Nutrition Focused Physical

Exam
Diagnosing Malnutrition
By: Brandi Leavitt
Academy/A.S.P.E.N Clinical characteristics of
Malnutrition
3 Types - ASPEN
Consensus Committee
★ Starvation-related
malnutrition
★ Chronic disease
related malnutrition
★ Acute disease or
injury related
malnutrition

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Why is it important?
★ 30-50% of hospitalized adults are considered malnourished in the
modern healthcare system
★ Concerning: not receiving appropriate & timely nutrition intervention
→ continue to decline (in patient setting & once discharged)
★ Often lead to worsened clinical outcomes:
1. Infectious complications
2. Development of pressure ulcers
3. Risk of falls
4. Increase length of stay
5. 30-day readmissions
6. Mortality
★ May be malnourished due to:
1. Lack of adequate nutrients (protein & fat)
2. Increase energy needs (certain disease states)
3. Impaired nutrient transport, absorption or metabolism

The collaboration between healthcare professionals & RDs in

identifying nutrition related risks & implement necessary interventions
are critical 3
Consequences of Malnutrition

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No single parameters is definitive for
malnutrition
The Academy of Nutrition and Dietetics & American Society of
Parenteral and Enteral Nutrition (A.S.P.E.N.) - guidelines for
identification & assessment in adult patients

★ MUST MEET AT LEAST 2 OF THE 6 CRITERIA FOR DIAGNOSIS:

1. Insufficient energy intake
2. Weight loss
3. Loss of muscle mass
4. Loss of subcutaneous fat
5. Localized or generalized fluid accumulation
6. Diminished functional status measured by hand-grip
strength
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 “
Physical Exam- Muscle & Fat
★ Most Useful: Low BMI, no
weight changes
★ Least Useful: obese patients

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Assessing for
Muscle Loss
Muscle Wasting
★ Muscle wasting is determined by:
○ Palpation for bulk and tone
○ Depressions, flat or hollow areas, “squared-off”
appearance
○ Prominent or protruding bone

★ Keep in mind:
○ The upper body is more susceptible to muscle atrophy
first and has been identified as a good reflection of
overall muscle mass
○ Muscle loss from inactivity or immobility is most
prominent in the pelvis and legs

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Regions to Assess
Upper Body: Lower Body:
★ Temple ★ Thigh
★ Collar bone ★ Knee
★ Shoulder ★ Calf
★ Shoulder blade
★ Hand

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Temples- Temporalis Muscle

Severe Mild to Moderate Normal

Hollowing, scooping, Slight depression Can see/feel

depression well-defined muscle
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Clavicle Region- Deltoid Muscle
Patient arms at side; observe shape

Severe Mild to Moderate Normal

Shoulder to arm joint Acromion process Rounded, curved

looks square. Bones may slightly at
prominent. Acromion protrude arms/shoulder/
protrusion very neck
prominent
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Shoulder/Acromion Bone - Deltoid Muscle
Patient arms at side; observe shape

Severe Mild to Moderate Normal

Shoulder to arm joint Acromion process Rounded, curved

looks square. Bones may slightly at
prominent. Acromion protrude arms/shoulder/
protrusion very neck
prominent
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Scapular Bone Region - Trapezius, Supraspinatus,
Infraspinatus Muscle
Ask patient to extend hands straight out, push against solid object

Severe Mild to Moderate Normal

Prominent, visible bones, Mild depression or Bones not prominent,

depressions between bone may show slightly no significant
ribs/scapula or depressions
shoulder/spine 13
Dorsal Hand- Interosseous Muscle
Look at thumb side of hand; look at pads of thumb when tip of
forefinger touching tip of thumb

Severe Mild to Moderate Normal

Depressed area between Slightly depressed Muscle bulges,

thumb-forefinger cold be flat in some
well nourished
people 14
Thigh/Patellar Region - Quadriceps
Legs propped up on bed/chair, bent at knee

Severe Mild to Normal

Moderate

Obvious Mild depression Well- rounded,

depression/line on of inner thigh developed
thigh; thin muscle

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Posterior calf region - Gastrocnemius muscle
Legs propped up on bed/chair, bent at knee or with leg hanging off
side of the bed

Severe Mild to Normal

Moderate

Thin, minimal to no Less bulging of Well-rounded,

muscle definition the muscle yet developed
and firmness has some muscle
shape and
slight firmness
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Assessing for
Subcutaneous
Fat Loss
Regions to Assess
1. Orbital Region

2. Upper Arm Area

★ Triceps

3. Thoracic & Lumbar Region

★ Rib Cage
★ Lower back
★ Iliac crest

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Orbital & Cheek Area- Fat Pad Surrounding Eyes &
Buccal Fat Pads

Severe Mild to Moderate Normal

Hollow look, Slightly dark Slightly bulged fat

depressions, dark circles, somewhat pads, fluid retention
circles, loose skin hollow look may mask loss

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Upper Arm Region - Triceps
With arm bent at 90 degree angle, use forefinger and thumb to
gently pull down/pinch fat and skin (not muscle) between fingers

