FROM THE ACADEMY

Nutrition-Focused Physical Exam Hands-On

T
HE PREVALENCE OF MALNU- Standards of Practice/Standards of Pro- evaluate the presence of edema
trition in hospitalized patients fessional Performance for RDNs in both or fluid accumulation;
is very high, at 30% to 50%.1 adult and pediatric populations.6,7 To  identify clinical signs of micro-
However, the number of pa- ensure that all patients are properly nutrient deficiencies and
tients diagnosed with malnutrition by assessed, the NFPE must be taught in toxicities;
physicians is as low as 3%.2 This gap is ways that ensure competency and self-  measure handgrip strength us-
reflective of dysfunctional systems efficacy. Whereas other disciplines ing a dynamometer; and
within the hospital to identify patients examine patients during their assess-  demonstrate basic NFPE skills
at risk and then subsequently to diag- ment, an RDN’s examination is specific with actual patients.
nose malnutrition in a standardized to nutrition because the focus of the
way. Nurses, registered dietitian nutri- NFPE is to determine whether the fat, In addition, the workshop facilitates
tionists (RDNs), and nutrition and die- muscle, fluid, and micronutrient status discussion on malnutrition documen-
tetics technicians, registered, can of a patient has diminished due to tation and coding, and RDN partici-
screen patients, but RDNs are the pri- inflammation, illness, and/or low pants take part in hands-on breakout
mary health care providers who should nutrient intake. This focus is specific to sessions (including interactive case
conduct comprehensive assessments of the nutrition diagnosis of malnutrition studies), in which there is a low trainer
at-risk patients for the purpose of iden- and, as such, requires special training. to participant ratio (1:6) to allow for
tifying malnutrition. To aid RDNs in The use of the NFPE may result in more individualized instruction. By
identifying and assessing for malnutri- identifying one of the two characteris- utilizing a variety of training tech-
tion, the Academy of Nutrition and Di- tics required to diagnose malnutrition niques, the workshop is able to take a
etetics (Academy) and American in adults.3 If RDNs do not perform a number of different approaches to
Society for Parenteral and Enteral thorough NFPE, the nutrition assess- improve RDNs’ self-efficacy in the area
Nutrition have published consensus ment is not complete and, as a result, of physical assessment. This increases
statements with recommended charac- malnutrition may go incorrectly undi- the number of RDNs able to perform
teristics for adults3 and indicators for agnosed. By systematically training NFPEs across the country, which will in
pediatrics4 for the identification and clinical RDNs in this specialized skill, turn result in an increase in appro-
documentation of malnutrition (under- patients with or at risk for malnutrition priate and efficient nutrition diagnoses
nutrition). In the adult malnutrition will benefit. of malnutrition.
characteristics, four out of the six char- The goal of the Academy’s NFPE Research shows that nutrition inter-
acteristics are components of the nutri- Hands-On Training Workshop is to in- vention for a patient with malnutrition,
tion focused physical exam (NFPE), crease the number of RDNs performing or a patient who is at risk for malnu-
which is a system-based examination NFPEs to assess malnutrition in health trition, can decrease length of stay,
of each region of the body.5,6 To further care settings across the United States, in falls, pressure ulcers, infections, com-
assist RDNs with developing the skills both adult and pediatric populations. plications, readmissions, and overall
and knowledge necessary to perform The Academy’s NFPE workshop pro- health care costs.8-12 Although the
nutrition-focused physical exams gram is a novel approach, with work- NFPE is only one component of the
(NFPEs) at their workplace, the Acad- shops held at medical centers nutrition assessment, it can provide
emy has developed an interactive, throughout the nation led by Academy necessary supportive data to identify
hands-on training workshop. NFPE Trainers who travel to the RDNs and diagnose a patient with, or who is
Every clinical RDN should be using to conduct workshops. at risk for, malnutrition.
the NFPE on all patients to identify An NFPE workshop provides pre- Integral members of interdisciplinary
malnutrition. NFPE is part of the workshop materials, multiple NFPE teams, RDNs are the experts in nutrition.
resources, continuing education units, RDNs should therefore be at the forefront
and post-workshop support. The of assessing patients for the nutrition
This article was written by Beth workshop includes lectures, demon- diagnosis of malnutrition. However,
Mordarski, RDN, LD, NFPE project
manager, Academy of Nutrition and strations, hands-on training, and an RDNs have varied levels of knowledge,
Dietetics, Chicago, IL. NFPE skills assessment. During the full training, and comfort in documenting
day of training, RDNs learn how to: malnutrition and performing NFPEs.
2212-2672/Copyright ª 2016 by the RDNs at workshops across the country
Academy of Nutrition and Dietetics.  assess for muscle wasting and fat verbalize encountered or perceived
http://dx.doi.org/10.1016/j.jand.2016.03.004
loss; barriers to performing NFPEs. Some

