Nutrition-Focused Physical Exam-ASPEN (2016)

ABOUT ASPEN
The American Society for Parenteral and Enteral Nutrition (ASPEN) is

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physicians, dietitians, nurses, pharmacists, other allied health
professionals, and researchers—that envisions an environment in
which every patient receives safe, efficacious, and high-quality patient
care.
ASPEN’s mission is to improve patient care by advancing the

science and practice of clinical nutrition and metabolism.
ABOUT THE CLEVELAND CLINIC

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Copyright © 2016. American Society for Parenteral and Enteral

Nutrition.
ISBN 978-1-889622-29-3 Print edition
ISBN 978-1-889622-30-9 Ebook edition
Printed in the United States of America.

NUTRITION-FOCUSED
PHYSICAL EXAM
AN ILLUSTRATED HANDBOOK
CONTRIBUTORS
Peggy Hipskind, MA, RD, LD
Advanced Practice II Dietitian
Nutrition Therapy
Center for Human Nutrition
Digestive Disease and Surgery Institute
Cleveland Clinic
Marianne Galang, RD, LD, CSO

Advanced Practice I Dietitian
Nutrition Therapy
Cleveland Clinic
Andrea Jevenn, RD, LD, CNSC

Nutrition Support Team
Cleveland Clinic
Cassandra Pogatschnik, RD, LD, CNSC

Center for Gut Rehabilitation and Transplant
Cleveland Clinic
EDITOR
Cindy Hamilton, MS, RD, LD, FAND
Director
Cleveland Clinic
PREFACE
The Cleveland Clinic Center for Human Nutrition (CHN) has developed
this Illustrated Nutrition-Focused Physical Exam (NFPE) Handbook to
assist bedside clinicians in the nutrition assessment of their patients
and to help discern the presence and degree of malnutrition. The
Academy-ASPEN Consensus Statement and Characteristics for
Identification of Malnutrition (2012) has been a catalyst to realizing
the importance of incorporating the NFPE as part of a comprehensive
nutrition assessment. Most healthcare disciplines perform a physical
exam of their patients, and a NFPE should be part of the nutrition
clinician’s skill set.
With the release of the Consensus Statement the CHN embarked

on a departmental goal to standardize our approach in assessing the
nutritional status of our patients. A comprehensive training program
was developed centered around online education modules and live
patient simulations. All clinicians, including dietitians, dietetic
technicians, nurses, nurse practitioners, fellows, physicians, and our
clerical staff embraced the importance of this effort. The project
became so successful that we were able to offer it to dietitians and
students from other institutions.
Based on our experiences and training scores of dietitians on how

to diagnose malnutrition, it became evident that a learning tool was
needed with step-by-step instructions on how to perform a NFPE and
visual aids to demonstrate how to assess physical findings. The
authors of this handbook contributed their expertise to provide
photos, illustrations, and specific tips and techniques in performing
the NFPE. We hope this handbook is a useful resource, enhances the
skill set of clinicians and promotes confidence to perform a NFPE.
We especially would like to express our gratitude to ASPEN, who

with great enthusiasm, was willing to provide us with the opportunity
to collaborate to produce this handbook. We appreciate the
relationship cultivated with ASPEN over many years, which is one of
collegiality and a shared vision.
CINDY HAMILTON, MS, RD, LD, FAND

01 Introduction
02 Preparation for the Physical Exam

Overview
Systematic approach to a nutrition assessment
Assessment and interview techniques and tips
Exam techniques and tips
Exam techniques using inspection/palpation
03 Inflammation
Overview
Common diagnoses associated with etiology of malnutrition (Table 1)
Markers of inflammation: vital signs (Table 2)
Markers of inflammation: biochemical markers (Table 3)
Imaging studies (Table 4)
04 Physical Exam of Subcutaneous Muscle and Fat Stores

Overview
Symmetry
Special considerations: obesity, critical illness, and sarcopenia
Additional tools for body composition assessment
Head-to-toe approach
Head and face
Upper chest
Upper back
Midaxillary line
Arms
Hands
Lower extremities
05 Assessment of Fluid Status: Accumulation and Dehydration

Overview
Fluid accumulation/edema
Impact of edema on nutrition
Academy-ASPEN fluid accumulation characteristics that support a diagnosis of
malnutrition (Figure 1)
Differential diagnosis of edema (Table 1)
Medications known to cause generalized/peripheral edema (Table 2)
Terminology used to describe edema (Table 3)
Grading of pitting edema (Table 4)
Evaluation of fluid accumulation/edema (Table 5)
Dehydration
Labs and vital signs associated with dehydration (Table 6)
Areas of focus to evaluate for dehydration (Table 7)
06 Examination of Functional Status

Overview
Reduced grip strength as a supportive clinical characteristic for malnutrition (Table 1)
Measuring functional status
Techniques for using a dynamometer
07 Assessment of Micronutrient Status

Overview
Skin
Nails
Hair
Orofacial
08 Appendix: Nutrition-Focused Physical Exam Checklist

01
INTRODUCTION
Performing a nutrition-focused physical exam (NFPE) is a necessary

component of a comprehensive assessment to determine a patient’s
nutritional status. Other components of the assessment such as
medical, surgical, social, and diet histories; laboratory data; and other
pertinent tests are also required, but no one component can
determine nutritional status. The NFPE will help verify the physical
changes to the body due to undernutrition or overnutrition.
When determining patient nutrition status, the NFPE has not

always been widely incorporated into the practice of many clinicians
due to a lack of training or full understanding of its role as part of a
comprehensive nutrition assessment. Many healthcare professionals
incorporate a physical exam into their patient assessment, so it
follows that the NFPE should be included to best understand an
individual’s nutrition status. It is particularly critical for hospitalized
patients to have a full assessment. Full visualization, followed by
examination inclusive of touch or palpation, is integral to determine
body composition of fat and muscle, as well as the extent of fluid
shifts. Additionally, the development of rashes, sores, or color
changes to the skin, hair, nails, or oral cavity as a result of vitamin or
mineral losses, can be noted as an early sign of depletion. By
incorporating all components of a nutrition assessment, the nutrition
problem can be wholly recognized and a care plan can be
appropriately designed.
This handbook discusses the components of the NFPE and
includes pictorial representations of various stages of muscle and fat
depletion (normal–mild–moderate–severe), vitamin and mineral
losses, and fluid balance. Techniques and tips that can be used in
daily practice when examining patients, as well as charts and
references, are provided. The Academy-ASPEN clinical
characteristics are discussed, along with the influence of inflammation
and functional status.1 This guide is intended to help the clinician
develop their NFPE skills.
02
PREPARATION
FOR THE PHYSICAL EXAM
OVERVIEW
To conduct a complete NFPE, the clinician must be prepared in
advance and incorporate a series of steps during the exam. To
begin, gather information on intake and weight change using the
Academy-ASPEN clinical characteristics.1
Systematic Approach to a Nutrition Assessment
Gather the following information:
History and clinical diagnosis: Reviewing the medical record for the
past medical/surgical history, present illness, and clinical course
will offer insight into the possible etiology and presence of
malnutrition. Acute conditions may be present with chronic
conditions.2 Refer to Section 3: Inflammation as a guide to
recognize the presence of inflammatory conditions and the degree
of inflammation that may provide guidance to the appropriate
etiology.
Clinical signs and symptoms and the physical exam: This data may
help determine the presence and acuity of inflammation.
Anthropometric data: This data provides weight and weight history,

allowing the clinician to take into account weight changes noted as
the amount of change, percent of change, and rate of change of
the potential or underweight conditions.
Laboratory data: Review laboratory data for indications of

inflammation/protein-calorie malnutrition.
Dietary data: Nutritional intake from all sources (oral, enteral,

parenteral) may be gathered from the medical record, the patient,
and the caregiver. Evaluation of current intake should be compared
to both the estimated needs of the individual as well as the normal
intake for that individual. Identifying the degree of change of intake
is important in determining the degree of malnutrition. Some
conditions may affect the ability of patients to receive adequate
intake to meet nutrition needs and/or the ability to utilize nutrients.
These conditions include some surgical procedures, previous
hospitalizations, appetite and nutrition intake changes, route of
nutrition support (oral/enteral/parenteral), pain, nausea, vomiting,
diarrhea, constipation, fluid challenges (ascites/edema), and
certain medications.1
Functional status, as determined by strength and physical

performance: This is reviewed in comparison to normal activities
and baseline strength.3 Functional assessment must be viewed as
changes occurring in relation to the nutrition status. Changes in
muscle wasting that make activities more challenging are
considered to be nutrition-related functional changes.3-5
Assessment and Interview Techniques and Tips

