Nutrition Focused Physical Examination: Overview …

1 Tuesday, 1:00 2:30, B6. Nutrition Focused Physical examination : Overview and application Lola Rosewig Objectives: Identify advances in clinical assessment and management of selected healthcare issues related to persons with developmental disabilities Notes: 4/7/2016. HOSPITAL MALNUTRITION. Overview . IS WIDESPREAD. ASPEN(American Society of Parenteral Malnutrition and Enteral Nutrition ), Nov 2013, JPEN. Multiple studies find that approximately one in Nutrition - Focused Nutrition - Focused Physical Exam every three adult patients admitted to a hospital in the United States is suffering from malnutrition Physical examination : O V E RV I E W AN D AP P L I C AT I O N. Documentation and Application LOLA ROSEWIG, MPH, RD. CLINICAL DIETITIAN.

2 U N I V E R S I T Y O F M I C H I G A N H E A LT H S Y S T E M. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral PEDIATRIC MALNUTRITION IMPACT OF HOSPITAL MALNUTRITION Nutrition : Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). Reported a prevalence of 6% 51% in Morbidity and Mortality hospitalized children. Development of pressure ulcers However, it is well known that a gap exists Reduced muscle mass decreased strength/..Jane V. White, PhD, RD, FADA 1 ; Peggi Guenter, PhD, RN 2;. Gordon Jensen, MD, PhD, FASPE 3 ; Ainsley Malone, MS, RD, CNSC;. between diagnosing malnutrition in debility risk of falls Marsha Schofield, MS, RD 5 ; tbe Academy Malnutrition Work Group.

3 Hospitalized patients and actually coding the :S. Malnutrition Task Force; and tbe Board of Directors Nosocomial infections for it. Quality of life Increased length of stay (LOS) LEADING THE SCIENCE AND. I PRACTICEOF CLINICAL Nutrition . Readmission and Institutionalization Cost Academy of Nutrition Abdelhadi et al. JPEN 2016 and Dietetics 1. 4/7/2016. NO SINGLE PARAMETER IS DEFINITIVE Special Report ..,. , u:AoOWG TMCSOCN.. MACTICS M C U M C M MLI1"Mtl0f f , NO SINGLE PARAMETER IS DEFINITIVE. FOR ADULT MALNUTRITION Consensus Statement of the Academy of Nutrition u t r it ion in CJjnical Practice Vo lume 30 Number I. February2015147 161. FOR PEDIATRIC MALNUTRITION. C 2014 American Society and Dietetics/American Society for Parenteral and for Parenteral and Enteral u t r it ion Food/Nutrient Intake and Academy o f utrition and Enteral Nutrition : Indicators Recommended for the MUST MEET AT LEAST 2 OF THE 6 CRITERIA FOR Identification and Documentation of Pediatric Dietetics [ X ) ( : 42.]

4 DIAGNOSIS: Assessment of Energy and Protein Needs Malnutrition (Undernutrition) host ed at Insufficient energy intake ($)SAGE Growth Parameters / Anthropometric Weight loss Patricia Becker, MS, RD, CSP, LDN, CNSC 1 ;Liesje Nieman Carney, RD, CSP, LDN3 ;. 2 4. Measurements: Mark R. Corkins, MD, CNSC, FAAP ; Jessica Monczka, RD, LDN, CNSC ;. Loss of muscle mass Elizabeth Smith, RD, LDN, CNSC 3 ; Susan E. Smith, RD, CSP, LD5; Percentiles/z-scores Bonnie A. Spear, PhD, RDN, LD6; Jane V. White, PhD, RD, LDN, FAND7; Academy of Loss of subcutaneous fat Nutrition and Dietetics; and American Society for Parenteral and Enteral Nutrition Weight for age Localized or generalized fluid accumulation (that may Height/length for age sometimes mask weight loss) BMI/weight-for-length for age Diminished functional status as measured by hand-grip Weight Gain Velocity strength Mid-Upper Arm Circumference (MUAC).

5 _l_,'ool =Michigan's Inalnutrition diagnostic tool Handgrip Strength Nutrition - Focused Physical Findings White et al. 2012. Nutrition CARE PROCESS Nutrition ASSESSMENT. Nutrition Assessment Biochemical Food/ Nutrition - Data, Medical Anthropometric related History Tests and Measurements Nutrition - Focused Procedures Physical EXAM Monitoring & Nutrition Evaluation Diagnosis Nutrition - PA R T O F T H E N U T R I T I O N C A R E P R O C E S S Focused Client History Physical Nutrition Findings Intervention 2. 4/7/2016. OVERALL APPEARANCE/ OVERALL APPEARANCE/. Nutrition - Focused Physical EXAM. FIRST IMPRESSIONS FIRST IMPRESSIONS. GETTING STARTED: The NFPE begins with a general Body positioning (muscle contractures, paralysis). Prepare for patient interaction observation of the patient.

