Nutrition Focused

Physical Exam
(NFPE)
Ashley Strickland, RDN, LDN, CNSC
Indiana Academy of Nutrition and Dietetics Annual
Conference
April 13, 2017
Course Objectives

 Discuss the importance of developing a

competency process to deem clinicians competent
to practice an NFPE.
 Review the A.S.P.EN/A.N.D Clinical Criteria used
to identify malnutrition
 Understand how to assess muscle and fat sites for
signs of wasting

2
Course Overview
• Each participant will read 4 Articles:
Pre-Reading

• Review curriculum utilizing power point presentation

• Break Out Sessions (Fat, Muscle and Edema Assessment)
• Using the 3 case studies, complete a physical assessment simulation in order to
determine if malnutrition diagnosis is appropriate
Initial
Competency • Perform Head to Toe Exam based on A.S.P.E.N/Academy guidelines, and meet
competency

• Each Dietitian will complete 2 Physical Assessments identifying

patients with Malnutrition. Validation will be completed by Subject
Matter Experts
1-3 Months &
Annual
competency

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Subject Matter Expert

 The following has been completed by the subject matter expert:

 Independent contractor for The Academy of Nutrition and Dietetics as a
trainer to provide malnutrition workshops to dietitians across the nation.
 Attended a 2 day seminar, title “The Nutrition Focused Physical Examination”
at Rutgers School of Health Related Professions. Competencies acquired were
validated by a medical professional, upon completion of this seminar.
 Attended a 1 day seminar, titled “Diagnosing Malnutrition: Understanding the
Role of Muscle and Fat Loss” at Novant Health Presbyterian Medical Center.
Competencies acquired were validated by a medical professional, upon
completion of this seminar.
 Completed an online education program, titled “Patient Simulation: Putting
Malnutrition Screening, Assessment, Diagnosis, and Intervention into Practice”.
1 hour of continuing education was obtained, upon completion of this
program.
 Completed multiple peer reviewed nutrition focused physical exams
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Order Entry
Malnutrition Documentation
(Dietitian Note)

6
Scope of Practice in Nutrition Care for
RDNs
• The RDN can conduct a nutrition focused physical examination
• “Nutrition-focused physical findings assessment (often referred to as
clinical assessment): Assessed findings from evaluation of body
systems, muscle and subcutaneous fat wasting, oral health, hair, skin
and nails, signs of edema, suck/swallow/breath ability, appetite and
affect.”
• Differentiate normal vs non-normal findings
• Assess and intervene in findings that are relevant to the patient’s care
• Refer and collaborate with the medical/Interdisciplinary team

JAND 2013 113 (6 Suppl): S56-71

Malnutrition Prevalence

 1/3 hospitalized patients are malnourished upon admission

 A major contributor to increased morbidity and mortality, decreased quality
of life, increased length of stay, and readmissions
 Nutrition interventions are low risk and cost effective

Tappenden et al. JPEN 2013

Goal for Inter-professional Approach to
Address Malnutrition

 Create a culture where nutrition is valued

 Include multiple disciplines in nutrition care
 Identify and diagnose all patients with malnutrition or those that are at risk for
becoming malnourished
 Implement comprehensive nutrition interventions
 Develop discharge nutrition care and education plans

Tappenden et al. JPEN 2013

Etiology-Based Malnutrition
Definitions
Nutritional Risk Identified
Compromised intake or loss of
body mass

Inflammation present?
No/Yes

Yes Yes
No Mild-Moderate
Marked
Inflammatory
degree response

Starvation Related Chronic Disease-Related Acute Disease or Injury-

Malnutrition Malnutrition Related Malnutrition
(pure chronic (organ failure, pancreatic (major infection, burns,
starvation, anorexia cancer, rheumatoid trauma, closed head
nervosa) arthritis, sarcopenic injury
obesity)

Jensen GL.JPEN 2009;33:710

 Malnutrition Etiologies

 Acute Illness/Injury
 Severe inflammation

 Chronic Illness
 Mild to moderate inflammation

 Occurring for 3 months or longer

 Social/ Environmental Circumstances

 Chronic starvation, NO inflammation
Acute Illness/Injury with
Severe Inflammation
• Inflammation is acute and of severe degree
– Examples:
• Major infection/sepsis
• ARDS, burns, trauma
• Closed head injury
• Major surgery (any surgery that involves a major organ)