The next step of evaluation is to interview the patient or patient
caregiver. If the patient is unable to verbally communicate, family and
caretakers may help provide necessary information for the NFPE as
well as provide supportive data and dispel conflicting information.
When obtaining and sharing patient information, be sure to follow the
Health Insurance Portability and Accountability Act (HIPAA) guidelines
for patient privacy.6
During the interview, maintaining focus on the severity and duration
of nutrition-related issues is imperative to appropriately use the
Academy-ASPEN clinical characteristics.1
The goals when first approaching a patient include the following:
Develop rapport
Introduce and explain the reason for your visit
Gain the patient’s consent to participate in the interview and

physical exam
Interview questions should not be leading, but rather be open and

probing to solicit information. As it is not always possible to calculate
the exact amount of calories that someone has consumed over a
particular amount of time, obtaining as much information on changes
to eating patterns prior to (and during) periods of weight change may
be helpful in estimating the percentage of needs that are being met.
Examples of probing questions include the following:
Have you noticed a change in the amount that you eat at meals?
When you are feeling well and eating normally, is your eating
different?
Are you eating less than half of your normal amount?
Are you skipping meals?
How long have you not been eating normally?
Does your infusion of enteral/parenteral feedings meet the daily

prescribed volume or is this interrupted?
Feedback is important and information gathering is most helpful

while performing the exam.3 Frequently, more information may be
revealed during the physical exam than in the interview alone.4
Prior to conducting the physical exam, explain the purpose of the

exam in a manner considerate to the patient’s condition, such as
introducing the physical exam as a tool to evaluate/assess for a
baseline of muscle and fat stores.
Avoid terminology that may add to emotional distress. Refrain from

discussing any potential for recovery of weight, fat, and/or muscle,
as this may not be possible. Do not make false reassurances that
may not be achievable.
Exam Techniques and Tips

Coordinate the entire examination to include examination of muscle
and fat stores, micronutrient deficiencies, and fluid accumulation. A
systematic and timely approach to the NFPE and continued practice
by the clinician will help develop an efficient and personal approach to
examining patients. The physical findings should correlate with other
clinical evidence from the medical record, the patient, or the caregiver
(weight loss, BMI, appetite, nutrition intake changes, functional ability,
labs).
Physical exam techniques include inspection, palpation, percussion,

and auscultation. Inspection and palpation are the main techniques
used for the NFPE. Inspection includes a broad observation of
physical appearance, posture, color, texture, size, smell, and
symmetry. Palpation includes using the hands to examine for bulk,
tone, texture, size, quality of volume/mass, swelling, symmetry, and
temperature.1, 2
Perform the exam at the initial visit and repeat during

hospitalization to determine any notable changes indicative of a
change in nutrition status.
1. Start with a general visual survey:

a. Pay attention to position/posture/physique:
i. Is the patient sitting or lying in bed and able to maintain their
posture? Are there visible losses of muscle and/or fat?
ii. Does the patient appear underweight?
b. Is there presence of edema/ascites that may have skewed the

patient’s weight? Are the legs elevated (as gravity will influence
where fluid moves in the body)? For instance, upright positioning
often enhances idiopathic edema.7 Does the patient appear
dehydrated?
c. Are there notable micronutrient deficiencies found on the skin,

hair, nails, or oral cavity?
2. Head-to-toe exam:
a. Proper positioning is needed to perform an accurate and more
reliable exam, assuming that the patient is able to adjust
positioning without any medical or physical concerns (fall risk,
injury, etc).
b. Move blankets, clothing, gowns, and compression stockings to

assure patient dignity and privacy.
c. Take note of both the right and left sides of the body: Are the
changes unilateral or bilateral?
d. Continued communication with the patient during the physical

exam may reveal additional information of the body areas being
assessed. For example: Does your face appear thinner to you?
Do your glasses or dentures fit differently? Are your clothes
fitting differently? Does your appearance look different in any
way? (Specify each area as it is being assessed.)
i. Has the patient noticed any changes in weight?
ii. Do clothing or jewelry not fit well?
iii. Does the patient notice any physical signs of weakness that
may be related to changes in nutrition intakes or physical
changes?
iv. What is the patient’s activity now compared to previous
activity?
01. Inquire as to type of activity, such as activities of daily
living (ADL), the amount of activity in a day, the time
spent on additional activity (hours per day, days per
week).
v. Are there any rashes or differences in hair, skin, or nails?
vi. Are there any chewing or swallowing difficulties?
vii. Are there any sores in the patient’s mouth or dentition
changes?
Exam Techniques Using Inspection/Palpation

1. Fluid
a. Inspection: assesses the overt presence and general severity of
edema
b. Palpation: assesses the quality and severity of edema
2. Muscle/fat
a. Inspection: observe for texture, size, and note symmetry and
posture
b. Palpation: examine for bulk and tone of muscle, adequacy of fat

stores, and edema
3. Skin exam technique and possible findings

a. Inspect for color, pigmentation, rashes, textures, and wounds
b. Palpate for texture and temperature
4. Nail exam technique and possible findings

a. Inspect and palpate for color and hygiene
5. Hair exam and possible findings

a. Inspect for pigmentation/shine (consider chemical alteration),
distribution, and texture
6. Head/orofacial exam and possible findings

a. Eyes: inspect with penlight for color and abnormalities to
appearance and discharge
b. Nose: inspect for color, texture, and discharge
c. Lips: inspect for cracks, lesions, color and texture
d. Mouth: inspect with penlight for color, texture, swelling, lesions,

dental caries, and erosions
e. Neck: inspect and palpate for swelling and symmetry
References
1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition
and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics
recommended for the identification and documentation of adult malnutrition (undernutrition).
J Acad Nutr Diet. 2012;112(5):730-738.
2. Jensen G, Hsiao PY, Wheeler D. Adapted with permission from ASPEN Adult Nutrition
Support Core Curriculum, 3rd ed. (Adult Nutrition Assessment Tutorial): JPEN J Parenter
Enteral Nutr. 2012;36(267), DOI: 10.1177/0148607112440284.
3. Secker DJ, Jeejeebhoy KN. How to perform subjective global nutritional assessment in
children. J Acad Nutr Diet. 2012;112:424-431.
4. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of
nutritional status? Classical article. Nutr Hosp. 1987;11(1):8-13.
5. Puthucheary Z, Montgomery H, Moxham J, Harridge S, Hart N. Structure to function: muscle

failure in critically ill patients. J Physiol. 2010;588(23):4641–4648.
6. “Uses and disclosures requiring an opportunity for the individual to agree or to object,”
Health Insurance Portability and Accountability Act. HIPAA Privacy Rule at 45 CFR
164.510(b). August 14, 2002.
7. Sterns RH. Clinical manifestations and diagnosis of edema in adults. In: Post TW, ed.
UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com. Accessed January 30,
2014.
03
INFLAMMATION
OVERVIEW
The Academy-ASPEN clinical characteristics to identify
malnutrition include determining the etiology of malnutrition.
Etiology is determined by two main factors: the presence of
inflammation related to the disease process causing a state of
malnutrition, and the length of time the disease/medical condition has
been affecting the patient’s nutrition status. To determine the etiology
of malnutrition, the clinician needs to consider if there is an
inflammatory process present and, if so, to what intensity.
Understanding individual patient situations in the context of different
inflammatory processes will help more clearly define the varying
effects and rate at which malnutrition may develop. Several
diagnoses can be categorized as an acute inflammatory condition or
a chronic inflammatory condition (Table 1). When there is no
inflammatory condition present, as with pure starvation, it can be
categorized as a social or environmental cause of malnutrition.1
Caution should be taken when deciding which etiology is actually
causing the malnutrition. For example, a patient with diabetes who
lost her job several months ago may not be malnourished due to the
diabetes, but rather because of economic hardship.
TABLE 1. COMMON DIAGNOSES ASSOCIATED WITH ETIOLOGY
OF MALNUTRITIONa
Context of Social or
Context of Acute Illness or
Context of Chronic Illness Environmental
Injury
Circumstances
Heightened, high-intensity Prolonged, lower-intensity
No signs of inflammation
inflammatory state inflammatory state
Abdominal abscess Organ failure Achalasia
Acute respiratory distress
Cancer Alcoholism
syndrome
Burns Cardiovascular disease Amyotrophic lateral sclerosis
Trauma Celiac disease Dementia
Major infection/sepsis Congestive heart failure Drug abuse
Major surgery Cystic fibrosis Eating disorders
Cerebrovascular accident Economic hardship
Chronic pancreatitis Guillain-Barré syndrome
Diabetes Mental disorders
Human immunodeficiency
Muscular dystrophies
virus
Lupus Pain
Obesity Sickle cell anemia (pain)
Pancreatic pseudocyst
Rheumatoid arthritis
a
This chart is not intended to be a complete list of nutritional- or nonnutritional-related
etiologies.
Because determining the presence and degree of inflammation is not

always straightforward, consider the following points for guidance:
Acute inflammation signs and symptoms include swelling,

erythema, hyperthermia, pain, marked C-reactive protein (CRP)
elevation, and leukocytosis. Acute inflammation is a defense,
clearance, adaptation, and repair response.3
Chronic inflammatory markers may be the same as those with
acute inflammation (eg, leukocytosis, fever, elevated CRP), but to
a lesser degree and over a prolonged duration of time. Chronic
illnesses or conditions may even lack the classic signs seen in the
acute inflammatory process.2,3 The purpose of a low-grade
inflammatory response is restorative and to achieve homeostasis.2
Abnormal vital signs (Table 2), biochemical markers (Table 3), and
imaging studies (Table 4) may indicate the presence of an
inflammatory process; however, they may not be related to the
patient’s nutritional status. These should be considered as
supportive information when determining the etiology of
malnutrition.
TABLE 2. MARKERS OF INFLAMMATION: VITAL SIGNS

