AssessTech: Nutrition Focused Physical Findings

NFPA in the NCP Clinical judgment (critical thinking) must be used to select indicators and determine the appropriate measurement techniques and reference standards for a given patient population and setting.

*Case Example* Indicator(s): Clubbing of nails Assessment Data Collected: Presence or Absence of indicator (use P or A) Criteria for Evaluation: Comparison to Goal or Reference Standard: Personal Goal: The patient will have uniform, rounded and smooth nails, absent from clubbing OR Reference Standard: Absence of clubbing of nails or clubbing of nail (A)

Micronutrient Derangements - Nutrition Etiologies (E from PES)

*Inadequate nutrient intake caused by:* > Medications that affect nutrient metabolism > Alcohol and drug addition > Decreased ability to consume sufficient amount > Lack of or limited access to food/supplies > Food and nutrition-related knowledge deficit > Lack of prior exposure to accurate nutrition-related information > Psychological causes - eating behavior serves a purpose other than nourishment (pica) *Physiological causes:* > Altered gastrointestinal track structure or function (short-bowel syndrome) > Increased demand for nutrients (wound healing) > Compromised organ function > Metabolic disorders, inborn errors of metabolism

Physical Exam Techniques Inspection

*Inspection = most frequently used; broad observations followed by a closer look, may use "naked eye" or pen light* *Technique* Sight, smell, and sound used to observe textures, sizes, colors, shape, odors, and sounds *Type of information obtained* > Body composition > Body habitus: obesity/cachexia > Fluid status > Mental status/level of consciousness > Skin integrity > Wound healing > Feeding devices > Jaundice > Ascites

Cardiovascular/Pulmonary Normal Health

*Normal cardiovascular/pulmonary function is characterized by normal breath sounds, normal heart rate and respirations and absence of:* Absent breath sounds Bradycardia/ Tachycardia Bradypnea/ Tachypnea Dyspnea (SOB) Decreased breath sounds/Increased breath sounds Respiratory crackles -- How can an abnormal cardiovascular/pulmonary finding affect nutrition status? - decrease ability to eat if can't catch breath (how to prepare, shop, eat) - also not able to exercise if too weak

Genitourinary system

*Normal function includes normal healthy kidney and reproductive function, with the absence of the following:* Anuria Delay in sexual development and/or puberty Amenorrhea Menorrhagia Oliguria Polyuria -- What could amenorrhea be indicative of? What nutrition problem could menorrhagia lead to? AMENORRHEA - eating disorder (low body weight) - also very high weight (obese) - hormonal imbalance > thyroid malfunction > PCOS - certain medications What nutrition problem could menorrhagia lead to? Anemia from excess bleeding

Why Should RDNs Use Nutrition-Focused Physical Assessment? II

*Reveals/confirms areas that indicate malnutrition and nutrient deficiencies, including:* > Macronutrients - energy, fluid, protein > Micronutrients - vitamins and minerals *Differs from the MD's physical exam in that NFPA:* > Focuses on areas that are most influenced by nutrition > Is used to form a nutrition diagnosis like inadequate energy intake (not a medical diagnosis, like anorexia nervosa > The diagnosis identified can be treated with a nutrition intervention, such as nutrition counseling (vs. a medical intervention, like medications or surgery) *Parts of another HCP's physical findings may be used for all or part of the NFPA (i.e. vital signs, edema)*

Micronutrient Derangements - Signs and Symptoms (S from PES)

*SIGNS AND SYMPTOMS* > Vitamin intake (B12, thiamin, etc.) - specify amount as compared to the standard or goal > Mineral intake (iron, Mg, etc.) - specify amount as compared to the standard or goal > Presence of: cachexia, jaundiced sclera, pale conjunctiva, corkscrew hairs, koilonychias, etc. > Pt reports presence of: asthenia, increased night blindness, increased loss of hair, etc. > Verbalizes inaccurate or incomplete information > History of multiple bowel resections *MONITORING AND EVALUATION* Note, your M&E indicators should be the same ones used in your signs and symptoms. Example: S/S - Bitot's spots: present M&E - Indicator: Bitot's spots Criteria: absent Time Frame: 2 weeks

Why Should RDNs Use Nutrition-Focused Physical Assessment?

