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Nutrition Focused Physical Assessment
- 1. Nutrition- Focused Physical Assessment Danielle Anderson Sodexo Dietetic Intern November 13, 2013
- 2. Ice Breaker “Sweet Confessions” What was your first job? What is your favorite recipe to impress guests?
- 3. Objectives Review the importance of nutrition-focused physical assessments Describe four techniques used to assess the nutritional status of patients Identify signs and symptoms of malnutrition or nutrition deficiency
- 4. Screening Process First step in identifying nutrition risk Facility specific Nurses play a huge role Let’s look at a our first research study
- 5. Screening Tools for Malnutrition Research Article: Comparison of five malnutrition screening tools in a hospital inpatient sample Aims and objectives Design Methods Conclusion Relevance Simple Tools: MST - Malnutrition Screening Tool SNAQ – Short Nutritional Appetite Questionnaire MNA-SF - Mini Nutritional Assessment Comprehensive Tools: MUST - Malnutrition Universal Screening Tool NRS 2002 - Nutritional Risk Screening 2002 Academy of Nutrition and Dietetics Evidence Analysis Library MNA-SF and MST - >90% sensitivity and >90% specificity
- 6. Malnutrition Malnutrition is fairly common in hospitals and can lead to delayed healing and increased length of stay and medical costs. Research Article – Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality. http://i.dailymail.co.uk/i/pix/2012/11/22/article-2237126- 11D51D64000005DC-414_634x422.jpg
- 7. Importance of NFPA Research Article - Is Serum Albumin a Marker of Malnutrition in Chronic Disease? The Scleroderma Paradigm Albumin Relevance - In hospitals, low albumin is often caused by physiological stress and/or systemic inflammatory responses.
- 8. Basic Exam Techniques Begin with a general inspection of body and skin. Start at head and move downwards. Techniques involved: Inspection: Observe what you see, hear, or smell Auscultation: Listen, using a stethoscope or naked ear, to sounds produced by different parts of the body Percussion: Use fingertips to tap lightly against body structures to assess location and density of underlying body masses or organs Palpation: Use touch to evaluate location, texture, size, temperature, warmth, coolness, tenderness, and mobility
- 9. Skin Technique: Inspection and palpation Inspect: Color and uniform appearance, thickness, symmetry, hygiene, and presence of lesions, tears, bruising, edema, rashes, or flakiness. Palpate: moisture, temperature, texture, turgor, and mobility Possible Diagnoses: Dehydration, edema, infection http://farm7.staticflickr.com/6172/6188066471_a9159c41be_o.jpg
- 10. Head Technique: Inspection and palpation Inspect: Eyes Palpate: Patient’s hair Possible Diagnoses: Hypothydroidism, hyperthyroidism, protein deficiency, dehydration, vitamin A deficiency, lack of riboflavin Hyperthyroidism Bitot’s Spots
- 11. Mouth Technique: Inspection Inspect: Tongue, color and surface of lips, corners of the mouth, mucosa, gums, palate, and teeth/dentures. Determine if there is pain when chewing or swallowing. Possible Diagnoses: Dehydration, riboflavin deficiency, anemia, vitamin c deficiency, niacin deficiency, B-12 deficiency
- 12. Neck Technique: Inspection Inspect: Any obvious abnormalities such as a mass or visible thyroid tissues that moves upward when the patient swallows Possible Diagnoses: Iodine deficiency or local infection https://23andme.https.internapcdn.net/res/img/phenotype/pendre d/6Rrjq9x4s4bEA8fpAJOnxg_goiter.jpg
- 13. Abdomen Techniques: Inspection, Auscultation, Percussion, and Palpation Inspect: Symmetry, contour, texture, and color. Listen: Assess bowel motility Percuss: Detect presence of gaseous distention, fluid or solid mass Touch: Examine texture, distention, muscle rigidity, and tenderness. Possible Diagnoses: Ascites, gas, bowel obstruction, hernia, cysts, gastroenteritis, early intestinal obstruction, peritonitis, or paralytic ileus.
