sharolyn tsamoutales, graduate student intern bowling green state university, 2012 physical...
TRANSCRIPT
S H A R O LY N T S A M O U T A L E S , G R A D U A T E S T U D E N T I N T E R NB O W L I N G G R E E N S T A T E U N I V E R S I T Y , 2 0 1 2
PHYSICAL ASSESSMENT TO DETERMINE NUTRITIONAL
DEFICIENCIES
NUTRITION-FOCUSED PHYSICAL ASSESSMENT
During initial patient (pt) evaluation an RD’s assessment can be further enhanced by performing a “head to toe” visual interpretation of a pt’s physical signs and symptoms in determining appropriate Medical Nutrition Therapy.
Throughout this process, it is important to exercise thoughtful consideration for pt’s comfort level.
NUTRITION-FOCUSED PHYSICAL ASSESSMENT
• Seldom are nutrient deficiencies isolated, multiple deficiencies are most common
• Physical signs of nutrient deficiencies are typically observed after prolonged diet inadequacy
• Non-nutritional related symptoms may be observed
CLINICAL ASSESSMENT
Consideration of physical observations and interpretation of:
- Hair - Neurological- Eyes - Additional - Oral health observations - Thyroid gland - Hydration status- Nails- Skin
HAIR ASSESSMENTHAIR SHOULD HAVE A SHINY, NORMAL TO THICK APPEARANCE
THAT IS NOT EASILY PLUCKED.
Clinical Findings
• Thinning, sparse, Alopecia
• Easily plucked, brittle• Dry • “Corkscrew”, coiled
hair
Potential Deficiency
• Protein, Biotin, Zinc, Essential Fatty Acids (EFA), Iron• Zinc, Protein• Vitamin A, EFA,
Zinc• Vitamin C
HAIR IMAGES
Alopecia Corkscrew
EYE ASSESSMENTEYES SHOULD APPEAR BRIGHT AND CLEAR WITH HEALTHY MEMBRANES
AND NORMAL MOVEMENT
Clinical Findings
• Nyctalopia, • Pale Conjunctiva• Ophthalmoplegia
• Xerophthalmia• Fissuring in corners,
redness
Potential Deficiency
• Vitamin A, E• Vitamin A, Iron• Thiamin (B1),
Phosphorus • Vitamin A, Protein• Riboflavin (B2),
Pyridoxine
EYE IMAGES
Pale conjunctiva Ophthalmoplegia
ORAL HEALTH ASSESSMENTMOUTH SHOULD APPEAR FREE OF SORES AND SWELLING, WITH NORMAL
PINK/RED GUMS AND TONGUE. NORMAL TEETH, TASTE AND SMELL.
Clinical Findings
• Cheilosis, Angular stomatitis, or Perlèche• Magenta glossitis• Pale, Sore tongue• Atrophic lingual
papillae
Potential Deficiency
• Riboflavin, Pyridoxine, Niacin, Iron, Zinc • Riboflavin• Riboflavin, B12, Iron• Riboflavin, Niacin,
Folate, B12, Protein, Iron
ORAL HEALTH IMAGES
Angular stomatitisAtrophic lingual
papillae
ORAL HEALTH ASSESSMENTMOUTH SHOULD APPEAR FREE OF SORES AND SWELLING, WITH NORMAL
PINK/RED GUMS AND TONGUE. NORMAL TEETH, TASTE AND SMELL.
Clinical Findings
• Swollen, retracted, bleeding gums• Loose teeth• Hypoguesia• Hyposmia
Potential Deficiency
• Vitamin C
• Vitamin C• Zinc• Zinc
ORAL HEALTH IMAGES
Swollen, retracted, bleeding gums Loose teeth
THYROID GLAND ASSESSMENTLOCATED ON THE FRONT OF THE NECK FLANKING THE TRACHEA,
SHOULD NOT APPEAR ENLARGED
Clincal Findings
• Hypothyroidism, Goiter
Potential Deficiency
• Iodine
NAIL ASSESSMENTNAILS SHOULD HAVE A SMOOTH APPEARANCE FREE OF RIDGES AND
DISCOLORATION, WITH A NORMAL, PALE, CRESCENT SHAPED, LUNULA
Clinical Findings
• Koilonychia• Longitudinal central
ridges• Longitudinal nail
beading• Absent Lunula • Brown-gray color• Transverse ridging,
dry, brittle
Potential Deficiency
• Iron, Protein • Iron, Folic Acid,
Protein • B complex (B1, 2, 3,
5, 6, 7, 9, 12), Protein• Protein, Iron, • B12• Protein, EFA
NAIL IMAGES
Koilonychia Absent lunula.
