Putting the Nutrition-Focused Physical Assessment Into Practice in Long-Term Care
Affiliations: 1Wellspring Healthcare, Greensboro, NC; 2Friedrich Nutrition Counseling, Salisbury, NC
Abstract: The nutrition-focused physical assessment (NFPA) has been part of the dietetics didactic curriculum for more than a decade; however, using NFPA techniques to improve the comprehensive nutrition assessment step of the Nutrition Care Process (ie, a systematic approach to providing high-quality nutrition care) has been limited for a variety of reasons, including the perception that macronutrient and micronutrient deficiencies are rare in developed countries. Studies addressing the prevalence and incidence of malnutrition have provided a compendium of inconclusive findings, partially because of a lack of consensus on the criteria needed to diagnose malnutrition. Nevertheless, numerous studies have reported vitamin and/or mineral deficiencies in undernourished populations, including older adults, due to suboptimal intake of nutrients and/or impaired nutrient absorption and utilization. In this article, the author describes NFPA techniques and highlights how they can be used to identify characteristics of malnutrition, micronutrient deficiencies, and other nutrition problems among older adults living in long-term care facilities.
Key words: Comprehensive nutrition assessment, malnutrition, Nutrition Care Process, nutrient deficiencies, nutrition diagnoses, nutrition-focused physical assessment.
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Malnutrition is a complex syndrome that develops following two primary trajectories. It can occur when the individual does not consume sufficient amounts of micronutrients (ie, vitamins, minerals, phytochemicals) and macronutrients (ie, protein, carbohydrates, fat, water) required to maintain organ function and healthy tissues. This type of malnutrition can occur from prolonged undernutrition or overnutrition. In contrast, inflammation-related malnutrition develops as a consequence of injury, surgery, or disease states that trigger inflammatory mediators that contribute to increased metabolic rate and impaired nutrient utilization.1-3 Research studies attempting to quantify the prevalence and incidence of malnutrition and specific nutrient deficiencies have provided inconclusive findings. Historically, the diagnosis of malnutrition has been loosely quantified using an array of criteria, including anthropometric benchmarks, biochemical test results, and physical assessment findings.1-15 The Agency for Healthcare Research and Quality identified malnutrition, including vitamin and mineral deficiencies, as one of the common syndromes of older adults associated with increased risk for institutionalization and mortality that may be impacted by primary and secondary prevention measures.16 Moreover, vitamin and/or mineral deficiencies have been reported in undernourished elderly persons2,16 and individuals who have undergone gastrointestinal surgeries that minimize nutrient absorption (eg, gastric bypass surgery).17
Registered dietitians (RDs) and registered dietitian nutritionists (RDNs) are vital members of the healthcare team because they are trained to identify physical characteristics that may impact nutrient intake, reflect suboptimal nutrient intake, or indicate excessive nutrient intake, all of which can lead to a variety of medical problems.18 In 2012, the International Guideline Committee working with the American Society for Parenteral and Enteral Nutrition, the European Society for Parenteral and Enteral Nutrition Congresses, and the Malnutrition Task Force from the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) published a standardized set of diagnostic characteristics to be used to identify and document adult malnutrition in routine clinical practice.19 Incorporating the characteristics of malnutrition in clinical practice requires nutrition-focused physical assessments (NFPAs) to evaluate physical changes, including shifts in body composition, loss of subcutaneous fat, and muscle wasting.18 Subsequently, when RDs/RDNs use NFPA techniques, they can have a greater positive impact on care by more readily identifying nutritional issues that are impairing health and that might otherwise remain unrecognized. In the long-term care setting, residents’ complex clinical pictures can make it especially challenging to identify the cause(s) of their health problems, whether the etiology is medical or nutritional; thus, using more comprehensive assessment tools is particularly beneficial in this setting. Because NFPA techniques facilitate more comprehensive assessments, they enable problems to be more readily identified and efficient and effective care to be provided, improving outcomes and quality of life. What follows is an overview of the NFPA and how it can be used in long-term care settings to screen for malnutrition and other nutrition problems.