Jensen GL. Malnutrition and inflammation – “burning down the house.” JPEN, 2014.
Chronic Illness with
Mild-Moderate Inflammation
 Inflammation is chronic and of mild-moderate degree
– Examples:
 Organ failure (kidney, liver, heart, lung, gut
 Cancer
 Rheumatoid arthritis
 CHD
 Cystic fibrosis
 Celiac disease
 IBD
 CVA
 Chronic pancreatitis
 DM
Jensen GL. Malnutrition and inflammation – “burning down the house.” JPEN, 2014.
Social or Environmental Circumstances
NO inflammation
• Chronic starvation without inflammation
– Examples:
• Depression (currently a questionable dx for this category)
• Economic hardship
• Cognitive or emotional impairment
• Inability or lack of desire to manage self-care
• Physical conditions: ingestion of foreign bodies
• Anorexia nervosa
• Poor oral/dental conditions

Jensen GL. Malnutrition and inflammation – “burning down the house.” JPEN, 2014.
 Severe Malnutrition : Must have at least 2 categories
ICD-10: E44 Severe Malnutrition Severe Malnutrition Severe Malnutrition
Severe, Protein- in the context of in the context of in the context of
Calorie Malnutrition Acute Illness/Injury Chronic Illness Social/Behavioral/
Environmental
Circumstances

Weight Loss Weight Loss Weight Loss Weight Loss

>2% in 1 week >5% in 1 month >5% in 1 month
>5% in 1 month >7.5% in 3 months >7.5% in 3 months
>7.5% in 3 months >10% in 6 months >10% in 6 months
>20% in 12 months >20% in 12 months

Intake Energy Intake Energy Intake Energy Intake

≤50% energy intake ≤75% energy intake ≤50% energy intake
compared to estimated compared to estimated compared to estimated
energy needs for ≥ 5 days energy needs for ≥1 month energy needs for ≥1 month

Body Fat Body Fat Body Fat Body Fat

Moderate depletion Severe depletion Severe depletion

Muscle Mass Muscle Mass Muscle Mass Muscle Mass

Moderate depletion Severe depletion Severe depletion

Fluid Fluid Accumulation Fluid Accumulation Fluid Accumulation

Moderate to Severe Severe Severe
Accumulation
Grip Strength Reduced Grip Strength for Reduced Grip Strength for Reduced Grip Strength for
age and gender or age and gender or age and gender or
Regressed Functional Status Regressed Functional Status Regressed Functional Status
 Moderate Malnutrition - Must have at least 2 categories
ICD-10: E43 Moderate Moderate Moderate
Malnutrition of Malnutrition in the Malnutrition in the Malnutrition in the
Moderate Degree context of Acute context of Chronic context of
Illness/Injury Illness Social/Environment
al Circumstances

Weight Loss Weight Loss Weight Loss Weight Loss

1-2% in 1 week 5% in 1 month 5% in 1 month
5% in 1 month 7.5% in 3 months 7.5% in 3 months
7.5% in 3 months 10% in 6 months 10% in 6 months
20% in 12 months 20% in 12 months

Intake Energy Intake Energy Intake Energy Intake

<75% energy intake <75% energy intake <75% energy intake
compared to estimated compared to estimated compared to estimated
energy needs for >7days energy needs for ≥1 month energy needs for ≥3
months

Body Fat Body Fat Body Fat Body Fat

Mild depletion Mild depletion Mild depletion

Muscle Fat Muscle Mass Muscle Mass Muscle Mass

Mild depletion Mild depletion Mild depletion

Fluid Fluid Accumulation Fluid Accumulation Fluid Accumulation

Mild Mild Mild
Accumulation
Grip Strength Reduced Grip Strength Reduced Grip Strength Reduced Grip Strength
Not applicable Not applicable Not applicable
Albumin/Prealbumin

 Albumin/prealbumin:
 Not good indicators of nutritional status!

