Download Nutrition-Focused Physical Assessment

Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Nutrition-Focused Physical Assessment:
Practical Methods to Start and Move Your Clinical Practice Forward
Suggested CPE Learning Codes: 3000, 3010, 3030, 3080, 5000, 5010, 5020, 5090; Level 2
Registered Dietitian Nutritionists are interested and moving forward, yet there remains a wide range of personal
comfort and skills in the bedside completion of a nutrition-focused physical assessment as one piece of the
Nutrition Care Process. Speaker will address roadblocks to the performance of nutrition-focused physical
assessment and provide examples and resources to address skills for both individuals and within clinical
nutrition departments.
Objectives:
1. Demonstrate how dietitians can move forward to create and increase their skills and confidence to
provide nutrition-focused physical assessment as one part of a nutritional assessment.
2. Provide examples and model ways to support clinical staff engagement and resources for dietitians to
start and grow in physical assessment skills.
3. Demonstrate the strength of evidence that nutrition-focused physical assessment contributes to daily
interdisciplinary patient care and the Nutrition Diagnosis of adult disease-related malnutrition.
Note: Nutrition Physical Assessment is included in:
Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of
Professional Performance for Registered Dietitians June 2013 Suppl. 2 Volume 113 Number 6
Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and
Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert)
in Nephrology Nutrition, September, 2014
American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics: Revised 2014
Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists
(Competent, Proficient, and Expert) in Nutrition Support, December 2014 Volume 114 Number 12;
Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for
Nutrition Care. Malnutrition (NI-5.2). Nutrition Focused Physical Findings (PD-1.1) Accessed 3/16/15.
Below: References and Resources for group or self learning.
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
70:20:10 Model for Learning and Development
Lombardo, Michael M; Eichinger, Robert W (1996). The Career Architect Development Planner (1st ed.). Minneapolis: Lominger.
p. iv. ISBN 0-9655712-1-1.
Lombardo and Eichinger expressed the rationale behind the 70:20:10 model this way in The Career Architect Development Planner.:
“Development generally begins with a realization of current or future need and the motivation to do something about it. This might come
from feedback, a mistake, watching other people’s reactions, failing or not being up to a task – in other words, from experience. The odds
are that development will be about 70% from on-the-job experiences, working on tasks and problems; about 20% from feedback and
working around good and bad examples of the need, and 10% from courses and reading.”
Accessed 3/12/2015
Clinical Characteristics of Adult Disease-Related Malnutrition; Academy/ASPEN 2012:
Note how physical assessment, including anthropometric data is present.
Bedside Clinical Characteristics: Assessment
Energy Intake
Common Methods To obtain data:
Diet history, medical history, intake records, meal
records, family/caregiver verbalization
Weight Loss within time frame
Weight records, verbal reports by patient, caregivers,
medical records, nutrition care records
Physical Findings: Body Fat and Muscle Mass
Nutrition-Focused Physical Assessment, historic
records of same
Fluid Accumulation
Observation, Physical assessment by MD, RN;
Nutrition-focused physical assessment, other team
records
Reduced Hand Grip Strength
Dietitian functional assessment; (PT, OT more likely to
perform for different reasons than nutrition)
Subjective Global Assessment: Ottery http://pt-global.org
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
This tool is a useful place to start and prioritize physical assessment target areas to learn.
The PG-SGA-abridged is a nutrition risk screen tool;
The Full PGA includes these physical assessment measures. There is also a functional measure.
Fat Stores
Orbital fat pads
Triceps skin fold
Fat overlying lower ribs
Muscle Status
Temples (temporalis muscle)
Clavicles (pectoralis & deltoids)
Shoulders ( deltoids)
Interosseous muscles
Scapula (latissimus dorsi, trapezius, deltoids)
Thigh (quadriceps)
Calf (gastrocnemius)
Fluid Status
Ankle edema
Sacral edema
Ascites
Documentation is CRITICAL
Inclusion of physical and functional nutrition-specific data is critical to describe in documentation.
Language and samples to help get started are available on pages below (p. 11, 12, 13).
Print independently at www.eatrightpro.org
References, Resources and Further Learning
Patient Generated Subjective Global Assessment
First page is nutrition risk screen. NFPA is completed on back and
sum supports diagnosis and is consistent with the Consensus
characteristics
The Minnesota Semi Starvation Experiment: Subject interview
many years later. Listen to subject and observe body language,
physical descriptions, emotional and psychological impacts of
starvation described. View this video to see key physical signs of
starvation-related malnutrition. This will help become familiar
with physical appearance of various parts of the body, the
functional impact of muscle wasting and fat loss, as well as
psychological and emotional impacts of starvation. (See reference
below to purchase for better video quality.)
http://pt-global.org
Order DVD or Video from:
Mark Cole 970-491-5920,
[email protected], Colorado State
University, Academic Computing
Network Services, Mailstop 1018, Fort
Collins, CO 80523
http://www.epi.umn.edu/cvdepi/video/the-minnesotasemistarvation-experiment/
From Theory to Practice: Optimizing Recognition and
Documentation of Adult Malnutrition;
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http://www.eatrightstore.org/product/
7286B968-6A30-487E-902F-
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
White, Scollard, Merriman;
CD recording with sample policies, documents to assist in
implementation of a process to identify, document and track
adult malnutrition in an institution. Recorded in 2012 and one
ICD-9 code changed (263.1 to a CC after the recording)
1B779D5C51E2 $19
Bates Pocket Guide to Physical Examination and History Taking
3rd Edition; Lynn S. Bickley, Lippencott
Reviews the process of physical exam in
general.