*Standard practice for RDNs since 2012* *Provides objective information that cannot be gleaned from other assessment domains, including:* > Muscle and fat wasting (next week) > Swallowing function > Appetite > Affect/neurological status > Vital signs > Hydration status *Biochemical markers previously used to assess nutrition status are more indicative of inflammation, disease severity and morbidity and mortality* > Albumin, prealbumin

Subclass: Skin

*Use inspection and palpation to assess for: color, moisture, texture, elevation, temperature, lesions, turgor* Skin turgor - pinch small area on the forearm or sternal area between thumb and forefinger >> Adequate hydration: If the skin easily returns to place when released >> Under hydration or edema: The skin will not quickly return

Subclasses: Digestive System, Abdomen

A flat, rounded, or concave abdomen; Normal bowel sounds (5-35/minute), normal appetite; Absences of feeding devices - G-tube, J-tube. Color similar to other areas of the body. *Normal health includes the absence of the following indicators:* Anorexia, decreased appetite, early satiety, increased appetite, excessive appetite Abdominal bloating, distension, ascites (shiny and firm abdomen) >> Symmetrical - obesity, gas, fluid retention >> Asymmetrical - hernia, bowel obstruction, cyst Constipation, diarrhea, fatty stool, liquid stool, loose stool, excessive belching or flatus Epigastric pain, heartburn, nausea, vomiting, retching Drainage - gastrointestinal, gastric, pancreatic, wound, or intestinal fistula drainage volume

Objectives

Conduct a nutrition focused physical exam to assess clients for evidence of malnutrition as well as micronutrient deficiencies Understand the components of the Nutrition Care Process and how to apply this process in the assessment, reassessment and documentation of nutrition care for individuals and groups Conduct a nutrition assessment and document an appropriate nutritional diagnosis using a problem (P), etiology (E), signs and symptoms (S) statement Plan and implement nutrition interventions to resolve identified nutrition problems by addressing individual client needs Demonstrate an understanding of the pathophysiology of various disease states and the role of nutrition in the development and treatment of those disease states by correctly identifying nutrition diagnoses and interventions Enhance and apply critical thinking skills to nutrition care

Overhydration - Potential Causes

Excessive fluid intake - IV fluids, surgical procedures Interstitial fluid retention - Hypoalbuminemia Disease processes - Renal failure, liver failure, ascites, heart failure, severe HTN

NFPA in the NCP

Domain: Nutrition focused physical findings Definition: Nutrition-related physical signs or symptoms associated with pathophysiological states NA and NM&E Indicators: Blood pressure, central adiposity, disoriented, pale complexion, polyuria, clubbing of nails Indicate the value (98.6⁰F or presence (P) or absence (A) as applicable) >> if you don't write either it means you didn't assess it Measurement methods/data sources for these indicators: Direct observation, patient report, health record Interventions: Any nutrition intervention appropriate for the patient and setting Diagnoses: Excessive or inadequate intake of vitamins/minerals, fluid, parenteral/enteral nutrition; overweight/obesity, underweight, unintended weight loss, malnutrition (undernutrition).

Subclass: Throat and Swallowing

How can an abnormal throat/swallowing finding affect nutrition status? - can't get enough energy intake >> lead to weight loss - choking if they have dysphagia - can determine the need for modified diet texture or for feeding tube to be placed -- *Normal throat/swallowing is characterized by the absence of:* Choking during swallowing, swallow impairment, Food sticks on swallowing, Dysphagia, Odynophagia - painful swallowing Cough Esophageal lesion Gagging/ Hypoactive gag reflex Hoarse voice Suck, swallow, breath incoordination (infants) Free of tracheostomy

Micronutrient Derangements - Possible Nutrition Diagnoses (P from PES)

INTAKE DOMAIN Inadequate /excessive vitamin intake (B12) Inadequate /excessive mineral intake (Mg) Inadequate energy intake Inadequate protein-energy intake Increased nutrient needs (iron) Impaired nutrient utilization Inadequate/excessive enteral infusion Parenteral nutrition composition inconsistent with needs Limited food acceptance OTHER DOMAINS Altered nutrition-related laboratory values Altered GI function Food and nutrition-related knowledge deficit Self-monitoring deficit Unsupported beliefs/attitudes about food- or nutrition related topics Disordered eating pattern Limited access to food

Subclass: Hand and Nails Indicators of Normal Health

Inspect and palpate for color, texture, shape, length, symmetry, cleanliness. Nail bed free of splints, uniform in shape, rounded and smooth Nails are translucent with a pink hue, flat or slightly convex Capillary refill time less than 3 seconds (indicates good circulation) Base angle = 160 degrees Absence of the following indicators on the next slide

