Nutrition Focused Physical Exam Malnutrition & Inflammation PDF Fall 2024

9/10/24 Nutrition Focused Physical Exam Malnutrition and Inflammation LECTURE 2 – FALL 2024 1 1 Purpose of Nutrition Focused P...

9/10/24 Nutrition Focused Physical Exam Malnutrition and Inflammation LECTURE 2 – FALL 2024 1 1 Purpose of Nutrition Focused Physical Examination v To identify the risk for malnutrition or the existence of malnutrition v To identify symptoms and particularly signs associated with malnutrition risk and frank malnutrition v To distinguish between signs and symptoms associated with malnutrition, inflammation, and/or both v Signs versus symptoms ◦ Signs: what the clinician observes; can be verified with objective data ◦ Symptoms: are subjective; patient experiences and reports to the clinician 2 1  9/10/24 Overview of Physical Exams v Head to toe approach v Global to focused exam Perform physical exam if trained and competent; do not perform physical exam v Individually tailored if not trained and competent v Four basic techniques ◦ Inspection: general observation ◦ Palpation: tactile examination ◦ Percussion: tapping on surface to determine underlying structure ◦ Auscultation: listening for sounds made by internal organs 3 3 Universal Precautions v Universal precautions apply to all patients and settings. They are designed to prevent transmission of infectious agents via blood, body fluids, non-intact skin, secretions, excretions, and mucous membranes. v Standard Precautions: Includes the use of hand washing, appropriate personal protective equipment such as gloves, gowns, masks vTransmission-Based Precautions: can be used for patients with known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Should be used in addition to standard precautions. Airborne Precautions for infections spread in small particles in the air (ex: chicken pox) Droplet Precautions for infections spread in droplets by coughing, talking, or sneezing (ex: influenza) Contact Precautions used for infections spread by skin to skin contact (ex: herpes simplex virus) v Refer to each facility’s policies & procedures for specifics before completing NFPE 4 2  9/10/24 Visual Inspection o Look at the whole person o Head to toe approach o Overall appearance o Contractures, amputations o Feeding and vascular access devices o Wounds, drains, ostomies o Ability to communicate 5 5 Visual Inspection v Notice and Evaluate ◦ Loose clothing, loose rings ◦ Dentition; teeth, lips, gums ◦ Mental Status ◦ alert, oriented, drowsy, confused ◦ Muscle wasting & fat stores ◦ Jaundice ◦ Edema, Ascites ◦ Eyes, nails, skin 6 6 3  9/10/24 Nutrient Deficiencies v Eyes Bitot’s spots (white/gray spots on conjunctiva) – vitamin A deficiency Keratomalacia (drying/softening of cornea) – vitamin A deficiency Pale conjunctiva – iron v Hair Observe distribution, color, texture Corkscrew hair, unemerged coiled hairs – vitamin C Thin, sparse, patchy – protein, biotin, zinc, iron 7 7 vitamin A Bitot’s Spot v Distinct elevated white patches that appear on the conjunctiva 8 8 4  9/10/24 vitamin A Keratomalacia Softening, drying and ulceration of the cornea 9 9 iron Pale Conjunctiva 10 10 5  9/10/24 vitamin C Corkscrew Hair 11 11 Oral Signs of Nutrient Deficiency § Riboflavin: soreness and intraoral burning; cheilosis; angular stomatitis, glossitis with a magenta tongue § Niacin: intraoral burning; glossitis; tongue swollen, with red tip and sides; swollen, red fungiform papillae; filiform papillae become inflamed and lose their epithelial tufts (giving the characteristic slick red appearance) § 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 and atrophic (smooth and shiny) tongue Glossitis: swelling/inflammation of tongue Stomatitis: inflammation of mouth and lips Cheilosis: chapped, fissured lips Angular