6 Body Language First impression and Physical Body habitus Standard and universal precautions characteristics to note during interview: Physical exam techniques: What is the apparent state of health? Amputations Inspection close observation What is the level of consciousness? Ability to communicate Does the patient show signs of Physical distress? Palpation tactile examination Affect How is the patient dressed? Percussion elicit a sound wave Do you see any obvious signs of nutrient deficiencies? Auscultation listening to body sounds Is there any involuntary movements or signs of paralysis? Litchford, 2013 Litchford, 2013. ASSESSING FOR MUSCLE LOSS ASSESSING FOR MUSCLE LOSS ASSESSING FOR MUSCLE LOSS. Regions to assess: Temporalis Clavicular region: Upper body: Pectoralis major, deltoid, Temple trapezius muscles Collar bone Shoulder Shoulder blade Hand Lower body: Thigh/knee Calf Image: Litchford 2013.

7 3. 4/7/2016. ASSESSING FOR MUSCLE LOSS ASSESSING FOR MUSCLE LOSS ASSESSING FOR MUSCLE LOSS. Shoulder region: Hand: Interosseous muscle Deltoid muscle Image: Nicholls, Horace (Photographer) [Public domain], via Wikimedia Commons Image: Litchford 2013. ASSESSING FOR MUSCLE LOSS ASSESSING FOR MUSCLE LOSS ASSESSING FOR FAT LOSS. Anterior thigh/ Posterior calf: Gastrocnemius Regions to assess: patellar region: and soleus Orbital region (orbital fat pads). Quadriceps femoris group Upper arm region (triceps brachii). Mid-axillary at the iliac crest Ribs 4. 4/7/2016. ASSESSING FOR FAT LOSS ASSESSING FOR FAT LOSS ASSESSING FOR FAT LOSS. Orbital region Upper arm: Mid-axillary, just above the iliac crest (orbital fat pads) triceps brachii ASSESSING FOR FAT LOSS ASSESSING FLUID STATUS ASSESSING FLUID STATUS.

8 ETIOLOGY: Ribs Edema Definition: abnormal retention of fluid in interstitial spaces and When plasma proteins are depleted, there is cavities decreased oncotic pressure (colloid osmotic Commonly found: ankles, feet, sacrum, scrotum, vulva pressure), and thus increased capillary filtration. Ascites This results in increased fluid accumulation in the interstitial spaces (edema). Anasarca Several common conditions are associated with fluid accumulation. Rule these out before using fluid retention as a malnutrition criteria. CHF. Kidney disease Liver disease Lymphatic obstruction Image: Nicholls, Horace (Photographer) [Public domain], via Wikimedia Commons Critical illness 5. 4/7/2016. ASSESSING FLUID STATUS ASSESSING FLUID STATUS ASSESSING FLUID STATUS.

9 PITTING EDEMA: PITTING EDEMA: PITTING EDEMA: Excess interstitial fluid O'Sullivan Hogan Presence of pitting 1+ Barely detectable 2mm depression, after pressure is impression immediate rebound applied for at least 5 2+ Slight indentation 4 mm pit, a few seconds 15 seconds to seconds to rebound rebound No universally agreed upon definition of 3+ Deeper indentation 6 mm deep pit, 10-12. 30 seconds to seconds to rebound grades rebound Typically classified as 4+ >30 seconds to 8 mm very deep pit, 1+ (mild) to 4+ (severe) rebound >20 seconds to Useful for relative rebound changes O'Sullivan, and Schmitz (Eds.). (2007). Physical rehabilitation: assessment and treatment (5th ed.). Philadelphia: F. A. Davis Company. Image: Litchford 2013 Hogan, M (2007) Medical-Surgical Nursing (2nd ed.)

10 Salt Lake City: Prentice Hall Source: ASSESSING FLUID STATUS ASSESSING FLUID STATUS Physical Exam Parameters Useful in the Assessment of Nutritional Status Exam areas Tips Severe Malnutrition Mild-Moderate Well Nourished Subcutaneous fat loss Malnutrition Orbital Region View patient when Hollow look, Slightly dark circles, Slightly bulged fat HYDRATION: OBJECTIVE MEASURES: Surrounding the Eye standing directly in front of them, touch above cheekbone depressions, dark circles, loose skin somewhat hollow look pads. Fluid retention may mask loss Skin turgor/elasticity Vital signs Upper Arm Region- Arm bent, roll skin Very little space Some depth pinch, but Ample fat tissue Triceps/biceps between fingers, do not between folds, fingers not ample obvious between folds include muscle in pinch touch of skin Skin tenting Intake/output Thoracic and Lumbar Region - Ribs , Lower Have patient press hands hard against a Depression between the ribs very apparent.