Mosby’s Expert 10-minute Physical Examinations 2nd ed. Elsevier
Mosby
Reviews key sequence of physical
examination in simplified form
Nutrition Focused Physical Assessment: Making Clinical
Connections; Mary D. Litchford PhD, RDN, Case Software and
Books case study CD and book
www.casesoftware.com
A Colour Atlas and Text of Diet-Related Disorders, Mclaren;
Wolfe (short and long versions) out of print, but occasionally can
locate on secondary market
Simulation: Physical Assessment. Patient Simulation: Putting
out of print, but occasionally can locate on
secondary market
Malnutrition Screening, Assessment, Diagnosis and
Intervention into Practice
http://anhi.org/courses
online simulation program; need to register
first. Free.Abbott Nutrition Institute
Alliance to Advance Patient Nutrition.
Resources, education related to adult malnutrition, especially in
acute care hospitals
Nutrition 411: the Physical Assessment Revisited: Inclusion of the
Nutrition-Focused Physical Exam
Nancy Collins PhD RD LDN FAPWCA et al. Ostomy Wound
Management, Vol. 56-Issue 11, November 2010
Krause’s Food and Nutrition Care Process 13 ed. Mahan, EscottStump, Raymond, Pp 171, 172, 1050, 1075-78.
http://malnutrition.com/
Mini-Nutrition Assessment (MNA) (this is a nutrition risk screen
tool targeting age 65+)
Video, free App, handouts, professional and patient generated
forms.
Nutrition-Focused Physical Examination: Enhancing Your Clinical
Toolbox
http://www.eatrightstore.org/product/9F1A22C0-50C4-453B8BF0-DC8A4DAA11B0
http://www.mna-elderly.com
Putting the Nutrition-Focused Physical Assessment Into Practice
in Long-Term Care, Mary Litchford PhD, RD, LDN
http://www.annalsoflongtermcare.com/co
ntent/putting-nutrition-focused-physicalassessment-practice
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http://www.o-wm.com/content/physicalassessment-revisited-inclusion-nutritionfocused-physical-exam
Pp 171, 172, 1050, 1075-78.
audio recording, two experienced advanced
practitioners teach how to perform and
implement nutrition-focused physical
examinations (PE) into daily practice
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Annals of Long Term Care
Nursing example of oral physical exam
A Pocket Guide to Physical Examination and Nutritional
Assessment, Jane E McDonald MD, CCFP, 1994. Out of print,
sometimes found on secondary market.*
Free videos physical assessments (not nutrition-specific)
Free, physical assessment (not nutrition-specific)
https://www.youtube.com/watch?v=J0CDjztEXw
Much of below is excerpted from this
pocket guide.
http://www.learnerstv.com/Free-MedicalVideo-lectures-ltv032-Page1.htm
https://www.youtube.com/results?search_
query=physical%20examination%20head%2
0to%20toe&sm=1
Nutrition and Hair, Lynne J. Goldberg, MD, Yolanda Lenzy, MD,
Clinics in Dermatology (2010) 28, 412–419
Nutrition and Nail Disease, Michael W. Cashman, BA, Steven
Brett Sloan, MD, Clinics in Dermatology (2010) 28, 420–425
The Nutritional Dimension of Physical Assessment Kathy A.
Hammond, Nutrition 15:411– 419, 1999
Hand Grip Dynamometer
Jamar – Digital Hydraulic Hand Dynamometer
There are other brands of dynamometers on the market.
Consensus Statement of the Academy of Nutrition and Dietetics
/American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and
Documentation of Adult Malnutrition (Undernutrition)
Contact your organization’s Occupational
Therapy or Rehabilitation Services
equipment buyer, as they likely have a
contact representative with contract
pricing. Ask about the OT dept brand
preference and an OT may be able to help
teach the equipment usage. Nutrition
application is different than OT’s. Note
different equipment types for adults and
children.
http://malnutrition.andjrnl.org/Content/art
icles/1-Consensus_Statement.pdf
Jane V. White, PhD, RD, FADA; Peggi Guenter, PhD, RN; Gordon Jensen, MD,
PhD, FASPEN; Ainsley Malone, MS, RD, CNSC;
Marsha Schofield, MS, RD; the Academy Malnutrition Work Group; the
A.S.P.E.N. Malnutrition Task Force; and the A.S.P.E.N. Board of Directors
Nutrition-focused Physical Examination:
Skin, Nails, Hair, Eyes, and Oral Cavity
Scope of Practice and Legal Issues in Nutrition-focused Physical
Examination
Marsha R. Stieber, MSA, RD, CNSC
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Dietitians in Nutrition Support, Support Line
Volume 33, No. 2 page 7-13
Dietitians in Nutrition Support, Support Line
April 2011, page 2-6
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Oral Manifestations of Nutrient Deficiency;
Riva Tougher-Decker, MS PhD.
