Nutrition Focused Physical Examination: Overview and ...

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: 4/7/20161O V ERV I EWANDA P P L ICAT I ONNUTRITION-FOCUSEDPHYSICALEXAMINATION:L O LA R O S E W I G,M P H,RDC L I N I C AL D I E T I T I ANU N I V E R S I TYOFM I C H I G ANHEALTHS Y S T EMOVERVIEWM alnutritionNutrition-FocusedPhysicalExam DocumentationandApplicationHOSPITALMALNU TRITION IS WIDESPREAD ASPEN(AmericanSocietyofParenteral and Enteral Nutrition ), Nov 2013,JPEN Multiplestudiesfindthatapproximatelyonei n every three adult patients admittedtoahospital intheUnitedStatesissufferingfrommalnutri tionPEDIATRIC MALNUTRITION Reportedaprevalenceof6% 51%in hospitalizedchildren.

2 However,itiswellknownthatagapexists betweendiagnosingmalnutritionin et al. JPEN2016 IMPACT OF HOSPITALMALNUTRITION MorbidityandMortality Developmentofpressureulcers Reducedmusclemass decreasedstrength/ debility riskoffalls Nosocomialinfections Qualityoflife Increasedlengthofstay(LOS) ReadmissionandInstitutionalization CostConsensusStatement:Academyof NutritionandDietetics andAmericanSocietyforParenteral andEnteralNutrition:CharacteristicsRecom mendedfortheIdentificationandDocumentati on ofAdultMalnutrition(Undernutrition). ,PhD,RD,FADA1;PeggiGuenter,PhD,RN2;Gordo nJensen,MD,PhD,FASPE;AinsleyMalone,MS,RD ,CNSC;MarshaSchofield,MS,RD53;tbeAcademy MalnutritionWorkGroup; ; IS DEFINITIVEFORADULT MALNUTRITION MUSTMEETATLEAST2 OFTHE6 CRITERIAFORDIAGNOSIS: Insufficientenergyintake Weight loss Lossofmusclemass Lossofsubcutaneousfat Localizedorgeneralizedfluidaccumulation( thatmay sometimesmaskweightloss) Diminishedfunctionalstatusasmeasuredbyha nd-grip strengthWhiteet al.

3 ,..,.. U MC MMLI1" ,.ConsensusStatementoftheAcademyof NutritionandDietetics/AmericanSocietyfor ParenteralandEnteralNutrition:Indicators Recommended fortheIdentification andDocumentationofPediatricMalnutrition (Undernutrition)PatriciaBecker,MS,RD,CSP ,LDN,CNSC1 Liesje NiemanCarney,RD,CSP,LDN3;; ,MD, CNSC,FAAP2;JessicaMonczka,RD,LDN,CNSC ;4 ElizabethSmith,RD,LDN, CNSC3 ,RD,CSP,LD5;; ,PhD,RDN,LD6; ,PhD,RD,LDN,FAND7;AcademyofNutritionandD ietetics;andAmericanSocietyfor ParenteralandEnteralNutritionutritioninC JjnicalPracticeVolume30 Number IFebruary2015147 161C2014 AmericanSocietyforParenteralandEnteral utritionandAcademyofutritionandDietetics [X)( ($) ,'ool =Michigan'sInalnutritiondiagnostictoolNO SINGLEPARAMETER IS DEFINITIVEFOR PEDIATRIC MALNUTRITION Food/NutrientIntake AssessmentofEnergyandProteinNeeds GrowthParameters/AnthropometricMeasureme nts.]

4 Percentiles/z-scores Weightforage Height/lengthforage BMI/weight-for-lengthforage WeightGainVelocity Mid-UpperArmCircumference(MUAC) HandgripStrength Nutrition -FocusedPhysicalFindingsNUTRITI ON-FOCUSEDPHYSICALEXAMPARTOFTHENUTRITION CAREPROCESSNUTRITION CARE PROCESSN utritionAssessmentNutritionDiagnosisNutr itionInterventionMonitoring &EvaluationNUTRITIONASSESSMENTFood/Nutri tion-RelatedHistoryBiochemical Data,Medical Testsand ProceduresAnthropometric MeasurementsNutrition- Focused Physical FindingsClientHistory4/7/20163 Nutrition - Focused PHYSICALEXAMGETTINGSTARTED: Prepareforpatientinteraction Standardanduniversalprecautions Physicalexamtechniques: Inspection closeobservation Palpation tactileexamination Percussion elicitasoundwave Auscultation listeningtobodysoundsOVERALLAPPEARANCE/F IRST IMPRESSIONSL itchford, 2013 The NFPE beginswithageneralobservationofthepatien t.

5 Firstimpressionandphysical characteristicstonoteduringinterview: Whatistheapparentstateofhealth? Whatisthelevelofconsciousness? Doesthepatientshowsignsofphysicaldistres s? How isthe patient dressed? Doyouseeanyobvioussignsofnutrientdeficie ncies? Isthereanyinvoluntarymovementsorsignsofp aralysis?OVERALLAPPEARANCE/FIRST IMPRESSIONS Body positioning(musclecontractures,paralysis ) Body Language Body habitus Amputations Abilitytocommunicate AffectLitchford, 2013 ASSESSING FOR MUSCLELOSS Regions to assess: Upperbody: Temple Collarbone Shoulder Shoulderblade Hand Lower body: Thigh/knee CalfASSESSING FOR MUSCLELOSST emporalisImage: Litchford 2013 ASSESSING FOR MUSCLELOSSC lavicular region:Pectoralismajor,deltoid, trapeziusmuscles4/7/20164 ASSESSING FOR MUSCLELOSSS houlder region:DeltoidmuscleImage: Nicholls, Horace (Photographer)[Public domain], via WikimediaCommonsASSESSING FOR MUSCLELOSSASSESSING FOR MUSCLELOSS Hand.

