NFPE in Action

Nutrition Focused Physical Exams (NFPE) are an up-and-coming set of skills that clinical dietitians can use to identify and help diagnose malnutrition. The exam is a head-to-toe assessment of a patient's physical appearance, focusing on fat and muscle presence and signs of deficiency. NFPE is not widely used in hospitals yet, but I was lucky enough to spend some of my secondary clinical rotation at Calvert Memorial Hospital (CMH) in Prince Frederick, MD where their RDs implement NFPE during each patient's initial assessment.

Image courtesy of Salud Today

The most intimidating part of NFPE, for me, was simply the idea of physically examining a patient. On my first day at CMH, I had that same feeling you get before jumping into a pool of cold water. Once I examined my first patient, the feeling of intimidation was gone. So, for anyone who is curious about using NFPE, here are three things I think are essential for all beginners to know:

1. It will be awkward at first - No matter how much you read about the process, you will probably fumble around and you will likely forget a step. Most patients will have no idea if it's your first or 50th time unless you make it apparent. Try practicing on fellow students/colleagues to become acclimated with where to feel and what "normal" feels like. In my experience, I found that the exam seemed less awkward when I maintained conversation while examining the patient.
2. It's not black and white - Unlike diagnostic tests where the results are typically "positive" or "negative,” these results are measured on a broad scale ranging from normal to severe with every step in between. Try to gain as much background information from the medical chart before going to see the patient to get an impression on what to expect. If a patient has a documented 10% weight loss in two months, you can probably expect to find evidence of severe fat/muscle wasting. Then look and feel to see if the physical exam matches your expectation. As example, I had patient with the weight loss described above and, through NFPE, I found that the patient had severe wasting in the temporalis and clavicle/acromion, but all other examined areas were found to have moderate wasting at most.
3. Include the patient - Just like with most traditional assessments, you'll want to ask the patient about any weight changes and their eating habits. But also ask questions about changes they may have noticed or if they're feeling weaker than normal. For some patients, what may seem like a mild-moderate indicator is normal for their body. While examining the patient, talk to them about what you find and briefly explain why. For example, in the patient I mentioned above I said “Your collar bone doesn’t have a lot of muscle to it--have you noticed it stick out more than normal?” The patient answered “yes,” and I responded that it could be because of the weight loss and encouraged her to eat more protein to help gain the muscle back.
   Although I think I still need much more hands-on practice, I am very glad I was able to have this experience. During my three days with the wonderful RDs of CMH, I was able to feel each degree of subcutaneous fat and muscle wasting. I strongly encourage all interns and current RDs to learn NFPE. NFPE is an excellent tool for RDs to help identify malnutrition, but it also allows patients to recognize the connection between how they eat and how that can affect their body.