NFPE - Idaho Health Associates Part 1 Scollard July …...Etiology-Based Disease-Related...

6/27/18

NUTRITION-FOCUSED PHYSICAL EXAMINATION FOR ADULTS: PART 1

Registered Dietitian Nutritionists are interested and moving forward, yet there remains a wide range of personal comfort and skills in the bedside completion of a nutrition-focused physical examination (NFPE), which is one component of the Nutrition Care Process.

This presentation will address roadblocks to the performance of nutrition-focused physical assessment and provide examples and resources to assist the learner, encourage perseverance and support skill building.

These notes and references related to NFPE, are for educational purposes only. These notes do not constitute medical or professional advice and should not be taken as such. Use of this information is subject to the sole professional judgment of the health professional. These notes are not a substitute for exercise of judgment by the health professionals.

6/27/2018

© MySurgeryPlate LLC 2018 1

NUTRITION-FOCUSED PHYSICAL EXAMINATION FOR ADULTS: PART 1

OBJECTIVES

Utilize the power of the nutrition-focused physical examination both in telling the patients’ story and identification of the type

and degree of malnutrition as part of a complete nutritional assessment.

Apply simple techniques to use to increase skills in conducting a nutrition-focused physical examination within the professionals’

scope of practice.

Demonstrate how documentation of the nutrition-focused physical examination contributes to interdisciplinary patient

care and provides evidence for the nutrition diagnosis of disease-related malnutrition.

Interpret information contributed from the care team for the plan of care by being alert to opossible malnutrition.

6/27/2018


MODEL FOR LEARNING AND DEVELOPMENT

70:20:10

Lombardo and Eichinger expressed the rationale behind the 70:20:10 model this way in The Career Architect Development Planner.:

“Development generally begins with a realization of current or future need and the motivation to do something about it. This might come from feedback, a mistake, watching other people’s reactions, failing or not being up to a task – in other words, from experience. The odds are that development will be about 70% from on-the-job experiences, working on tasks and problems; about 20% from feedback and working around good and bad examples of the need, and 10% from courses and reading.”

Lombardo, Michael M; Eichinger, Robert W (1996). The Career Architect Development Planner (1st ed.).

Minneapolis: Lominger. p. iv. ISBN 0-9655712-1-1Accessed 3/12/2015

10% FORMAL

TRAINING

20% FEEDBACK &

COACHING

70% EXPERIENCE

6/27/2018


Etiology-Based Disease-Related Malnutrition

CLINICAL CHARACTERISTICS OF PROTEIN-ENERGY MALNUTRITION (Aspen/Academy Consensus 2012)

Nutrition Risk Screen

acute disease-related malnutrition

chronic disease-related

malnutrition

starvation or semi-starvation (social or

environmental circumstances)

Inflammation? yes? or no?

ENERGY INTAKE

WEIGHT LOSS

BODY FAT & MUSCLE MASS

FLUID ACCUMULATION

REDUCED GRIP

STRENGTH

Jensen GL. JPEN 2009;33:710

6/27/2018


Bedside Clinical Characteristics: Protein-calorie Malnutrition

Assessment Common Methods To Obtain Data:

Energy Intake Diet history, medical history, intake records, meal records, family/caregiver verbalization

Weight Loss within time frame Weight records, verbal reports by patient, caregivers, medical records, nutrition care records

Physical Findings: Body Fat and Muscle Mass

Nutrition-Focused Physical Assessment, historic records of same

Fluid Accumulation Observation, Physical assessment by MD, RN; Nutrition-focused physical assessment, other team records

Reduced Hand Grip Strength Dietitian functional assessment; (PT, OT more likely to perform for different reasons than nutrition)

Program Focus

Fat Stores Muscle Status Fluid Status Orbital fat pads Temples (temporalis muscle) Ankle edema Triceps skin fold Clavicles (pectoralis & deltoids) Sacral edema Fat overlying lower ribs Shoulders ( deltoids) Ascites Interosseous muscles Scapula (latissimus dorsi, trapezius,

deltoids)

Thigh (quadriceps) Calf (gastrocnemius)

Consensus & MDS 3.0 “Crosswalk”

Consensus Characteristic

MDS Section Common source of data

Energy Intake O: Special Treatments 05 h. Eating or Swallowing Weight Loss within time frame

K: Swallowing/Nutritional Status

K. 2 Height & Weight K. 3 Weight Loss

Physical Findings: Body Fat and Muscle Mass

K: Swallowing/Nutritional Status L. Oral/Dental M. Skin Conditions

K. 1 Oral exam L. 1 Dental M. All that apply

6/27/2018


Fluid Accumulation Reduced Hand Grip Strength

G. Functional Status

Suggested Approach on the Path to Skill:

1. Observe and listen to your patients! Eye level if possible.

2. Take some of the resources supplied; read, study. Pick one area or topic to start with. All of it at once is too much and will overwhelm. Plan your learning with one topic/step at a time.

