Malnutrition is widely prevalent in hospitalized patients yet highly underdiagnosed (1).

Registered dietitians (RDs) play an important role in identifying malnutrition in at-risk patients by conducting comprehensive nutrition assessments.

By performing an important component of the nutrition assessment, called a nutrition-focused physical exam (NFPE), RDs can help identify malnutrition.

Many RDs, however, are faced with barriers that prevent them from performing NFPEs such as inadequate training and education or discomfort with touching patients (2).

This article serves as a beginner’s guide on how to confidently conduct a thorough NFPE.

The Importance of Nutrition-Focused Physical Exam

The NFPE is a system-based examination of each region of the body to assess for physical findings related to nutrition.

The exam requires a critical eye to determine color, shape, texture and size of the patient.

It also employs palpation, which requires the use of touch with the tips and pads of fingers to evaluate and assess texture, size and tenderness.

Those regions include: 

  • General inspection
  • Vitals
  • Skin
  • Nails
  • Head and hair
  • Eyes and nose
  • Mouth
  • Neck and chest
  • Abdomen
  • Musculoskeletal

The specific focus of the NFPE is on nutrition to determine whether the fat, muscle, fluid and micronutrient status of a patient has diminished due to inflammation, illness or poor nutrient intake.

Performing a NFPE can provide you with the necessary supportive data to identify and diagnose a patient with, or who is at risk of, malnutrition.

Identifying malnutrition early allows you to provide timely nutrition interventions, which can decrease length of stay, falls, pressure ulcers, readmissions as well as overall health care costs (3, 4, 5). 

Components of the Exam

Before you begin a NFPE, introduce yourself to the patient and if present, the family members too.

Explain the rationale for the exam and then ask the patient for permission to examine them. 

Remember to wash and dry your hands thoroughly and wear gloves before starting. 

You will then assess for muscle loss, fat loss, fluid status and micronutrient deficiencies. 

Muscle Loss

There are several areas you will want to assess for muscle loss. 

These include:

  • Temple region (temporalis muscle): Use your thumbs or fingers to palpate the muscle over the temporal bone. Do so in a scooping motion forward, back and diagonal.
  • Clavicular region (pectoralis major and deltoids): Use fingers to press along the clavicle bone to palpate for muscle tone. Assess for squaring at the junction of neck and shoulders for muscle loss.
  • Scapular region (Trapeziums, supraspinus, infraspinus muscles): Have patient extend arms forward and press on a hard surface — such as the wall or your hand — then palpate the engaged muscles around the scapula.
  • Dorsal hand (interosseous muscle): Ask the patient to make an “OK” sign by pressing their thumb and index finger together, then palpate muscle near the metacarpal bone. 
  • Patellar region (quadriceps muscle): Have patient bend leg while laying in bed. Use your hand to cup above, below and around the patella to assess muscle of the quadriceps.
  • Posterior calf region (gastrocnemius muscle): With the patient’s leg bent have them engage the muscle by pointing or flexing their toes. Then grasp and cup regions of the calf to assess the muscle.

Fat Loss

Examine the following areas for subcutaneous fat loss:

  • Orbital Region (surrounding the eye): Use your thumbs or fingers to palpate under the eye and above the cheek bone for fat loss.
  • Upper Arm Region (triceps and biceps): With the patient’s arm at a 90 degree angle, grasp the middle of the arm between their elbow and armpit. Then roll down to separate muscle from fat and then pinch the fat between your fingers to assess feel and space.
  • Thoracic and Lumbar Region (Ribs, lower back, midaxillary line): Examine chest for visible ribs and pinch above the iliac crest to examine for fat loss.

Fluid Status

Examine and identify whether generalized or localized fluid accumulation is present in extremities. 

In activity-restricted patients examine the scrotum or vulva for edema or ankles in mobile patients. 

Assessing overall fluid status can be difficult in patients with diseases such as congestive heart failure, cirrhosis or renal failure. 

Micronutrient Status

You can use your physical findings to determine related micronutrient deficiencies.

A few examples are listed below (6): 

  • Hair: Easily plucked hair with no pain that is also dull and dry may indicate a protein or essential fatty acid deficiency.
  • Eyes: White or grey spots on the conjunctive — called Bitot’s spots — may indicate a vitamin A deficiency.
  • Face: A unhealthy pale appearance may indicate an iron, folate, vitamin B12 and vitamin C deficiency.
  • Mouth: Angular stomatitis or cheilitis may indicate a riboflavin, niacin, iron, vitamin B6 and vitamin B12 deficiency.
  • Lips: Soreness or burning may indicate a riboflavin deficiency.
  • Tongue: A sore, swollen, raw-beefy red tongue may indicate a folate or niacin deficiency.
  • Gums: Gingivitis, swollen, spongy or retracted gums may indicate a vitamin C, niacin, folate or zinc deficiency. 
  • Taste: Dysgeusia (altered sense of taste) may indicate a zinc deficiency.
  • Teeth: gray-brown spots or molting may indicate excess fluoride intake.
  • Nails: Koilonchia (spoon-shaped, concave) may indicate iron or protein deficiency.
  • Skin: Eczema may indicate a riboflavin or zinc deficiency.

Documenting Your Findings

After diagnosis, RDs should discuss the degree of malnutrition with the interdisciplinary team and provide findings from the NFPE that support your findings.

Include the findings from your NFPE exam in your PES statement (problem, etiology and signs and symptoms).

For example: 

  • Moderate malnutrition related to inadequate oral intake with mild acute pancreatitis as evidenced by patient consuming ~50% less of meals; weight loss of 4# (~1%) x1 week; mild subcutaneous fat loss (orbital region) and mild muscle wasting (temporalis and deltoids).
  • Severe malnutrition related to inadequate calorie intake with chronic EtOH abuse as evidenced by consumption of ~6-8 beers and one meal per day; significant weight loss of 22# (12.5%) x5 months; severe muscle wasting (temporalis, pectoralis, deltoids, gastrocnemius) and fat loss (orbital region, triceps and ribs).

How to Get Comfortable with NFPEs

Performing an NFPE can be intimidating — especially if you didn’t receive much training on how to thoroughly perform one. 

The only way to get comfortable with NFPEs is through hands-on practice and experience. 

If you’re uncomfortable with performing NFPEs on a patient, ask a family member or friend if you can perform one on them.

This will allow you to practice the necessary NFPE skills so you know which areas of the body to assess, and how to touch.

If you know another RD coworker that regular performs NFPEs, ask if you can shadow them or if they can coach you on a few patients.

The Bottom Line

A NFPE helps RDs determine nutritional status by identifying and diagnosing malnutrition.

The exam focuses on characteristics such as muscle wasting, subcutaneous fat loss, edema and specific micronutrient-related deficiencies.  

While many RDs feel uncomfortable or ill-trained to perform NFPEs, the only way to get comfortable with them is through hands-on practice. 

It also helps to understand their usefulness in diagnosing malnutrition so that early nutrition interventions can be implemented, which in turn can drastically improve health outcomes and cut health care costs.