physical exam

• Steps in Nutrition Care Process

  • Nutrition Assessment/ Reassessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring and Evaluation
• Domains of Nutrition Assessment

  • Food/ nutrition-related history
  • Anthropometric measurement
  • Biochemical data, medical tests, and procedures
  • Nutrition-focused physical findings
  • Client history
  • Assessment, Monitoring, and Evaluation Tools
  • Etiology category
  • Progress evaluation
• Nutrition-focused physical exam (NFPE)


  Includes 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
• Nutrition-focused physical exam (NFPE)


  Head to toe assessment of a resident's physical appearance and function to help determine signs of nutrient deficiencies and to identify malnutrition
• Nutrition-focused physical exam (NFPE)


  Physical assessment of the patient, looking for clinical symptoms of nutrient-related deficiencies
• Nutrition-focused physical exam (NFPE)


  Simple and quick clinical examination focusing on body composition impacted by nutrition
• Areas of interest in NFPE

  • muscle mass
  • subcutaneous fat stores
  • hair
  • skin
  • eyes
  • oral cavity
  • fingernails
  • edema or ascites
  • handgrip strength
  • general appearance
• Muscle wasting


  Muscle mass is catabolized during inflammation, especially among critically ill patients to provide amino acids for gluconeogenesis and protein synthesis
• Muscle wasting


  • Characterized by loss of bulk and tone, noted by palpitation
  • Areas to be assessed: temples, clavicles, deltoids, acromion, interosseous muscles, scapula, quadriceps, patellar region, and calf
  • Muscle mass in the upper body is a good indicator of muscle stores
  • Well-nourished: muscle mass will have definition and be visible and can be flat, bulging, or rounded; bones are not prominent
• Assessing muscle wasting in the temple region


  Use the thumbs or index and middle fingers to palpate the muscle over the temporal bone; ask the patient to pretend to chew a gum
• Assessing muscle wasting in the clavicle region


  Patient should be sitting or standing; shoulders in neutral position; use fingers to press above and below the clavicle bone to palpate for muscle loss; and then down the neck to shoulder junction
• Assessing muscle wasting in the shoulder, acromion process, deltoid muscle region

  Patient's arms at side; use hand to cup shoulder to feel and assess for musculature
• Assessing muscle wasting in the scapula region


  Ask patient to extend arms forward and press on hard object (wall or your hand), palpate above, below, and around the scapula to assess muscles
• Assessing muscle wasting in the hand region


  Ask patient to make "OK" sign then palpate muscle near the metacarpal bone
• Assessing muscle wasting in the thigh/ patellar region


  Ask patient to sit and prop leg on stool or bend leg up in bend with thigh off the bed; use hand to cup above, below, and around the patella to assess muscle
• Assessing muscle wasting in the calf region


  Ask patient to bend leg (can hold or support patient's ankle) while grasping/cupping calf region to assess the muscle
• Subcutaneous Fat Loss


  • Areas to be assessed: orbital areas, triceps, and the iliac crest
  • Well-nourished: Adequate tissue should be noted on palpation; bones should not be visible
• Assessing subcutaneous fat loss in the orbital region


  Use the thumbs or index fingers to palpate under the eyes, above the cheekbone for loss of fat
• Assessing subcutaneous fat loss in the cheek region


  Use index and middle finger to palpate below cheekbone
• Assessing subcutaneous fat loss in the upper arm region


  Flex arm bent at 90 degrees; grasp arm in between elbow and armpit; pinch fat between fingers to feel; do not pinch muscle nor pinch too hard
• Assessing subcutaneous fat loss in the ribs


  Have patient push against an object then examine chest and back for apparent ribs
• Assessing subcutaneous fat loss in the iliac crest


  Pinch above the iliac crest to examine for fat loss
• Edema or ascites


  • Fluid retention may mask losses of muscle mass, fat stores, and weight
  • Edema – can be pitting or non-pitting
  • Non-pitting edema - if the clavicle and acromion regions feel spongy
• Handgrip strength


  • Assesses strength in the upper extremity
  • Most practical measure of function at the bedside
  • Measured by squeezing a handgrip dynamometer
  • Impaired handgrip strength has been correlated with increases in postoperative complications, hospital length of stay, and hospital readmission rates
  • Non-nutrition-related factors: age, arthritis, carpel tunnel syndrome, and other disorders impacting hand function and strength
• Considerations before NFPE


  • Patient needs to be physically present and cooperative
  • Ideal: patient is standing or sitting, wears minimal clothing, can provide correct answers to questions
  • Position of a bedridden patient can impact muscle mass and fat stores
  • Prepare for patient interaction
  • Be familiar with your patient's anatomy
  • Is there prior injury, surgery, or non-nutrition related issue, that would cause your patient to have an abnormal presentation of an area on their body
  • NPFE begins with general observations (first impression) and physical characteristics of the patient
  • Other barriers: critical illness, with its lines, tubing, and other devices; obesity; COVID-19