Nutrition-

Focused

Physical

AssessmentDanielle Anderson

Sodexo Dietetic Intern

November 13, 2013

Ice Breaker

“Sweet Confessions”

What was your first job?

What is your favorite recipe to impress guests?

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

Screening Process

First step in identifying nutrition risk

Facility specific

Nurses play a huge role

Let’s look at a our first research study

Screening Tools for Malnutrition

Research Article: Comparison of five malnutrition

screening tools in a hospital inpatient sample

Aims and objectives

Design

Methods

Conclusion

Relevance

Academy of Nutrition and Dietetics Evidence

Analysis Library

MNA-SF and MST - >90% sensitivity and >90%

specificity

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

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

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.

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

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

Head Technique: Inspection and palpation

Inspect: Eyes

Palpate: Patient’s hair

Possible Diagnoses: Hypothydroidism,

hyperthyroidism, protein deficiency,

dehydration, vitamin A deficiency, lack of

riboflavin

Bitot’s SpotsHyperthyroidism

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

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 infectionhttps://23andme.https.internapcdn.net/res/img/phenotype/pendred/6Rrjq9x4s4bEA8fpAJOnxg_goiter.jpg

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.

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

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

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

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 **

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

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”

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

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

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.

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.