 “[Albumin and prealbumin], although probable indicators of

inflammation, do not specifically indicate malnutrition and do
not typically respond to feeding interventions in the setting of
active inflammatory response. Thus, the relevance of
laboratory tests of acute phase protein levels, as indicators of
malnutrition, is limited”.
 “Serum proteins such as serum albumin and prealbumin are not
included as defining characteristics of malnutrition because
recent evidence analysis shows that serum levels of these
proteins do not change in response to changes in nutrient
intake”.
17
 Severity of Malnutrition

• “Mild Malnutrition”
Evidence is lacking to be able to distinguish between mild
and moderate malnutrition in the clinical setting, therefore
there is no standard definition of mild malnutrition

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Be familiar with you patient’s anatomy!

 Prior to performing an NFPE on your patient, it is important to be familiar

with their general anatomy, line placements, ostomies, etc..
 Does the patient have a PICC?
 Male versus female
 Age
 Are there any ostomies or lines that would inhibit you from taking their gown or
blankets off?
 Is the patient stable to reposition?
 Is there any prior injury, surgery, or non-nutrition related issue, that would cause
your patient to have an abnormal presentation of an area on their body (i.e.
amputations, arthritis, previous surgery, cupital tunnel and carpal tunnel
syndrome, paralysis, etc…)

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BODY FAT

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Assessment: Body Fat Loss
Orbital Region

Exam area Tips Severe Mild – Well -

Malnutrition moderate nourished
malnutrition
Orbital region View patient Hollow look, Slightly dark Slightly
– surrounding when depressions, circles, bulged fat
the eye standing dark circles, somewhat pads. Fluid
directly in loose skin hollow retention
front of look may mask
them, loss
touch above
cheekbone

Nutrition in Clinical Practice 28 (6): 639-650

Facial Muscles
 Orbital Region (Orbital fat pads)

Mild-
Normal Severe
Moderate

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 Assessment: Body Fat Loss
Upper Arm Area

Exam area Tips Severe Mild – Well-

malnutrition moderate nourished
malnutrition
Upper arm Arm bent, roll Very little Some depth Ample fat
region – skin space pinch, but not tissue
triceps/bicep between between ample obvious
fingers, folds, between
do not fingers touch folds of skin
include
muscle in
pinch

Nutrition in Clinical Practice 28 (6): 639-650

Triceps/Bicep Muscles
Triceps

Mild-
Normal Severe
Moderate

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Assessment: Body Fat Loss
(Thoracic and Lumbar Region)

Exam area Tips Severe Mild – Well-

malnutrition moderate nourished
malnutrition
Thoracic and Have patient Depression Ribs Chest is full,
lumbar region press hands between the apparent, ribs do not
– ribs, lower hard ribs very depressions show. Slight
back, against a solid apparent. between to no
midaxillary object Iliac them protrusion of
line crest less the iliac crest
prominent pronounced.
Iliac crest
somewhat
prominent

Nutrition in Clinical Practice 28 (6): 639-650

Thoracic/Lumbar Region and
Midaxillary Line
 Thoracic/Lumbar Region and
Midaxillary Line

Normal Mild-
Moderate Severe
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MUSCLE

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Assessment: Muscle Loss
Temple Region
Exam area Tips Severe Mild – Well-
malnutrition moderate nourished
malnutrition
Temple View patient Hollowing, Slight Can see/feel
region/ when scooping, depression well-defined
Temporalis standing depression muscle
muscle directly in
front of
them, ask
them to turn
head
side to side

Nutrition in Clinical Practice 28 (6): 639-650

Temple region/ Temporalis muscle
Temporal Region

Mild-
Normal Severe
Moderate

33
 Assessment: Muscle Loss
(Clavicle Bone Region)

Exam area Tips Severe Mild – Well-

malnutrition moderate nourished
malnutrition
Clavicle bone Look for Protruding, Visible in Not visible in
region – prominent prominent male, some male, visible
Pectoralis bone. Make bone protrusion in but not
major, sure female prominent in
deltoid, patient is not female
trapezius hunched
muscles forward

