Nutrition Assessment Final

Definition of the nutrition-focused physical exam

• hands-on, focused physical assessment done by the dietitian as part of the Nutrition Care Process (NCP)

• Used to identify nutrition-related problems

• Involves assessing muscle and fat stores, oral health, swallow ability, appetite, and overall appearance

• Helps confirm or identify a nutrition diagnosis (PES statement)

• Guides nutrition intervention goals (e.g., texture changes, intake goals)

• Provides baseline data for monitoring and evaluation of outcomes

• Focused assessment (select body systems)

• the comprehensive history and physical exam performed by physicians and nurses

The clinical characteristics considered for a diagnosis of malnutrition

ASPEN AND: energy intake, weight loss, body fat, muscle wasting,loss of subcutaneous fat, fluid accumulation, reduced grip strength (2/6)

GLIM: Phenotype: Weight Loss (%), Low Body Mass Index, Reduced Muscle Mass

etiologic: Reduced Food Intake, inflammation or disease burden

One of each at least

Tools we need/can use to conduct the NFPE

Steps to the NFPE

• General Survey – Assess resident’s appearance and compare findings with medical records and other patient data.

• Body Habitus Evaluation – Assess body habitus (shape/build), BMI, and weight changes.

• Hands-On Physical Assessment – Evaluate body systems, skin, hair, nails, and oral cavity for signs of nutrient deficiencies or excesses.

Techniques of the NFPE

inspection: Close observation of the details of the patient’s appearance, behavior, and movement

•Palpation à Tactile examination to feel pulsations and vibrations à use fingertip pads to assess areas of skin elevation, depression, texture, size, temperature, tenderness, and mobility

normal values for blood pressure

<120/80 

normal values for heart rate

• Children (1–3 years): 80–130 bpm

• Preschoolers (3–5 years): 80–120 bpm

• School-age (6–12 years): 70–100 bpm

• Adolescents (13–18 years): 60–100 bpm

• Adults (18+): 60–100 bpm

normal values for respiratory rate

12-20 breaths per minute

Characteristics of fat and muscle loss in different areas of the body
(what is moderate versus severe loss look like)

Edema scale

0+ No pitting

1+ Mild pitting 2mm disappears rapidly

2+ moderate pitting 4mm 10-15 seconds

3+ moderately severe 6mm >1 minute

4+ severe pitting 8mm >2 minute

Factors that contribute to dehydration

Elderly
History of dysphagia (trouble swallowing)
Depression
Congestive heart failure
Draining wounds
Meds that promote fluid loss
NPO or fluid restriction
Unplanned weight loss (rapid weight loss is often due to fluid)

how to assess fluid status

Skin Tenting (Lightly pinch skin using the thumb and forefinger, BUT Turgor (elasticity) is slower in older adults)

Measure capillary refill time (Gently squeeze each nail, color should return in 3 secs)

wound healing stages

stage 1 hemostasis (non-healing, wound is being closed by clotting)

stage 2 inflammation (partial granulation, swelling, warmth)

stage 3 Proliferative (partial granulation transitioning to fully granulating, beefy red, pink epithelial tissue covers the wound)

stage 4 fully granulating (from pink scar to translucent silver then white)

Niacin deficiency

Pellagra

3 D’s- dermatitis, diarrhea, and dementia

thick, scaly, darkly pigmented rash

B12 deficiency

pernicious anemia, tingling or numbness in hands & feet, impaired cognitive status

pressure ulcer stages

Suspected Deep Tissue Injury: Purple or Maroon Area, Discolored Intact Skin or Blood-Filled Blister

Stage 1: Non-Blanchable Erythema (Intact Skin, Localized Redness)

Stage 2: Partial Thickness (Open, reddened skin, only in the epidermis)

Stage 3: Full Thickness Skin Loss (Subcutaneous fat and slough may be visible but bone, tendon, and/or muscle are not)

Stage 4: Full Thickness Tissue Loss (Exposed bone, tendon, or muscle, Slough may be present, Often includes tunneling or
undermining, Depth varies by location)

Unchageable/Unclassified: Full thickness tissue loss, Depth of tissue is obscured by slough and/or eschar

Acanthosis Nigricans NFPE findings

Increased brownness of skin, areas of darker, thick, velvety skin in
body folds and creases, can turn to black

insulin resistance, obesity, type 2 diabetes, polycystic ovary syndrome (PCOS), and sometimes low vitamin D levels.

