106 | How to successfully manage nutrition in your hospitalised patients as a veterinary nurse
I promise you, there is so much more we can do to truly champion nutrition for all of our patients - and by the end of this episode, you’re going to see how massive a role we play as nurses and technicians in this.
Today we’re doing another of our evidence-based episodes, where I take some of the newest guidelines out there in vetmed, and turn reading 20-30 page articles into a 20-minute episode you can listen to on the way to the clinic. And in this episode, we’re diving into the 2021 AAHA Nutrition and Weight Management Guidelines for Dogs and Cats.
If you feel like there’s more you could be doing to support your inappetant patients, or feel like placing feeding tubes is something you don’t do enough, then this episode is for you.
And if you take one thing away from this episode, I want it to be this: These guidelines make it really clear that nutrition isn’t just an optional add-on to a health check. It is literally described as the fifth vital assessment. That means every single exam visit, alongside temperature, pulse, respiration, and pain. Nutrition belongs right there with the basics. And a huge part of making that happen in practice? Us.
So let’s look at what the evidence says about it.
Nutrition is the fifth vital sign - and we need to start looking at it with just as much importance as a TPR.
Let’s start with what a nutritional assessment actually is, because this is the first step in supporting our patients’ nutrition. Assessment is often underperformed (or not performed fully), but it’s essential - and it lays the foundation for everything else we’re going to talk about.
The WSAVA (the World Small Animal Veterinary Association) recommends that nutrition is treated as the fifth vital assessment in small animal practice, and the AAHA guidelines echo this completely.
The idea is simple: we should be assessing nutrition at every single exam visit, for every patient, for their entire life. Not just when there’s a problem, and not just when someone brings it up. Every time.
Now, before you panic, this doesn’t mean a 45-minute nutritional chat at every appointment because absolutely none of us have the time to do that. It’s actually a lot more simple.
The guidelines describe two levels of assessment: an initial screening evaluation (similar to what we’re already doing in most consultations), and an extended evaluation in patients with nutritional risk factors identified on their screening evaluation.
So what does the nutritional screening evaluation tell us as veterinary nurses?
The screening evaluation includes a nutritional history, an assessment of the patient’s environment and activity level, body weight, body condition score, muscle condition score, and a full physical exam.
Straightforward enough, right? We’re already weighing patients, we’re already doing physical exams - none of this is anything new. What we NEED to do, however, is make sure this information - particularly the BCS, MCS and relevant diet history - is consistently recorded every time the patient comes in.
If during that screening we spot what the guidelines call a ‘nutritional risk factor’ - things like an unusual diet, unexplained weight change, a concerning BCS or MCS, dental disease, or a new medical condition - that’s when we need to perform an extended evaluation. This includes a more detailed dietary history, assessment of diagnostic results where appropriate, and a more tailored nutritional plan.
The other really important thing emphasised in these guidelines is the need for continual reassessment, and actually looking back at those results to spot patterns and changes over time. Particularly things like percentage weight change, and changes to body and muscle condition scores. So when we’re looking at these patients, we need to examine the trends, not just the numbers.
Using body and muscle condition scoring in small animal practice
BCS and MCS assessment are essential to providing nutritional support. MCS, particularly, is still underutilised in practice, and we know from recent studies in the US that consistent muscle condition scoring is associated with improved nutritional management.
Using these scoring systems is also an area we can truly champion as veterinary nurses and technicians. So if you’re not using them, download the charts (you can find them in the guidelines linked below this episode), print them off, and stick them up on your consult room wall and in your ward. Get into the habit of assessing each patient you see, and then recording that information on their file.
So what is a body condition score?
Body Condition Score or BCS is a physical assessment of body fat mass.
The guidelines recommend everyone use the 9-point scale, which is validated to correlate with body fat percentage measured by DEXA scanner (the gold standard for measuring body composition).
On this scale, each incremental step represents roughly a 5% change in body fat.
A BCS above 5 out of 9 is considered overweight, and each point above 5 represents being approximately 10% overweight. And when we’re scoring these patients, we need to use whole numbers only. No decimal places, because we need to make scores as consistent and objective as possible, particularly when reassessing a patient to monitor change. If one nurse scores a patient a 7 and another calls them a 6.5, that ambiguity adds up over time and makes our patient’s results harder to interpret.