3. Identify your target patient population. Research and study to determine common nutrient and energy deficiencies/excesses associated with that population and the manifestations of the deficiency (or excess), including medications that impact nutrition.

4. Target study using suggested references above, and other references on

the best techniques and methods to use for that targeted nutrient issue in your targeted population.

5. Start observations with patient body areas that are exposed, are

readily available to see and that you are comfortable talking about with the patient. Okay to do a little education along the way and ask questions during the observation. (hair, hands, nails, neck, back, exposed skin). Patients generally love the attention and care when someone takes the time with them.

6. Find a friend to practice. Practice introducing self, asking permission of patient, telling the patient in lay terms what you are doing. “May I look at your fingernails? Sometimes we can see how someone has been doing nutritionally by looking at fingernails.”

7. Do not need to write a long chart note about your observations. Descriptive phrases are very powerful when read in context of the entire nutritional assessment. Describe findings using language on the document “Parameters Useful in the Assessment of Nutritional Status.” Electronic health records have drop downs and click boxes to help.

8. Be sure to document the connection between physical and functional

observations/tests with the patient’s food intake-absorption-losses-

6/27/2018


increased requirements. Tie these messages together for patient education. Ie. Eating protein foods and helping to get strong, or heal a wound.

NFPE: Sight, Hearing, Touch and Smell.

Focus on Inspection and Palpation to detect signs of deficiency or excess.

Inspection – Observe your patient

- Describe the size, shape, color, position and symmetry of any abnormalities. - Odors, especially from the mouth (alcohol, dental disease or hygiene, acetone

(diabetes), ammonia or musty (liver), uremic breath (renal) - How patient moves, body build - Appearance of distress or illness - Color, skin rashes

Palpation – Touch, temperature, vibration

Light palpation for nutritional exam. Fingertips, gently applied over skin surface ½ to 1 cm.

- Moisture - Texture/thickness - Accumulation of fluid - Temperature

Inspection (sight)

Palpation (Touch)

Auscultation (Hearing)

Percussion (Touch/hearing)

6/27/2018


- Atrophy - Turgor/elasticity - Bulk, tone, swelling, symmetry

Technique

1. Visual observation 2. Head to toe or Hand to Head to Toe

Fluid: Inspection and palpation

- Edema - Severity of edema

Muscle:

- Inspection: symmetry, size, posture - Palpation: muscle bulk and tone, adequacy of fat stores, edema

Skin

- Inspect for color, pigmentation, rashes, textures, wounds - Palpate for texture and temperature

Nails

- Shape, color Hair

- Shine, pigmentation, texture, - Falling out

Head

- Eyes: color and abnormalities - Nose: color texture, discharge - Lips: cracks, lesions - Mouth: dental quality, lesions, erosions; tongue color, smoothness - Neck: palpate for swelling and symmetry

(adapted from McDonald and ASPEN NFPE handbook)

6/27/2018


From Nutrition411.com http://www.nutrition411.com/content/vitamin-and-mineral-deficiencies-physical-assessment Accessed 6/16/2018

Vitamin or Mineral PHYSICAL SIGNS OF DEFICIENCY

Vitamin A • Hair follicle blockage with a permanent “goose-bump” appearance

• Dry, rough skin • Small, grayish, foamy deposits on the

conjunctiva adjacent to the cornea • Drying of the eyes and mucous

membranes • Night blindness

Vitamin D • Rickets (children)

Vitamin K • Small hemorrhages in the skin or mucous membranes

Thiamine • Weight loss • Muscular wasting • Sometimes edema (wet beriberi) • Malaise • Mental confusion • Tense calf muscles • Distended neck veins • Jerky movement of eyes • Staggering gait and difficulty walking • Infants may develop cyanosis • Round, swollen (moon) face • Foot and wrist drop