Subclasses: Mouth, Teeth and Tongue Indicators of Normal Health

Inspect for moisture, swelling, color, dentition, lesions around oral cavity. Ask about taste changes. Lips smooth, with distinct boarders, without cracks or sores; Tongue dull red, moist, glistening, without swelling; Normal surface, taste, gums; Normal teeth, fully anchored. *Absence of the following indicators:* > Cleft palate > Drooling, excessive salivation > Halitosis, ketotic breath, uremic breath > Excessive thirst > Retains food in mouth > Broken denture/teeth, missing or loose teeth > Mottling or enamel (floridosis) > Blue lips or tongue

Physical Exam Techniques

Inspection Palpation Percussion* Auscultation* *Not required to perform a nutrition-focused physical exam. However, it is important to interpret clinical findings reported in the medical record.

What advantages does NFPA have over other medical tests/procedures that assess body composition?

It's cheap It's easier to access than other tests

Summary

NFPE is a head-to-toe systematic exam that: Reveals/confirms areas that indicate micronutrient deficiencies, malnutrition, fluid status Differs from the MD's physical exam - focuses on areas that are most influenced by nutrition >> Skin, hair, nails, eyes, and mouth/tongue/teeth, often reveal micronutrient deficiencies Takes practice to increase accuracy and efficiency Is cheaper and more easily accessible than other body composition assessment methods

Subclass: Hair Indicators of Normal Health

Use inspection and palpation to assess for quantity, distribution, texture, color. Hair should be shiny, smooth, firm, evenly distributed. Normal-appearing or thick hair Normal-appearing hair shaft and emergence from skin Absence of the following indicators: > Dry hair, hair lacks luster, brittle hair > Fine hair > Easily pluckable hair > Lanugo hair formation > Hypertrichosis

Overhydration - NFPA S/S

Vital signs - increased blood pressure Overall findings - fatigue Edema - Peripheral edema, sacral edema, anasarca, pitting edema Cardiovascular/pulmonary - dyspnea (SOB), respiratory crackles Genitourinary system - Input>output; light colored urine, oliguria

Subclass: Eye Indicators of Normal Health

Ask about increased dryness, as well as changes in vision (night blindness). Use inspection to assess for color of sclera and conjunctiva, fullness and color of orbital region and corneas for foamy spots. *Palpate for dryness. Eyes should be: bright, clear, shiny, smooth cornea Pink and moist membranes, smooth corneas, white sclera, pink moist membranes Normal eye movement to follow objects Superior eyelid covering a portion of the iris when open Vision 20/20 with or without corrective lenses *Absence of the following indicators:* > Circles under eyes, sunken eyes > Conjunctival discoloration, hemorrhage > Jaundiced sclera

Physical Exam Techniques Auscultation

Auscultation = listening to auscultation of the bowel, heart, or lungs Technique - stethoscope used to listen to: all 4 abdominal quadrants, heart sounds and breath sounds *Type of information obtained* - Normal bowel sounds - gurgling, high-pitched sounds every 5-15 seconds >> Hypoactive - quieter, every 15-20 seconds (paralytic ileus) >> Hyperactive - continuous, high-pitched (diarrhea, obstruction) - Heart rhythm, murmurs - Lung sounds - continuous "musical" sounds, wheezing *This technique requires practice and acute listening skills --- we might not complete this assessment, but will read the MD or RNs notes about it and interpret those

Diseases/Scenarios with Frequent Micronutrient Derangements

Alcoholism Anemia Anorexia, nausea, dysphagia Altered GI function/structure Coronary artery disease/heart failure Cystic fibrosis Diabetes mellitus Immune Deficiencies Impaired wound healing Liver and biliary disease Organ transplants Geriatric patients (see pic for full list)

Interpreting the Data

An isolated nutrient deficiency is rarely identified from NFPE data alone Signs and symptoms of a deficiency occur after prolonged diet inadequacy Findings should be correlated with diet history, medical condition, lab data Always consider possible non-nutritional causes that could explain the findings

