Updated: Feb 24, 2020
The Nutrition-Focused Physical Exam is an essential part of the Dietitian's Nutrition Assessment and the Nutrition Care Process!
I became a dietitian when the NFPE was just being implemented, and I was definitely not confident when I started! However, it is nothing for the RD to fear. This guide will help you understand what to look for and document in your assessment.
The NFPE was introduced in the clinical setting to help diagnose malnutrition and make nutrition interventions earlier for the patients who needed it. In the NFPE, the Dietitian looks for features such as muscle and fat loss, muscle wasting, and decreased strength. The NFPE helps with the diagnosis of nutritional deficiencies that may require supplementation or other methods to treat and prevent various types of malnutrition.
The Two Parts of The Nutrition-Focused Physical Exam are:
Nutrient Deficiency Assessment
Both of these include hands on and observational techniques.
Let's look at them in more detail:
The Malnutrition Assessment
Six characteristics have been identified in the diagnosis of malnutrition, and at least two much be present for a diagnosis of malnutrition. These areas will be your focus of the assessment. For each characteristic, there are very specific parameters set to determine either "moderate malnutrition" or "severe protein-calorie malnutrition" in one of the three categories of malnutrition:
Malnutrition in the context of Chronic Illness
Malnutrition in the context of Acute Illness or Injury
Malnutrition in the content of Societal/Environmental Circumstances
By understanding your patient's history and diagnoses, you will know which of the three contexts of malnutrition you are assessing. If your patient has cancer, for example, you will likely be assessing for malnutrition of chronic illness. If the patient has recently fallen and broken a hip and is recovering from hip surgery with an associated weight loss, you would be assessing for malnutrition of acute illness or injury. If the patient is elderly, lives alone, and has barriers to self-feeding, you may be assessing for malnutrition of societal/environmental circumstances.
The six characteristics of malnutrition and how to evaluate them are as follows:
Energy Intake: Recent/current caloric intake is compared with the estimated energy needs that you determined in the patient's assessment. You will calculate the patients "percentage intake of estimated energy requirement" over the past 7 days, 1 month, and 3 months to determine if they are consuming less calories than they require.
Weight Loss: Current Body Weight, Usual Body Weight, and a Weight History will help you determine if there has been a weight change over time. You will also want to consider under and overhydration in this assessment. The percentage and time period of weight loss standards for a malnutrition diagnosis can be identified in the malnutrition chart.
Body Fat: This is where you will get hands-on! You will get consent from your patient to touch them to evaluate their nutrition status. Loss of subcutaneous fat can be observed visually in the orbital, triceps, and rib areas. You can also grasp the area between your thumb and forefinger and gently pull the skin to identify sub-q fat status. You will classify this as "mild," "moderate," or "severe" depletion.
Muscle Mass: Loss of muscle mass can be observed by sunken areas in the temples, protrusion of the clavicles, shoulders or scapula, and wasting in the calf or thigh. As with fat, you will classify the depletion of muscle as mild, moderate, or severe.
Fluid Accumulation: General or local fluid accumulation can be identified in the abdomen as ascites, edema in the extremities, or vulvar/scrotal edema. Fluid accumulation may be indicative of protein malnutrition, and you will classify it as mild, moderate, or severe.
Functional Status: This is measured with hand grip strength. Most clinical settings will be equipped with a dynamometer to conduct this assessment. Note that in settings such as the ICU, this will likely not be applicable to measure.
Once you have all these parameters assessed, you can make a diagnosis of malnutrition using the chart for "determining adult malnutrition" from the consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition. This should be in your toolkit at all times! You can find it here: https://www.andeal.org/vault/2440/web/files/ONC/Table_Clinical%20Characteristics%20to%20Document%20Malnutrition-White%20JV%20et%20al%202012.pdf.
Nutrient Deficiency Assessment
Part 2 of the Nutrition-Focused Physical Exam is the assessment of nutrient deficiencies, including protein, fatty acid, vitamin and mineral deficits.
It is easiest to approach this in a head-to-toe manner, and in an ideal world you would have a good 15-20 minutes to perform it. In reality, you may have just a few minutes with your patient in a clinical hospital setting and much longer in an outpatient setting. Getting familiar with the signs of nutrient deficiencies will enable you to notice them easily regardless of the time constraints.
It is important to note that vitamin deficiencies without serum or tissue testing or dietary analysis is completely subjective, and if deficiencies are suspected, it is best practice to conduct a proper dietary intake analysis and speak with the physician about testing for deficiencies. With this combination of information, your nutrition plan of care may include supplements and/or consumption of specific nutrient-containing foods. This list is not comprehensive, and represents an overview of what you can look for in a limited-time assessment with your patient.
Hair loss: Zinc deficiency
Hair depigmentation: Copper deficiency
Corkscrew hairs: Vitamin C deficiency
Dry, dull, easily plucked hair: deficiency of Protein, Biotin, Vitamin C.
Eye lesions: deficiency of Zinc, Vitamin C
Pale conjunctiva: Iron deficiency
Tearing, burning, itching with fissures on eye corners: Riboflavin deficiency
Dry eyes and mucous membrane: Vitamin A deficiency.
Swollen or bleeding gums: deficiency of Vitamin C
Smooth, red, thickened tongue: B12 deficiency .
Purple swollen tongue; soreness or burning of lips, mouth, tongue: Riboflavin deficiency.
Cheilosis (fissures on corners of mouth): deficiency of B6, Riboflavin.
Tongue or mouth lining inflammation: B6 deficiency.
Dentures, missing or loose teeth, enamel loss: Calcium deficiency.
Round, swollen moon face: Thiamin deficiency
Goiter, nodules: deficiency (or excess) of Iodine
Distended neck veins: Thiamin deficiency
Lesions, wounds, open areas: deficiency of Zinc, Vitamin C, Folate, Protein.
Petechiae (red/purple pinpoint discolorations): Vitamin C deficiency.
Skin pallor: deficiency of Iron, Copper, Folate.
Flaky, dry skin: Fatty acid deficiency.
Dermatitis: Niacin deficiency.
Small hemorrhages in skin or mucus membranes: Vitamin K deficiency.
Dry, rough skin; hair follicle blockage with "goose-bumps": Vitamin A deficiency.
Swelling, ascites: deficiency of Protein, Vitamin C.
Arms and Legs
Edematous limbs: Protein deficiency.
Bone or joint pain, rickets: deficiency of vitamin D, Calcium.
Hands and Nails
Concave, brittle nails with raised edges or spoon-shaped: deficiency of Iron, Protein.
Tremors, Spasms, Tics: Magnesium deficiency.
Staggering gait, tense calf muscles, jerky eye movement: Thiamin deficiency.
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Your Brilliant Dietitian Coach
Escott-Stump, S. (2015). Nutrition & Diagnosis-Related Care, 8th Ed. Philadelphia, PA: Wolters Kluwer.
Width, M. & Reinhard, T. (2018). The Essential Pocket Guide for Clinical Nutrition, 2nd Ed. Philadelphia, PA: Wolters Kluwer.