Riboflavin • Tearing, burning, and itching of the eyes with fissuring in the corners of the eyes

• Soreness and burning of the lips, mouth, and tongue with fissuring and/or cracking of the lips and corners of the mouth

• Purple swollen tongue • Seborrhea of the skin in the nasolabial

folds, scrotum, or vulva • Capillary overgrowth around the corneas

Niacin • Dermatitis or skin eruptions • Dementia • Diarrhea • Tremors • Sore tongue • Skin that is exposed to sunlight will

develop cracks and a scaly form of dermatitis with pigmentation

• Anorexia • Indigestion

6/27/2018


• May also show signs of riboflavin deficiency

Vitamin B6 • Tongue inflammation • Inflammation of the lining of the mouth • Fissures in the corners of the mouth

Folate • Weakness, fatigue, and depression • Pallor • Dermatologic lesions

Vitamin B12 • Lemon-yellow tint to the skin and eyes • Smooth, red, thickened tongue

Vitamin C • Impaired wound healing • Edema • Swollen, bleeding, and/or retracted gums

or tooth loss; mottled teeth; enamel erosion

• Lethargy and fatigue • Skin lesions • Small red or purplish pinpoint

discolorations on the skin or mucous membranes (petechiae)

• Darkened skin around the hair follicles • Corkscrew hair or unemerged, coiled

hair Magnesium • Tremors, muscle spasms, and tetany

• Personality changes Iron

• Skin pallor • Pale conjuctivia • Fatigue • Thin, concave nails with raised edges

Zinc • Delayed wound healing • Hair loss • Skin lesions • Eye lesions • Nasolabial seborrhea • Decubitus ulcers

Copper • Hair and skin depigmentation

• Pallor Iodine • Goiter

Chromium • Corneal lesions

6/27/2018


Below are different approaches to consider for connections between a patient condition, food intake/absorption/loss/increased

requirements and nutrient deficiency.

Nutrition History Screen

Mechanism of Deficiency If History of… Suspect Deficiency of…

Inadequate intake Deficiency of all foods, ask about alcoholism, weight loss, poverty, dental disease, AIDS, taste changes

Calories, protein, thiamin, niacin, folate, pyridoxine, riboflavin

lack of fruits, vegetables, grain

Vitamin C, thiamin, niacin, folate, dietary fiber

meat, dairy products, eggs, Protein, vitamin B12 Food idiosyncrasies, allergy Lactose intolerance

Inadequate absorption

Drugs-antacids, anticonvulsants, cholestyramine, laxatives, neomycin, alcohol

Selected vitamins and minerals,

Malabsorption, diarrhea, weight loss, steatorrhea, AIDS

Vitamins A, D and K, calories protein, iron, calcium, magnesium zinc, B12

surgery such as gastrectomy, B12, iron

resection of small intestine B12 bile salts, if greater than 10 cm of distal ileum), all others (if jejunal),

Increased losses

Alcohol abuse Magnesium, zinc, phosphorus Blood loss Iron Diabetes poorly controlled Calories Diarrhea Protein, zinc, electrolytes Draining abscesses, wounds Protein Peritoneal or hemodialysis Protein, water soluble

vitamins, zinc Drugs (especially diuretics, laxatives)

Potassium, magnesium

Increased requirements Fever Calories Increased physiologic

demands (infancy, adolescence, pregnancy, lactation)

Various nutrients

Surgery, trauma, burns, infection

Calories, protein

(Excerpted from Alpers, et al; Manual of Nutritional Therapeutics 6th ed. Table 4-12, Pg. 66)

6/27/2018


Basic Types of Skin Lesions Erosion An erosion is loos of the superficial epidermis Ulcer An ulcer is an area of skin loss extending through the

epidermis into the dermis. This can result from the reduction of vascular nutrient supply to the skin

Crack A crack is a linear lesion or fissure in the skin, often extending to the dermis

Macule A macule is a localized area of color change without elevation or infiltration. Macules can be hypo-pigmented in vitiligo or

pigmented (freckles) Papule A papule is a solid elevation of skin less than 5 mm in

diameter, i.e., xanthomas. A nodule is similar but larger than 5 mm and can be edematous or solid.