And what about muscle condition scores - why are they important and when should we use them?
Muscle Condition Score or MCS is a separate assessment from BCS, and this is something that I think gets overlooked a lot in practice. It assesses muscle mass through visualisation and palpation of the muscles over the spine, scapulae, skull, and pelvis. The guidelines recommend using a descriptive scale: normal muscle mass, or mild, moderate, or severe muscle loss. You may also see these recorded numerically in some clinics, with 3/3 being normal, 2 representing mild-moderate loss, and 1 representing significant loss of muscle condition.
The vital take-home point about body and muscle condition is this: BCS and MCS are not the same thing, and they don’t always move in the same direction. A patient can be overweight with a high BCS, but still have significant muscle loss. This is something we see a lot in older patients, in cats especially, and in animals with chronic disease.
And muscle loss has been shown to negatively affect outcomes. So we need to be assessing both, every time, and recording them separately. This information will dictate how we manage these patients, so confidently assessing and scoring them is essential for us as nurses and technicians.
Next, we need to think about how to collect a nutritional history correctly. So, what questions should we ask and how should we ask them?
We’ve established that a nutritional history is a core part of every screening assessment. But how do we get that nutritional history? What questions do we ask, how do we ask them, and where do we fit into this as veterinary nurses? Well, the answer is simple: our role is bigger than you might think. We’re well placed to ask these questions, provide support, and encourage our caregivers to open up to us.
How we ask these questions is just as important as what we ask.
The research that’s been done on vet-client nutrition conversations shows that the questions we ask have a massive impact on the quality of the information we get back.
And one of the biggest findings is that a question like ‘what food is your pet on?’ doesn’t actually get us very far. That kind of closed, what-prefaced question tends to result in limited information and can actually prompt defensive responses from clients, especially if they’re feeding a non-conventional diet and are worried about potential judgemen.
What works better is open-ended questioning. Things like ‘tell me about what a typical feeding day looks like for your pet’, or ‘walk me through what they eat from morning to night’. These questions let clients share information organically, and you’ll often learn things you would never have thought to ask about directly.
There’s also a specific area that our caregivers are consistently less likely to give us the full details on, and that’s treats. The research shows that if you use the word ‘treats’, you’ll often get an underestimate, or maybe nothing at all. The guidelines suggest using different language: ‘snacks’, ‘rewards’, ‘extra foods’, ‘anything they get in addition to their main meals’. And this is really important because treats, table scraps, and supplements can make up a surprisingly high portion of a patient’s daily intake.
A complete nutritional history should include the main diet, any additional food items and treats, supplements, foods used to give medications, the feeding method and frequency, how food is stored and measured, and any changes in intake or appetite.
There are several diet history forms available such as those from the WSAVA, which I’ve linked below the episode. Asking clients complete these at home before their appointment is particularly useful, because people tend to give more accurate and complete answers when they’re not on the spot and have time to consider their answers fully.
As nurses and technicians, this history-taking is something we do incredibly well. We’re often in a great position to ask these questions in a relaxed way, without the client feeling like they’re being judged, and setting that supportive relationship up early is very important - particularly if we’re going to make nutritional recommendations and expect them to follow these.
So once we’ve got this history and assessed our patient, we need to think about managing nutrition in hospital.
We all know how much work getting these inappetent patients to eat again can be. We’ve all felt that frustration of wishing we had a feeding tube and could just get some calories in to that anorexic patient. We’re also usually the ones trying desperately to get things like stress, nausea and pain under control, while finding a diet the patient likes, and getting their treatment on board. Sometimes we’re juggling so many things, especially with complicated patients or a full ward, that before we know it it’s the afternoon, and we’ve not managed to get them eating anything at all..
But these guidelines are really, really clear on this point: nutritional assessment for hospitalised patients should happen on admission and at minimum daily for the duration of their stay. And this is absolutely something we can champion as nurses and technicians - so in the mornings, with your clinical exams and vitals, take an extra couple of minutes to include a review of their nutritional status. That way, we can flag changes early, and we’ve got plenty of time to do things like review their treatment plan with the vet, or ask if a feeding tube would be appropriate.
What does that nutritional assessment look like in our hospitalised patients?
On admission, we need to gather some key historical information - most of which we’ve already done if we or our vet have completed a nutritional assessment.
