Malnutrition is a lack of energy, protein, or other nutrients that changes body composition and function — weight and muscle are lost, wounds heal slowly, and infections and falls become more likely. It is a medical diagnosis, not a nursing diagnosis; the nursing diagnoses used most often are Inadequate Protein-Energy Nutritional Intake, Impaired Swallowing, Risk for Adult Pressure Injury, and Risk for Adult Falls. The nurse screens every client, measures weight and intake accurately, involves the dietitian early, removes the barriers to eating, and watches for refeeding syndrome when feeding starts.
At a glance
- What it is
- Undernutrition from too little intake, poor absorption, or higher needs from illness. Overnutrition and single-nutrient deficiencies are also forms of malnutrition.
- Main causes
- Poor appetite, trouble chewing or swallowing, acute or chronic illness, nausea or pain, depression or isolation, cognitive decline, poverty, alcohol use, and conditions that reduce absorption.
- Key signs
- Unplanned weight loss, low body weight for age, muscle and fat wasting, weakness, poor wound healing, oedema, and frequent infections.
- Nursing focus
- Screen on admission, weigh accurately, record intake, refer to the dietitian, help at mealtimes, protect the airway and skin, and prevent falls.
- Act now
- After feeding starts in a severely malnourished client: new weakness, confusion, shortness of breath, swelling, or an irregular pulse can mean refeeding syndrome — report it and check electrolytes as ordered.
Why malnutrition happens
The body needs a steady supply of energy and protein. When intake falls short, it uses its stores. Stored glucose (glycogen) runs out quickly, so the body breaks down fat and muscle protein for fuel. Lost muscle includes the muscles used for breathing, coughing, swallowing, and walking, which is why malnourished clients tire easily, fall, and develop chest infections.
Illness makes this worse. Infection, surgery, injuries, cancer, and chronic heart, lung, or kidney disease cause inflammation, which raises energy needs, speeds up muscle breakdown, and reduces appetite at the same time. This is called disease-related malnutrition, and it is the most common type in hospitals. It can occur in a person of any weight, including a person with obesity.
Without enough protein, zinc, and vitamins, the skin thins and wounds heal slowly, the immune system weakens, and the heart and gut lose function. Older adults are at particular risk because appetite, taste, teeth, and swallowing often decline with age, and illness, medicines, low income, or living alone can make eating harder.
Refeeding syndrome is a danger once feeding restarts. Carbohydrate triggers insulin release, which moves potassium, phosphate, and magnesium into the cells and uses up thiamine. Blood levels can fall quickly, causing weakness, confusion, heart rhythm problems, breathing failure, and fluid overload. This is why feeding in a severely malnourished client is started gradually and electrolytes are watched closely.
How malnutrition is diagnosed (GLIM criteria)
The Global Leadership Initiative on Malnutrition (GLIM) requires at least one physical finding and one cause, after a positive screening test.
| Type | Criterion | Example threshold (adults) |
|---|---|---|
| Physical finding | Unplanned weight loss | More than 5% within 6 months, or more than 10% over more than 6 months |
| Physical finding | Low body mass index (BMI) | Below 20 if younger than 70; below 22 if 70 or older (lower cut-offs are used in Asian populations) |
| Physical finding | Reduced muscle mass | Measured by a validated method or by physical examination |
| Cause | Reduced intake or absorption | 50% or less of energy needs for more than 1 week, any reduction for more than 2 weeks, or a chronic gut condition that limits absorption |
| Cause | Inflammation | Acute illness or injury, or chronic disease |
The dietitian and provider make the formal diagnosis and grade it as moderate or severe. The nurse’s job is to screen, measure, and report accurately so it is not missed.