- 14. Extremities Technique: Inspection Inspect: Condition of the skin, spooning of nails, muscle pain and bones/joints Possible Diagnoses: Vitamin D deficiency, inadequate intake of vitamin C, thiamine deficiency, iron deficiency
- 15. Subcutaneous Fat Loss Orbital fat pad “Hollow eye” + Prominent brow bone Inspect (Inspection) for loss of fat pad under eye Well-nourished: slightly bulged fat pad Mild-moderate fat loss: dark circles, somewhat hollow Severe fat loss: Pronounced, hollow, depressed, dark circles, loose skin
- 16. Subcutaneous Fat Loss (Cont’d) Triceps (Triceps brachii) Area on arm most identified with fat loss Pinch skin (Palpation) between thumb and forefinger over the back of the upper arm over the tricep muscle Well-nourished: Ample fat tissue between fold of skin Mild-moderate fat loss: Fingers almost touch, some depth to pinch Severe fat loss: Very thin layer of skin between folds or fingers touching
- 17. Subcutaneous Fat Loss (Cont’d) Chest/Lower Ribs Inspect the mid-axillary line at the costal margin or lower ribs for Loss of fullness or loose skin Well-nourished: ample fat tissue; chest wall and ribs should not be visible Mild-moderate fat loss: loose skin, somewhat apparent ribs Severe: Skin is stretched, prominent well-defined ribs **Picture **
- 18. Bilateral Muscle Wasting Temple Observe patient straight on and from either side . Look for prominence of brow bone - scooping or hollowing Scooping or hallowing at the temple indicates wasting of temporalis muscle Well-nourished: observe well-defined muscle Mild-mod wasting: slight depressing of temporalis muscle Severe wasting: hollowing, scooping depression
- 19. Bilateral Muscle Wasting (Cont’d) Deltoid, shoulder, pectoris, clavicle Clavicle: observe pectoral and deltoid muscle. Look for prominent protruding of bone Well-nourished: clavicle bone not prominent in men but slightly visible in women Mild-Mod: Some protrusion of clavicle Severe: protruding/prominent bone Shoulders: Observe straight on with arms at side. Look for squaring of shoulders and a loss of roundness at junction of shoulder and neck, and junction of shoulder and arm. Well-nourished: Rounded, curves at the junction of shoulder/neck and shoulder/arm Mild-mod: Some protrusion of acromion process (PICTURE) Severe: Protruding or prominent bone “squaring of shoulder”
- 20. Bilateral Muscle Wasting (Cont’d) Interosseous Muscle (dorsal interossei) Observe muscle between thumb and index finger on back of hand (palm down). Have patient press thumb and forefinger back and forth with pressure to inspect muscle Well-nourished: May bulge in male and be flat/bulge in female Mild-Mod: Slightly depressed or flat Severe: flat or depressed area between thumb and forefinger
- 21. Additional Tools for NFPA Skinfold calipers Bioelectrical impedance analysis (BIA) Dynamometer Stethoscope Watch with second hand Pen light Measuring tape Tongue blade Reflex hammer Blood pressure cuff
- 22. Summary Physical assessment – Necessary part of performing a comprehensive nutritional assessment Four techniques are used to assess the nutritional status of patients Performing a NFPA can identify multiple signs of malnutrition or nutrition deficiencies.