Cheilitis: cracking/inflammation at corners of mouth 12 12 6  9/10/24 Oral Signs of Nutrient Deficiency Cheilosis, Riboflavin Angular Cheilitis Stomatitis Folic Acid Deficiency Riboflavin Deficiency B12 Deficiency 13 13 Oral Signs of Nutrient Deficiency § Vitamin C: sore and bleeding gums; gums deep blue-red color; 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 mucosa Scurvy, swollen/bleeding gums 14 14 7  9/10/24 Oral Examination Findings Eroded enamel (Bulimia) Caries, missing teeth, fluorosis Candidiasis, oral thrush Erosive glossitis, iron deficiency 15 15 Nails v Thinning, flattening, concave, or spoon-shaped nails 16 16 8  9/10/24 Skin Assessment v Interpretation of Skin Findings 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, vitamin C 17 17 Skin Assessment Petechiae Perifollicular Hemorrhage Pellagra Purpura Follicular Hyperkeratosis Pallor 18 18 9  9/10/24 Pellagra Dermatitis Clinical findings of a niacin deficiency before (A) and after (B) treatment in an alcoholic patient v Pellagra traditionally the 4 D’s, Diarrhea, Dermatitis (scaly rash), Dementia (mental disorientation, delusions, depression), Death; also glossitis 19 19 20 20 10  9/10/24 Pressure Injuries v A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical (or other) device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure, or pressure in combination with shear. National Pressure Ulcer Advisory Panel (NPUAP) redefined pressure injuries in 2016; term “pressure injury” replaced “pressure ulcer” The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, condition of the soft tissue. v Inadequate nutrition is major risk factor for pressure injury development 21 21 Pressure Injuries 22 22 11  9/10/24 Pressure Injuries 23 23 Pressure Injuries: MNT v Increased energy, protein, and fluid requirements o Energy: 30-35kcal/kg § Particularly for stages II, III, IV, unstageable, DTI § 25-30kcal/kg may be adequate for stage I o Protein: 1.25-1.5g/kg § 1.5-2g/kg may be indicated for stages III, IV, unstageable, DTI o Fluid: >30ml/kg § Unless patient on fluid restriction (ie renal, liver, heart failure) v Micronutrient supplementation o Multivitamin § If oral intake or enteral nutrition inadequate to meet needs o Vitamin C § 1000-2000mg/day in divided doses for stages III, IV, unstageable, DTI o Zinc Sulfate § If deficiency suspected, 220mg daily for 10-14 days 24 24 12  9/10/24 Fluid Accumulation (Edema) v Edema is the increase in interstitial fluid volume that results in palpable swelling of a tissue or organ. It occurs when fluid balance between the 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. 25 Etiology and Disease States Commonly Associated with Edema Etiology Common Disease States Signs/Symptoms Increased Renal failure, heart failure, cirrhosis, Bilateral pitting edema, hydrostatic pressure sodium or fluid overload, medications possibly ascites Increased Venous obstruction Unilateral pitting edema, hydrostatic pressure erythema, tenderness Decreased capillary Nephrotic syndrome, protein-losing Bilateral pitting edema, osmotic pressure enteropathy, liver disease, severe ascites malnutrition Increased capillary Acute respiratory distress syndrome, Bilateral pitting edema permeability trauma, burns, inflammation/sepsis, malignancy Lymphatic Malignancy, lymph node dissection Unilateral or bilateral dysfunction non-pitting edema Table 1; Ratliff A. Support Line. 2015;37(5):5-10 26 13  9/10/24 Fluid Accumulation (Edema) 27 27 Fluid Accumulation (Edema) Ø It may occur through the body (generalized) or in particular body parts Ø Inspection & palpation are most frequently used to access edema, to a lesser extent percussion (ascites) and auscultation (pulmonary edema) Brain; cerebral edema Eyes; corneal edema, periorbital edema Lungs; pulmonary edema Arms