Subclass: Head (including nose) Indicators of Normal Health

Symmetrical to slightly asymmetric head; Oval, symmetrically positioned, and pink/glistening mucosa; Normal sense of smell; Unobstructed nasal passages Absence of the following indicators: > Bulging or sunken fontanella, macrocephaly/microcephaly > Anosmia/hyposmia (inability/decreased sense of smell) > Headache > Epistaxis (nose bleed) > Nasal mucosa dry > Nasogastric tube for feeding or suction

Signs of Overall Normal Health

Body weight in normal range for height Vital signs in normal range Neurological and psychological stability: >> Alert and oriented x 3 - person, place and time; appropriate response to questions and environmental stimuli >> Normal reflexes and sensations >> Gross and fine motor skills required to complete tasks/ADLs

Subclass: Skin Indicators of Normal Health

Uniform color; Smoothness; A healthy appearance Absence of the following indicators: > Discoloration: Acanthosis nigricans, pale complexion, jaundice > Decrease skin turgor, impaired skin integrity, dry skin, peeling skin, psoriasis, scaling skin, skin rashes > Pruritus (itching) > Ecchymosis (bruising) > Impaired wound healing, stasis ulcers, pressure injuries

NFPA in the NCP II

Clinical judgment (critical thinking) must be used to select indicators and determine the appropriate measurement techniques and reference standards for a given patient population and setting. *Case Example* Indicator(s): Blood pressure Assessment Data Collected: Blood pressure = 138/92 mmHg Criteria for Evaluation: Comparison to Goal or Reference Standard: Personal Goal: Blood pressure <130/85 mmHg Reference Standard: Normal Blood pressure <120/80 mmHg

Clinician's Responsibilities

Review the medical record, social history, labs, medications, referral/consult Practice universal precautions >> Wash hands, clean equipment between encounters, wear protective clothing when indicated Introduce yourself and explain the reason for visit > let them know you will be touching a few areas, don't just go for it Obtain patient's nutrition history Prepare the patient for the physical exam >> Inform the patient why the examination is being performed >> Respect the patient's privacy and comfort - close door/curtains, allow them to empty bladder, keep the patient's body covered except for the area being examined Communicate abnormal findings to the nurse or physician

Subclass: Overall Findings Indicators

Short stature for age Tall stature Cachexia Obese* (they look obese, not the actual classification) Ectomorph (lean build) Mesomorph (muscular build) Endomorph (large build with higher body fat %) Cushingoid appearance ("moon face") Neglect of personal hygiene Asthenia (weakness) Lethargic Buffalo hump

Steps to Performing a Basic NFPA

Start with general inspection, which can help determine areas that need further inspection Overall appearance Skin Head/hair Eyes Mouth/teeth/tongue Neck/upper body Musculoskeletal/lower extremity Hand/Nails *The order can be subject to the clinician's preference

Nutrition-focused physical findings - part 1

Overall findings Vital signs Neurological exam Digestive system Micronutrient deficiencies Cardiopulmonary Genitourinary system Hydration

Physical Exam Techniques Palpitation

Palpitation = touch *Technique* - palms and fingertip pads to feel vibrations and pulsations > Palpate extremities - assess fluid status and muscle/fat stores > Palpate abdomen - assess contour and symmetry of organs > Use light palpation - assess pulse (jugular, radial, pedal) > Use deep palpation - assess body structures (tender areas last) *Type of information obtained* > Areas of tenderness > Muscle rigidity and distention > Fluid retention and pitting edema > Abdominal masses and girth > Skin integrity and moisture > Body temperature > Guarding or rebound tenderness (guarding a tender area)

Physical Exam Techniques Percussion

Percussion = the act of striking one object against another to produce vibration and sound waves. Technique - use of fingertip pads. Assess sounds to identify organ border, position, and shape. *Type of information obtained* > Abdomen: Tympany (a hollow drum-like sound = obstruction); dullness (ascites) > Lungs: Dullness (fluid/tissue in place of air) *This technique requires practice and acute listening skills

Physical Findings Related to Micronutrient Deficiencies

Reported as single or multiple-nutrient deficiencies Most prevalent single-nutrient deficiencies >> Iron, vitamin A, iodine Micronutrient deficiencies: >> Play a role in the development and/or progression of acute or chronic diseases >> Are associated with adverse changes in overall health >> Can be present in the absence of malnutrition and with adequate total energy intake Biochemical tests provide qualitative and quantitative data for the particular fluid or tissue sample, however, they may not be reflexive of overall body storage in relation to excess or deficiency >> NFPA can provide a cost-effective approach to identifying micronutrient deficiencies