- 23. Resources Iizaka S, Sanada H, Matsui Y, et al. Serum Albumin level is limited nutritional marker for predicting wound healing in patients with pressure ulcer: Two multicenter prospective cohort studies. Clinical Nutrition. 2011; 30: 738-745 Neelemaat F, Meijers J, Kruizenga H, et al. Comparison of five malnutrition screening tools in one hospital inpatient sample. Journal of Clinical Nursing. 2010; Moccia L, DeChicco R. Abdominal Examinations: A Guide for Dietitians. Support Line. 2011; 33: 16-21 Collins N, Harris C. Nutrition 411: The Physical Assessment Revisited: Inclusion of the Nutrition-Focused Physical Exam. Ostomy Wound Management. 2010; 56: http://www.o-wm.com/content/physical-assessment-revisited-inclusion-nutrition- focused-physical-exam. Accessed November 1, 2013. Alp Ikizler T. The Use and Misuse of Serum Albumin as a Nutritional Marker in Kidney Disease. Clinical Journal of the American Society of Nephrology. 2012; 7: (9) 1375-1377.doi:10.2215/CJN.07580712. Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010. Clinical Nutrition. 2013; 32: (5) 737–745. http://dx.doi.org/10.1016/j.clnu.2012.11.021.
Editor's Notes
- I’m Danielle Anderson, Sodexo Dietetic Intern and I want to thank everyone for being here today. We’re going to concentrate on the nutrition-focused physical assessment (NFPA). It is used to identify physical signs and symptoms of nutrition deficiencies or malnutrition risk. These findings, combined with evidence from the patient’s chart, help determine the patient’s nutritional status and assist with developing a nutrition care plan. Despite their importance, physical examination skills are still not a requirement for dietetic internship programs and currently there is no defined education pathway for dietitians to learn these skills.
- When a patient is first admitted to the hospital they are typically screened by collecting the following information: Height Weight Unintentional weight change Food allergies Diet Lab values Change in appetite Nausea/vomiting Bowel habits Chewing/swallowing Diagnosis
- Journal of Clinical Nursing – November 2010 – Give Examples to look at Screening tools: Quick & Easy tools: Malnutrition Screening Tools(MST) , Short or Simplified Nutritional Appetite Questionnaire (SNAQ), and Mini Nutritional Assessment (MNA-SF) and comprehensive screening tools: Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002) Aims & Objectives of the study: Compare five malnutrition screening tools against a recognized definition of malnutrition Design: Cross sectional study, which is observational in nature. (Researchers record the information, often used to make conclusions about possible relationships or gather preliminary data to support further research and experimentation. Designed to look at a variable at a particular point in time. ) Methods: The malnutrition screening tools were compared to the definition of malnutrition in 275 hospital inpatients. Sensitivity, specificity, positive predictive value and negative predictive value were determined. Conclusion: The simplified tools MST and SNAQ are suitable for use in a hospital inpatient setting and performed just as well as the comprehensive tools on validity. The MNA-SF showed excellent sensitivity, but poor specificity . There was a discrepancy between this study and the AND EAL when it came to the MNA-SF specificity claim. However both claimed the MST was a great screening tool for identifying patients at risk for malnutrition. This provides insight into the most valid and practical nutritional screening tools used in hospitals to improve recognition and treatment of malnutrition.
- 2013 RESEARCH ARTICLE from Clinical Nutrition Journal titled “Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality.” The Australasian Nutrition Care Day Survey (ANCDS) was the largest multicenter study in Australasian region. It reported prevalence of malnutrition and poor food intake in 3122 patients across 56 hospitals in Australia and New Zealand. 1-in-3 malnourished patients and 1-in-5 well-nourished patients consumed nothing or up to 25% of the food offered during their hospital stays. The goal of this study was to take into account disease type and severity, and also explore associations between nutritional status, food intake, and health related outcomes (LOS, mortality, and readmission) in participants from the ANCDS. Results: This study found that patients who were malnourished or consumed <25% of the hospital offered food had significantly longer LOS, higher in-hospital mortality rates and readmissions rates than well-nourished patients. Practicality: Malnutrition obviously has a negative impact on a patient’s recovery. In order to ensure patients’ intake is adequate, protocols for recording patients' food intake after each meal need to be implemented (similar to those for authorizing medication charts soon after medications are administered). Facilities should consider “consumption of ≤25% of the offered food” as a screening (and rescreening) tool to initiate appropriate medical nutrition therapy.
