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Idaho Academy of Nutrition & Dietetics Annual Meeting – Boise, Idaho

Nutrition Focused Physical Assessment(NFPE)

Ainsley Malone, MS, RD, CNSC, FAND,FASPEN

Disclosure• I have nothing to disclose

Objectives

• Outline the importance of a nutrition focused physical examination in the overall nutrition assessment process.

• Explain nutrition-focused physical assessment techniques for identifying and grading malnutrition of subcutaneous fat loss and muscle loss

• Describe edematous conditions and demonstrate how to assess for the presence of edema

What is NFPE?Exam which uses physical assessment and physical function findings to help determine nutritional status and diagnose

malnutrition

A comprehensive nutrition assessment must include a NFPE.

MacronutrientMacronutrientFat (orbital, triceps, ribcage)

Muscle (temples, shoulders, clavicles, scapula, thigh, calves)Fluid (extremities)

MicronutrientSkin, Nails, Hair, Head/neck, Oral cavity, Eyes, Nose/Face

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Why Should Dietitians Use NFPE?• Reveals and confirms problem areas that indicate malnutrition

and micronutrient deficiencies

• A unique contribution to patient assessment

• An important component of Subjective Global Assessment (SGA) – Looks similar to newest adult malnutrition criteria – SGA has been validated in multiple patient populations as a tool to

assess malnutrition– ASPEN-Academy criteria was created to be a more objective

framework for assessing malnutrition

Baker JP, et al. Nutritional assessment: a comparison of clinical judgment and objective measurements. NEJM, 1982.Detsky AS, McLaughlin JR, et al. What is subjective global assessment? JPEN, 1987.

How…?Prepare Yourself

• Review the medical record, social history, labs, medications

• Discuss with medical team to assess appropriateness of performing the examination

• Gather necessary equipment– Wash hands– Wear gloves/personal protective equipment when appropriate

• Prioritize the areas you wish to examine

• Obtain patient’s nutrition history

Prepare the Patient• Introduce yourself and explain the process

• Respect patient privacy and ask permission– Draw curtains, close doors – Expose areas of body only as needed

• Before the examination, ask the patient or family p ymember nutrition related questions

• Explain the process as you perform the exam

Inspection– Most frequently used– Broad observation followed by closer

lookCritical evaluation

How…?Techniques of the physical exam

– Critical evaluation

PalpationPalpation– Examining body structures,

pulsations by touch

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Auscultation– Listening to body sounds– Heart, lungs, intestines– Broad observation followed by closer

look

How…?Techniques of the physical exam

Percussion– Produces sounds to locate organ

borders– Identifies if organ is solid or filled

with fluid or gas

Muscular System OverviewPerforming a physical exam is best done using a “head to toe” approach

Exam Area: Temples -Temporalis MuscleView patient when standing directly in front of them, ask patient to

turn head side to sideSevere Mild - Moderate Normal

Hollowing, scooping, depression

Slight depressionCan see/feel well-

defined muscle

Exam Area: Orbital Area - Fat Pad Around EyeView patient when standing directly in front of them,

touch above cheekboneSevere Mild - Moderate Normal

Hollow look, depressions, dark circles, loose skin

Slightly dark circles, somewhat hollow

look

Slightly bulged fat pads. Fluid retention

may mask loss

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Exam Area: Clavicle & Acromion Bone - Deltoid MusclePatient arms at side; observe shape

Severe Mild - Moderate NormalShoulder to arm joint looks square. Bones

prominent. Acromion protrusion very

prominent

Acromion process may slightly protrude

Rounded, curves at arm/shoulder/neck

Exam Area: Scapular Bone Region Trapezius, Supraspinatus, Infraspinatus Muscles

Ask patient to extend hands straight out, push against solid object. Severe Mild - Moderate Normal

Prominent, visible bones, depressions

between ribs/scapula or shoulder/spine

Mild depression or bone may show

slightly

Bones not prominent, no significant depressions

Exam Area: Thoracic & Lumbar Region –Ribs, Lower Back, Midaxillary Line

Have patient press hands hard against a solid objectSevere Mild -Moderate Normal

Depression between the ribs very apparent;

iliac crest very prominent

Ribs apparent, but depressions less

pronounced; iliac crest somewhat prominent

Chest is full, ribs do not show. Slight to no protrusion of the iliac

crest.