Vital Sign Indicator Abnormal Special Considerations
May be masked by antipyretics (ie,
Fevers ≥37.7°C (99.9°F)
salicylates, acetaminophen, NSAID)
Hypothermia <35.0°C (95.0°F) Rule out other causes
May be masked by antiarrhythmics (ie,
Pulse (heart rate) >100 beats/min
amiodarone, disopyramide, quinidine)
<90 mm Hg
Blood pressure a Rule out other causes
>40 mm Hg drop
from normal
Respiratory rate a >20 breaths/min Rule out other causes
a
Based on systemic inflammatory response syndrome (SIRS) criteria for sepsis.
TABLE 3. MARKERS OF INFLAMMATION: BIOCHEMICAL
MARKERS4,a
Biochemical Indicator Normalb Increased Levels Decreased Levels
Inflammation
Liver failure
Albumin 3.5-5.0 g/dL Dehydration
Nephrotic syndrome
Fluid overload
Fluid status change
Chronic kidney Liver failure
Prealbumin 15-35 mg/dL
disease Inflammation
Steroid use
C-reactive protein
<1.0 mg/dL Inflammation N/A
(CRP)
Diabetes
Hyperthyroidism
Pancreatic cancer
Reactive
Pancreatitis
70-100 mg/dL hypoglycemia
Glucose, fasting or Trauma
Alcohol consumption
Stroke
Glucose, random Insulinoma
Heart attack
<125 mg/dL Infection
Surgery
Organ failure
Cushing’s syndrome
Infection
Some medications
Anemia
Some medications
Sepsis
White blood cells Smoking
Chemotherapy
Infection
Leukocytosis or 4,500-10,000/mL Infectious diseases
Inflammatory
Leukopenia Autoimmune
diseases
diseases
Leukemia
Tissue damage
Infection
Kidney disorders
Major Leukemia
surgery/trauma/burns Anemia
Platelets Allergic reactions Viral infections
Thrombocytosis Cancer Chemotherapy
150,000-400,000/mL
or Heart attack Alcohol consumption
Thrombocytopenia Iron deficiency Autoimmune
Hemolytic anemia diseases
Inflammatory Some medications
diseases
Pancreatitis
Nitrogen balance Positive Negative: Fasting
Illness
Infection
Stress
Body fluid cultures Negative Positive: Infection
a
This chart is not intended to be a complete list of nutritional- or non-nutrition-related lab
values.
b
These ranges vary from lab to lab.
TABLE 4. IMAGING STUDIESa

Imaging Study Indicators Acute Condition Chronic Condition
Pneumonia
Chest x-ray Scleroderma
Infiltrations
Abscess
Abdominal or pelvis x-ray Acute pancreatitis Chronic pancreatitis
Bowel obstruction
Gastric emptying study Gastroparesis

Bowel Perforation Dysmotility
Intestinal leak Fistulas
Small bowel follow through
Abscesses
Esophagogastroduodenoscopy Gastritis
Irritable bowel disease
(EGD) Esophagitis
Radiation enteritis
Crohn’s or ulcerative colitis
Strictures
Colonoscopy flare
Endocarditis Congestive heart failure
Transesophageal echo (TEE)
Vegetations Heart valve abnormalities
a
This chart is not intended to be a complete list of conditions.
References
1. Malone A, Hamilton C. The Academy of Nutrition and Dietetics/The American Society for
Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics: Application in
Practice. Nutr Clin Pract. 2013;28:639-650.
2. Kushner I, Samols D, Magrey M. A Unifying Biologic Explanation for “High-Sensitivity” C-

Reactive Protein and “Low-Grade” Inflammation. Arthritis Care Res. 2010;62:442-446.
3. White JV, Guenter P, Jensen G, et al. Consensus Statement: Academy of Nutrition and
Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics
Recommended for the Identification and Documentation of Adult Malnutrition
(Undernutrition). JPEN 2012;36:275-283.
4. Pagana, KD, Pagana, TJ, Pagana, TN. Mosby’s Diagnostic and Laboratory Test
Reference. 12th ed. St Louis, MO: Mosby, 2015.
04
PHYSICAL EXAM
OF SUBCUTANEOUS MUSCLE AND FAT
STORES
OVERVIEW
One of the primary reasons to perform NFPE is to assess for
presence of and changes in muscle and fat mass, as part of
defining malnutrition according to the Academy-ASPEN clinical
characteristics (Table 1).1 Observation and palpation techniques of
various parts of the body are used to determine muscle and fat
stores, which is a subjective process.2 Subjectivity of muscle and fat
assessment amongst clinicians may be mitigated through training with
experienced clinicians and repetitive practice using a NFPE.2,3
Obtaining data about muscle and fat loss in patients from physical
exam has been shown to be readily available in the vast majority of
hospitalized patients, including critically ill patients.4
TABLE 1. ACADEMY-ASPEN MALNUTRITION CLINICAL
CHARACTERISTICS FOR MUSCLE AND FAT ASSESSMENT1
Degree of Malnutrition
Nonsevere (Moderate) Severe
Acute Illness/Injury (fat or
Mild Moderate
muscle loss severity)
Chronic Illness (fat or muscle
Mild Severe
loss severity)
Social/Environmental
Circumstance (fat or muscle Mild Severe
loss severity)
Muscle wasting, or muscle atrophy, is a loss of bulk and tone that

is detectable by palpation.2,5 As stated by Puthucheary et al, “the
loss of bulk and tone of muscle may not affect the person in a non-
inflammatory state, yet presenting in a more compromised position
with decreased muscle mass promotes further reduction of muscle
mass in critical illness.”6 This statement reinforces the importance of
determining the etiology of malnutrition based on inflammatory
activity, not just the length of time the condition has been present. The
moment of the assessment, along with the clinical condition, may
affect a clinician’s decision regarding etiology and degree of
malnutrition. This section will provide guidance about the specific
locations to assess for muscle and fat reserves, as well as
categorizing findings as normal, mild/moderate losses, or severe
wasting.
Special Considerations: Obesity, Critical Illness, and Sarcopenia

Body composition, particularly the amount of lean and fat tissue, is a
predictor of morbidity and mortality in critical illness.6 When assessing
for muscle and fat loss, there are certain circumstances or conditions
that may interfere with a reliable physical exam. Patients that are
obese may not readily exhibit visual signs of muscle and fat losses
since excess adipose tissue limits observation and palpation of
underlying muscle mass. Also, patients in the intensive care unit (ICU)
may not be able to be fully examined because of limited patient
participation; medical or hemodynamic instability; presence of edema;
and presence of IV lines, drainage tubes, and other medical devices.7
The loss of muscle mass and subcutaneous fat can be evident

within the first week of an ICU admission. It is therefore imperative to
assess these patients early in the hospital stay, then serially.8
Reexamination of ICU patients is important since changes (like
medical device placement or removal and manifestation of edema)
occur rapidly to reveal or hide areas that can be assessed for muscle
and fat mass.7 Additionally, increased patient mobility may allow for
more areas to be examined that may not have been previously
accessible to the clinician.
Sarcopenia is recognized as an inflammatory condition related to

oxidative stress and has long been associated with the loss of muscle
mass in the aging population. More recent findings indicate there is
not only a loss of lean muscle mass but also a decreased functional
component of sarcopenia. Changes in strength do not always
correlate with changes in muscle size; yet, low muscle mass may
result in reduced gait speed or decreased muscle strength with a
normal gait speed. Therefore, the inflammatory state associated with
sarcopenia and its potential effects on muscle and function need to
be considered when performing the NFPE.3
Additional Tools for Body Composition Assessment