thiamine def

cyanosis:Increased concentration in cutaneous blood vessels gives skin a
bluish cast

wasting definition (PEM)

• A low weight-for-height
• May be described as “thinness” or “underweight.
• Often develops rapidly but can be reversed quickly
with appropriate nutrition support
• A more sensitive indicator of change in nutritional
status than is height-for-age

stunting definition (PEM)

• A low height-for-age
• May be described as “shortness.
• Generally the result of long-term, inadequate food
intake or poor diet quality

Beau’s Lines def and may be related to

horizontal, deep grooves or ridges running across fingernails or toenails

Severe infection, heart attack, uncontrolled diabetes, malnutrition, chemotherapy

zinc/protein def

percent weight for height formula

(actual weight/expected weight)x100

percent height for age formula

(actual weight/expected weight)x100

cachexia

Marked physical wasting and malnutrition typically
associated with some chronic disease

Not eating losing muscle mass

Koilonychia

•Spoon-shaped concave nails

•Causes may include iron deficiency, malnutrition, protein deficiency, diabetes, lupus, and Raynaud’s

cheilitis def and can mean what?

inflammation of the lips, causing symptoms like cracking, scaling, redness, and itching, often at the corners

fungi, bacteria, nutrient deficiency (B-vitamins, iron)

stomatitis

inflamed and sore mouth – malnutrition, B-vitamins, iron

SGA forms based on

4 elements of patient’s history:

1.recent loss of body weight

2.changes in usual diet

3.presence of significant GI symptoms

4.patient’s functional capacity

3 elements of physical exam:

1.loss of subcutaneous fat

2.muscle wasting

3.presence of edema or ascites

SGA A

•No decrease in food intake

•< 5% weight loss

•No/minimal symptoms affecting food intake

•No deficit in function

•No deficit in fat or muscle mass

SGA B (Moderately malnourished)

• definite decrease in food intake

• 5%-10% weight loss without stabilization or gain

• mild/some symptoms affecting food intake

• Moderate functional deficit or recent deterioration

• Mild/moderate loss of fat and/or muscle mass

SGA C

(Severely malnourished)

severe deficit in food/nutrient intake

>10% weight loss which is ongoing

significant symptoms affecting food/nutrient intake

severe functional deficits

Mild to moderate inflammation: type of malnutrition?

Chronic disease-related malnutrition

(ex: organ failure, pancreatic cancer, rhematoid artheritis)

marked inflammatory response means what?

acute disease or injury-related malnutrition (ex: major infection, burns, trauma)

static vs functional tests

Static tests (direct):
Measurements based on measurement of nutrient or metabolite in blood, urine, or body tissue (fail to reflect overall nutrition

Functional tests (indirect): Based on ultimate outcome of a nutrient
deficiency which is failure of the physiologic
processes that rely on that nutrient
• Example: Measurement of dark adaptation
of eyes (assesses vitamin A status)

somatic vs visceral protein

• Somatic Proteins: found within skeletal muscle
• 75% of all body proteins

Visceral Proteins: protein within
organs or viscera of the body (liver,
kidneys, pancreas, heart, RBCs, serum)
• 25% of all body proteins

pos nitrogen balance

intake exceeds output

neg nitrogen balance

output exceeds intake

nitrogen balance=equilibrium

healthy adult state

prealbumin def/uses

• Synthesized in liver
• Transport protein for thyroxine
and carrier for retinol-binding protein
• Short half life (2-3 days)
• Sensitive indicator of protein status (best)

Decreases rapidly in early malnutrition, but does not
mean patient has diagnosis of malnutrition
• Increases rapidly once adequate nutrition therapy begins
• Assesses recent dietary intake
• Increased in CKD on dialysis
• Decreases in hyperthyroidism, protein wasting, nephrotic
syndrome

albumin def/uses

• Indicator of depleted protein
status and decreased
protein intake over several
weeks
• DOES NOT = Malnutrition
• Works to maintain fluid
balance in the blood
• Long half life 14-20 days
• Responds slowly to
nutritional change

“Worst one”

transferrin def/uses

• transport protein for iron

• shorter half-life

• considered better index of changes in protein status compared to albumin

ferritin def/uses

storage form of iron

hemoglobin def/uses

• Contains iron in RBC, carries Oxygen and
CO2
• Index of the blood’s oxygen carrying
capacity

hematocrit def/uses

Packed cell volume
• Percentage of RBC that make up the
entire volume of blood

stages of iron depletion

1. Depleted stores

2. early functional iron deficiency (without anemia)