We need to know:
What does this patient normally eat?
Have there been any changes in appetite recently?
Have there been any episodes of anorexia, hyporexia, or dysrexia (a change in the type of food eaten or unusual food preferences)?
These details are essential because they tell us what’s normal for that individual patient, and help us make a nutritional plan.
Once we’ve got this information, we need to combine it with our physical exam findings.
This should not just include our vitals, but also assessment of mentation, a check for ascites or oedema, and a review of available diagnostic results where tests have been performed. For example, potassium levels commonly drop in anorexic patients, and hypoalbuminaemic patients are at increased risk of malnutrition - so if abnormalities are present, we need to know about it.
Body weight also needs to be checked at least daily; not to monitor weight gain or loss in the traditional sense, but because daily weight changes in a hospitalised patient are one of our best indicators of hydration status.
And once we’ve got that information, we need to create a nutritional plan for our inpatient.
This means calculating the patient’s resting energy requirement, or RER. The RER is the energy needed in calories to maintain homeostasis at rest, and it is calculated using the formula:
70 x body weight in kilograms to the power of 0.75.
For a hospitalised patient, we usually feed using RER as our baseline, rather than adding life stage factors or calculating metabolic energy rquirements - but not always. It will depend a little on the patient, their age and individual factors, and their response to feeding. Calculations, whichever you use, are not one-size-fits-all, and the most important thing is monitoring the patient’s response and adjusting your plan as necessary.
In patients with a history of anorexia or hyporexia, we’ll begin by feeding a percentage of RER rather than their full amount, because illness changes energy requirements in complex ways, and overfeeding can be just as problematic as underfeeding - risking complications like refeeding syndrome.
For patients who are at an ideal or underweight BCS, we base our calculations on their current weight to prevent overfeeding. For patients who are overweight or obese, the guidelines recommend basing calculations on their ideal body weight, because we don’t want to be feeding to their excess fat mass.
Once we’ve created those feeding orders, we need to ensure they’re clear and accessible for the entire team.
The guidelines are clear about this: our feeding plans need to be written clearly, not verbally communicated, and they need to be reassessed daily.
They should specify the food or foods being offered, the amount, the feeding frequency, and the method. This might sound obvious, but it’s something easy to overlook, particularly when things are busy - which is often when they’re most important.
And how do we support our anorexic patients as veterinary nurses and technicians?
The guidelines describe a systematic and logical approach to managing anorexia and hyporexia in hospitalised patients. Before we even think about assisted feeding, we should be trying supportive techniques: offering a variety of food types, warming food to body temperature, removing Buster collars during feeding attempts, making sure food and other resources are well-separated, and ensuring the patient is in as low-stress an environment as possible. These things might seem small, but they add up to make a significant difference, and they’re often the things that we’re really good at incorporating into our daily nursing care.
If the patient still isn’t meeting their energy needs through voluntary intake, the next step is medication support with things like appetite stimulants, antiemetics, analgesics and prokinetics, depending on the individual patient. We need to be treating the underlying drive behind the inappetence before doing things like stimulating appetite, so always check for pain, nausea and stress, and manage this first. Of course, this is a conversation to have with the vet as prescribing is their role, but as the person acting as the patient’s eyes and ears in the ward, our input on their needs is really valuable.
If supportive techniques and medications are not achieving adequate intake, enteral feeding via a tube is strongly recommended within 72 hours of the patient consuming less than a third of their RER - and that includes the time before hospitalisation. So if a patient comes in having barely eaten for three days, they need their tube placed on day 1-2, not day 3 of hospitalisation.
That enteral nutritional support needs to come from a feeding tube rather than oral syringe feeding, and the guidelines are really clear about this. They cite two reasons for this: first, the risk of food aversion, where patients learn to associate food with an unpleasant experience and stop eating voluntarily, and second, the risk of aspiration.
Tube feeding - be that with a nasal tube, oesophagostomy tube or gastrostomy tube - is safer, less stressful for the patient, and allows us to deliver accurate volumes reliably. And for patients where enteral feeding isn’t possible (because the GI tract won’t tolerate it), parenteral nutrition can be considered, but it’s reserved for very specific cases, typically in referral ICU settings with 24-hour care.
And what should we be feeding our hospitalised patients?