Longitudinal central ridge Longitudinal nail beading
SKIN ASSESSMENTSKIN SHOULD APPEAR NORMALLY SMOOTH AND FREE OF DISCOLORATION
Clinical Findings
• Purpura• Petechiae• Pellegra• Follicular
hyperkeratosis• Nasolabial seborrhea,
scaling, dry, goose bump• Pallor
Potential deficiency
• Vitamin C, K, Folic acid• Vitamin C, K• Niacin, Tryptophan• Vitamin A, B, C, E, EFA• Vitamin A, Zinc, EFA,
Riboflavin, Pyridoxine
• Iron, B12, Folic acid, Vitamin E
SKIN IMAGES
Purpura Petechiae
SKIN IMAGES
Nasolabial seborrhea Dry, goose bump
SKIN ASSESSMENTSKIN SHOULD APPEAR NORMALLY SMOOTH AND FREE OF DISCOLORATION
Clinical Findings
• Dermatitis• Cellophane
appearance• Desquamation,
Pigmentation
Potential Deficiency
• Zinc, Niacin• Protein
• Niacin, Protein
SKIN IMAGES
Desquamation, Pigmentation
Protein edema
NEUROLOGIC ASSESSMENT
Clinical Findings
• Dementia
• Confabulation, Beri-beri• Peripheral
Neuropathy, Paresthesias
Potential Deficiency
• Thiamin, Vitamin E Niacinamide, B12, • Thiamin
• Thiamin, Pyridoxine, B12
NEUROLOGIC IMAGES
Beri-beri Tetany
NEUROLOGIC ASSESSMENT
Clinical Findings
• Ataxia
• Tetany
Potential Deficiency
• Thiamin, Pyridoxine, B12, Vitamin E• Thiamin, Niacin,
B12, Calcium, Vitamin D, Vitamin E, Magnesium
ADDITIONAL PHYSICAL ASSESSMENTS
Clinical Findings
• Parotid enlargement• Osteomalacia,
Rickets• Persistant Cough• Dyspnea
Potential Deficiency
• Protein
• Vitamin D
• Thiamin• Folic Acid, B12, Vitamin E
ADDITIONAL PHYSICAL IMAGE
• Parotid swelling • Osteomalacia, Rickets
ADDITIONAL PHYSICAL ASSESSMENTS
Clinical Findings
• Marasmus
• Kwashiorker
Potential Deficiency
• Macronutrients, micronutrients• Protein, Iron, Folic
Acid, Vitamin C
ADDITIONAL PHYSICAL ASSESSMENTS
Marasmus Kwashiorker
HYDRATION STATUS ASSESSMENTCLINICAL PHYSICAL FINDINGS
Underhydration
• Imput < output• Decrease in weight• Sunken, dry eyes• Oliguria, dark urine• Sticky salvia, dry
membranes• Poor skin turgor• Cool, pale clammy
skin
Overhyration
• Imput > output• Increase in weight• Puffy, swollen eyes• Light colored urine• Moist skin• Anasarca, edema• Dyspnea, lung
crackles
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin A Syndromes- Nyctalopia- Xeropthalmia- Follicular
hyperkeratosis
Signs and symptoms- Poor Vision- Corneal ulceration- Dry Hair- Dry Skin- Itchy Skin- Weak fingernails
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B1, ThiaminSyndromes- Beri-beri- Wernicke’s
encephalopathy- Korsakoff
syndrome
Signs and symptoms- Muscle cramping - Hyporeflexia- Paresthesia- Poor Memory- Chest pain- Tachycardia- Dyspnea
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B2, RiboflavinRelated Syndrome- Ariboflavinosis, Pellagra - Cheilosis- Edema - Seborrheic
dermatitis- Growth retardation
Signs and Symptoms- red, scaly, oily skin
rash- Mouth sores- Swollen tongue- Fissures of the
mouth and lips- Itchy eyes
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B3, Niacin/NicotinamideRelated Syndrome- Pellagra
Signs and Symptoms- Dermatitis- Diarrhea- Depression- Dementia- Dysphagia/
hypersalivation- Abdominal/nausea
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B6,PyridoxineRelated Syndrome-Polyneuropathy
Signs and symptoms
- Numbness, tingling, weakness of the limb- Diarrhea- Swollen tongue- Seizures- Nausea
- Depression- Impaired mental
faculties- Itchy, red skin rash- Vomiting
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B9, Folic Acid/FolateRelated Syndrome
- Macrocytic anemia- Increased risk of
heart disease, dementia, and cancer
Signs and Symptoms- Pallor- Depression- Diarrhea- Swollen tongue- Fissures of mouth,
lips- Dyspnea upon
exertion
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B12Related Syndrome