Upper Arm Assessment Technique

Mild -Moderate

Normal

Severe

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Exam Area: Upper Arm Region -Triceps/BicepsArm bent, roll skin between fingers, do not include muscle in pinch

Severe Mild - Moderate NormalVery little space

between folds, fingers touch

Some depth pinch, but not ample

Ample fat tissue obvious between folds

of skin

BeforeAfter

Keys A. JAMA. 1948;138:500-511

Exam Area: Dorsal Hand - Interosseous MuscleLook at thumb side of hand; look at pads of thumb when tip of

forefinger touching tip of thumbSevere Mild - Moderate Normal

Depressed area between thumb-

forefingerSlightly depressed

Muscle bulges, could be flat in some well nourished people

Exam Area: Anterior Thighs – Quadriceps& Patellar Region

Ask patient to sit, leg propped up, knee bent Grasp quads to differentiate muscle vs. fat tissue

Severe Mild -Moderate NormalDepression/line on thigh,

obviously thinBones prominent, little sign of muscle around

knee

Mild depression on inner thigh

Knee cap less prominent, more rounded

Well rounded, well developed

Muscles protrude, bones not prominent

kneep

Exam Area: Posterior Calf Region -Gastrocnemius Muscle

Grasp the calf muscle to determine amount of tissueSevere Mild -Moderate Normal

Thin, minimal to no muscle definition

Not well developed Well-developed bulb

of muscle

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Things to Consider: Etiology of Muscle Wasting Causes of Muscle Atrophy

• Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

• Polio• Guillain-Barre syndrome

M t th ( h

• Muscular dystrophy • Osteoarthritis • Dermatomyositis and

polymyositis• Rheumatoid arthritis

• Motor neuropathy (such as diabetic neuropathy)

• Injury • Burns • Long-term corticosteroid

therapy

• Spinal cord injury • Stroke• Lengthy ICU stay

Malnutritionhttp://www.nlm.nih.gov/medlineplus/ency/article/003188.htmGarmin, Anderson, et al 1997 Metab

Summary: Fat Loss

3 areas – Orbital Region– Upper Arm Area

• Triceps

• Biceps• Biceps– Thoracic & Lumbar Regions

• Rib cage

• Lower back

• Mid-axillary line

Summary: Muscle Loss

Upper Body• Temporalis

• Clavical Bone Region– Pectoralis Major, Deltoid,

Trapezius

Lower Body• Patellar Area

• Anterior Thigh (Quadriceps)

• Posterior Calf • Acromion Bone Region

– Deltoids

• Scapula Bone Area– Trapezius, Supraspinatus,

Infraspinatus

• Hands (Interosseous Muscles)

(Gastrocnemius)

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What is fluid retention?

• Edema is the abnormal retention of fluid in interstitial

spaces and cavities (e.g., peritoneal/abdominal cavity)

• Systemic fluid retention may not clinically manifest until it

accounts for at least 10% of body weight or when accounts for at least 10% of body weight or when

interstitial fluid volume is increased by 2.5-3 liters.

• Fluid accumulation around the heart, fluid in the lungs,

small pockets of ascites, or hematomas can be seen on

imaging studies.

