Nutrition-Focused Physical Findings

Blood Pressure: elevated (adults)

- Systolic blood pressure (SBP) mm Hg: 120 - 129 AND - Diastolic blood pressure (DBP) mm Hg: < 80

Blood Pressure: Stage 1 hypertension (adults)

- Systolic blood pressure (SBP) mm Hg: 130 - 129 OR - Diastolic blood pressure (DBP) mm Hg: 80 - 89

Blood Pressure: normal (adults)

- Systolic blood pressure (SBP) mm Hg: < 120 AND - Diastolic blood pressure (DBP) mm Hg: < 80

Blood Pressure: Hypertensive crisis-Emergency

- Systolic blood pressure (SBP) mm Hg: > 180 AND/OR - Diastolic blood pressure (DBP) mm Hg: > 120

Blood Pressure: Stage 2 hypertension (adults)

- Systolic blood pressure (SBP) mm Hg: ≥ 140 OR - Diastolic blood pressure (DBP) mm Hg: ≥ 90

Steps 1-2 in Clinical Reasoning

1. Identify abnormal findings or symptoms ◦ Example: ◦ Low Hgb/Hct, elevated MCV, dx of mild cognitive impairment ◦ Diet hx indicates pt prefers veggies & breads; dislikes milk, meat & eggs 2. Localize the findings anatomically ◦ Example: ◦ Identify physical signs of anemia, numbness in feet or hands, beefy red tongue

eNCPT Categories-NFPF

1. Overall findings 2. Adipose 3. Bones 4. Cardiovascular-pulmonary system 5. Digestive system 6. Edema 7. Extremities 8. Eyes 9. Genitourinary system 10. Hair 11. Head 12. Hand and nails 13. Mouth 14. Muscles 15. Neck 16. Nerves, cognition, and feelings 17. Skin 18. Teeth 19. Throat and swallowing 20. Tongue 21. Vital signs

Step 3-4 in Clinical Reasoning

3. Interpret findings in terms of probable process ◦ Example: ◦ Labs, health history, diet history, and physical signs that suggest nutritional anemia 4. Make hypothesis about the nature of the patient's problem ◦ Example: ◦ Nutrition diagnoses that address dietary history, labs, and physical findings

Steps 5-6 in Clinical Reasoning

5. Test the hypothesis and establish a working diagnosis ◦ Example: ◦ Request lab work for serum vitamin B12, folate, methylmalonic acid 6. Develop a plan agreeable to the patient ◦ Example: ◦ Nutrition interventions specific to the nutrition diagnosis

Eating Disorders: AN

Anorexia Nervosa: ◦ Lanugo hair formation ◦ Brittle hair and nails ◦ Dry, yellowish skin ◦ Mild muscle wasting and weakness ◦ Slowed breathing and pulse ◦ Delayed growth and development ◦ Amenorrhea

Vitamin Deficiencies: Thiamin

Beriberi ◦ Fatigue ◦ Vomiting ◦ Palsies of the eye movement ◦ Pretibial (shin) edema --> ◦ Difficulty climbing stairs or standing on one leg, ataxia ◦ Mental impairment leading to confusion, delusions, hallucination, or psychosis ◦ Tachycardia ◦ Chest pain, abdominal discomfort ◦ Hypotension

Eating Disorders

Bulimia Nervosa ◦ Chronically inflamed or sore throat ◦ Swollen salivary gland in neck and jaw ◦ Worn tooth enamel ◦ GERD ◦ Russel's Sign

Excesses

Lead poisoning ◦ Blue-black line on the gums ◦ Abdominal pain ◦ Constipation ◦ Nausea ◦ Vomiting ◦ Changes in mood ◦ Peripheral neuropathy ◦ Memory loss ◦ Encephalopathy

Respiratory rate

Normal Range at Rest (adult): 14-20 breaths/min

Heart rate or pulse rate

Normal Range at Rest (adult): 60-100 beats/min

Oxygen saturation

Normal Range at Rest (adult): 97-99%

Temperature

Normal Range at Rest (adult): 97.8-99°F

Blood pressure

Normal Range at Rest (adult): <120/<80 mm Hg

Digestive System: Abdomen

Observe abdomen for ascites, obesity, pregnancy, bloating, constipation, abnormal lesions, concave shape Ask: ◦ Are you having any abdominal pain or tenderness? ◦ Have you had any nausea or vomiting? ◦ Do you have any abdominal distention or feel bloated? ◦ Do certain foods upset your stomach, give you heartburn, reflux, or excessive belching? ◦ Are you experiencing early satiety, altered taste, or poor appetite? ◦ Have you had any changes in bowel habits (diarrhea, constipation)?