How the NFPA Fits Into the Nutrition Care Process
The Nutrition Care Process (NCP) is a systematic approach to providing high-quality nutrition care, and it was published as part of the Nutrition Care Model in 2003.20 The NCP provides RDs/RDNs with the following four-step process to individualize care: (1) conduct a comprehensive nutrition assessment; (2) make a nutrition diagnosis; (3) decide on a nutrition intervention; and (4) monitor and evaluate the resident to see if the intervention is working. The NFPA is part of step one—the comprehensive nutrition assessment—and it enables the RD/RDN to identify physical findings that may be associated with nutrition-related medical problems (Figure). The International Dietetics and Nutrition Terminology Reference Manual defines nutrition-related physical findings as “findings from an evaluation of body systems, muscle and subcutaneous fat wasting, oral health, suck, swallow/breathe ability, appetite, and affect.”21 As such, the NFPA is a pivotal step in the nutrition assessment process; however, it does not replace the comprehensive medical history and physical examination performed by physicians, physician extenders, and nursing professionals. Instead, it is an additional hands-on assessment tool that RDs/RDNs can use to bring medicine, nutritional sciences, food science, and technology together to address suspected nutrition-related health problems.
NFPA techniques are a vital component of the comprehensive nutrition assessment because they enable all data points to be considered before identifying potential nutrition diagnoses, which are different from medical diagnoses. The Academy of Nutrition and Dietetics defines nutrition diagnoses as nutrition problems that can be resolved or improved independently through treatment/nutrition intervention by a food and nutrition professional. Because residents enter long-term care settings with a myriad of diseases and conditions that impact food intake, they may experience the health consequences of long-term impaired nutrient utilization. By using NFPA techniques, the RD/RDN will enhance the comprehensive nutrition assessment process, as these techniques can help identify and support nutrition diagnoses and provide objective markers to measure health outcomes following interventions, making them an especially useful tool in the long-term care setting.18
How NFPA Techniques Are Incorporated Into the Comprehensive Nutrition Assessment
To identify potential nutrition-related problems, dietetic professionals review data from residents’ medical charts, which are gathered by the medical team during the physical examination and upon comprehensive medical history taking. They may also review other supportive data sources, including nursing notes, vital signs documentation, rehabilitation therapy assessments and progress notes, food and water intake data, anthropometric measurements, medication lists, laboratory test results, measures of hydration status, and family input, depending on what is available. The pattern of data points provides a template for the RD/RDN to use to identify physical changes indicative of declining nutritional status or nutrient toxicities.
When using NFPA techniques, the process begins with a general survey of the individual’s appearance. The RD/RDN observes the individual’s apparent state of health as it relates to dietary intake and notes the individual’s state of physical health, level of frailty or fitness, emotional status, breathing, ability to communicate, posture, physical limitations that might impair the ability to eat without assistance (eg, limited use of hands, inability to sit upright), and appearance of the skin (eg, pallor, yellowing), face (eg, muscle wasting), mouth (eg, sores, dryness), teeth (eg, gingival bleeding, decay, edentulism), hair (eg, loss, thinning), and nails (eg, spooning, discoloration). The RD/RDN then compares his or her observations of the resident’s general appearance with the nutrition-related concerns identified from a review of the patient’s comprehensive medical history, physical examination findings, and a review of other available clinical data, keeping in mind that not all first impressions reflect risk factors for nutrition-related problems. It is important for the RD/RDN to differentiate the usual from the abnormal as he or she considers the probable process underlying the resident’s nutrition diagnosis and its subsequent implications.
Next, the RD/RDN notes the patient’s body habitus, calculates his or her body mass index (BMI), notes changes in weight, and compares these assessments. An important consideration during this process is whether the individual’s reported appetite and BMI are consistent with the visual assessment of the individual’s body habitus. For overweight and obese residents, the RD/RDN looks for physical signs that are commonly associated with poorly managed chronic diseases (eg, increased pedal edema and shortness of breath with worsening congestive heart failure as a sign of excessive sodium intake; abnormal lab values and unplanned weight gain as a sign of poorly managed type 2 diabetes).
The next step requires the RD/RDN to initiate the hands-on assessment. Before proceeding with this step, the RD/RDN should explain to the resident and his or her family what this assessment entails and ask whether the resident/family grants permission for the assessment to be conducted. Throughout the assessment, the RD/RDN looks for signs of declining nutritional status, including micronutrient and macronutrient deficiencies, characteristics of malnutrition,19 and signs and symptoms of macronutrient and micronutrient toxicities. Undernourished and malnourished individuals may present with muscle wasting, loss of subcutaneous fat, and fluid accumulation. Loss of muscle mass can be identified by lightly palpating muscles in the face (temporalis and masseter), hands (interosseous and thenar), upper body (pectoralis, deltoids, scapular, trapezius, triceps, and biceps), and lower body (quadriceps and gastrocnemius). Common sites of subcutaneous fat loss include the face (orbital and buccal regions), upper arm (fat overlying triceps), and abdomen (fat overlying the ribs). Fluid accumulation associated with malnutrition may occur in the extremities or present as ascites.