- Journal of American College of Nutrition - 2010 Design: Cross-sectional, multicenter study of patients from the Canadian Scleroderma Research Group Registry. Results: 258 patients were studied using the comprehensive Malnutrition Universal Screening Tool (MUST). Of these patients, 21.3% were deemed high malnutrition risk. However, only 2% of patients had below normal albumin levels. Conclusions: Therefore, the study concluded that serum albumin levels are not always useful in determining malnutrition risk. Albumin Relevance- Physiological stress from critical care or prolonged illness can affect these measures. As long as inflammatory markers such as C-reactive protein (CRP) levels are elevated, albumin/PA should not be used. Therefore, it is imperative that dietitians get a better physical snapshot of the patient, looking beyond height and weight and gaining the knowledge, confidence, and experience necessary to conduct a nutrition-focused physical examination. This can provide valuable clues in planning individualized nutrition interventions for each patient.
- An overall skinny, wasted appearance indicates an inadequate total energy intake. Protein-energy malnutrition may present as loss of appetite, flaking dermatitis, pigmentation skin changes, temporal muscle wasting, distended abdomen, hepatomegaly (enlarged liver), muscle wasting, and weakness of the extremities.
- Minimal perspiration or oiliness should be present, and the skin should range from cool to warm to the touch. The texture should be smooth, soft, and even. To assess turgor and mobility, gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then release the skin. The skin should feel resilient, move easily when pinched, and return to place immediately when released. Skin turgor measurement, whilst part of the initial assessment of patients with suspected dehydration, is only moderately reliable and other clinical signs should be sought to confirm this diagnosis If you encounter any skin lesions (a catch-all term that collectively describes any pathologic skin change or occurrence), describe them according to the following characteristics: configuration (size, shape, color, texture, elevation, or depression); exudate (color, odor, amount, consistency); and location and distribution on the body (1).
- Hair should be smooth, symmetrically distributed, and no splitting or cracked ends. . Coarse, dry, brittle hair is associated with hypothyroidism; fine, silky hair is associated with hyperthyroidism.7 Hair that is sparse, thin, and easy to pull out may be a sign of a protein deficiency. Eyes: The eyes are also a good place to spot particular nutrient deficiencies such as vitamin A. A deficiency in vitamin A can show up as poor vision at night or in dim light (night blindness), impaired visual recovery after a glare, sensitivity to light, blurring, conjunctival inflammation, and excessive dryness, followed by progressive cloudiness and softening of the corneas (ie, keratomalacia).2 With advancing vitamin A deficiency, dry, “foamy,” silver-gray deposits (Bitot’s spots) may appear on the delicate membranes covering the whites of the eyes.9 A lack of riboflavin also may play a role in some of these symptoms, including light sensitivity, blurring, and inflammation of the conjunctiva. (1)
- A patient’s oral health is extremely important to nutrition professionals because this is typically the point where food and fluids . Abnormal conditions can contribute to pain when chewing or swallowing, which can obviously lead to malnutrition. To conduct an oral exam, start by asking the patient to close his/her mouth. Inspect and palpate the lips for symmetry, color, edema, and any surface abnormalities. Dehydration — most notably dry tongue, longitudinal tongue furrows, and dry mucous membranes. Dry cracked, lips (chelitis) may also be d/t dehydration (or wind chapping, dentures, or excessive lip licking). Riboflavin deficiency - scaling of the lips (cheilosis) and Painful cracking at the corners of the mouth (Angular cheilitis) in the elderly is mostly associated with the use of dentures. Malocclusion resulting from worn teeth leaves the angular region wet and the elastotic old skin deepens the furrow at the angular region. Anemia: Pale color of the lips is influenced by a variety of conditions, but may be a sign of anemia. After having the patient remove any dental appliances, use a tongue blade and bright light to inspect the mucosa, gums, and teeth. The mucous membrane should be pinkish red, smooth, and moist. Be sure to note any lesions or inflammation present. The gums should have a slightly flecked, pink appearance with a clearly defined, tight margin at each tooth. The surface of the gums beneath dentures should be free of inflammation, swelling, or bleeding. Bleeding gums may be the result of ill-fitting dentures or indicative of a vitamin C or riboflavin deficiency. Inspect the mouth for any teeth that are loose, cracked, or in otherwise poor condition. Ask the patient to extend the tongue and inspect for any swelling and variation in size or color, coating, or ulcerations. The tongue should appear dull red, moist, and glistening with an anterior surface that is smooth, yet roughened with papillae and small fissures. Of particular note is a smooth red tongue with a slick appearance since this may indicate a niacin or vitamin B12 deficiency. Ask the patient to tilt their head back for you to inspect the palate. The whitish hard palate should be dome-shaped, while the pinker soft palate should be contiguous with the hard palate. Observe the palate for any abnormal nodules, redness, or inflammation (1)
- Inspect the neck for any obvious abnormalities. For example, a mass that fills the base of the neck or visible thyroid tissue that glides upward when the patient swallows (you can ask them to swallow a sip of water) may indicate an enlarged thyroid, or goiter, which may be caused by an iodine deficiency. Marked edema of the neck may be associated with a local infection.
