Malnutrition And Nutrition-Focused Physical Exam For SSAND

11/10/2015 International Global Guidelines Group-2009-reps from multiple international societiesDeveloped etiology-based approach todiagnosis adult malnutrition in acute caresettingEtiology based terminology was proposed-incorporated a current understanding ofinflammationAcute disease or injury-related malnutrition-Acute inflammation of severe degree-sepsis, SIRS, infection, severe burns, ARDS,trauma, or closed head injuryIdentify etiology-based malnutrition and therole of inflammationDiscuss the diagnostic characteristics neededto identify and document adult malnutritionin the clinical settingKnow how to perform an adult nutritionfocused physical examStarvation-related malnutrition-Chronic starvation without inflammation-anything that limits access to food: foodinsecurity or compromised intake relatedto psych. issues Chronic disease-related malnutrition-Chronic inflammation of mild to moderatedegree-organ failure, cancer, RA, HIV, diabetes,sarcopenic obesity,CHF, pressure ulcers Jointly published in theMarch 2010 issues of JPENand Clinical NutritionJensen GL. et al. Clin Nutr 2010; 29(2):151-153Jensen GL. et al. JPEN 2010; 34(2): 156-1591

11/10/2015 Malnutrition is most simply defined as anynutritional imbalanceAdult undernutrition typically occurs along acontinuum of inadequate intake and/or increasedrequirements, impaired absorption, alteredtransport and altered nutrient utilization 262.0: Other severe proteincalorie malnutrition263.0: Malnutrition of moderatedegree263.1:Malnutrition of a milddegree263.2: Arrested developmentfollowing protein-caloriemalnutrition263.8: Other protein-caloriemalnutrition263.9: Unspecified protein-caloriemalnutrition E43: Unspecified severe proteincalorie malnutritionE44.0: Moderate protein-caloriemalnutritionE44.1: Mild protein-caloriemalnutritionE45 Retarded developmentfollowing protein-caloriemalnutritionE46: Unspecified protein-caloriemalnutritionE64.0: Sequelae of protein-caloriemalnutritionDefinition: a protective tissue response to injury ordestruction of tissues, which serves to destroy, dilute, or walloff both the injurious agent and the injured tissuesHow does inflammation present itself?Acute inflammationChronic inflammationLack of classic signs ofinflammationMinor elevation of CRPbeats/min)Purpose: defense, repairOnly about 3% of patients admitted to acute care settings inthe U.S. are diagnosed with malnutritionNutrition Risk IdentifiedCompromised intake or loss of body massICD-10-CM799.4 CachexiaFever ( 99.9 F)SwellingErythemaHypothermia ( 95 F)HyperglycemiaElevated BPElevated CRPLeukocytosisTachycardia (HR 100Current estimates of the prevalence of adult malnutritionrange from 15% to 60% depending on the patient populationand criteria used to identify its occurrenceWhite et al, JPEN, 2012 Consensus StatementICD-9-CM “Malnutrition is a major contributor to increased morbidityand mortality, decreased function and quality of life,increased frequency and length of hospital stay and higherhealthcare costs.”Purpose: maintainhomeostasisInflammation present?No or YesNoStarvation relatedmalnutrition (purechronic starvation,anorexia)YesMild to Moderate DegreeChronic DiseaseRelated Malnutrition(organ failure,Cancer ,rheumatoidarthritis, sarcopenicobesity)Mild-moderate inflammation(Chronic inflammation)Examples:Organ failure (liver, heart, lung,kidney)CancerRheumatoid arthritis orosteoarthritisCardiovascular diseaseCongestive heart failureCystic fibrosisCeliac diseaseInflammatory Bowel DiseaseCVAChronic pancreatitisDiabetesObesityYesMarked Inflammatory ResponseAcute Disease orInjury-RelatedMalnutrition (majorinfection, burns,trauma, closed headinjury)Severe Inflammation(Acute inflammation)Examples:Major infection/sepsisSystemic inflammatory responsesyndrome (SIRS)Acute respiratory distresssyndromeBurnsTraumaClose head injuryMajor surgeryAcute pancreatitisCellulitisJensen GL, ASPEN Adult Core Curriculum, 3rd edition 20122