Imaging techniques, including computed tomography (CT), magnetic
resonance imaging (MRI), and portable ultrasound (US) can be used
to visualize lean soft tissue (if available). These images are commonly
performed for analytical and diagnostic purposes, but can also be
used to investigate lean soft tissue, an emerging trend to more clearly
evaluate muscle and fat as part of a nutrition assessment.
Additionally, some clinical departments may have access to air
displacement plethysmography technology, dual-energy x-ray
absorptiometry, and bioelectric impedance for a similar purpose.
Assessing for loss of muscle and fat over time may prove beneficial in
identifying changes that are otherwise limited to the physical
examination process.9 The expense of these technologies and access
to the necessary equipment may not always be available. NFPE does
not rely on expensive equipment and can be done quickly and easily
by trained clinicians on most patients.4 Thus, inclusion of a physical
exam, assessment of functional status, and determination of the
severity of illness are all beneficial components when attempting to
identify malnutrition or other nutrition-related derangements.10
Head-to-Toe Approach
The key to assessing body composition is to be familiar with the
regions where muscles and fat can be readily accessed and
examined. A head-to-toe approach provides a systematic, organized
fashion for a thorough NFPE.7 The upper body, rather than the lower
body, is more often used to help identify losses of fat and muscle as
it is typically less affected by edema, is more accessible to the
clinician, and has been identified as a good reflection of overall
muscle mass.11 A thorough, bilateral review of the body during
physical exam is important to differentiate between nutrition-related
wasting and those impacted by various diseases or deconditioned
states. For instance, a patient who has a stroke or a broken leg may
present with distinct variations in muscle tone on each side of the
body. Nutrition-related muscle wasting is typically symmetrical, but
other diseases also promote this type of wasting and should be ruled
out during the nutrition assessment. To ensure the most accurate
depiction of muscle and fat during the head-to-toe approach, patients
need to be properly positioned.7
TIPS
Orbital Region: Orbital fat pads
POSITIONING: Frontal and lightly palpate above cheekbone
Temple Region: Temporalis muscle
POSITIONING: Frontal and lateral views; lightly palpate area
Clavicle Bone Region: Pectoralis major, deltoid, trapezius

POSITIONING: Upright and not hunched over
Acromion Bone Region: Deltoid
POSITIONING: Upright and arms at side to observe shape
EXAM AREAS: HEAD AND FACE (FAT AND MUSCLE)
Normal
Orbital Region: Orbital Fat Pads
Slightly bulged Fat pads
Temple Region: Temporalis Muscle
Well-defined muscle, flat or slight bulge
Mild – Moderate
Slightly dark circles, somewhat hollow look
Slight dep ression
Severe
Hollow look, depressions around eye, dark circles, loose saggy
skin
Deep hollowing/scooping, lacking muscle to the touch, facial
bone structures very defined
EXAM AREA: UPPER CHEST (MUSCLE)

Normal
Well-defined muscle surrounding bone, clavicle bone typically
not visible in males and may be slightly prominent in females
Rounded curves at arms, shoulder, and neck
Mild – Moderate
More prominent clavicle bone, less prominent muscle when
palpated
Acromion process may slightly Protrude
Severe
Protruding and prominent bone with low surrounding muscle
mass when palpated
Shoulder to arm joint looks square, bones more prominent,
acromion process very prominent
EXAM AREA: UPPER BACK (MUSCLE)

Normal
Scapular Bone Region: Trapezius, supraspinatus, infraspinatus
Bones not prominent, no significant depressions
Mild – Moderate
Mild depression around scapula or bone may slightly show
Severe
Prominent, visible scapula bone; notable depressions between ribs,
scapula, and/or shoulder/spine
EXAM AREA: MIDAXILLARY LINE (FAT)
Normal
oracic and Lumbar Region: Ribs, lower back, midaxillary line at
iliac crest
Chest is full, ribs do not show, slight to no protrusion of the iliac
crest
Mild – Moderate
oracic and Lumbar Region: Ribs, lower back, midaxillary line
Ribs somewhat more apparent, depressions not very pronounced,
iliac crest somewhat prominent
Severe
oracic and Lumbar Region: Ribs, lower back, midaxillary line
Depression between ribs very apparent, iliac crest is very
prominent
TIPS
POSITIONING: Ask patient to extend arms out and push against
solid object (clinician may use hand as support for patient to
push against).
If patient is unable to sit or stand, ask patient to roll to the side,
extending arms as able, and push against a solid object.
POSITIONING: Ask patient to extend arms out in front or out to

sides of their body and push against solid object (clinician may
use hand as support for patient to push against).
If unable to stand, patient may lie on their back (this may not be
optimal to assess due to interfering factors in positioning).
TIPS
POSITIONING: With arm bent at 90-degree angle, use a gentle
rolling motion between thumb and fingers down the tricep to
separate muscle and assess fat. Once fingers have pinched the
area under the tricep, take note of the amount of fat between the
fingers.
POSITIONING: Observe muscle pads where forefinger and

thumb intersects while patient is making an “OK” sign. View and
palpate dorsal and palmar sides of the hand.
EXAM AREA: ARMS (FAT)
Normal
Upper Arm Region: Area under the tricep muscles
Ample fat tissue obvious between folds of skin pinched between
finger
Mild – Moderate
Some depth to pinch, not ample
Severe
Very little space between folds, fingers practically touching
EXAM AREA: HANDS (MUSCLE)

Normal
Palmar: Opponens pollicis, adductor pollicis, first dorsal interossi
Muscle bulges, could be flat in some well-nourished individuals
Dorsal: Interosseous muscles

Flat/mild bulge between dorsal bones, bulging/flat muscle
between index finger and thumb
Mild – Moderate
Slight depression

Slight depression between dorsal bones
Severe
Depressed areas, particularly between thumb and forefinger

Depressed areas between dorsal bones, particularly between
thumb and forefinger; bones very prominent
EXAM AREA: LOWER EXTREMITIES (MUSCLE)

Normal
Anterior igh Region: Quadriceps
Well rounded, well developed
Patellar Region: Quadriceps
Muscles protrude, kneecap not prominent
Posterior Calf Region: Gastrocnemius
Well-developed bulb of muscle
Mild – Moderate
Mild depression on inner thigh
Kneecap more prominent
Not well developed
Severe
Depression/line on thigh, not well developed
Kneecap prominent, little sign of muscle around knee
in, minimal to no muscle definition
TIPS
POSITIONING: Ask patient to sit up with leg propped up/bent at
knee; grasp quadriceps/gastrocnemius muscles to distinguish
between muscle versus fat.
If patient is unable to sit up, have patient bend knee (while lying
down) so that calf and quadriceps are lifted off the bed.
References
and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics
recommended for the identification and documentation of adult malnutrition
(undernutrition). J Acad Nutr Diet. 2012;112(5):730-8.
3. Jensen GL. Malnutrition and inflammation—“burning down the house”: Inflammation as an

adaptive physiologic response versus self-destruction? JPEN J Parenter Enteral Nutr.
2015;39(1):56-62.
4. Nicolo M, Compher CW, Still C, Huseini M, Dayton S, Jensen GL. Feasibility of Accessing
Data in Hospitalized Patients to Support Diagnosis of Malnutrition by the Academy-ASPEN
Malnutrition Consensus Recommended Clinical Characteristics. JPEN J Parenter Enteral
Nutr. 2014;38(8):954–959.
5. Secker DJ, Jeejeebhoy KN. How to perform subjective global nutritional assessment in
children. J Acad Nutr Diet. 2012;112:424-431.
6. Puthucheary Z, Montgomery H, Moxham J, Harridge S, Hart N. Structure to function:

muscle failure in critically ill patients. J Physiol. 2010;588(23):4641–4648.
7. Fischer M, Jevenn A, Hipskind P. Evaluation for muscle and fat loss as diagnostic criteria
for malnutrition. Nutri Clin Prac. 2015;30(2):243-247.
8. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical
illness. JAMA. 2013;310(15):1591-600.
9. Prado CM, Heymsfield SB. Lean tissue imaging: A new era for nutritional assessment and
intervention. JPEN J Parenter Enteral Nutr. 2014;38(8):940-53.
10. Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition
risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.
11. Keys A. Caloric undernutrition and starvation, with notes on protein deficiency. J Am Med
Assoc. 1948;138(7):500-511.
05
ASSESSMENT OF FLUID
STATUS:
ACCUMULATION AND DEHYDRATION
OVERVIEW
Part of the NFPE for diagnosing malnutrition includes the
clinical evaluation of fluid status, specifically how it affects
weight changes.1 Under ordinary circumstances, the human body is
excellent at tightly regulating hydration and can easily adapt to fluid
and electrolyte shifts while maintaining normal functions.2 Healthy
kidneys are able to maintain water and salt balance in the body, so
unless there is an underlying systemic disorder, changes solely in
water or salt intake should not cause edema.3 Volume depletion,
caused by interstitial and intravascular fluid movement into a third
space, can present clinically as edema.4 Gross deficiency of protein
for an extended period of time, as well as the physiological response
to refeeding syndrome, can result in edema.4 Fluid accumulation is
rarely a direct manifestation of malnutrition, but can present as weight
gain, thereby concealing weight loss,1 as well as muscle and fat loss.
On the other hand, dehydration can be a result of various medical
conditions, or not maintaining adequate nutrition, and manifest in an
inaccurately low weight.2 This section reviews physical exam
techniques to assess a patient’s fluid status as part of establishing a
proper malnutrition diagnosis.
Fluid Accumulation/Edema
Edema is an excess of interstitial fluid accumulation that can be
caused by a multitude of clinical conditions (Table 1) and medications
(Table 2).4 Clinically known as swelling, edema can be palpable and
account for 10%-30% of body weight.5,6 Systemic fluid retention may
not clinically manifest until it accounts for at least 10% of body
weight3 or when interstitial fluid volume is increased by 2.5 to 3
liters.7 Extra fluid around the heart, fluid in the lungs,6 small pockets
of ascites, or hematomas might not be visible on exam, but rather
only on imaging studies. Therefore, a significant amount of fluid
retention can be present without a patient actually appearing overtly
edematous.4 Less obvious clues might be present instead, like ill-
fitting shoes or rings, rapid weight increase, declining serum sodium
levels, dyspnea, increased blood pressure, or distended neck
veins.4,6,8
TABLE 1. DIFFERENTIAL DIAGNOSIS OF EDEMA4,6,7,a
Clinical Presentation Disease Association Additional Considerations
Cardiovascular disease
Congestive heart failure
Hepatic disease
Ascites, peripheral edema also
(cirrhosis)
Anasarca or Renal disease
generalized edema Nephrotic syndrome
Glomerulonephritis
Medications Peripheral edema also
Thickening of the skin; nonpitting, can be
Myxedema
on lower extremities, hands, or face
Trauma
Burns
Localized edema Angioedema
Hives
Skin infection Erysipelas, cellulitis
Cirrhosis Anasarca, peripheral edema also
Ascites Severe right-side heart
Anasarca, peripheral edema also
failure
Peripheral edema Right-side heart failure
Cardiomyopathy
Pericardial disease
Renal disease
Primary renal sodium
retention
Peripheral and periorbital edema,
Nephrotic syndrome
occasionally with ascites
Localized venous or
lymphatic disease
Capillary leak syndrome
Pregnancy
Idiopathic edema
Hypoalbuminemia Generalized edema also
Nutritional deficiency Generalized edema also
Refeeding syndrome Generalized edema also
Beriberi
Pretibial myxedema Brawny, on the shins, thickening of the
dermis but may also involve toes/feet
Venous obstruction
Unilateral limb Peripheral also, most common in legs (ie,

Venous
after lymph node dissection from cancer,
edema insufficiency/thrombosis
causing nonpitting lymphedema)
Lymphatic obstruction
Venous obstruction
Bilateral limb
Venous insufficiency
edema
Lymphatic obstruction
a
List is not all-inclusive.
TABLE 2. MEDICATIONS KNOWN TO CAUSE
GENERALIZED/PERIPHERAL EDEMA4,6,a
Drug Class Medications
isocarboxazid
phenelzine sulfate
Antidepressants (MAOIs):
tranylcypromine sulfate
selegiline
calcium channel blockers (ie, amlodipine,
diltiazem, verapamil)
beta-blockers (ie, propranolol, atenolol,
Antihypertensives: labetalol, carvedilol, metoprolol)
direct vasodilators (ie, hydralazine, minoxidil)
others: clonidine,
methyldopa, guanethidine
estrogen
progesterone
testosterone
Hormones:
corticosteroids
anabolic steroids
growth hormone
aspirin
ibuprofen
NSAIDs: naproxen
cyclooxygenase-2 inhibitors (ie, valdecoxib,
rofecoxib, celecoxib)
rosiglitazone
Thiazolidinediones:
pioglitazone
gabapentin
Anticonvulsants:
pregabalin
docetaxel
Antineoplastics:
cisplatin
pramipexole
Anti-Parkinson’s:
ropinirole
cyclosporine
Others: immunotherapies
interleukin 2
a
List is not all-inclusive.
Fluid accumulation can be generalized or concentrated in one area

(Table 3), chronic or acute in nature, unilateral or bilateral, pitting or
brawny. Distinction of these characteristics can help determine
etiology.4,8 Peripheral edema gravitates to dependent areas of the
body and is contingent on body positioning.4,8 Routine observation of
symptoms with a physical exam is just as important as monitoring
weight fluctuations to determine if edema is worsening or improving.6
TABLE 3. TERMINOLOGY USED TO DESCRIBE EDEMA4,6,8

Term Definition
Accumulation of fluid in the abdomen causing distention; percussed
Ascites
shifting dullness and fluid wave
Anasarca Massive, generalized, whole-body edema
Peripheral Less serious than pulmonary edema; characterized primarily by swollen

lower extremities, with a tendency to accumulate in dependent areas (ie,
edema
thighs, sacrum with bed rest) and may cause ambulating difficulties
Reflective of the movement of excess interstitial fluid; leaves indentation
Pitting edema
when at least 5 seconds of pressure is applied to edematous area
Nonpitting No indentation is created after pressure is applied to the edematous area,
edema or characterized by thickening, dark color, dry/scaly patches, induration,
brawny edema liposclerosis
Impact of Edema on Nutrition

Based on the Academy-ASPEN consensus statement, fluid
accumulation is one of the characteristics that supports a diagnosis of
malnutrition (Figure 1).1 Therefore, it is important to assess and
monitor for changes (Tables 4 and 5); but caution should be
exercised, as edema is rarely the direct result of malnutrition.1,7
Mainly, edema explains rapid increases in weight, but it can also
mask the severity of weight decline,1 thereby impacting diagnostic
accuracy of the presence and severity of malnutrition. Edema can
also interfere with accurately visualizing and examining for muscle and
fat loss.
FIGURE 1. ACADEMY-ASPEN FLUID ACCUMULATION
CHARACTERISTICS THAT SUPPORT A DIAGNOSIS OF
MALNUTRITION1
Fluid Accumulation
Nonsevere Malnutrition Severe Malnutrition
Acute Injury or Illness Mild Mod → Severe
Chronic Illness Mild Severe
Social/Environmental Circumstances Mild Severe
TABLE 4. GRADING OF PITTING EDEMA5
NO EDEMA
Method 1
Depth and Duration: No impression or distortion observed, bone
structure easily identified
Method 2
Depth and Rebound Time: No impression or distortion observed,
bone structure easily identified
Method 3
Overall Severity of Edema: Absent
1+ EDEMA
Method 1
Depth and Duration: Slight pitting without distortion, rapidly
disappears
Method 2
Depth and Rebound Time: Barely detectable depression,
immediate rebound
Method 3
Overall Severity of Edema: Mild
Isolated to bilateral ankles and/or feet
2+ EDEMA
Method 1
Depth and Duration: Somewhat deeper pit, distortion not easily
apparent, disappears 10-25 sec later
Method 2
Depth and Rebound Time: Deeper pit that takes a few seconds to
rebound
Method 3
Overall Severity of Edema: Moderate
Includes lower arms with hands and/or lower legs with feet/ankles
3+ EDEMA
Method 1
Depth and Duration: Noticeably deep pitting, entire extremity
looks full, swollen; indentation can last longer than 1 min
Method 2
Depth and Rebound Time: Pit even more pronounced, taking
about 10-12 sec to rebound
Method 3
Overall Severity of Edema: Severe
Generalized bilateral pitting edema, inclusive of upper and lower
extremities and face
4+ EDEMA
Method 1
Depth and Duration: Very deep pitting, extremity is grossly
misshapen, indentation lasts 2-5 min
Method 2
Depth and Rebound: Very deep, 8 mm pit taking longer than 20
sec to rebound
Method 3
Overall Severity of Edema: N/A
TIPS
Assessing the quality of edema with palpation
Peripheral edema classification is subjective. Despite its
subjectivity, use of a schematic can assist with recording
changes in edema over time.3,5,6
1. Locate an area of the lower extremities where the skin
overlies a bone, such as the shin, malleolus, or dorsum of the
foot.
2. Using the pad of your finger or thumb, press down on the skin
with moderate pressure for at least 5 seconds.
3. Lift finger from skin and observe indentation to determine
severity:
a. If indentation appears after pressure is applied, how deep
is it?
b. How much time passes until the area refills with fluid?
c. How far up the leg can the edema be appreciated?
Remember, brawny edema will not leave an indentation, so use
of the grading scale would not be appropriate.
TIPS
Seek out less obvious areas of fluid accumulation (flanks,
abdomen, thighs, sacral area) by moving blankets and clothing.
If swelling is not observed, ask patient:
Does clothing or jewelry fit differently?
Have you noticed any weight changes?
Be sure to correlate physical exam findings with other clinical
evidence (ie, vital signs, input/output records, labs, weights, etc).
TABLE 5. EVALUATION OF FLUID ACCUMULATION/EDEMA