Nutrition in Clinical Practice 28 (6): 639-650

Clavicle bone region, Pectoralis Major,
Deltoid, Trapezious Muscles

Trapezius

Clavicle

Pectoralis
Clavicle Region
MILD-
NORMAL MODERATE

SEVERE
 Assessment: Muscle Loss
(Acromion Bone Region-Deltoid Muscle)

Exam Area Tips Severe Mild- Well

Malnutrition Moderate Nourished
Malnutrition
Clavicle & Patient arms Shoulder to Acromion Rounded,
Acromion at arm process curves at
bone side; observe joint shape may slightly arm,
region – shape looks protrude shoulder,
Deltoid square. neck
muscle Acromion
protrusion
very
prominent

Nutrition in Clinical Practice 28 (6): 639-650

Acromion Bone region-Deltoid
Muscle
Acromion Bone Region-Deltoid
Muscle MILD-
NORMAL MODERATE

SEVERE
Assessment: Muscle Loss
Scapular Bone region, Trapezious, Supraspinatus,
Infraspinatus muscles

Exam Area Tips Severe Mild- Well

Malnutrition Moderate Nourished
Malnutrition
Scapular bone Ask patient to Prominent, Mild Bones not
region – extend hands visible depression prominent,
Trapezius, straight out, bones, or bone may no
supraspinatus push against depressions show slightly significant
infraspinatus solid object between ribs/ depressions
muscles scapula or
shoulder/spin
e

Nutrition in Clinical Practice 28 (6): 639-650

Scapular Bone region, Trapezious,
Supraspinatus, Infraspinatus Muscles
 Scapular Bone region, Trapezious,
Supraspinatus, Infraspinatus Muscles

Normal Mild- Severe

Moderate

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Assessment: Muscle Loss
Dorsal Hand-Interosseous Muscle

Exam Area Tips Severe Mild- Well

Malnutrition Moderate Nourished
Malnutrition
Dorsal hand – Look at Depressed Slightly Muscle
Interosseous thumb area depressed bulges,
muscle side of hand; between could be
look at pads thumb flat in some
of and well
thumb when forefinger nourished
tip individuals
of forefinger
touching tip
of
thumb

White et al, J AcadNutr Diet 2012

Dorsal Hand-Interosseous Muscle
Assessing Dorsal Hand-Interosseous
Muscle
 Assessing Dorsal Hand-Interosseous
Muscle

Normal Mild Severe

46
Assessment: Muscle Loss in the Lower
Body-Quadriceps
Exam Area Tips Severe Mild- Well
Malnutrition Moderate Nourished
Malnutrition
Anterior thigh Ask patient to Depression/li Mild Well
region – sit, ne depression rounded,
Quadriceps prop up leg on thigh, on inner thigh well
muscle on obviously thin developed
low furniture.
Grasp quads
to
differentiate
amount of
muscle tissue
from fat
tissue
Nutrition in Clinical Practice 28 (6): 639-650
Quadriceps (Anterior Thigh)
Assessment: Quadriceps

Normal Severe
Mild-
Moderate
49
Assessment: Muscle Loss in the Lower
Body-Patellar Region

Exam Area Tips Severe Mild- Well

Malnutrition Moderate Nourished
Malnutrition
Patellar Ask patient to Bones Knee cap less Muscles
region sit prominent, prominent, protrude,
– Quadriceps with leg little more bones not
Muscle propped sign of muscle rounded prominent
up, bent at around knee
knee

Nutrition in Clinical Practice 28 (6): 639-650

Assessing for Muscle Loss-Patellar
Region

z
Assessment: Patellar Region

Mild-
Normal Severe
Moderate

52
Assessment: Muscle Loss in the Lower
Body-Posterior Calf (Gastrocnemius)

Exam Area Tips Severe Mild- Well

Malnutrition Moderate Nourished
Malnutrition
Posterior calf Grasp the calf Thin, minimal Not well Well
region – muscle to to developed developed
Gastrocnemiu determine no muscle bulb of
s amount of definition muscle
muscle tissue

Nutrition in Clinical Practice 28 (6): 639-650

Posterior Calf (Gastrocnemius)
Assessment: Posterior Calf
(Gastrocnemius)