Nursing assessment
Subjective data
- Usual weight and any unplanned weight loss; clothes, rings, or dentures that now fit loosely
- Appetite, how much of each meal is eaten, and how long intake has been reduced
- Problems chewing or swallowing, coughing or choking with food or drinks, mouth pain, or poorly fitting dentures
- Nausea, vomiting, diarrhoea, abdominal pain, or early fullness
- Fatigue, weakness, dizziness, and recent falls
- Who shops and cooks, money for food, and whether the client lives alone
- Low mood, grief, loneliness, memory problems, and alcohol use
- Medicines that reduce appetite or cause nausea, dry mouth, or taste changes
Objective data
- Measured height and weight (not estimated), weighed on the same scale at the same time of day
- BMI and percentage of weight lost; remember that oedema or fluid retention can hide weight loss
- Muscle wasting at the temples, collarbones, shoulders, hands, and thighs; loss of fat under the skin
- Grip strength, mobility, and ability to feed self
- Skin: dryness, thinning, slow-healing wounds, redness over bony areas; hair loss; brittle nails
- Mouth: sores, cracked lips, sore tongue, missing teeth, oral hygiene
- Signs of dehydration, and oedema in the legs or abdomen
- Percentage of each meal eaten and fluid intake, recorded every meal
- Labs as ordered: electrolytes including potassium, phosphate, and magnesium; glucose; CBC; kidney function. Albumin and prealbumin fall with inflammation and are not reliable measures of nutrition on their own
Common screening tools
| Tool | Typical setting | What it asks about |
|---|---|---|
| MST (Malnutrition Screening Tool) | Hospital adults | Recent weight loss and reduced appetite |
| MUST (Malnutrition Universal Screening Tool) | Hospital and community adults | BMI, recent weight loss, and effect of acute illness on intake |
| NRS-2002 | Hospital adults | Nutritional status, severity of illness, and age |
| MNA-SF (Mini Nutritional Assessment, short form) | Older adults | Intake, weight loss, mobility, stress, cognition, and BMI or calf size |
Nursing diagnoses used with malnutrition
- Inadequate Protein-Energy Nutritional Intake — not eating enough calories or protein to meet the body’s needs
- Inadequate Nutritional Intake (formerly Imbalanced Nutrition: Less Than Body Requirements) — intake too low to maintain health, heal, or grow
- Risk for Inadequate Nutritional Intake — for clients whose intake is still adequate but who have risk factors
- Impaired Swallowing and Risk for Aspiration — after stroke, in dementia, or with neuromuscular weakness
- Risk for Adult Pressure Injury — low body weight, low protein intake, and reduced mobility
- Risk for Adult Falls — muscle loss, weakness, and dizziness
- Fatigue and Frail Elderly Syndrome — in older adults with weight loss, weakness, and declining function
Worked care plans
Four plans in the same ADPIE shape. The scenario is an 81-year-old man who lives alone and was widowed eight months ago. He had a stroke three years ago. He was admitted after a fall at home with dehydration and a urinary tract infection. He is 175 cm tall and weighs 54 kg (BMI 17.6). His daughter says he weighed 62 kg six months ago, a loss of about 13%. His nutrition screen on admission was positive, and the dietitian has been consulted.
1. Inadequate Protein-Energy Nutritional Intake
Problem-focusedSubjective: “I’m just not hungry since my wife passed. I have tea and toast most days.” “Cooking for one isn’t worth it.” Says his dentures hurt when he chews meat.
Objective: Weight 54 kg, down from 62 kg six months ago. BMI 17.6. Hollow temples, prominent collarbones, thin arms and thighs. Weak grip. Ate about a quarter of each meal since admission. Loose, poorly fitting lower denture.
Inadequate Protein-Energy Nutritional Intake related to decreased appetite, grief, poorly fitting dentures, and limited ability to prepare meals, as evidenced by a 13% weight loss in six months, BMI 17.6, muscle wasting, and eating about 25% of meals.