3. iron deficiency anemia

low anemia (Microcytic) lab

<80 MCV

normal anemia/ Normocytic lab

80-99 MCV

high anemia (Macrocytic

>100 MCV

high/low levels of blood calcium can represent

Low: (hypocalcemia):

• Renal disease

• Pancreatitis

High: (hypercalcemia):

• Bone resorption (e.g., bone breakdown)

• Excess vitamin D intake

high/low levels of sodium can represent

Elevated (hypernatremia): dehydration, excessive output, loss of ADH control which reduces sodium concentration by
increasing water retention

Decreased (hyponatremia): overhydration, fluid retention, excess sodium loss through diuretic use, vomiting, diarrhea

high/low potassium can represent

Elevated: (hyperkalemia)
due to renal failure most
commonly
• Decreased: (hypokalemia)
due to diuretics
(excessive loss in urine),
IV fluids, vomiting,
diarrhea, eating disorders

triglycerides lab values

• Normal: <150mg/dL
• Borderline High: 150-199mg/dL
• High: 200-499mg/dL
• Very High: >500mg/dL

total cholesterol lab value

<200mg/dL

LDL lab optimal??

Optimal: <100mg/dL

HDL lab

Optimal: ≥60mg/dL (men >45, women
>55)

Hemoglobin A1C def/uses

Form of hemoglobin that is measured to identify the 3-month average plasma glucose concentration

Used to diagnose diabetes

• 6.5% or higher indicates DM
• 5.7-6.4% indicates Pre-
diabetes
• <5.7% = normal

Biochemical indicators of Diabetes Mellitus

• Fasting blood glucose (126 mg/dL or higher on two separate tests,100-125 mg/dL is considered prediabetes
• Random plasma glucose test (>/=200 mg/dL)
• Hemoglobin A1C (6.5% or higher indicates DM, 5.7-6.4% indicates Pre-diabetes, <5.7% = normal)
• Oral glucose tolerance test

Biochemical indicators of coronary heart disease

Triglycerides, LDL, HDL, Total Cholesterol (Lipid
Panel), Homocysteine, C-Reactive Protein (inflammation) 1- 3mg/dL and >3mg/dL (moderate-high risk)

Biochemical labs of liver function

AST ALT ALP bilirubin

AST ( Alanine Aminotransferase)

Enzyme in liver

Normal: 7-55 IU/L

Alkaline Phosphatase (ALP)

Normal 30-130U/L

enzyme in liver

Aspartate Aminotransferase (AST/SGOT)

Enzyme in liver

Normal 10-40 U/L

Bilirubin

Major pigment of bile, produced by spleen, liver, and bone marrow

Can be absorbed by the liver and excreted in bile

Serum level >2mg/dL=jaundice
Normal levels= 0.1-1.2mg/dL

biochemical labs of kidney function

BUN, creatinine, GFR

BUN

• Urea is a waste product made in the liver when protein is broken down and is removed by the kidneys in urine

• is an indicator of how well the kidneys are removing nitrogen waste from the blood.

• If BUN is high, it may suggest the kidneys are not filtering properly (or there’s dehydration or high protein breakdown).

• If BUN is low, it can be due to reduced production (like liver disease) or overhydration.

• Normal: 7–20 mg/dL

Creatinine

• Waste product of normal
  breakdown of muscle tissue

• normally filtered out by the
  kidney
  • Used to evaluate renal
  function
  • Elevated when 50% or more of
  kidney’s nephrons are destroyed
  • Poor clearance by kidney
  • Reference Range = 0.6-
  1.2mg/dL

Glomerular filtration rate (GFR)

estimate of how well the kidneys are filtering blood, based mainly on how efficiently they clear creatinine.

• It reflects the rate at which the kidneys filter waste from the blood.

• It can be estimated using serum creatinine levels in a formula (since creatinine builds up when kidney function decreases).

• It can also be estimated by comparing creatinine levels in urine and blood.

If creatinine is high in the blood and low in the urine, that suggests the kidneys are not filtering well (poor clearance → lower GFR)

types of bones

1) cortical –

• very dense,

• forms outer shells of bones

• (80% of bones)

• found primarily in limb bones

• trabecular

• fine

• sponge-like

• inner shell

• (20% of bones)

• found primarily in skull and vertebral bones

• faster turnover rate

Glossitis

inflammation of tongue, def b12