6 InterosseousmuscleImage: Litchford 2013 ASSESSING FOR MUSCLELOSSA nteriorthigh/patellarregion: QuadricepsfemorisgroupASSESSING FOR MUSCLELOSSP osterior calf: Gastrocnemius and soleusASSESSING FOR FAT LOSS Regions to assess: Orbitalregion(orbitalfatpads) Upperarmregion(tricepsbrachii) Mid-axillaryattheiliaccrest Ribs4/7/20165 ASSESSING FOR FAT LOSS Orbitalregion(orbitalfatpads)ASSESSING FOR FAT LOSS Upperarm:tricepsbrachiiASSESSING FOR FAT LOSS Mid-axillary,justabovetheiliaccrestASSES SING FOR FAT LOSS RibsImage: Nicholls, Horace(Photographer)[Publicdomain], via WikimediaCommonsASSESSING FLUID STATUS Edema Definition: abnormalretentionoffluidininterstitialsp acesand cavities Commonlyfound: ankles, feet, sacrum, scrotum, vulva Ascites AnasarcaASSESSING FLUID STATUSETIOLOGY: Whenplasmaproteinsaredepleted,thereis decreasedoncoticpressure(colloidosmoticp ressure),andthusincreasedcapillaryfiltra tion.

7 Thisresultsinincreasedfluidaccumulationi ntheinterstitialspaces(edema). Severalcommonconditionsareassociated CHF Kidneydisease Liverdisease Lymphaticobstruction Criticalillness4/7/20166 ASSESSING FLUID STATUSPITTING EDEMA: Excessinterstitialfluid Presenceofpittingafterpressureis appliedforatleast5 seconds Nouniversallyagreedupondefinitionofgrade s Typicallyclassifiedas 1+(mild)to4+(severe) UsefulforrelativechangesImage: Litchford 2013 ASSESSING FLUID STATUS PITTING EDEMA: O Sullivan, and Schmitz (Eds.). (2007). Physicalrehabilitation: assessment and treatment (5th ed.).Philadelphia: F. A. DavisCompany. Hogan, M(2007)Medical-SurgicalNursing (2nd ed.)

8 Salt Lake City: Prentice HallO SullivanHogan1+Barelydetectable impression2mmdepression, immediaterebound2+Slightindentation 15secondsto rebound4mmpit, afew secondstorebound3+Deeper indentation 30secondstorebound6mmdeeppit, 10-12 secondstorebound4+>30secondsto rebound8mmverydeeppit,>20secondstoreboun dASSESSING FLUID STATUS PITTING EDEMA:Source: FLUID STATUS HYDRATION: Skinturgor/elasticity SkintentingASSESSING FLUID STATUS OBJECTIVEMEASURES: Vitalsigns Intake/output Weight Fluidmaymaskweightand/ormuscleloss History Urineconcentration Imaging APPEARANCE: Skin/MucousmembranesPhysical Exam Parameters Usefulinthe Assessment ofNutritionalStatusExamareasSubcutaneous fat lossTipsSevereMalnutritionMild-ModerateM alnutritionWellNourishedOrbitalRegion Surrounding theEyeViewpatientwhenstandingdirectlyinf rontofthem,touchabovecheekboneHollow look, depressions,dark circles,looseskinSlightly dark circles, somewhathollowlookSlightly bulgedfat may mask lossUpperArmRegion-Triceps/bicepsArmbent ,roll skin betweenfingers,donot includemuscleinpinchVery littlespace betweenfolds,fingers touchSomedepthpinch,but notampleAmplefattissue obviousbetweenfolds of skinThoracicandLumbarRegion-Ribs.

9 LowerBack,MidaxillarylineHavepatientpres s handshard againsta solid objectDepressionbetween theribsvery apparent. IliacCrestvery prominentRibsapparent, depressionsbetween themlesspronounced. IliacCrestsomewhat prominentChestisfull,ribsdonot show. Slighttono protrusionof theiliac patientwhen standing directly in frontof them,ask patienttoturnhead sidetosideHollowing,scooping, depressionSlightdepressionCansee/feelwel l-defined muscleClavicleBoneRegion-PectoralisMajor , Deltoid,Trapezius MusclesLookfor prominent patientisnothunched forwardProtruding,prominent boneVisibleinmale,some protrusioninfemaleNotvisibleinmale, visiblebutnot prominentinfemaleClavicleandAcromionBone Region-DeltoidMusclePatientarmsatside.

10 ObserveshapeShouldertoarm joint protrusionvery prominentAcromionprocessmay slightlyprotrudeRounded,curvesat arm/shoulder/neck4/7/20167 Physical Exam Parameters Usefulinthe Assessment ofNutritionalStatusScapular BoneRegion Trapezius, Supraspinus, InfraspinusMusclesAsk patienttoextend handsstraightout, push againstsolid ,visible bones,depressions betweenribs/scapula or shoulder/spineMild depressionor bonemay show slightlyBonesnotprominent, nosignificant depressionsDorsalHand-InterosseousMuscle Look atthumbsideof hand; look atpadsof thumbwhentipof forefinger touching tip of thumbDepressed area betweenthumb-forefingerSlightly depressedMusclebulges,couldbe flatinsomewell nourished peopleLowerbodyless sensitivetochangePatellar Region QuadricepMuscleAsk patienttositwith leg propped up,bentat kneeBonesprominent,little signof musclearound kneeKneecapless prominent,more roundedMusclesprotrude, bonesnotprominentAnterior Thigh Region-QuadricepsMusclesAsk patienttosit,prop leg uponlow furniture.