Vesicle A vesicle is a small blister, less than 5 mm in diameter, consisting of clear fluid within or below the epidermis. A bulla

is similar but larger than 5 mm. Scale A scale is an accumulation of thickened keratin which flakes

off easily. Scales usually indicate inflammatory change. Crust A crust is the dried exudate of serum, pus, or blood on the skin

surface Excerpted from MacDonald

Resources for Further Learning

(Including open access on some articles as of this date)

NUTRITION-FOCUSED PHYSICAL EXAM VIDEO AND STUDY GUIDE DIETITIANS IN NUTRITION SUPPORT DIETETIC PRACTICE GROUP OF THE ACADEMY OF NUTRITION AND DIETETICS

https://www.dnsdpg.org/store.cfm Member and Non-Member pricing

The Minnesota Semi Starvation Experiment: Subject interview many years later. Listen to subject and observe body language, physical descriptions, and emotional and psychological impacts of starvation described. View this video to see key physical signs of starvation-related malnutrition. This will help become familiar with physical appearance of various parts of the body, the functional impact of muscle wasting and fat loss, as well as psychological and emotional impacts of starvation. (See reference below to purchase for better video quality.) http://www.epi.umn.edu/cvdepi/video/the-minnesota-semistarvation-experiment/

Order DVD or Video from: Mark Cole 970-491-5920, [email protected], Colorado State University, Academic Computing Network Services, Mailstop 1018, Fort Collins, CO 80523

NUTRITION FOCUSED PHYSICAL EXAM HANDS-ON TRAINING WORKSHOP--ACADEMY OF NUTRITION AND DIETETICS NUTRITION FOCUSED PHYSICAL EXAM POCKET GUIDE ACADEMY OF NUTRITION AND DIETETICS STORE BETH MORDARSKI RDN, LD AND JODI WOLFF, MS RDN LD

http://www.eatrightpro.org/resource/practice/professional-development/face-to-face-learning/nfpe-workshop http://www.eatrightstore.org/product/924b0333-dbf7-4cad-9fcf-a127005693e5

6/27/2018


Bates Pocket Guide to Physical Examination and History Taking 3rd Edition; Lynn S. Bickley, Lippincott

Reviews the process of physical exam in general.

Mosby’s Expert 10-minute Physical Examinations 2nd ed. Elsevier Mosby

Reviews key sequence of physical examination in simplified form

Nutrition Focused Physical Assessment: Making Clinical Connections; Mary D. Litchford PhD, RDN, Case Software and Books case study CD and book 2012

Reference www.casesoftware.com

Simulation: Physical Assessment. Patient Simulation: Putting Malnutrition Screening, Assessment, Diagnosis and Intervention into Practice. Program date October 2015 Certificate of Training in Adult Malnutrition

http://anhi.org/courses Online simulation program; need to register first. Free. Abbott Nutrition Institute http://anhi.org/malnutrition-ce

Nutrition-Focused Physical Exams, By Carrie Dennett, MPH, RDN, CD Today's Dietitian Vol. 18 No. 2 P. 36 February 2016 Issue

http://www.todaysdietitian.com/newarchives/0216p36.shtml

Nutrition 411: the Physical Assessment Revisited: Inclusion of the Nutrition-Focused Physical Exam Nancy Collins PhD RD LDN FAPWCA et al. Ostomy Wound Management, Vol. 56-Issue 11, November 2010

http://www.o-wm.com/content/physical-assessment-revisited-inclusion-nutrition-focused-physical-exam

Krause’s Food and Nutrition Care Process 13 ed. Mahan, Escott-Stump, Raymond, Pp 171, 172, 1050, 1075-78.

Pp 171, 172, 1050, 1075-78.

Mini-Nutrition Assessment (MNA) (this is a nutrition risk screen tool targeting age 65+) Video, free App, handouts, professional and patient generated forms.

http://www.mna-elderly.com Video

Nutrition Focused Physical Exam Pocket Guide 2nd Edition B. Mordarski and Jodi Wolff Academy of Nutrition and Dietetics Pediatric Nutrition Focused Physical Exam Pocket Guide B. Mordarski and Jodi Wolff

http://www.eatrightstore.org/product/924B0333-DBF7-4CAD-9FCF-A127005693E5 http://www.eatrightstore.org/product/09B7BD90-321F-45F4-854A-78658769E13C

PUTTING THE NUTRITION-FOCUSED PHYSICAL ASSESSMENT INTO PRACTICE IN LONG-TERM CARE, MARY LITCHFORD PHD, RD, LDN ANNALS OF LONG TERM CARE

http://www.annalsoflongtermcare.com/content/putting-nutrition-focused-physical-assessment-practice

Nursing example of oral physical exam https://www.youtube.com/watch?v=J0-CDjztEXw

A Pocket Guide to Physical Examination and Nutritional Assessment, Jane E McDonald MD, CCFP, 1994. Out of print, sometimes found on secondary market.*

Excellent and well-organized thought process.