Inspection Palpation
At initial visit At initial visit
When to Reevaluate at routine intervals, ie, Reevaluate at routine intervals, ie,
with reassessment of nutrition with reassessment of nutrition
perform
status or when a significant change status or when a significant change
in medical condition occurs in medical condition occurs
Use of head-to-toe procedure:
- Face, arms, hands Focused evaluation of:
Areas of
- Sacral area, scrotum, vulva - Sacral area, flanks
concern
- Flanks, abdomen - Thighs, calves, feet
- Thighs, calves, feet
Observe body position (ie, sitting,
Observe body position (ie, sitting,
standing, lying down), as gravity
standing, lying down), as gravity
influences fluid accumulation
influences fluid accumulation
Special
considerations Observe if swelling is:
Observe if swelling is:
- generalized or localized
- generalized or localized
- unilateral or bilateral
- unilateral or bilateral
- pitting or brawny
Dehydration
While dehydration is not a characteristic used to determine
malnutrition,1 it is important to understand that a dehydrated patient
will clinically present with a falsely low weight. This can skew the final
diagnosis for malnutrition by overestimating the perceived amount of
weight loss. It can be very difficult to measure dehydration, even for
experienced practitioners.9 The clinical exam tends to be insensitive,
nonspecific,2,9,10 and is not dependent upon a single indictor.9,10
Observations from a physical exam, in conjunction with assessment
of weight, vital signs, and laboratory values, will lead to proper
evaluation of hydration (Figure 2 and Table 6).2
FIGURE 2. CLINICAL SYMPTOMS OF DEHYDRATION2,9,10

TABLE 6. LABS AND VITAL SIGNS ASSOCIATED WITH
DEHYDRATION2
Lab/Vital Sign Result Additional Considerations
↑ Hypernatremia
In cases of water loss
Serum sodium
In cases of water and sodium loss
↓ Hyponatremia
In cases of water loss, but
↑ Hyperkalemia potassium retained (ie, renal
Serum potassium failure)
↓ Hypokalemia In cases of significant GI or urine
losses
Plasma osmolality ↑
BUN/Cr ratio ↑ Often greater than 20:1
Hematocrit ↑ Due to reduction in plasma volume
↑
Albumin Due to reduction in plasma volume
Hyperalbuminemia
In cases of loss of bicarbonate (ie,
Metabolic acidosis GI losses via diarrhea or high
fistula/ostomy output)
In cases of hydrogen ion loss (ie,
Metabolic alkalosis diuretics, significant emesis, or
nasogastric tube suctioning)
Urine sodium In cases of hypovolemia (unless
↓
concentration accompanied by salt-wasting state)
Postural signs initially, then
Blood pressure ↓ Bradycardia persistent despite posture as
dehydration worsens
Heart rate ↑ Tachycardia
TIPS
Conditions that increase risk of dehydration include2,10:
excessive diarrhea or vomiting
profuse sweating
gastrointestinal hemorrhage
gastrointestinal losses via fistulae or ostomies
polyuria (ie, diabetes insipidus, use of diuretics)
fevers
burns
advanced age
exposure to warm environments
prolonged exercise
TABLE 7. AREAS OF FOCUS TO EVALUATE FOR

DEHYDRATION2,11
MOUTH—LIPS, GUMS, TONGUE
Technique
Visual inspection, penlight is useful
Normal
Will appear moist
Dehydrated
Lack of saliva pooling, thick-appearing saliva, dry mucous
membranes, fissured tongue, lips/tongue sticking together, cracked
lips, complaints of thirst
EYES
Technique
Visual inspection, penlight is useful
Normal
Membranes will appear moist
Dehydrated
Stinging or burning feeling, membranes look dry, redness, watery
eyes
SKINa
Technique
Turgor assessment:
Pinch skin for a few seconds on the back of the hand, forearm, or
sternum
Normal
Aer letting go, skin should quickly return to its original position
Dehydrated
Aer letting go, skin slowly returns to the original position
NAILS
Technique
With patient’s hand at a level above the heart, apply pressure to the
nail bed until it turns white (indicates blood was forced from
tissue), then remove pressure
Normal
Blood should return, causing nail bed to turn pink within 2 sec aer
pressure is relieved
Dehydrated
Refill times longer than 2 sec could indicate dehydration (also:
shock, peripheral vascular disease, hypothermia)
a
This is a reliable indicator in younger patients, but in those patients who are obese or >55-60
years old, turgor may not be accurate (skin elasticity is best preserved on sternum or inner
aspect of thigh).2
References
recommended for the identification and documentation of adult malnutrition
(undernutrition). J Acad Nutr Diet. 2012;112(5):730-8.
2. Sterns RH. Etiology, clinical manifestations, and diagnosis of volume depletion in adults.
In: Post TW, ed. UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com.
Accessed February 2, 2016.
3. Rosenthal LD, Cumbler E. Evaluation of Peripheral Edema. Epocrates.

https://online.epocrates.com/noFrame/showPage?
method=diseases&MonographId=609&Active SectionId=11. Updated October 19, 2015.
Accessed 2/2/2016.
4. Braunwald E, Loscalzo J. Chapter 36: Edema. In: Longo DL, Kasper DL, et al. Harrison’s
Principles of Internal Medicine. 18th ed. New York, NY. McGraw Medical; 2012: accessed
online January 28, 2016. http://accessmedicine.mhmedical.com/content.aspx?
bookid=331&sectionid=40726754
5. Edema grading. Med-Health.net. www.med-health.net/edemagrading.html. Accessed

1/30/16.
6. Sterns RH. Clinical manifestations and diagnosis of edema in adults. In: Post TW, ed.
UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com. Accessed January 30,
2016.
7. Chapter 15: I have a patient with edema. How do I determine the Cause? In: Stern SDC,
Cifu AS, Altkorn D, ed. Symptom to Diagnosis: An Evidence-Based Guide, 2nd ed. New
York, NY. McGraw Medical; 2009:248-265.
8. Phelps KR. Chapter 29: Edema. In: Walker HK, Hall HD, Hurst JW, ed. Clinical Methods:
The History, Physical, and Lab Examinations. 3rd ed. Boston, MA: Butterworths;
1990:144-147.
9. Crecelius C. Dehydration: Myth and Reality. J Am Med Dir Assoc. 2008;9 (5):287–288.
10. Jequier E, Constant F. Water as an essential nutrient: the physiological basis of hydration.
Eur J Clin Nutr. 2010;64(2):115-23.
11. Martin, LJ. Capillary nail refill test. MedlinePlus.

http://www.nlm.nih.gov/medlineplus/ency/article/003394.htm. Updated April 30, 2015.
Accessed January, 30, 2016.
06
EXAMINATION
OF FUNCTIONAL STATUS
OVERVIEW
Reduced muscle strength is a noted predictor of survival during
critical illness.1 The decline in strength and physical performance
resulting from loss of muscle and function are detectable in advanced
malnutrition syndromes (Table 1).2 Nutrient deficiencies and
malfunctioning organ systems contribute to the decline in functional
status. Inflammation and/or infection can increase the risk for or
worsen a malnutrition condition with a decreased response to nutrition
interventions and a potential increase in mortality.2 The combination of
immobility, inflammation, feeding, and insulin resistance is a pro-
inflammatory process and protein turnover and drugs may have a
synergistic impact on muscle catabolism.1
TABLE 1. REDUCED GRIP STRENGTH AS A SUPPORTIVE

CLINICAL CHARACTERISTIC FOR MALNUTRITION3
Etiology of Malnutrition Nonsevere (Moderate) Severe
Acute illness or injury N/A Measurably reduced
Chronic illness N/A Measurably reduced
Social or environmental
N/A Measurably reduced
circumstances
Measuring Functional Status
The use of a handgrip dynamometer as a measurement of muscle
strength is a validated tool for determining functional status of an
individual.2,4,5 Impaired grip strength may help identify patients at risk
for increased postoperative complications, increased length of
hospitalization, rehospitalization, and decreased physical status.
Findings from handgrip dynamometry are a relevant marker of
functional status and useful in the assessment of nutrition status.5
In some clinical settings, use of the dynamometer may not be

available or practical.5 Identifying other potential performance
measures to aid in the evaluation of functional status may also be
useful as they become accepted/validated.3 Although handgrip
dynamometry is a tool for measurement of functional status, other
measures of physical performance, such as a 30-second chair stand,
stair climb test, 4x10 meter fast-paced walk, timed up-and-go test,
and 6-minute walk test, may show some performance abilities of
older persons.5 Quality of life tools that also consider functional
ability, such as the Katz Index of Independence in Activities of Daily
Living, Lawton Instrumental Activities of Daily Living, Karnofsky
Performance Scale Index, and Eastern Cooperative Oncology Group
Performance status tool (ECOG), may provide supplemental
information of performance status of an individual.5 Validated nutrition
assessment tools that include functional status measures are
Subjective Global Assessment (SGA),6 Dialysis Malnutrition Score
(DMS),7,8 and Patient-Generated Subjective Global Assessment (PG-
SGA).9
Techniques for Using a Handgrip Dynamometer:

1. Have the patient sit upright, shoulders supported with the back of a
chair; or sit on the edge of the bed, with feet touching the floor,
back not hunched.
2. Testing should be performed using the dominant hand only or both
hands.
3. Have the patient relax his/her arm, elbow bent at 90 degrees.
4. The wrist should be in a neutral position.
5. Give the patient the dynamometer to hold, with their fingers

wrapped around the handle (the middle finger should be at a 90-
degree angle when gripped loosely).
6. During the test, support the patient’s forearm, or support the

dynamometer at the base.
7. Instruct and verbally encourage the patient to squeeze as hard as

possible until the needle on the dynamometer gauge is no longer
able to move. Record the result.
8. Repeat step 7 three times, then calculate the average score.