- Symmetry/contour: Inspect the symmetry and contour of the abdomen from a seated position at the patient’s side, then move to a standing position behind the patient’s head. Generalized symmetric distention may occur as a result of obesity, enlarged organs, fluid (eg, ascites), or gas; asymmetric distention or bulging may indicate bowel obstruction, hernia, cysts, or other conditions. The six Fs of Abdominal distention: Fluid (ascites) Fat (obesity) Flatulence (gas) Fetus (pregnancy) Feces (constipation) Full-sized tumor Texture: Skin abnormalities such as rashes, scars, stretch marks, or engorged veins. Color: Jaundice, cyanosis, redness, or bruising; glistening taut surface appearance suggests ascites LISTEN: This can be accomplished by placing the diaphragm of a warmed stethoscope on the abdomen and holding it in place with very light pressure. The idea is to listen for sounds and note their frequency and character. Audible clicks and gurgles that occur irregularly and range from 5 to 35 per minute are considered normal. Of course, prolonged gurgles called borborygmi commonly known as “stomach growling” may be heard. Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger, while decreased bowel sounds occur with peritonitis and paralytic ileus. If no sounds are discerned after 5 minutes of continuous listening, an “absence of bowel sounds” can be established. However, it is important to listen to all four quadrants of the abdomen to ensure no sounds are missed and to localize specific sounds. Normal, Hyperactive, Hypoactive Percuss: tympany, a high-pitched, drum-like sound, is usually heard over the stomach - (percuss cheek while making “chipmunk” cheeks), resonance, a low-pitched, hollow sound, is usually heard over normal lung tissue. - (percuss above the breast on your chest hyperresonance, a loud, booming sound, is usually heard over a hyperinflated lung, as in patients with emphysema. dullness, a soft, high-pitched, thudlike sound, can generally be heard over dense organs, such as the liver. - (percuss on your thigh) flatness, a soft, high-pitched sound, is generally heard over bones, muscles, and tumors
- Finally, with regard to the extremities other than the condition of the skin, softening of the bone and bone tenderness may be related to vitamin D deficiency; bone ache and joint pain may indicate an inadequate intake of vitamin C. Muscle tenderness and muscle pain may be related to a lack of thiamine; spooning of the nails may indicate an iron deficiency.
- includes muscle volume, tone, function and gender. The upper body is more susceptible to muscle loss, independent of functional status. Muscle loss from inactivity or bed rest is most prominent in the pelvis and upper leg. Muscle wasting determined by volume and tone of muscle , looking for flat or hollow areas where muscle should be, and prominence of bones. Neurological deficits may produce false-positive findings.
- The tools used may depend on the specific patient population or area of practice of the clinician. Ex: RD working with BMT patients may use a pen light to assess for oral mucositis in determining the ability of the patient to take oral nutrition
- Inspection, ausculation, palpation, and percussion