NCP Nutrition focused physical exam

What is the purpose of a nutrition focused physical exam?

Purpose is to identify the risk for malnutrition or the existence of malnutrition by looking for symptoms and signs associated with malnutrition risk and frank malnutrition.

To distinguish between signs & symptoms associated with malnutrition, inflammation, and/or both.

What is the difference between signs vs. symptoms?

What the clinician observes; can be verified with objective data.

vs.

Subjective, patient’s experiences and are patient reported.

What are the 4 basic techniques of a physical exam?

Inspection: general observation

Palpation: tactile examination

Percussion: tapping on the surface to determine the underlying structure

Auscultation: listening for sounds made by internal organs

What are the universal precautions for a physical exam?

Standard precautions: Includes the use of hand washing, appropriate PPE (gloves, gowns, masks)

Transmission-based precautions: These are for patients with known or suspected infections or epidemiologically important pathogens that can be transmitted via contact with skin or contaminated surfaces.

• Airborne precautions: for infections spread in small particles, i.e., chicken pox

• Droplet precautions: for infections spread in droplets by coughing, talking, or sneezing, i.e., influenza

• Contact precautions: used for infections spread by skin to skin contact, i.e., herpes simplex virus

What to look for in visual inspection in a physical exam?

Look at the whole person! Go for a head to toe approach. Overall appearance(loose clothing, rings, dentition, muscle wasting, jaundice, edema, eyes, nails, skin).

Contractures, amputations. Feeding and vascular access devices. Wounds, drains, ostomies.

Ability to communicate.

What are visual indications of nutrient deficiencies in EYES?

• Bitot’s spots (white/gray spots on conjunctiva) = vitamin A deficiency

• Keratomalacia (drying, softening, haziness, ulceration of the cornea) = vitamin A deficiency

• Pale conjunctive = iron deficiency

What are visual indications of nutrient deficiencies in HAIR?

• Corkscrew hair: unmerged coiled hairs = vitamin C

• Observe the distribution, colour, and texture of hair.

• Thin, sparse, patchy = protein, biotin, zinc, iron.

What are ORAL signs of VIT B deficiencies?

• Riboflavin: soreness and intraoral burning; cheilosis (chapped, fissured lips); angular stomatitis (inflammation of mouth and lips), glossitis (swelling/inflammation of tongue) with a magenta tongue

• Niacin: intraoral burning, glossitis with red tip and sides

• Folic acid: gingivitis; glossitis with atrophy or hypertrophy of filiform papillae; angular cheilosis

• Vitamin B12: intraoral burning; mucosal ulcerations and erosions; painful glossitis with a beefy red or fiery appearance eventually resulting in an atrophic (smooth and shiny) tongue

What are ORAL signs of NUTRIENT deficiency?

• Vitamin C: sore and bleeding gums; gums deep blue-red colour; loose teeth

• Iron: cheilosis; atrophic glossitis; gingivitis; candidiasis; intraoral burning or pain; mucosal ulcerations and erosions; pallor

• Zinc: marked halitosis (bad breath); stomatitis; white coating on tongue

What are signs of nutrient deficiencies in NAILS

Thinning, flattening, or spoon-shaped nails = iron deficiency

How to interpret SKIN assessment for nutrient deficiencies?

• Pellagra = niacin

• Purpura = vitamin K, vitamin C

• Petechiae = vitamin K, vitamin C

• Perifollicular hemorrhage = vitamin C deficiency

• Yellow-orange pigmentation = beta-carotene excess

• Pallor = iron, folate, B12

• Poor skin turgor = dehydration

• Slow wound healing = zinc, vitamin C, protein

• Follicular hyperkeratosis = vitamin A, C

What are pressure injuries?

This is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical (or other) device. It can present as intact skin or an open ulcer and may be painful. It results from intense and/or prolonged pressure, or pressure in combo with shear.

Inadequate nutrition is a major risk factor for pressure injury development because of slow wound healing, inadequate function of immune, collagen synthesis, and tensile strength.

What are the stages of pressure injuries and their characteristics?