For patients with no contraindications, high-fat diets tend to have a higher caloric density, which means the volume the patient needs to consume is smaller. This can be advantageous for patients who won’t eat enough, or in very volume-tolerant patients - because we’re getting more calories in for a smaller volume of food.
However, we need to consider this on an individual patient basis, because a patient with pancreatitis, for example, is not going to be a candidate for a high-fat diet.
So to summarise our role in inpatient nutrition as nurses and technicians, we need to assess the patient’s nutritional status on admission and daily, weigh every day, have a written feeding plan, try supportive techniques first, escalate appropriately, and don’t leave a patient consuming less than a third of their RER for 72 hours without considering a feeding tube. And as the eyes, ears, and hands on our patients all day, every day in the ward, our role in this cannot be overlooked.
How to approach nutrition as a team in practice: how can we make sure our patients are supported?
We all know how important nutrition is, but we also all often feel we can do more to support these patients. So knowledge isn’t the only thing we need here - we need to build the systems that make it happen consistently in practice.
The guidelines describe nutritional management as a true team effort. It involves the whole practice: the front desk team, who can send out diet history forms before appointments; veterinary nurses and technicians, who assess BCS, MCS, and take nutritional histories; the vet, who synthesises all of that information and makes the recommendation; and then the nurse or technician again, who explains and reinforces that recommendation to the client, answers questions, and performs follow-up monitoring.
And speaking of that follow-up monitoring, many of our medical patients will require ongoing nutritional support, particularly if they’re transitioning to a new diet, they have obesity requiring weight management, or we’re getting weight back on them after a period of illness.
And as these patients come through the door more frequently, our relationships with them and their families deepen. This means our clients and caregivers begin understanding more and more about how much we know and can do as nurses and technicians. We get to know our patients better too - meaning subtle changes become easier to spot, and patient outcomes improve as a result.
The guidelines specifically highlight that veterinary nurses and technicians are ‘poised to lead’ nutritional care in practice, and I genuinely believe this is the case. We have the skills, we have the client relationships, and we have the hands-on time with patients in the ward. Nutrition is an area where nurse-led care just makes sense - from diabetic weight checks, to CKD reassessments, nutritional support clinics, and even senior pet clinics, the importance of our role in supporting these patients just cannot be overlooked.
So there it is - nutritional assessment and inpatient nutrition according to the 2021 AAHA nutrition guidelines. But what key messages do you actually need to take away from this episode?
First, nutrition is the fifth vital assessment, meaning it belongs in every single examination. The BCS and MCS should be assessed and recorded at every visit, and those numbers should be documented so we can look at changes over time.
For hospitalised patients specifically: assess them on admission and every day. Weigh them daily. Have a written feeding plan. Try supportive measures for anorexic patients and then escalate to medication support if needed. And if a patient has been consuming less than a third of their RER for 72 hours, enteral feeding via tube, not syringe, is indicated where possible.
Nutritional history should be gathered using open-ended questioning, using diet history forms to help make this process easier. Ideally get your caregivers to complete these at home before the appointment where you can.
And finally: communicate with compassion. Nutrition conversations are often sensitive and emotive. They touch on a client’s ability to care for their pet, their own food beliefs, and even their emotional relationship with feeding at times. A big part of gaining trust and building relationships is validating the client’s concerns without necessarily agreeing with them. To maximise compliance, find the commo ground and keep the focus on what you both want, which is the best possible health for the patient.
We cannot overstate how much of this falls into our role as nurses and technicians. We are the ones caring for these patients in the ward, we are the ones talking about diet, assessing these patients in clinics, and often making nutritional recommendations. There are so many skills we can use within this, and more ways we can support our patients than we think.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Cline, M. G., Burns, K. M., Coe, J. B., Downing, R., Durzi, T., Murphy, M., & Parker, V. (2021). 2021 AAHA Nutrition and Weight Management Guidelines for Dogs and Cats. Journal of the American Animal Hospital Association, 57(4), 153–178. https://doi.org/10.5326/JAAHA-MS-7232
Freilich, L., & Jugan, M. C. (2024). Retrospective evaluation of enteral nutrition supplementation in 295 hospitalized dogs and cats (2014-2023). Journal of the American Veterinary Medical Association, 263(3), 1–7. https://doi.org/10.2460/javma.24.07.0494