and legs; peripheral edema Abdomen; ascites Genitals; vulvar and scrotal edema Feet; pedal edema 28 14  9/10/24 Fluid Accumulation (Edema) Severity grading of pitting edema 29 Abdominal Ascites v Ascites: accumulation of fluid in the peritoneal cavity, causing abdominal swelling v Commonly seen with cirrhosis 30 15  9/10/24 Assessment of Ascites v Differential between abdominal swelling due to ascites vs gas/fat/feces v Assess bulging of flanks (fluid pressing outward in the supine position) v Percuss abdomen from one flank to the other; listen for dullness of sound (fluid) versus area with tympany (air) near the top of the abdomen v Turn patient to the side; with ascites, area of dullness shifts 31 Skin Turgor 32 32 16  9/10/24 Skin Turgor 33 33 Muscle and Fat Assessment v Assess for muscle wasting (loss of bulk and tone) and fat depletion o Uses both inspection and palpation o Upper body most often assessed (accessibility and convenience) o Assessing muscle loss is difficult in overweight and obese patients, as well as the critically ill (edema, anasarca, positioning) 34 17  9/10/24 35 36 36 18  9/10/24 Oral/Facial Exam v Temporal wasting v Orbital fat pad v Bichats (buccal) fat pad v Prominent zygomatic process, zygomaticus major & minor muscles v Prominent nasolabial skin fold v Oral cavity: additional things to notice and assess o Missing dentition o Poorly fitting dentures o Ulcers o Oral thrush o Lack of saliva 37 Oral/Facial Exam 38 19  9/10/24 Oral/Facial Exam 39 Oral/Facial Exam 40 20  9/10/24 Oral/Facial Exam 41 Clavicles/Shoulders 42 21  9/10/24 Clavicles/Shoulders 43 Clavicles/Shoulders 44 22  9/10/24 Upper Arm 45 Forearm 46 23  9/10/24 Scapular, Thoracic & Lumbar 47 Scapular Region 48 24  9/10/24 Scapular Region v Infraspinatus v Supraspinatus v Trapezius 49 Thoracic & Lumbar Regions 50 25  9/10/24 Prominent Ribs v Visible articulations of ribs at junction with sternum 51 Dorsal Hand: Interosseous 52 26  9/10/24 Dorsal Hand: Interosseous 53 Dorsal Hand: Interosseous 54 27  9/10/24 Lower Extremities 55 Lower Extremities 56 28  9/10/24 Lower Extremities 57 Full Body: Muscle & Fat Wasting 58 29  9/10/24 Malnutrition 59 59 Malnutrition v Malnutrition is most simply defined as “any nutrition imbalance” v “An acute, subacute or chronic state of nutrition, in which varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to change in body composition and diminished function.” v Acute care setting: “malnutrition” & “undernutrition” used synonymously v IDNT: inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting 60 60 30  9/10/24 Malnutrition v Occurs along continuum o Inadequate intake o Increased requirements o Impaired absorption o Altered transport o Altered nutrient utilization v Individuals may present with inflammatory, hypermetabolic, and/or hypercatabolic conditions v Inflammation increases malnutrition risk; may contribute to suboptimal response to nutrition interventions; increased mortality risk 61 61 Malnutrition v Major contributor to o Increased morbidity and mortality o Decreased function o Decreased quality of life o Increased frequency and length of hospital stay o Higher healthcare costs 62 62 31  9/10/24 Malnutrition: Historically v Protein energy malnutrition v Marasmus v Kwashiorkor v Etiology-based definitions of malnutrition 63 Malnutrition: Historically v 1930 (Cecily Williams): Kwashiorkor was thought to be nutritional disease of children, associated with a maize diet o Derived from the name mothers in Ghana used to describe the disease in their children: “the disease of the first son when the second son is born” o Reflects the association between of kwashiorkor during the weaning process from breast-feeding to a protein deficient, grain based diet v 1970: Protein Energy Malnutrition (PEM) o Marasmus: weight