- Client eats at least half of each meal plus the supplements the dietitian orders within 5 days
- Weight stays stable during the hospital stay, then rises toward his usual weight
- Potassium, phosphate, and magnesium stay within the normal range while intake increases
- Client and daughter agree on a plan for meals at home before discharge
- Weigh him on admission and as ordered, on the same scale at the same time of day
- Record the percentage of each meal and supplement taken; start a calorie count if ordered
- Work with the dietitian on his energy and protein needs, food preferences, and supplements between meals
- Set him up for meals: sit him upright, open packages, offer hand hygiene and oral care first, and stay or return to help
- Offer small, frequent, high-protein meals and snacks; avoid interrupting mealtimes
- Ask for a dental or denture review and a soft diet until it is fixed
- Because his intake has been very low, check potassium, phosphate, and magnesium as ordered and report low results before feeding is increased
- Screen for low mood and ask about grief support; refer to social work for meal delivery and help at home
By day 5 he was eating 50–75% of meals and drinking two supplements a day. Weight was stable. Phosphate dipped on day 2 and was replaced as ordered; it was normal by day 4. Meal delivery was arranged. Goal partially met; continue plan and weekly weights after discharge.
2. Impaired Swallowing
Problem-focusedSubjective: “Water goes down the wrong way sometimes.” Daughter says he coughs at most meals and takes a long time to eat.
Objective: Coughs and has a wet-sounding voice after sips of thin liquid. Food left in the left cheek after meals. Slight left-sided facial weakness from the old stroke. Lungs clear, no fever.
Impaired Swallowing related to neuromuscular weakness after stroke, as evidenced by coughing and a wet voice with thin liquids, food pocketing in the left cheek, and prolonged mealtimes.
- Client swallows the food and drink textures recommended by speech-language pathology without coughing or choking
- Lungs stay clear and temperature stays normal
- Client and daughter describe safe swallowing steps before discharge
- Hold oral food, fluids, and medicines until a swallow screen is done per facility policy, and request a speech-language pathology (SLP) evaluation
- Give the food and liquid textures the SLP orders; many facilities use IDDSI levels
- Sit him fully upright for meals and keep him upright afterwards for the time the SLP or policy recommends
- Offer small bites and sips, one at a time, and use any technique the SLP teaches, such as a chin tuck
- Check the mouth for pocketed food after meals and give oral care
- Ask the pharmacist whether medicines can be given in a safer form; do not crush medicines that must not be crushed
- Keep suction available; watch for coughing, voice change, fever, or new crackles and report them
The SLP recommended a soft diet with mildly thick liquids. He ate without coughing, his lungs stayed clear, and he had no fever. His daughter demonstrated the chin tuck and mouth check. Goal met; continue plan.
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3. Risk for Adult Pressure Injury
Risk diagnosis- Low body weight with little fat over the bony areas
- Inadequate protein and energy intake
- Reduced mobility and long periods in bed or a chair
- Dehydration
- Older age with thin, fragile skin
No “as evidenced by” — this names a problem that has not happened yet. His skin is intact; redness over the sacrum fades when pressed.
Risk for Adult Pressure Injury related to low body weight, inadequate protein-energy intake, reduced mobility, and dehydration.
- Skin stays intact over all bony areas throughout the stay
- Client changes position or accepts repositioning on schedule
- Complete a pressure injury risk assessment (for example, the Braden Scale) on admission and as policy requires
- Inspect the skin over the sacrum, hips, heels, elbows, and shoulder blades at least once a shift and with each position change
- Reposition on the schedule set by facility policy and his skin response; keep the head of the bed as low as his condition and swallowing safety allow when he is not eating
- Use a pressure-redistributing mattress and cushion, and float the heels off the bed
- Keep skin clean and dry, and moisturise dry skin; do not massage bony areas
- Support the nutrition plan; protein and fluids are part of skin protection
On day 5 his skin was intact, and the sacral redness had faded. Risk not realised; continue plan.
4. Risk for Adult Falls
Risk diagnosis- Muscle weakness from protein-energy malnutrition
- Fall at home before admission
- Dizziness on standing from dehydration
- Urinary tract infection with urgency and getting up at night
- Age over 65 and an unfamiliar environment
No “as evidenced by” — a risk diagnosis lists risk factors only.