The RD/RDN evaluates for signs of dehydration and vitamin and/or mineral deficiencies by assessing the oral cavity and skin. While assessing the oral cavity, the RD/RDN should note the strength of the muscles of mastication and evaluate the cranial nerves that control the senses of smell and taste as well as the ability to chew, control the tongue, and swallow.18 Signs of vitamin and/or mineral deficiencies may also be observed in the nails (eg, discolored, brittle) and by self-reported optical changes (eg, night vision problems, unexplained chronic dry eye), nervous system changes (eg, tingling in extremities), and/or cognitive changes (ie, self-reported or observations by staff or family). Macronutrient deficiencies (eg, protein, carbohydrate, fat, water) may be observed by changes in the tongue, skin, degree of wound healing, and frequency of infections.18 When abnormal findings are identified, the RD/RDN corroborates them with the resident’s medical history, physical examination findings, and any other available data, such as vital signs, laboratory findings, color of urine, capillary refill test results, and water intake data.18 In some cases, additional data might be needed to corroborate observations. In such cases, the RD/RDN should collaborate with the resident’s interdisciplinary healthcare team to determine if all pertinent data, which includes any of the resident’s concerns about food and fitness and verbal or nonverbal cues of discomfort, have been considered when observing for nutrition diagnoses. What follows is an illustrative case that shows how these NFPA techniques are applied in practice.
An Illustrative Case
A female nursing home resident with a medical history of gastric bypass surgery, recent history of falls, and anemia reports reduced appetite, weakness, and paresthesias. She is 66 inches tall, weighs 180 lb, and has a BMI of 29, suggesting she is overweight. She has experienced a 5% weight loss (7.5 lb) in 90 days. She takes iron supplements, but her hemoglobin and hematocrit levels remain low and her mean corpuscular volume is within the high normal range. The resident’s dietary intake appears to be adequate for key nutrients, and she does not take any vitamin or protein supplements.
Using NFPA techniques, an examination of the resident reveals yellow skin tone, along with a beefy red tongue upon inspection of her oral cavity. The resident also notes that her tongue is sore. These findings are consistent with vitamin B12 deficiency. Based on the data points used in the comprehensive nutrition assessment, the resident’s RD/RDN makes a nutrition diagnosis of impaired nutrient utilization related to gastric bypass surgery as evidenced by abnormal laboratory values and NFPA findings of a sore, beefy red tongue and pale yellow skin tone.20 Additional laboratory tests are needed to confirm the diagnosis of a vitamin B12 deficiency, and the RD/RDN works collaboratively with the resident’s physician and physician extenders to identify vitamin supplements designed to meet the vitamin B12 requirements of an adult who has undergone gastric bypass surgery. Additional nutrition assessments, including NFPA techniques, are used to monitor the effectiveness of the nutrition intervention and serve to measure the quality of care the resident is receiving at her long-term care facility.
Conclusion
NFPA is a vital tool for RDs/RDNs to incorporate into the nutrition assessment process, particularly in long-term care settings, where residents have complex clinical pictures. The NFPA provides these healthcare professionals with objective tools to make more accurate nutrition diagnoses, demonstrating value to the medical team by enabling best practices to be applied to address these individuals’ nutrient needs and improve their overall health and quality of life. In the long-term care setting, NFPA can be an essential component of resident-centered care, facilitating individualized nutrition interventions to promote positive outcomes.
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Disclosures: The author has received speaker honoraria from Abbott Nutrition and is a consultant for ProSynthesis Laboratories. The series editor has received speaker honoraria from Abbott Nutrition and has served as a consultant or paid advisory member for Abbott Nutrition.
Address correspondence to: Mary Litchford, PhD, RD, LDN, CASE Software & Books, 5601 Forest Manor Drive, Greensboro, NC 27410; mdlphd@yahoo.com
Article series summary: This is the fourth article in a continuing series on nutrition issues in long-term care. The first article in the series was published in the May 2013 issue and discussed evidence-based organizational strategies to prevent weight loss in frail elders. The article can be accessed at www.annalsoflongtermcare.com/article/using-evidence-based-organizational-strategies-prevent-weight-loss-frail-elders. The second article was published in the August 2013 issue and discussed management of obesity in long-term care. The article can be accessed at www.annalsoflongtermcare.com/article/managing-obesity-long-term-care. The third article was published in the October 2013 issue and discussed end-of-life nutrition. The article can be accessed at www.annalsoflongtermcare.com/content/nutrition-end-life-tube-feeding-solution.