11/10/2015 Inflammation increases the risk for or mayworsen severity of malnutritionAcute inflammatory response:Increases catabolism and decreasesprotein synthesisIncreases REE, leads to negative nitrogenbalance Negative acute phase response proteins:Albumin, transferrin, prealbumin Positive acute phase response proteins: CRP Elevated blood glucose High or low WBC The academy accepted ASPEN/ESPEN definitions May 2012, AND/ASPEN published Consensus Statement( 1 mg/dl reflective of significant inflammation)EGD/ colonoscopy:colitis, gastritis,inflammatory boweldisease Chest x-ray: presence of Abdominal X-ray:infiltrates, pneumonia 6 standardized characteristics recommended to identifyand document adult malnutrition; incorporated thecurrent understanding of role of inflammationabscess, pancreatitis,hepatitis, bowelobstructionWhite et al, JPEN, 2012 Consensus Statement-Insufficient energy intakeUnintentional weight lossLoss of body fatLoss of muscle massFluid accumulationDiminished functional capacity**2 or more recommended for diagnosisWhite et al, JPEN, 2012 Consensus StatementAcute Illness orInjuryChronic Illness orDiseaseEnvironmental orSocialCircumstance(Starvation)Reduced DietaryIntake 7d intake 75% total EER 1 mo intake 75% total EER 3 mo intake 75% total EERUnintended WtLoss1-2% in 1 wk5% in 1 mo7.5% in 3 mo5% in 1 mo7.5% in 3 mo10% in 6 mo20% in 1 yr 5% in 1 mo 7.5% in 3 mo 10% in 6 mo 20% in 1 yrLoss ofSubcutaneous FatMild LossMild LossMild LossMuscle LossMild LossMild LossMild LossFluid accumulation Mild EdemaMild EdemaMild EdemaReduced GripStrengthN/AN/AN/AWhite et al. JPEN, 2012 Consensus Statement3

11/10/2015Acute Illness orInjuryChronic Illness orDiseaseEnvironmental orSocialCircumstance(Starvation)Reduced DietaryIntake 5d intake 50% total EER 1 mo intake 75% total EER 1 mo intake 50% total EERUnintended WtLoss 2% in 1 wk 5% in 1 mo 7.5% in 3 mo 5% in 1 mo 7.5% in 3 mo 10% in 6 mo 20% in 1 yr 5% in 1 mo 7.5% in 3 mo 10% in 6 mo 20% in 1 yrLoss ofSubcutaneous FatModerate LossSevere LossSevere LossMuscle LossModerate LossSevere LossSevere LossFluidAccumulationModerate to SevereEdemaSevere EdemaSevere EdemaReduced GripStrengthMeasurably ReducedMeasurably ReducedMeasurably ReducedWhite et al. JPEN, 2012 Consensus Statement Nutrition focused physical assessment Patient interview Medical record Collaboration with other healthcare teammembers InspectionBroad observation of color, shape, texture, size. Involvessenses of sight, smell and hearing. Palpation Review Medical record,food intake data, H&P,nursing notesIdentify nutrition-relatedconcernsIntroduce yourself andshake handsAsk questions r/t health &nutrition historyExplain what you wouldlike to doAsk the patient’spermission before startingBody habitus- physique or body type* Ectomorphic- underweight* Mesomorphic- Normal weight* Endomorphic- Overweight or obeseExamining body structures using touch (assess texture, size,temp, tenderness, mobility) PercussionAssessment of “sounds”4

11/10/2015 OrbitalAreas of subcutaneous fat loss (3): Orbital fatpads, triceps, thoracic/lumbar regionTricepsAreas of muscle loss (7): temples, shoulders,clavicles, scapulae, hands, thighs, calvesRibs & ChestExamine region surrounding the eyeView patient when standing directly in front of them. Inspectfor loss of bulge under eye (fat pad); characterized byhollow eye Normal: Slightly bulged fat pad Mild-Moderate: slightly dark circles, somewhat Severe fat loss -pronounced, hollow, depressed, hollowdark circles, loose skinFluid collection or “puffiness” around eyes:May be caused by: fluid retention, CHF, renal failure,nephrotic syndrome, hypoalbuminemia, allergies, steroid use,periorbital cellulitis, myxedemaInspect upper arm region:With arm bent at 90 degree angle, pinch skin over the triceps musclebetween thumb and forefinger (do not include muscle in pinch) Normal-ample fat tissue between folds of skin Mild-Moderatedepth to pinch SeverePatient with bilateral thyroid eyediseasefat loss- Fingers almost touch, somefat loss- very little space between folds orfingers touching5