-Neuropathy-Macrocytic AnemiaSigns and Symptoms
- Pallor- Sore, Red, swollen tongue
- Numbness or tingling in upper & lower limbs progressing to the trunk
- Dyspnea- Depression- Memory loss - Low energy, weak
muscles, - light-headedness- Increased risk over age
51
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin CRelated Syndrome- ScurvySigns and Symptoms- Bleeding gums- Loose teeth - Halitosis- Nosebleed
- Poor wound healing- Purpura- Corkscrew hair- Anemia - Painful joints,
muscles- Numbness in
extremities- Skin rash or spots
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin DRelated Syndrome- Osteomalacia- RicketsSigns and Symptoms- Tingling, numbness,
burning of lips, tongue, hands
- Weak bones- Bone protusions- Bone pain- Bowing in legs- Muscle weakness- Muscle pain
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin ERelated Syndrome- Hemolytic anemia- Neurologic problems
Signs and Symptoms- Pallor- Demetia- Night blindness- Dyspnea- Ataxia- Tetany- Muscle weakness- Follicular
hyperkeratosis
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin KRelated Syndrome- Bleeding disorders- Birth Defects
Signs and Symptoms- Purpura- Petechiae- Nosebleeds- Menorrhagia- Poor wound
clotting- Gastrointestinal
bleeding
NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
IronRelated Syndrome- Pica- Restless Led
Syndrome
Signs and Symptoms- Fatigue- Alopecia- Pale Conjunctiva
- Pale, Sore tongue- Atrophic lingual
papillae- Koilonychia- Longitudinal central
ridges- Absent Lunula in nail- Pallor- Cold extremities
REFERENCES
• 1.Seshadri D, De D. Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol [serial online] 2012 [cited 2012 Jun 23];78:237-41. Available from: http://www.ijdvl.com/text.asp?2012/78/3/237/95437
• 2.R W Vilter, and J J Will. Nutrition and Nutritional Deficiency Diseases• Annual Review of Medicine Vol. 9: 191-208 (Volume publication date February 1958)• DOI: 10.1146/annurev.me.09.020158.001203
• 3. Centers for Disease Control and Prevention (CDC). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children During the Domestic Medical Screening Examination http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html
• 4. Peggy K.Yen, RD,MPH. Nutritional Anemia. Geriatric Nursing 2000 • Volume 21 • Number 2, pg 111-112.
• 5.Paillaud, Elena1; Merlier, Isabelle1; Dupeyron, Catherine. Oral candidiasis and nutritional deficiencies in elderly hospitalized patients. British Journal of Nutrition, Volume 92, issue 5 (November 1, 2004), p. 861-867
• 6.Collinsworth, Reatha. Determining nutritional status of the elderly surgical patient: Steps in the assessment process. AORN Journal, Volume 54, issue 3 (September, 1991), p. 622-628,630-631
• 7 Stotts, Nancy, RN. Nutritional Assessment before Surgery. AORN Journal, February 1982, Vol35, No 2 207-214.
• 8. Miller, Stanley J, MD. Nutritional Deficiency and the Skin. Journal of the American Academy of• Dermatology. Volume 21 , issue 1 (July, 1989), p. 1-30
• 9. Sinn, N. Physical fatty acid deficiency signs in children with ADHD symptoms. Prostaglandins, Leukotrienes & Essential Fatty Acids, Volume 77, issue 2 (August, 2007), p. 109-115.
• 10. CDC Report: Why Vitamin B12 Deficiency Should Be on Your Radar Screen. A Continuing Education Update Course WB1349. http://www.cdc.gov/ncbddd/b12/documents/b12-030910.pdf http://www.cdc.gov/ncbddd/b12/cases.html
• 11.Charney P. PhD RD, Malone A. MS RD CNSD. ADA Pocket Guide to Nutrition Assessment. Second edition. pgs 40-61.
• 12. Academy of Nutrition and Dietetics Nutrition Care Manual • https://elearning.bgsu.edu/webapps/portal/frameset.jsp?tab_id=_2_1&url=%2fwebapps%2fblackboard%2fexecute%2flauncher%3ftype%3dCourse%26id
%3d_15729_1%26url%3d