Nutrition Exam Menu

The Client Provides Subjective and Objective Information and Feedback, Listen and Look for It!

Written by Adele Huls

The Client Provides Subjective and Objective Information and Feedback, Listen and Look for It

To help you get started with doing a Nutrition-focused Physical Exam and take full advantage of the time you have with your client, I would suggest that while you are observing for signs of lesions, visit with your client. The client is, after all, the focus of the nutrition-focused physical exam and the nutrition assessment! Your job is to obtain, verify and interpret data.

Ask things like:
How is your appetite?
Does this sore on your tongue impact your ability to eat?
When did these sores on the corners of your lips first appear?
Tell me about your swollen legs
How did your broken hip happen?
What is the story behind your foot drop?
Tell me about the timeframe of your weight loss

The answers to these questions will, in many cases, give you access to subjective information (information reported to you) or “symptoms” that you would not have otherwise had.
Client subjective information can be invaluable in diagnoses and treatment. A client’s feelings are paramount in intervention acceptance and/or success. A client who “owns” his intervention can and will help the practitioner monitor and evaluate the intervention and make suggestions for new or additional interventions. So, involve the client whenever possible.

Subjective information is often AS important as objective information (or “signs” that are observed by you or others) when it comes to solving a nutritional deficiency mystery. All “evidence” is important in assigning the correct nutritional diagnosis(ses) and treatment.

NOW is the time to "try your eye" & "take a look" for nutrient-based lesions and unusual findings.
Like I have told students in Nutrition Assessment Labs at the University level, you need to Just Get Started and Do It! As you get started looking and studying you will become more and more adept at performing a nutrition-related physical exam. Remember you are looking for things that shouldn’t be there, for things that are missing that should be there, and for situations and abnormalities that can affect food intake. You are looking at the color of body parts as well as the surface area texture and moisture level vs dryness.

The best documentation is thorough documentation. You never know which piece of data will be the one that fits or matches the missing puzzle piece. Record everything unusual you see and “quotes” of subjective information the client reports to you.

A group setting is nice but not necessary. If you would feel more comfortable in skills acquisition in a workshop setting consider sponsoring one of our workshops in your area or check the calendar for a workshop being sponsored by another group that you can register for.

There are many resources out there to help you get started as well. A good medical dictionary with lesion pictures is invaluable. Eventually this web site will also be making available videos, DVDs, and a Guidebook. Look in your nutrition assessment and nutrition texts for lesion pictures too.