing Diagnosis Complete List and Guide
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026 (13th ed.). Thieme. https://shopware.thieme.de/media/09/cf/3b/1730800744/9781684206018_table%20of%20contents.pdf
- NANDA International. (2018). Nursing Diagnoses: Definitions and Classification, 2018–2020 (11th ed.). Thieme. https://ocw.ui.ac.id/pluginfile.php/8226/mod_folder/content/0/NANDA%202018-2020-3.pdf
- Ernstmeyer, K., & Christman, E. (Eds.). Nursing Fundamentals (Open RN). NANDA-I nutrition diagnoses. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK615325/table/ch3.tab9/
- Academy of Nutrition and Dietetics Evidence Analysis Library. Nutrition screening adults: Malnutrition Screening Tool. https://www.andeal.org/topic.cfm?menu=5382&cat=5925
- British Association for Parenteral and Enteral Nutrition. The ‘MUST’ Explanatory Booklet. https://www.bapen.org.uk/pdfs/must/must_full.pdf
- Nestlé Nutrition Institute. Mini Nutritional Assessment (MNA) User Guide. https://www.mna-elderly.com/sites/default/files/2021-10/mna-guide-english.pdf
- Malnutrition Quality Collaborative. Subjective Global Assessment (SGA) Form. https://malnutritionquality.org/wp-content/uploads/Subective-Global-Assessment-Form.pdf
- White, J. V., Guenter, P., Jensen, G., Malone, A., & Schofield, M. (2012). Consensus statement of the Academy of Nutrition and Dietetics/ASPEN: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). https://dietitiansondemand.com/wp-content/uploads/2017/09/ASPEN-AND-2012-Consensus-Statement-Regarding-Malnutrition-Diagnosis-1.pdf
- Cederholm, T., Jensen, G. L., Correia, M. I. T. D., et al. (2019). GLIM criteria for the diagnosis of malnutrition — A consensus report from the global clinical nutrition community. Journal of Cachexia, Sarcopenia and Muscle. https://doi.org/10.1002/jcsm.12383
- European Society for Clinical Nutrition and Metabolism. ESPEN Fact Sheet: GLIM Criteria. https://www.espen.org/images/files/ESPEN-Fact-Sheets/ESPEN-Fact-Sheet-GLIM.pdf
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- Jensen, G. L., Cederholm, T., et al. (2025). Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: An update. JPEN. https://pmc.ncbi.nlm.nih.gov/articles/PMC12053077/
- Evans, D. C., Corkins, M. R., Malone, A., et al. (2021). The use of visceral proteins as nutrition markers: An ASPEN position paper. Nutrition in Clinical Practice, 36(1), 22–28. https://doi.org/10.1002/ncp.10588 — https://pubmed.ncbi.nlm.nih.gov/33125793/
- American Society for Parenteral and Enteral Nutrition. Appropriate Use of Visceral Proteins in Nutrition Screening and Assessment. https://uat.nutritioncare.org/wp-content/uploads/2024/12/Appropriate-Use-Visceral-Proteins-Nutrition-Screening-Assessment.pdf
- National Institute for Health and Care Excellence. Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition (CG32). https://www.nice.org.uk/guidance/cg32/chapter/recommendations
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- Bankhead, R., Boullata, J., Brantley, S., et al. Enteral nutrition practice recommendations. JPEN. https://www.naspghan.org/files/documents/pdfs/training/curriculum-resources/nutrition/other%20guidelines_zeusdeleted_145_09102015010939/Bankhead_Enteral_practice_recommendations.pdf
- American Society for Parenteral and Enteral Nutrition. NOVEL nasoenteric tube placement and verification guidance card. https://nutritioncare.org/wp-content/uploads/2025/01/NOVEL-Lanyard-Card-Print.pdf
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- Muscaritoli, M., Arends, J., Bachmann, P., et al. ESPEN Practical Guideline: Clinical Nutrition in Cancer. https://www.espen.org/files/ESPEN-Guidelines/ESPEN-practical-guideline-clinical-nutrition-in-cancer.pdf
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- Becker, P., Carney, L. N., Corkins, M. R., et al. (2015). Consensus statement of the Academy of Nutrition and Dietetics/ASPEN: Indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics, 114(12), 1988–2000. https://pubmed.ncbi.nlm.nih.gov/25458748/
- Centers for Disease Control and Prevention. Strategies for prevention of catheter-related infections. https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infection/prevention-strategies.html
- Centers for Disease Control and Prevention. Updated recommendations on chlorhexidine-impregnated dressings: Summary of recommendations. https://www.cdc.gov/infection-control/hcp/c-i-dressings/summary-recommendations.html
- Children’s HealthWatch. The Hunger Vital Sign. https://childrenshealthwatch.org/hunger-vital-sign/
- Makelarski, J. A., Abramsohn, E., Benjamin, J. H., Du, S., & Lindau, S. T. (2017). Diagnostic accuracy of two food insecurity screeners recommended for use in health care settings. American Journal of Public Health. https://pmc.ncbi.nlm.nih.gov/articles/PMC5636681/
- Infusion Nurses Society. Guidance to address IV solution shortages (parenteral nutrition and lipid emulsion hang times). https://www.bd.com/content/dam/bd-assets/bd-com/en-us/document/bd-response-plan/INS-Response-To-IV-Shortage.pdf
Reviewed for clinical accuracy by Anna Curran, RN, BSN, PHN — July 2026
This content is intended for nursing students and licensed clinicians as an educational reference. It is not a substitute for facility protocol, provider orders, or independent clinical judgment.