• Stage I: discolouration, intact skin, most treatable

• Stage II: partial thickness loss of epidermis and dermis

• Stage III: full thickness loss of dermis. Subcutaneous fat becomes visible.

• Stage IV: full thickness loss of epidermis, dermis, and subcutaneous tissues. bone, tendon, and muscle become exposed.

• Unstageable: full thickness tissue loss with unknown ulcer depth due to obscurity by slough or eschar.

• Suspected deep tissue injury: purple or maroon localized area of discolored skin intact or with blood-filled blister.

Unstageable and suspected deep tissue injuries are treated like a Stage IV

What is the MNT for pressure injuries?

• Increased energy, protein, and fluid requirements

  • Energy: 30 - 35 kcal / kg

    • Particularly for stages II, III, IV, unstageable DTI

    • 25-30 kcal/kg may be adequate for stage I

  • Protein: 1.25 - 1.5 g/kg

  • Fluid: >30 ml/kg

• Micronutrient supplementation

  • Multivitamin: if oral intake or enteral nutrition inadequate to meet needs

  • Vitamin C: 1000 - 2000 mg/day in divided doses for stages III, IV, unstageable, DTI

  • Zinc sulfate: only if deficiency is suspected (excess can lead to copper deficiency), 220mg daily for 10-14 days.

What is edema?

This is the increase in interstitial fluid volume that results in palpable swelling of a tissue or organ.

Why does edema occur? AKA its etiology

This occurs when fluid balance between interstitium and capillaries is disrupted through a change in hemodynamics of the capillary system that includes increased hydrostatic pressure, decreased capillary osmotic pressure, lymphatic dysfunction, and or increased capillary permeability.

What are abdominal ascites?

This is accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Common problem seen with cirrhosis.

How to assess abdominal ascites?

First, need to differentiate between swelling due to ascites vs gas/fat/feces.

• Assess bulging of flanks (fluid pressing outward in the supine position)

• Percuss abdomen from one flank to the other; listen for dullness of sound versus area with tympany near the top of the abdomen

• Turn patient to the side, with ascites, the area of dullness shifts.

What is skin turgor?

This is when skin remains elevated after being pulled up and release. Used to assess degree of fluid loss or dehydration.

What is a muscle and fat assessment?

This is assessing for muscle wasting (loss of bulk and tone) and fat depletion

• Use both inspection and palpation

• Upper body most often assessed (accessibility and convenience)

• Assessing muscle loss is difficult in overweight and obese patients, as well as the critically ill (edema, anasarca, positioning)

What are the common areas for muscle wasting?

• Temporalis

• Trapezius

• Pectoralis major

• Biceps

• Deltoid

• Latissimus dorsi

• Scapular region

• Acromion bone region

• Iliac crest

• Quadriceps

• Gastrocnemius (calf)

What to look out for in an oral/facial exam?

Look out for

• Temporal wasting

• Orbital fat pad

• Bichats (buccal) fat pad

• Prominent zygomatic process, zygomaticus major & minor muscles

• Prominent nasolabial skin fold

• Oral cavity: missing dentition, poorly fitting dentures, ulcers, oral thrush, lack of saliva

What to look out for in the clavicles/shoulder/upper arm exam

Look out for

• Prominent clavicular bones, protruding

• Patient arms at side, observe shape, shoulder to arm joint looks square, bones prominent, prominent acromion protrusion

• Triceps/biceps: ask pt to bend arm, roll skin between fingers, do not include muscle in pinch; fingers touch or little space between folds

What to look out for in a scapular, thoracic, and lumbar physical exam

Look out for

• Scapular bone prominence, visible. Depression between ribs/scapula or shoulders/spine.

• Depression between rib bones prominent, iliac crest prominent.

What to look out for dorsal hand exam

AKA interosseous muscle

Look out for

• Depressed area between thumb-forefinger

What to look out for in a lower extremities physical exam

Note that this area of the body is less sensitive to change with malnutrition.

Look out for

• Quadricep muscle bone (knee cap) prominence, little sign of muscle around the knee.

• Depression line on anterior thigh

• Thin, minimal to no muscle definition in the gastrocnemius muscle.