Risk for Adult Falls related to muscle weakness, history of falls, orthostatic dizziness, urinary urgency, and unfamiliar surroundings.
- No falls during the hospital stay
- Client calls for help before getting up
- Client walks to the bathroom safely with an aid by discharge
- Complete a fall risk assessment on admission and as policy requires
- Check lying and standing blood pressure and pulse as ordered; have him sit on the edge of the bed before standing
- Keep the bed low, the call light and urinal within reach, and the path to the bathroom clear and lit
- Offer toileting on a regular schedule, including before sleep
- Use non-slip footwear and his glasses
- Request a physical therapy evaluation for strength, walking aid, and home safety
No falls. Dizziness on standing resolved as fluids were replaced. He used the call light at night and walked to the bathroom with a frame by day 5. Risk not realised; continue plan.
Interventions and rationales
Client and family teaching
- Eat small meals or snacks often rather than three large meals, and eat the protein part of the meal first
- Add protein and energy to everyday foods: eggs, milk, cheese, yogurt, beans, nut butters, fish, and meat
- Take nutrition supplement drinks as advised, between meals so they do not replace food
- Weigh yourself regularly on the same scale and tell your provider about unplanned weight loss
- Keep your mouth healthy: brush twice a day, see a dentist, and have dentures adjusted if they hurt
- If you have trouble swallowing, follow the food and drink textures your speech therapist recommends and sit fully upright to eat
- Ask about meal delivery services and community meal programmes if cooking or shopping is hard
- Eat with others when you can; company often helps appetite
- Tell your provider about low mood, loneliness, or grief that is affecting your eating
- Stay active with the exercises your physical therapist gives you; activity helps rebuild muscle
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Frequently asked questions
What is the nursing diagnosis for malnutrition?
Malnutrition is a medical diagnosis, so it goes in the “related to” part. Common nursing diagnoses are Inadequate Protein-Energy Nutritional Intake, Inadequate Nutritional Intake, Impaired Swallowing, Risk for Adult Pressure Injury, and Risk for Adult Falls.
What replaced Imbalanced Nutrition: Less Than Body Requirements?
In NANDA-I 2024–2026 it became Inadequate Nutritional Intake. The edition also added Inadequate Protein-Energy Nutritional Intake and risk versions of both. Check which edition your nursing programme uses.
What are the signs of malnutrition?
Unplanned weight loss, low body weight, muscle and fat wasting, weakness, tiredness, poor wound healing, frequent infections, dry skin, hair loss, and swelling. A person with obesity can still be malnourished.
Is albumin a good test for malnutrition?
Not on its own. Albumin and prealbumin fall with inflammation, infection, liver disease, and fluid shifts, whatever the person eats. Weight change, intake, muscle loss, and function are more reliable.
What is refeeding syndrome?
A dangerous fall in potassium, phosphate, and magnesium, often with fluid overload, when feeding restarts after a period of very low intake. Feeding is started slowly, electrolytes are monitored and replaced, and thiamine is given as ordered.
What is the nurse’s priority for a malnourished client?
Safety first: airway protection if swallowing is impaired, and watching for refeeding syndrome once feeding starts. Then accurate weights and intake records, early dietitian referral, and help at mealtimes.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Cederholm, T., et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. Clinical Nutrition, 2019;38(1):1–9.
- da Silva, J. S. V., et al. ASPEN consensus recommendations for refeeding syndrome. Nutrition in Clinical Practice, 2020;35(2):178–195.
- Evans, D. C., et al. The use of visceral proteins as nutrition markers: an ASPEN position paper. Nutrition in Clinical Practice, 2021;36(1):22–28.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019.
- Harding, M. M., Kwong, J., & Hagler, D. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 12th ed. Elsevier, 2023.
Screening tools, weight-loss and BMI cut-offs, energy and protein targets, supplement and feeding orders, electrolyte monitoring and replacement, thiamine products and doses, diet and liquid textures, and repositioning schedules vary by client, by provider, and by facility. Follow the provider’s and dietitian’s written orders and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgement.