Causes of Fluid Retention• Conditions

associated with fluid accumulation– Heart failure– Renal & liver

di

Increased capillary hydrostatic pressure

Hypervolemia; kidney disease, pregnancy, CHF

Loss of plasma proteins Kidney disease, liver disease,

burn victims, malabsorption, , malnutrition disease

– Lymphatic obstruction

– Critical illness

malnutrition Obstruction of lymphatic

circulation Obstructing tumor, infection,

damages to the lymph nodes or lymph node removal (cancers)

Increased capillary permeability

Usually from inflammatoryresponse or response to infections

Fluid Accumulation – Academy/ASPEN Clinical Characteristics Of Malnutrition

– Is an essential part of our physical exam– Is SUPPORTIVE evidence, RARELY ever directly

related to malnutrition– Weight loss is frequently masked by fluid retention

and weight gain may be presentg g y p– Interferes with ability assess muscle wasting and fat

loss

AND/ASPEN Clinical Characteristics - Edema

ContextAcute Illness or Injury

Chronic Illness or Social / Environmental CircumstancesContext Injury Circumstances

Malnutrition Moderate Severe Moderate Severe

Edema Mild Moderate to severe

Mild Severe

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Feasibility of accessing data in hospitalized patients… Nicolo et al. JPEN 2013

• Cross-sectional survey at 4 different hospitals: 2 tertiary teaching,1 urban, 1 rural; included 262 adults

• Determined availability of data to support the proposed AND/ASPEN malnutrition characteristics/ S o c c e c

• Data on edema available at time of nutrition assessment– All patients – 84.4%, Non-ICU – 85.9%, ICU – 82.7%

• Edema used as one of the characteristics to define malnutrition– All patients – 26.6%, Non-ICU – 16.2%, ICU – 39.1%

Assessment Strategy

• Perform general survey, then head-to-toe

• Use inspection and palpation

• Determine if onset is acute vs chronic– Acute: < 72 hours– Chronic: better? worse? same?Chronic: better? worse? same?

• Correlate physical findings of fluid accumulation with other evidence – vital signs, input/output records, labs, weight, etc.

Assessing Fluid Retention• Primarily found in dependent areas such as the sacrum,

ankles, feet, scrotum, vulva• The clinician may evaluate generalized or localized fluid

accumulation during a physical exam• Localized:oc e

–extremities, abdomen (ascites), and/or vulva/scrotal area

• Generalized:– if severe, is referred to as anasarca

• Vital signs, intake and output, weight, history, imaging studies

Dependent Edema – Ambulatory Patients Legs, Ankles, Feet

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Dependent Edema – Bed Bound Patients Scrotum, Vulva, Sacrum

Additional fluid

Other AreasEdema And

Ascites

Assessing Edema

• Press firmly but gently with your thumb for at least 5 seconds over

– The dorsum of the foot

– Behind each malleolus

– Over the shins

S it f d i t d l f 1 t 4• Severity of edema is rated on a scale from +1 to +4

Grade DepthDescription

0none

No impression or distortion observed, bone structure

easily identified

1+ 2 mm or less

Slight pitting without distortion, rapidly

disappears

Somewhat deeper pit,

2+2 – 4 mm

distortion not easily apparent, disappears 10-25

seconds later

3+4 – 6 mm

Noticeably deep pitting, entire extremity looks full,

swollen; indentation can last longer than 1 minute

4+ 6 – 8 mmVery deep pitting, extremity

is grossly misshapen, indentation lasts 2-5 minutes

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Translating Edema To Degree Of MalnutritionExamine for edema

Tips Severe malnutrition

Moderate malnutrition

Well-nourished

Consider patient’s history, causes for fluidaccumulation

Patients who are bedridden are more likely to have

Deep to very deep pitting (+3 to +4 edema)

Mild to moderate pitting (+1 to +2 edema)

No signs of fluid accumulation

accumulation likely to have edema in the genital area and sacrum

Mobile patients will more likely have peripheral edema

To Summarize

• Performing a nutrition focused physical exam is a unique contribution from the RD

• Is a component of a complete nutrition assessment

• NFPE is important to identify key malnutrition characteristics

• Is performed using a “head to toe” approach• Is performed using a “head to toe” approach

• Doesn’t require much time to perform

• Assessment of muscle and fat mass utlize techniques of observation and palpation

• Exam confidence and competence easily obtained

Many Thanks!