Free videos physical assessments (not nutrition-specific)

http://www.learnerstv.com/Free-Medical-Video-lectures-ltv032-Page1.htm

Free, physical assessment (not nutrition-specific)

https://www.youtube.com/results?search_query=physical%20examination%20head%20to%20toe&sm=1

6/27/2018


Nutrition and Hair, Lynne J. Goldberg, MD, Yolanda Lenzy, MD, Clinics in Dermatology (2010) 28, 412–419

Nutrition and Nail Disease, Michael W. Cashman, BA, Steven Brett Sloan, MD, Clinics in Dermatology (2010) 28, 420–425

The Nutritional Dimension of Physical Assessment Kathy A. Hammond, Nutrition 15:411– 419, 1999

Hand Grip Dynamometer Jamar Plus® – Digital Hydraulic Hand Dynamometer www.performancehealth.com Methodology: American Society of Hand Therapists Dietetic Practice Groups of the Academy of Nutrition and Dietetics have the Grip Strength Toolkit training program as a free member benefit (CNM, DNS, HA, MNP, NDEP, ON)

Contact your organization’s Occupational Therapy or Rehabilitation Services equipment buyer, as may have contract pricing. Nutrition application is different than OT’s. Note different equipment types for adults and children.

Consensus Statement of the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) Jane V. White, PhD, RD, FADA; Peggi Guenter, PhD, RN; Gordon Jensen, MD, PhD, FASPEN; Ainsley Malone, MS, RD, CNSC; Marsha Schofield, MS, RD; the Academy Malnutrition Work Group; the A.S.P.E.N. Malnutrition Task Force; and the A.S.P.E.N. Board of Directors

http://malnutrition.andjrnl.org/Content/articles/1-Consensus_Statement.pdf

Nutrition-focused Physical Examination: Skin, Nails, Hair, Eyes, and Oral Cavity

Dietitians in Nutrition Support, Support Line Volume 33, No. 2 page 7-13

Scope of Practice and Legal Issues in Nutrition-focused Physical Examination Marsha R. Stieber, MSA, RD, CNSC

Dietitians in Nutrition Support, Support Line April 2011, page 2-6

Oral Manifestations of Nutrient Deficiency; Riva Tougher-Decker, MS PhD.

The Mt Sinai Journal of Medicine, October/November 1998 pg 355-361

Skeletal Muscle Paul D. Fadale

Basic Science Review for Surgeons, Simmons, Steed, WB Saunders, p. 316-325

FNCE 2013: Incorporating Physical Assessment in the Diagnosis of Malnutrition: A Change in Practice; M. Fischer, C. Hamilton, Cleveland Clinic 10/22/2013.

http://fnce.eatright.org/fnce/uploaded/635199493315675427-230.%20Fischer.pdf

Textbook of Physical Diagnosis: History and Examination 7e., Mark H. Swartz MD, Elsevier, Saunders 2014.

Select Chapters. Communicating with patients, and Chapt 29, specific for nutrition assessment

FNCE 2014: Incorporating NFPA into Dietetic Curriculum and Preceptor Training: Collaborative Approach; Halasa-Esper, Pohle-Krauza,

Excellent practical resource.