Mild-
Normal
Moderate Severe

55
EDEMA

56
Considerations: Edema

 Supportive criteria in the diagnosis of malnutrition

 Rarely a direct result of malnutrition
 Falsely elevates weight/masks weight loss
 Interferes with ability to assess muscle and fat wasting
Assessment: Edema
Exam Area Tips Severe Mild- Well
Malnutrition Moderate Nourished
Malnutrition
View Rule out Deep to very Mild to No sign of
scrotum/vulv other causes deep pitting, moderate fluid
a in activity of edema, depression pitting, slight accumulation
restricted patient at dry lasts a to swelling of
patient; weight moderate the
ankles in time (31-60 extremity,
mobile seconds) indentation
patient extremity subsides
looks swollen quickly (0-30
(3-4+) seconds), 1-
2+

Nutrition in Clinical Practice 28 (6): 639-650

Assessment: Edema
Method Measurement and
Rebound
+1 2 mm depression, barely
detected, immediate
rebound
+2 4 mm deep pit, a few
seconds to rebound
+3 6 mm deep pit, 10 – 12
seconds to rebound
+4 8 mm very deep pit, >
20
seconds to rebound

.
Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City: Prentice Hall
Edema: Legs, Ankles, Feet
Edema: Scrotum, Vulva
Hand Dynamometer

• The means are generated by the

manufacture and come with the
dynamometer.
• Reduced grip strength is defined as 2
standard deviations below the norm.
• Reduced handgrip strength is often
times, one of the first things to
decline with malnutrition and is
usually detected before fat and
muscle wasting is present.
• Important to work with therapist
(OT/PT) to understand how to
properly position your patients, as
well as what patients are most
applicable for using a hand
dynamometer. 62
Summary

 Identification of and timely, effective interventions for malnutrition are

important due to the adverse outcomes associated with malnutrition.
 Nutrition-focused physical exam is an essential component of a nutrition
assessment and assists with identifying malnutrition and other nutritional
problems.
References

• Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. 4 th ed. Chicago, IL: AND; 2012

• Fischer M, & Hamilton C. 2013. Incorporating physical assessment in the diagnosis of malnutrition: a change inpractice [PowerPoint slides]. Retrieved from
http://fnce.eatright.org/fnce/uploaded/635199493315675427230.%20Fischer.pdf

• Gabay C & Kushing I. Acute-Phase Proteins and Other Systemic Responses to Inflammation. NEJM. 1999 Feb; 340 (6): 448-454

• Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City: Prentice Hall. Retrieved from http://geriatrictoolkit.missouri.edu/cv/pitting_edema.htm

• Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum versus continuum. JPEN J Parenter EnteralNutr. 2009 Nov-Dec; 33: 710-16

• Jensen GL. Malnutrition and Inflammation – “Burning Down the House”: Inflammation as an Adaptive Physiologic Response versus Self-Destruction? JPEN. 2014 Apr

• JeVenn A. “Diagnosing Malnutrition: Understanding the Role of Muscle and Fat Loss.” Novant Health Presbyterian Medical Center, Charlotte, NC. 16 October 2014. Keynote
Speaker

• Malone A & Hamilton C. December 2013. The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition Consensus Malnutrition
Characteristics: Application in Practice. Nutrition in Clinical Practice, 28 (6): 639-650

• Price JA. et al. Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Dietetic Technicians,
Registered. J Acad NutrDiet. 2013 Jun; 113 (6 Suppl): S56-71

• Roberts S. (2014). Nutrition-focused physical exam of the oncology patient [PowerPoint slides].Retrieved
fromhttp://dpgstorage.s3.amazonaws.com/ondpg/documents/51d7c86825425524/Nutrition_Focusd_Physical_Exam.pdf

• Tappenden KA, Quantara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address
adult hospital malnutrition. JPEN J Parenter EnteralNutr. 2013 Jul; 37 (4): 482-497

• White J, Guenter P, Jensen G, Malone A, Schofield M; Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N Malnutrition Task Force; A.S.P.E.N Board of
Directors. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the
Identification and Documentation of Adult Malnutrition (Undernutrition). J AcadNutr Diet. 2012 May; 112 (5): 730-738
Acknowledgements

 Njeri Njuguna, MS, RDN, LDN, CPT

 Kimberly Chandra, RDN, LDN

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