Compare this result to the manufacturer’s chart that accompanies
the dynamometer.
CORRECT
INCORRECT
References
1. Puthucheary Z, Montgomery H, Moxham J, Harridge S, Hart N. Structure to function: muscle
failure in critically ill patients. J Physiol. 2010;588(23):4641–4648.
2. Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter
Enteral Nutr. 2012;36(3):267-274.
recommended for the identification and documentation of adult malnutrition (undernutrition).
J Acad Nutr Diet. 2012;112(5):730-8.
4. Mueller C, McClave S, Kuhn JM. The A.S.P.E.N. Adult Nutrition Support Core Curriculum.
Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2012.
5. Russell MK. Functional Assessment of Nutrition Status. Nutr Clin Pract. 2015;30(2):211-
218.
7. Zadeh K, Kleiner M, Dunne E, et al. A modified quantitative subjective global assessment of

nutrition for dialysis patients. Nephrol Dial Transplant. 1999;14:1732-1738.
8. Steiber AL., Kalantar-Zadeh K, Secker D, et al. Subjective global assessment in chronic

kidney disease: A review. J Ren Nutr. 2004;14 (4):191-200.
9. Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment
(PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nut.
2002;56:779–785.
07
ASSESSMENT
OF MICRONUTRIENT STATUS
OVERVIEW
Though not included as one of the Academy-ASPEN
characteristics to diagnose malnutrition, micronutrient
deficiencies can provide supporting evidence for the
malnutrition diagnosis.1 Determining micronutrient deficiencies or
excesses, and detecting clues to macronutrient deficiency by physical
exam, further provides insight into nutrient ingestion, digestion,
absorption, and metabolism. Micronutrient deficiencies and excesses
may be readily seen in the skin, nails, hair, eyes, and orofacial area.
Skin
Skin, the largest organ of the human body, accounts for 15% of total
body weight and can often reveal vitamin and mineral deficiencies.2
Micronutrient abnormalities may appear rapidly due to skin cell

turnover every 10 to 30 days.3,4
PHYSICAL ASSESSMENT MICRONUTRIENT CHART: SKIN2-4,a

Physical Sign
Petechiae (small hemorrhagic spots on skin)
Possible Nutrient Finding

Vitamin K and/or C deficiency
Possible Nonnutrient Causes

Hematologic disorder, liver disease, anticoagulant overdose
Physical Sign
Dermatitis (swollen, reddened skin that may blister or ooze)

Zinc and/or essential fatty acid deficiency

Dermatitis, allergic or medication rashes, psoriasis
Physical Sign
Pellagrous dermatosis (hyperpigmentation of areas exposed to
sunlight/trauma)

Niacin and/or tryptophan deficiency

Burns, Addison’s disease, psoriasis
Physical Sign
Flaky paint dermatitis (bilateral “peeling paint” looking skin of
areas usually not exposed to sunlight)

Protein-calorie deficiency

Environmental factors
Physical Sign
Xerosis (dry scaly, flaky skin)

Dehydration, essential fatty acid, and/or vitamin A deficiency

Environmental and/or hygiene factors, aging
Physical Sign
Poor pallor (pale skin color)

Iron, folate, and/or Vitamin B12 deficiency

Low volume, low perfusion states
Physical Sign
Nonhealing wounds

Zinc, ascorbic acid, and/or protein deficiency

Cellulitis
a
This chart is not intended to be a complete list of nutritional or nonnutrition causes for
presenting physical signs and symptoms. Adapted with permission from material from Jean
Rindal, BS, RN, MA, ANP and Kathy A. Hammond, MS, RD, LD, CNSD, RN from the Nutrition-
Focused Physical Assessment Skills for Dietitians Study Guide, Dietitians in Nutrition Support,
American Dietetic Association, 2000.
TIPS
Skin integrity and elasticity are altered by sun/ultraviolet light,
age, and hydration.2
Allergies and medications may cause rashes; nutritional
abnormalities may cause pigment changes and rashes.3,4
Nails
Nail growth is determined by the matrix cells with cell turnover varying
by digit location or by hereditary circumstances. On average,
thumbnail growth is 0.10-0.12 mm per day. Nails changes can be due
to nutritional deficiencies, as well as systemic diseases. Keratin, the
fibrous protein of which the nail is composed, should be firmly
adhered to the nail bed, feel smooth, and appear uniformly thick and
symmetrical.5 Healthy nails are translucent with a pink hue, flat or
slightly convex, and have a base angle equal to 160 degrees. Several
nail nutrient findings are depicted next.
PHYSICAL ASSESSMENT MICRONUTRIENT CHART: NAILS2-5,a
Physical Sign
Koilonychia (spoon shaped nails)
Iron deficiency, with or without anemia

Hereditary, infection, diabetes, hypothyroidism, acromegaly,
hematologic conditions, trauma, carpal tunnel syndrome
Physical Sign
Beau’s/transverse line (horizontal grooves)

Protein inadequacy, hypercalcemia

Trauma, coronary occlusion, skin disease, transient illness
Physical Sign
Poor blanching of nails (pale nail bed)

Vitamin A and vitamin C deficiency

Poor circulation
Physical Sign
Splinter hemorrhages

Scurvy or hemochromatosis

Septicemia, trauma, hemodialysis
Physical Sign
Poor nail plate health

Selenium deficiency

Trauma, environmental
Physical Sign
Flaky nails

Hypomagnesaemia

Trauma, environmental
Physical Sign
Clubbing (nail plate exceeding 180 degrees)

None

Respiratory disorder, cardiovascular disease, cirrhosis, colitis
a
TIPS
To assess capillary refill, gently squeeze the nail between the
thumb and forefinger to palpate; if bleeding occurs, may
indicate general malnutrition.
Lackluster or dull appearance to nail plate may indicate protein
deficiency; but may be indicative of infection or systemic lupus
erythematous.
Hair
Hair change and growth (0.3 mm growth per day) is similar to rapid
nail cell turnover and the skin’s ability to reflect changes in
micronutrient status. Healthy hair is shiny, smooth, resilient, and not
easily plucked.2 Poor quality of hair can be associated with protein,
zinc, essential fatty acid, and biotin deficiencies.1 Iron deficiency has
resulted in stunted hair growth.6
PHYSICAL ASSESSMENT MICRONUTRIENT CHART: HAIR2-4,6,a
Physical Sign
Alopecia (hair thinning or loss)

Protein, zinc, and/or biotin deficiency diffuse loss (including eye
brows): essential fatty acids or selenium deficiency

Male pattern baldness, hypopituitarism, hypothyroidism, cancer
treatment, chemical alteration, infection, psoriasis, Cushing
disease, medication
Physical Sign
Lightened hair color

Copper, selenium, and/or protein deficiency

Chemical alteration
Physical Sign
Corkscrew hair (located on arms)

Copper deficiency follicular hyperkeratosis from scurvy in the
elderly10

Chemical alteration
a
TIPS
Lackluster or dull hair may indicate iron, protein, and/or zinc
deficiency; consider chemical treatment. Ask the patient if their
hair has been colored or altered.
Palpate hair to determine if hair is resilient and not easily
plucked.
Orofacial
Examination of the eyes, face, lips, and oral cavity may reveal
micronutrient deficiencies and can correlate with findings of the skin,
nails, hair, and diet history. For example, vitamin A deficiency may
manifest as night blindness and may also present as Bitot’s spots on
the eye and keratomalacia.3 The Academy of Nutrition and Dietetics
supports the collaboration between dietetic and dental professionals
for disease prevention and nutrition and dental intervention of the oral
cavity.7
PHYSICAL ASSESSMENT MICRONUTRIENT CHART:

OROFACIAL1-4,7,a
Physical Sign
Nasolabial seborrhea (scaling around nostrils)

Vitamin B2, B3, and/or B6 deficiency

Tuberous sclerosis
Physical Sign
Bitot’s spot (gray spongy spot on white of the eye)

Vitamin A deficiency

Pinguecula (elderly), Gaucher disease (hereditary), pterygium
Physical Sign
Keratomalacia (hazy cornea)