868 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2016 by the Academy of Nutrition and Dietetics.
 FROM THE ACADEMY

of the most common barriers identified Script, an NFPE Skills Assessment Form, Nutrition and Dietetics/American Society
for Parenteral and Enteral Nutrition: In-
include: among other items) continue to be
dicators recommended for the identifica-
valuable tools when the participants tion and documentation of pediatric
 inadequate training and
perform NFPEs in their patient pop- malnutrition (undernutrition). J Acad Nut
education; Diet. 2014;114(12):1988-2000.
ulations, from inpatient to outpatient
 discomfort with touching 5. Charney P, Peterson S. Practice Paper of the
settings.
patients; Academy of Nutrition and Dietetics: Critical
When RDNs receive hands-on NFPE thinking skills in nutrition assessment and
 insufficient time; and
training they are empowered with diagnosis. J Acad Nutr Diet. 2013;115(11):
 lack of requirement by nutrition 1545. http://www.eatrightpro.org/w/media/
enhanced assessment skills to effec-
department. eatrightpro%20files/practice/position%20and
tively diagnose malnutrition and %20practice%20papers/practice%20papers/
initiate early nutrition intervention practice%20papers/practice%20paper%20
RDNs who have participated in the
within the interdisciplinary team. After critical%20thinking%20skills%20in%20
Academy’s NFPE Hands-On Training nutrition%20assessment.ashx. Accessed
diagnosis, RDNs should discuss the
Workshop have indicated multiple March 24, 2016.
degree of malnutrition with appro-
beneficial outcomes that not only help- 6. The Academy Quality Management Com-
priate physicians and nurses and pro- mittee and Scope of Practice Subcom-
ed break down the encountered or
vide specific assessment data to mittee of the Quality Management
perceived barriers, but also helped give
support the findings. NFPEs can lead to Committee. Academy of Nutrition and
them a big-picture understanding of Dietetics: Revised 2012 Standards of
the entire health care team developing Practice in Nutrition Care and Standards
the NFPE process. This allows RDNs to
a nutrition plan that will achieve the of Professional Performance for Regis-
incorporate a variety of physical find- tered Dietitians. J Acad Nutr Diet.
best outcomes for the patient.
ings from head to toe into a compre- 2013;113(6 suppl 2):S29-S45.
To learn more, locate a workshop in
hensive assessment of malnutrition. 7. Nevin-Folino N, Ogata BN, Charney PJ,
your region of the country, or obtain
One very important outcome of the et al. Academy of Nutrition and Dietetics:
information on being a host site, visit Revised 2015 Standards of Practice and
NFPE workshop for RDN participants is
the Academy’s Nutrition Focused Standards of Professional Performance for
an increased level of comfort and con- Registered Dietitian Nutritionists
Physical Exam Hands-on Training
fidence in performing NFPEs, especially (Competent, Proficient, and Expert) in
Workshop page (www.eatrightpro.org/ Pediatric Nutrition. J Acad Nutr Diet.
due to the hands-on experience pro-
NFPE). 2015;115(3):451-460.e35.
vided by the workshop. The breakout
For questions on the NFPE workshop, 8. Somanchi M, Tao X, Mullin GE. The facil-
sessions allow participants to practice itated early enteral and dietary manage-
please e-mail [email protected].
NFPE skills with their trainer and other ment effectiveness trial in hospitalized
participants to make sure they know patients with malnutrition. JPEN J Parenter
which areas of the body to assess, and References Enteral Nutr. 2011;35(2):209-216.
1. Jensen GL, Compher C, Sullivan DH, 9. Milne AC, Potter J, Vivanti A, Avenell A.
how to touch. Another uniquely bene- Protein and energy supplementation in
Mullin GE. Recognizing malnutrition in
ficial aspect of the workshop is the adults: Definitions and characteristics, elderly people at risk from malnutrition.
patient rounds portion, in which par- screening, assessment, and team Cochrane Database Syst Rev. 2009;2:
ticipants perform an NFPE on actual approach. JPEN J Parenter Enteral Nutr. CD003288.
2013;37(6):802-807. 10. Gariballa S, Forster S, Walters S, Powers H.
patients, with trainers by the partici-
2. Corkins MR, Guenter P, DiMaria-Ghalili RA, A randomized, double-blind, placebo-
pant’s side to demonstrate, coach, et al. Malnutrition diagnoses in hospital- controlled trial of nutritional supple-
debrief, and provide feedback with ized patients: United States, 2010. JPEN J mentation during acute illness. Am J Med.
each patient experience. Participants Parenter Enteral Nutr. 2014;38(2):186-195. 2006;119(8):693-699.
have said that this portion completes 3. White JV, Guenter P, Jensen G, et al. 11. Neelemaat F, Lips P, Bosmans JE, et al.
Consensus Statement of the Academy of Short-term oral nutritional intervention
the puzzle, tying together the skills and Nutrition and Dietetics/American Society with protein and vitamin D decreases falls
information, so that back at their fa- for Parenteral and Enteral Nutrition: in malnourished older adults. J Am Geriatr
cilities they are more efficient in per- Characteristics recommended for the Soc. 2012;60(4):691-699.
identification and documentation of adult
forming NFPEs and identifying patients 12. Philipson TJ, Snider JT, Lakdawalla DN,
malnutrition (undernutrition). J Acad Nutr Stryckman B, Goldman DP. Impact of oral
with malnutrition. The resources pro- Diet. 2012;112(5):730-738. nutritional supplementation on hospital
vided at the NFPE workshop (an NFPE 4. Becker PJ, Carney LN, Corkins MR, et al. outcomes. Am J Manag Care. 2013;19(2):
Pocket Guide, an NFPE Patient/RDN Consensus Statement of the Academy of 121-128.

AUTHOR INFORMATION
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
B. Mordarski is a consultant for the Academy of Nutrition and Dietetics, which may have a financial interest in the Nutrition Focused Physical
Exam (NFPE) Workshop described in this manuscript. B. Mordarski’s compensation from the Academy is paid by or in part by the revenue from
the NFPE workshop. Previously, B. Mordarski’s compensation was paid by a grant (with a concentration on malnutrition) provided by Abbott
Nutrition to the Academy of Nutrition and Dietetics. Abbott Nutrition did not have control over the content or publication of this article.
FUNDING/SUPPORT
There is no funding to disclose.

May 2016 Volume 116 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 869