Digestive System: Oral Cavity

Observe face, lips, and mouth for cheilosis, xerostomia, swollen parotid glands, and stomatits Ask: ◦ Does your mouth feel dry? ◦ Do you have increased difficulty swallowing medications? ◦ Do you have pain with chewing or swallowing? ◦ Do you have any broken or missing teeth? ◦ Do your gums bleed easily? ◦ Do you have sores or lumps inside your mouth? ◦ When was the last time you saw the dentist for a check-up?

Vitamin Deficiencies: Niacin

Pellagra ◦ Inflamed mucous membranes ◦ Dermatitis, scaly skin sores ◦ Diarrhea ◦ Delusions/dementia, mental confusion ◦ Death if left untreated

Vitamin Deficiencies: Vitamin B12

Pernicious anemia ◦ Lemon-yellow-tinged pallor ◦ Glossitis (Raw, beefy red tongue, smooth texture) ◦ Paresthesia in extremities ◦ Loss of sense of touch ◦ Changes in gait ◦ Stiffness in arms and legs ◦ Dementia ◦ Hallucinations ◦ Paranoia

Wounds

Pressure sores (Stage 1-4) ◦ Ankles, back, breast, buttock, dorsum of foot, elbow, head, heel, hip, knee, shoulder, coccyx, sacrum ◦ Require increased nutritional intake based on stage of wound

Vitamin Deficiencies: Vitamin C

Scurvy ◦ Perifollicular hemorrhage or petechiae ◦ Follicular hyperkeratosis ◦ Corkscrew hair ◦ Gingivitis (swollen, red gums that bleed easily)

Mineral Deficiencies

Zinc ◦ Delayed wound healing ◦ Acrodermatitis enteropathica ◦ Loss of appetite or taste ◦ Weight loss ◦ Beau's lines (transverse ridges) Iodine ◦ Goiter

What do we use Nutrition-Focused Physical Findings for?

• Determine and monitor/evaluate changes in: - excessive/inadequate intake - vitamins and/or mineral - fluid - parenteral/enteral nutrition • overweight/obesity • underweight • unintended weight loss • malnutrition (undernutrition)

Cushingoid Appearance

• Does the pt have an appearance that would be expected in a person with Cushing's disease? ◦ Does the pt have fatty tissue deposits, particularly around the midsection and upper back? ◦ Does the pt have a 'moon face?' ◦ Does the pt have a 'buffalo hump?' ◦ Does the pt have thin fragile skin that bruises easily? ◦ Observed any slow healing cuts, bites, infections?

Techniques of Physical Exam: Auscultation

• Use of the naked ear or stethoscope to listen to body sounds (heart and lung sounds, bowel sounds, blood vessels) • inspection and palpation are used most often in nutrition-focused physical exams. RDNs can be trained in percussion and auscultation.

Body Language

• What are the verbal/nonverbal messages related to... ◦ food? ◦ health? ◦ fitness, etc? ◦ preventative medicine/health promotion?

Techniques of Physical Exam: Percussion

• assessment of sounds to determine body organ borders, shape, and position • Use the striking/plexor finger (2nd or 3rd finger on dominant hand) to deliver a rapid tap or blow against the distal pleximeter finger (3rd finger on non-dominant hand) laid against the surface of the chest or abdomen to evoke a sound wave and tactile vibration against the pleximeter finger

Techniques of Physical Exam: Inspection

• close observation of details of the patient's appearance, behavior, and movement (facial expression, mood, body habitus, conditioning, skin color, edema • uses senses of sight, smell, and hearing

What are Nutrition-Focused Physical Findings?

• nutrition-related physical signs or symptoms associated with pathophysiological states derived from: - nutrition-focused physical exam (direct observation) - interview (patient/client report) - health record

Techniques of Physical Exam: Palpation

• tactile examination to feel pulsations and vibrations (edema, skin warmth, texture, tenderness, etc.) • use the palmar fingers or fingertip pads to assess areas of skin elevation, depression, texture, size, temperature, tenderness, and mobility

Edema

◦ +1 pitting edema ◦ +2 pitting edema ◦ +3 pitting edema ◦ +4 pitting edema ◦ Anasarca ◦ Ascites ◦ Edema of ankle, calf, eyelid, foot, hand, scrotum, thigh, vulva, sacrum, mucosa, lungs