Nutrition Focused Physical Assessment Part 1: Setting the Stage for Success Nutrition Focused Physical Assessment Part 2: Creating Your Malnutrition Toolbox Nutrition Focused Physical Assessment Part 3: Micronutrient Deficiencies

http://www.nestlenutrition-institute.org/Education/Pages/education.aspx Laura L. Frank, PhD, MPH, RDN, CD

Practice Paper of the Academy of Nutrition and Dietetics: Critical Thinking Skills in Nutrition Assessment and Diagnosis

Volume 115, Number 11, Page 1545 (November 2013)

6/27/2018


Lean Tissue Imaging: A New Era for Nutritional Assessment and Intervention

Carla M. M. Prado and Steven B. Heymsfield, JPEN J Parenter Enteral Nutr 2014 November, Vol 38, Number 8: 940-953 http://pen.sagepub.com/content/38/8/940

Nutrition-Focused Physical Examination in Pediatric Patients. Green Corkins K. Nutr Clin Pract. 2015 Apr;30(2):203-209. PMID: 25739708 [PubMed - as supplied by publisher]

Subjective Global Assessment: Physical assessment https://www.youtube.com/watch?v=py_xM06Ub6Y http://subjectiveglobalassessment.com/ http://subjectiveglobalassessment.com/subjective-global-assessment-in-literature

Patient-Generated Subjective Global Assessment First page is nutrition risk screen. NFPA is completed on back and sum supports diagnosis and is consistent with the Consensus characteristics http://pt-global.org Dr. Faith Ottery Nutrition Physical Exam “Stealth” Physical Exam This tool is a useful place to start and prioritize physical assessment target areas to learn. The PG-SGA-abridged is a nutrition risk screen tool; The Full PGA includes these physical assessment measures.

https://www.youtube.com/watch?v=py_xM06Ub6Y Physical Exam Part 1 https://www.youtube.com/watch?v=CHenIVEO8Vw Physical Exam Part 2 https://www.youtube.com/watch?v=Z1yyHI6RJH0 Physical Exam Part 3 https://www.youtube.com/watch?v=KLQIP6XfmnA Physical Exam Part 4 https://www.youtube.com/watch?v=h6CEnL_ck3k Physical Exam Part 5 https://www.youtube.com/watch?v=l6iIGXmrkEU Physical Exam Part 6 https://www.youtube.com/watch?v=nXwcd78YNVI Physical Exam Part 7 https://www.youtube.com/watch?v=enPumS4XGSQ Physical Exam Part 8

6/27/2018


https://www.youtube.com/watch?v=enPumS4XGSQ

Nutrient Deficiencies Associated with Nutrition-Focused Physical Findings of the Oral Cavity Nutrition in Clinical Practice 2013; 28(6):710-21 Rigassio Radler, Diane; Lister, Tracy

Nutrition in Clinical Practice, Volume 28 Number 6, December 2013 710–721

Physical Assessment Skills for Dietetics Practice: the past, the present and recommendations for the future, Riva Tougher-Decker PhD, RD, FADA Topics in Clinical Nutrition Vol. 21, No3. pp. 190-198

Evaluation of muscle and fat loss as diagnostic criteria for malnutrition. Fischer M, JeVenn A, Hipskind P Nutr Clin Pract. 2015 Apr;30(2):239-48. PMID: 25753808

Utilization of Nutrition-Focused Physical Assessment in Identifying Micronutrient Deficiencies. Esper DH Nutr Clin Pract. 2015 Apr;30(2):194-202. PMID: 25829342

Gallagher ML. Intake: the nutrients and their metabolism. In: Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St Louis, MO: Elsevier Saunders; 2012:32-128.

Sarcopenia https://vimeo.com/167868429?platform=hootsuite

Nutrition-Focused Physical Exam: An Illustrated Handbook [print version] ©2016 American Society for Parenteral and Enteral Nutrition; 56 pages, paperback, 70 color and 5 black and white Illustrations ISBN: 978-1-889622-29-3 (print), 978-1-889622030-9 (eBook)

https://netforum.avectra.com/eweb/shopping/shopping.aspx?site=aspen&webcode=shopping&&prd_key=5d003683-4f15-46c7-acf1-bdc742fef3b5

ENCPT NUTRITION TERMINOLOGY REFERENCE MANUAL Academy of Nutrition and Dietetics

Nutrition Focused Physical Findings PD-1.1

KENHUB FREE ANATOMY AND HISTOLOGY WEBSITE TO REFRESH HUMAN ANATOMY Body regions, directional terms

https://www.kenhub.com/

KHAN ACADEMY

https://www.khanacademy.org/science/health-and-medicine/advanced-muscular-system

NFPE - Idaho Health Associates Part 1 Scollard July …...Etiology-Based Disease-Related...

Documents

Transcript of NFPE - Idaho Health Associates Part 1 Scollard July …...Etiology-Based Disease-Related...