Severe Mild to Moderate Normal

Very little space Some depth pinch, but Ample fat tissue obvious
between folds, fingers not ample between folds of skin
touch (about 1 inch)
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Thoracic & Lumbar Region-
Ribs, Lower back, midaxillary line at the iliac crest
Have patient sit up with hands stretched out in front while pressing hands
against a solid object, assess for fat loss between ribs and at the lower back

Severe Mild to Moderate Normal

Ribs very apparent, Ribs apparent with mild Chest is full

depressions prominent depressions between them Ribs do now show
Iliac crest very Iliac crest somewhat Iliac crest with little
prominent prominent to no protrusion
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Assessing Fluid Status
Edema

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Edema
★ Take thumb and press on top of ankle, foot and/or
shin for 5 seconds

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Take Home Points
Risks Include: ICD-10-CM Codes
★ Multiple admissions ★ E44.1 MILD
★ GI disorders protein-calorie
★ Chronic disease malnutrition
★ Malignancies ★ E44.0 MODERATE
★ Lower socioeconomic status protein-calorie
★ Psychological disorders malnutrition
★ Alcohol & drug abuse ★ E43 Unspecified SEVERE
★ Older age protein-calorie
Minimum of 2+ Criteria malnutrition
★ R64 Cachexia
Interdisciplinary collaboration to
diagnose, treat & follow-up 24
For more information
★ Academy of Nutrition and Dietetics Nutrition
Focused Physical Exam Hands-On Training
Workshops.
★ NFPE Workshop at Rutgers Department of
Nutritional Sciences, Institute of Nutritional
Interventions, Newark, NJ.
★ Patient Simulation: Putting Malnutrition
Screening, Assessment, Diagnosis and
Intervention into Practice. Abbott Nutrition
Health Institute. http://anhi.org/courses.
★ Nutrition Focused Physical Assessment Part
1: Setting the Stage for Success; Nutrition
Focused Physical Assessment Part 2:
Creating Your Malnutrition Toolbox; Nutrition
Focused Physical Assessment Part 3:
Micronutrient Deficiencies. Laura L. Frank,
PhD, MPH, RDN, CD, Nestle Nutrition Institute.
https://www.nestlenutrition-institute.org/
Education/Pages/education.aspx
Nutrition Focused
Physical Exam Pocket
Guide, 2nd Ed.
Beth Mordarski, RDN, LD,
and Jodi Wolff, MS, RDN, LD
FAND
The Nutrition Focused Physical Exam
Pocket Guide provides the clinician with
tools for malnutrition assessment,
documentation and coding.
● ISBN: 978-0-88091-966-1
● 50 pages
● SKU 494718
https://www.eatrightstore.o
rg/product-type/pocket-gui
des/nutrition-focused-physi
cal-exam-pocket-guide-sec
ond-edition
25
Height Prediction from Ulna Length
Height = 153.492 – (7.97 x sex) + (0.974 x UL [in cm]
★ Sex:
○ Men: 1
○ Females: 2
Men: Height (cm) = 153.492 – (7.97 x 1) + (0.974 x UL [in
cm]
Females: Height (cm) = 153.492 – (7.97 x 2) + (0.974 x
UL [in cm]
★ conversion from cm → inch
○ # cm / 2.54 = # inches

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 Thank you!
Any Questions
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References
★ Abdelhadi RA, Bouma S, et al. Characteristics of hospitalized children with a diagnosis of malnutriton:
United States 2010. J Parenter Enteral Nutr, 2016; Published online before print.
doi:10.1177/0148607116633800.
★ Academy of Nutrition and Dietetics. Pocket guide for international dietetics & nutrition terminology
(IDNT) reference manual: Standardized language for the nutrition care process. (4th Ed). Chicago,
Illinois: Academy of Nutrition and Dietetics, 2013, p. 124-126.
★ Becker P, Carney LN, et al. Consensus statement of the Academy of Nutrition and Dietetics/ American
Society for Parenteral and Enteral Nutrition: Indicators recommended for the identification and
documentation of pediatric malnutrition (undernutrition). Nutr Clin Pract. 2015;30:147-161. doi:
10.1177/0884533614557642.
★ Corkins MR, Guenter P, DiMaria-Ghalili RA, Jensen G, Malone A, Miller S, Patel V, Plogsted S, Resnick H,
and the American Society for Parenteral and Enteral Nutrition. Malnutrition diagnoses in hospitalized
patients: United States, 2010. J Parenter Enteral Nutr. 2013;38(2); 186-195. doi:
10.1177/0148607113512154.
★ Esper DH. Utilization of nutrition-focused physical assessment in identifying micronutrient deficiencies.
Nutr Clin Pract. 2015;30(2):194-202. doi: 10.1177/0884533615573054.
★ Buecheler, K., Igel, A, “Training Your Staff to Perform Nutrition-Focused Physical Exams”. Fall 2017,
Future Dimensions in Clinical Nutrition Practice,
★ Wanik, J. “Nutrition Orientation.” January 2019, Hospital of Central Connecticut Department of Food and
Nutrition. Powerpoint
★ Tarnowki, Height Prediction from Ulna Length of Critically Ill Patients.

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