Malnutrition: Context

◦ Acute illness or injury - Marked inflammatory response - Often severe - Major infection, burns, trauma, closed head injury ◦ Chronic illness - Organ failure, cancer, rheumatoid arthritis, sarcopenic obesity ◦ Social or environmental circumstances - Knowledge/beliefs/attitudes negatively impacting intake, factors affecting access to food or nutrition-related activities of daily living

Vitamin Deficiencies: Vitamin D

◦ Bowed legs (rickets) ◦ Rachitic rosary (rickets) ◦ Kyphosis (osteoperosis) ◦ Broken/fractured bones

Overall Appearance-First Impressions (Con't)

◦ Do you notice unexpected odors, such as the fruity aroma of DM or alcohol or marijuana? ◦ How is the person dressed? How is their personal hygiene? ◦ Is the clothing appropriate for the season of the year and room temperature? (Cold intolerance may be related to hypothyroidism or nutritional anemia.) ◦ If the patient is wearing shoes, have the toes been cut out? Are the laces tied? (Untied laces may indicate pedal edema.) ◦ Is the patient wearing slippers? (Cut out holes and slippers may indicate gout or foot ulcers. Slippers may indicate pedal edema.)

Affect (emotion)

◦ Does the patient show signs of emotional distress? ◦ Does the patient seem depressed, inexpressive, or exhibit a flat affect? ◦ Is the patient overly anxious?

Amputations

◦ Does the pt have an amputation? ◦ Is the amputation consistent with the documentation in the medical record? ◦ Is the stump healed? ◦ If not, do you see signs of infection or smell strong odors?

Classifying Blood Pressure in Children and Adolescents (1 to 17 Years of Age)

◦ Hypertension is an average SBP or DBP ≥ 95th percentile of BP for sex, age, and stature on three or more occasions. ◦ Prehypertension is an average SBP or DBP ≥ 90th percentile but < 95th percentile for sex, age, and stature on three or more occasions. ◦ Adolescents with BP ≥ 120/80 mm Hg but < 95th percentile should be considered pre-hypertensive.

Tanner Stage (children and teens)

◦ Is the developmental age consistent with chronological age? ◦ Are there signs of nutrient deficiency that may have contributed to delayed growth and development? ◦ Are there signs or developmental delays that impact food intake?

Ability to Communicate

◦ Is the pt able to communicate? ◦ Is there a language barrier? ◦ Is the pt aphasic? ◦ Garbled language? ◦ Easily short of breath? ◦ Can the person hear you speaking? ◦ Does the pt answer questions appropriately? ◦ Does the pt project signs of readiness to make lifestyle changes?

Overall Appearance- First Impressions (con't 2)

◦ Look at the face, eyes, and hands. What does the color of the skin and/or sclera suggest? Pallor, jaundice, cyanosis, or healthy? ◦ Look at the hair and fingernails for signs of nutrient deficiencies or toxicities. (Changes in hair and nails can be related to medications.) ◦ Look at the mouth, teeth, and gums for signs of nutrient deficiencies. ◦ Listen to the patient talking. Do the dentures 'click' while the person is speaking? (This suggests poorly fitting dentures possibly related to unintentional weight loss.)

Malnutrition: Characteristics

◦ Non-severe vs. Severe ◦ Energy intake ◦ Weight loss ◦ Loss of subcutaneous fat ◦ Muscle loss (atrophy) ◦ Fluid accumulation (edema) ◦ Reduced grip strength

Overhydration

◦ Shortness of breath ◦ Orthopnea ◦ Edema ◦ Increased blood pressure ◦ Tachycardia ◦ Distended neck veins ◦ Death if left untreated

Overall Appearance-First Impressions

◦ What is the apparent state of health? ◦ Is the patient acutely or chronically ill? ◦ Does the patient appear frail, or fit, or obese? Tall or short? ◦ What is the level of consciousness? ◦ Is the patient awake, alert, confused, anxious? ◦ Does the patient show signs of physical distress? ◦ Does the patient have labored breathing? ◦ What is the person's posture? ◦ Any involuntary movements or signs of paralysis?

Body Habits

◦ What is the body type or physique? ◦ Is the patient an ectomorph, mesomorph, or endomorph? ◦ Is the BMI consistent with visual assessment of habitus? ◦ How does the pt describe appetite? ◦ Is the self-reported appetite consistent with visual assessment of habitus?

Vitamin Deficiencies: Vitamin A

◦ Xerosis (dryness) of skin and eyes ◦ Night blindness or impaired night vision ◦ Follicular hyperkeratosis ◦ Dry hair and brittle nails ◦ Hazy dry softened cornea ◦ Bitot's spots ◦ Keratomalacia ◦ Hardened cornea