Vitamin A deficiency

Hyperthyroidism
Physical Sign
Pale conjunctivae

Iron, folate, and/or Vitamin B12 deficiency

Low cardiac-output states
Physical Sign
Cheilosis

Vitamins B2, B3, B6, and/or iron deficiency

Environment, herpes
Physical Sign
Angular stomatitis (bilateral cracks and redness of lips)

Vitamin B2, B3, B6, and/or iron deficiency

Irritation from ill-fitting dentures, herpes, chapping from harsh
climate, infectious disease
Physical Sign
Spongy, bloody gums

Vitamin C deficiency

Gingivitis (due to poor hygiene, malocclusion, dental caries),
amyloidosis, acute myeloid leukemia, drugs, periodontal disease
Physical Sign
Mouth lesions

Zinc deficiency

Trauma, gra-versus-host disease, cancer treatment
Physical Sign
Dental caries

Excessive sugar intake

Eating disorders, radiation, poor hygiene
Physical Sign
Pale gum color

Iron deficiency

Low flow state
Physical Sign
Glossitis (inflammation of tongue, magenta in color)

Vitamin B2, B3, B6, B12, folate, and/or iron deficiency (severe)
Crohn’s disease, uremia, infection, malignancy, anticancer therapy,
trauma
Physical Sign
Enlarged parotid (bilateral)

Protein inadequacy

Mumps, portal cirrhosis, Sjogren syndrome (usually females),
allergic or inflammatory process, neoplasm, sarcoidosis,
sialolithiasis, bulimia
Physical Sign
Enlarged thyroid

Iodine deficiency

None
a
TIPS
EYES:
Probe patient and ask if they have difficulty seeing and/or
abnormal eye dryness that may indicate a vitamin A deficiency
(eye dryness may also be from general environment irritation).
Direct patient to look side to side to see entire eye.
ORAL CAVITY:
Direct patient to move tongue from side to side and lift tongue.
References
1. Hammond KA. The nutritional dimension of physical assessment. Medical Nutrition in
Dietetics. 1999; 15:411-419.
2. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination, 6th
ed. St. Louis, MO: Elsevier; 2006:169-229.
3. Hammond K. History and physical examination. In Matarese LE, Gottschlich MM, ed.
Contemporary Nutrition Support Practice, 2nd ed. A Clinical Guide. St. Louis, Missouri:
Elsevier Science; 2002:14-25.
4. Morrison SG. Clinical Nutrition Physical Examination. Support Line. 1997; 19:16-18.
5. Cashman MW. Sloan SB. Nutrition and nail disease. Clin Dermatol. 2010; 28:420-425.
6. Goldberg LJ, Lenzy Y. Nutrition and hair. Clin Dermatol. 2010; 28:412-419.
7. American Dietetic Association. Position of the American Dietetic Association: Oral health
and nutrition. J Am Diet Assoc. 2003; 103:615-625.
08
APPENDIX:
NUTRITION-FOCUSED PHYSICAL EXAM
CHECKLIST
NUTRITION-FOCUSED PHYSICAL EXAM CHECKLIST
Check if
Region Location Task
Performed
Throughout the entire examination, the RD
observes the skin for the following:
Skin Dermatitis, rashes, petechiae, ecchymosis,
scaliness, dryness, presence of pressure
ulcers, poor wound healing, poor turgor
Touch and observe for the following:
Hair Thinness, dullness, dryness, brittleness, patchy
growth, and easily pluckable
Standing directly in front of patient, palpate
*Temple temporalis muscles. Check for fullness and
firmness. Observe for depression, hollowing.
Have patient open mouth and shine penlight into
oral cavity. Next, have patient stick out tongue.
Observe:
Mouth Mucosa: pallor, dryness, decreased salivary
flow, ulcerations (mucositis)
Tongue: magenta or beefy red color; smooth,
Head slick appearance (glossitis)
Teeth Observe for tooth decay, missing teeth
Observe for sponginess, bleeding; swollen, red,
Gums
receding gums
Observe for bilateral cracks at corners of mouth,
Lips
redness (angular stomatitis/cheilosis).
Orbital pads: While standing directly in front of
patient, gently palpate area below eyes. Observe
for darkness, hollowness, and/or loose skin.
*Eyes
Observe for cracked or reddened corners of
eyes, foamy (Bitot’s Spots) areas on sclera; dull,
dry, or rough sclera; dull, milky, opaque cornea.
Upper Have patient assume upright posture and gently
Body palpate pectoralis muscles below/along clavicles
Chest
for fullness and firmness. Observe for
prominence of clavicles.
Palpate deltoid muscles for fullness and
*Shoulders
firmness. Observe for squaring of shoulders.
Have patient sit forward and palpate trapezius
and/or latissimus dorsi muscles for fullness and
Back
firmness. Observe for prominence of scapula,
spine, and ribs.
Midaxillary Have patient lift arm, and palpate ribs along
line midaxillary line. Observe for prominence of ribs
and iliac crest.
Have patient bend arm at 90-degree angle with
upper arm perpendicular to body; if patient unable
to cooperate, bend elbow at 90 degrees and
place forearm horizontally across body if
*Triceps
possible; grasp upper arm midway between
Skinfold
shoulder and elbow with palm and fingers and
gradually pull skin away from arm with fingers
while wiggling slightly to separate fat from
muscle.
Have patient make “OK” sign with thumb and first
finger and while palpating interosseous muscle
between thumb and first finger and the
interosseous muscles between remaining
fingers. Check for fullness and firmness.
*Hands Observe for depression.
Observe fingernails for missing, misshapen
(spoon shaped), splintered, transverse ridging,
discoloration, dullness, lackluster appearance,
mottling.
Palpate for fullness and firmness. Observe for
*Thighs roundness/fullness of muscle and prominence of
patella.
Have patient bend knees at 90-degree angle if
possible. Grasp calves with palm and fingers to
*Calves
Lower determine fullness and firmness. Observe for
roundness.
Body
Observe for swelling of feet. Note any asymmetry
between left and right. Press top of each foot with
*Lower thumb or finger with moderate pressure for
Legs/Feet several seconds, release, and observe for depth
of depression and refill time. Note any difference
in left versus right. Repeat on lower legs.
*Bilateral examination should be performed.

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ABOUT ASPEN

The American Society for Parenteral and Enteral Nutrition (ASPEN) is

ASPEN’s mission is to improve patient care by advancing the

ABOUT THE CLEVELAND CLINIC

NOTE: This publication is designed to provide accurate

This publication does not constitute medical or professional advice,

Copyright © 2016. American Society for Parenteral and Enteral

ISBN 978-1-889622-29-3 Print edition

ISBN 978-1-889622-30-9 Ebook edition

Printed in the United States of America.

Marianne Galang, RD, LD, CSO

Andrea Jevenn, RD, LD, CNSC

Cassandra Pogatschnik, RD, LD, CNSC

With the release of the Consensus Statement the CHN embarked

Based on our experiences and training scores of dietitians on how

We especially would like to express our gratitude to ASPEN, who

CINDY HAMILTON, MS, RD, LD, FAND

02 Preparation for the Physical Exam

04 Physical Exam of Subcutaneous Muscle and Fat Stores

05 Assessment of Fluid Status: Accumulation and Dehydration

06 Examination of Functional Status

07 Assessment of Micronutrient Status

08 Appendix: Nutrition-Focused Physical Exam Checklist

Performing a nutrition-focused physical exam (NFPE) is a necessary

When determining patient nutrition status, the NFPE has not

Anthropometric data: This data provides weight and weight history,

Laboratory data: Review laboratory data for indications of

Dietary data: Nutritional intake from all sources (oral, enteral,

Functional status, as determined by strength and physical

Assessment and Interview Techniques and Tips

The goals when first approaching a patient include the following:

Introduce and explain the reason for your visit

Gain the patient’s consent to participate in the interview and

Interview questions should not be leading, but rather be open and

Are you eating less than half of your normal amount?

Are you skipping meals?

How long have you not been eating normally?

Does your infusion of enteral/parenteral feedings meet the daily

Feedback is important and information gathering is most helpful

Prior to conducting the physical exam, explain the purpose of the

Avoid terminology that may add to emotional distress. Refrain from

Exam Techniques and Tips

Physical exam techniques include inspection, palpation, percussion,

Perform the exam at the initial visit and repeat during

1. Start with a general visual survey:

b. Is there presence of edema/ascites that may have skewed the

c. Are there notable micronutrient deficiencies found on the skin,

b. Move blankets, clothing, gowns, and compression stockings to

d. Continued communication with the patient during the physical

Exam Techniques Using Inspection/Palpation

b. Palpation: assesses the quality and severity of edema

b. Palpation: examine for bulk and tone of muscle, adequacy of fat

3. Skin exam technique and possible findings

b. Palpate for texture and temperature

4. Nail exam technique and possible findings

5. Hair exam and possible findings

6. Head/orofacial exam and possible findings

b. Nose: inspect for color, texture, and discharge