11/10/2015Have patient press hands against solidobject or against dietitian’s hand.Observe for loss of fullness or loose skin inarea of ribs, lower back, midaxillary line Immobility,bed-boundParaplegia, QuadriplegiaALS, muscular dystrophyCVAMyeloproliferative disorderInjuryBurnsSpinal cord injuryRheumatoid arthritisMalnutrition Normal- ample fat tissue; chest wall or ribs should Mild-Moderate: loose skin; somewhat apparent ribs Severe- skin is stretched; prominent, well-defined not be visibleribsUpper body more susceptible to muscle lossMuscle loss from inactivity or bedrest is mostprominent in the pelvis and upper legMuscle wasting determined by palpation for volumeand tone; flat areas or hollow areas where muscleshould be; prominence of bone6

11/10/2015 rve patient straight on, then ask patient to turnhead side to side; look for prominence of brow bone;scooping or hollowing indicating wasting oftemporalis muscle Normal- can observe and feel well-defined muscle Mild-Moderate- slight depression Severe- Hollowing, scooping depressionInterosseousObserve pectoral and deltoid muscle.Look for prominent protrusion of bone.Protrusion of bone indicates wasting ofpectoral and deltoid muscles Normal- clavicle bone notprominent in men but visible in womenMild-Moderate- some protrusion ofclavicle Severe- Protruding/ prominent boneObserve patient straight on with arms at side, sittingupright (if possible) looking for squaring of shoulders.Loss of roundness at junction of shoulder and neck &shoulder and arm (significant loss of deltoid muscle)Normal- Rounded, curves atthe junction of shoulder and neck &shoulder and arm Mild-Moderate- some protrusion ofacromion process Severe- Protruding or prominent bone;“squaring of shoulder”7

11/10/2015 Ask patient to extend handsstraight out, push against solidobject or against dietitian’s handNormal: Bones notprominent, no significantdepressionsMild-Moderate: Mild depression or bone may showslightlySevere: Prominent, visible bones, depressions,between ribs/scapula or shoulder/spineObserve interosseous muscle between thumb andforefinger with palm down (back of hand). Havepatient press thumb and forefinger back and forthwith pressure to inspect muscle (Make the “OK”sign)Normal- may bulge in male and be flat/ bulge infemaleMild-Moderate- slightly depressed or flatSevere- flat or depressed area between thumb andforefinger8

11/10/2015 Anterior Thigh:Quadriceps Patellar Region:Quadricep Posterior Calf:Gastrocnemius Muscles Ask patient to sit with leg propped up, bent at thekneeNormal- Muscles protrude,bones not prominentMild-Moderate- Knee capmore prominent, lessroundedSevere- Bones prominent, little sign of musclearound kneeAsk patient to sit, prop leg up on low furniture.Grasp quads to differentiate muscle tissue from fattissue Normal- well rounded, well developed Mild-Moderate- mild depression on inner thigh Severe-depression/line on thigh, obviously thin9

11/10/2015Grasp the calf muscle todetermine amount oftissue Normal: well-developedmuscle Mild-Moderate: not welldeveloped Severe: Thin, minimal tono muscle definition Hydration EdemaSkin turgor is the skin’sability to change shape andthen return to normal(elasticity)Apply pressure to patient’s nail bed for a few seconds, thenreleaseCount the number of seconds it takes for nail bed to turnfrom the white, blanched appearance to a full red, flushappearance Normal- 1-2 seconds Mild dehydration- 4 seconds Severe dehydration- 4 seconds Grasp the patient’s skin onthe back of the hand or lowerarm between two fingers sothat it is tented up; Hold fora few seconds then release Decreased skin turgor(slower return to normal)reflects late stages ofdehydration Pitting edemaNon-pitting edemaPulmonary edemaPleural edemaPeripheral edemaPedal edemaAscitesAnasarca10