Skeletal Muscle
Paul D. Fadale
FNCE 2013: Incorporating Physical Assessment in the Diagnosis of
Malnutrition: A Change in Practice;
M. Fischer, C. Hamilton, Cleveland Clinic 10/22/2013.
Textbook of Physical Diagnosis: History and Examination 7e.,
Mark H. Swartz MD, Elsevier, Saunders 2014.
FNCE 2014: Incorporating NFPA into Dietetic Curriculum and
Preceptor Training: Collaborative Approach; Halasa-Esper, PohleKrauza,
Nutrition Focused Physical Assessment Part 1: Setting the Stage
for Success
Nutrition Focused Physical Assessment Part 2: Creating Your
Malnutrition Toolbox
Nutrition Focused Physical Assessment Part 3: Micronutrient
Deficiencies
Practice Paper of the Academy of Nutrition and Dietetics:
Critical Thinking Skills in Nutrition Assessment and Diagnosis
The Mt Sinai Journal of Medicine,
October/November 1998 pg 355-361
Basic Science Review for Surgeons,
Simmons, Steed, WB Saunders, p. 316-325
http://fnce.eatright.org/fnce/uploaded/635
199493315675427-230.%20Fischer.pdf
Select Chapters. Communicating with
patients, and Chapt 29, specific for nutrition
assessment
Excellent practical resource.
http://www.nestlenutritioninstitute.org/Education/Pages/education.as
px Laura L. Frank, PhD, MPH, RDN, CD
Washington State University
Volume 115, Number 11, Page 1545
(November 2013)
Nutrition-Focused Physical Assessment (NFPA)
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
1. What is it? an examination of the body and physical function to help determine nutritional
status, signs of malnutrition and nutrient deficiencies.
a. Provides objective information, may find things missed from other types of assessment
such as reported diet history, can also connect with other findings from other
professionals
b. A process to help sort out and organize information. Is something directly related to a
nutrition problem? is it unrelated to nutrition? Helps determine interventions and
actions for the plan of care.
2. There are two general categories to address in Nutrition-Focused Physical Assessment for
nutrient deficiencies.
a. Macronutrients
i. Impact of energy and protein intake/deficits
b. Micronutrients
i. Vitamins/mineral deficiencies;
3. Objective: to identify physical characteristics pertinent to the evaluation of nutritional status
through*:
a. Height, weight measurement (adults)
b. BMI
c. Identification of edema/hydration
d. Identification of skin and mucosal changes
e. Identification of fat loss
f. Identification of muscle wasting, loss of strength
g. Identification of functional deficits
h. Identification of gastrointestinal factors that affect institution of feedings
i. Identification of nutritional neuropathies
j. Identification of psychological factors which influence nutritional intake
4. Equipment
a. Weigh scales
b. References for height, weight, head circumference, anthropometrics
c. Penlight
d. Tongue depressor
e. Ruler/insertion tape marked in centimeters
f. Wristwatch with 2nd hand
g. Sphygmomanometer (blood pressure cuff)
h. Tuning fork
i. Hand Dynamometer
j. Stethoscope
k. Magnifying glass
l. Gloves
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
m. Skinfold calipers (Lange or Harpendon Skinfold Caliper http://www.amazon.com/HarpendenSkinfold-Caliper-Model-C-136/dp/B002L6KGQO
5. Method – sight, hearing, touch, smell. 4 basic methods
a. Inspection- general overall and local in particular region
b. Palpation- examining by touch
c. Auscultation – movement of fluid and air,(bowl sounds-advanced level)
d. Percussion- tapping for sounds of solids, liquids, gas (provides minimal nutrition
information but is important for abdominal assessment and feeding tube placement for
advanced practice dietetics)
6. There are at least two approaches to the NFPA
a. First examine patient for nutritionally related physical signs. (A head-to-toe assessment
of patient), noting and describing lesions and problems. Use observed signs in aggregate
and in combination with related and relevant other findings as criteria for make clinical
judgments. (MA Kight, PhD, RD Diagnostic Nutrition Network April 1998)
b. Conducting nutrition and diet history, medical history, determining potential risk areas,
then observing targeted patient physical and functional attributes related to those areas
that are of most concern based on the diet and medical history.
c. See Physical Examination references.
d. Other parts of the nutritional assessment will drive one to look at typical physical
examination findings for that type of medical diagnosis, diet history, patient living
circumstances, etc.
7. Areas to address
a. Describe the size shape, color, position and symmetry of any abnormalities detected.
b. Learn to recognize normal variations among patients as well as ranges of normal within
an individual
c. Good lighting and exposure are essential
d. Include an assessment of olfaction (smelling ability)
e. See examples in Academy of Nutrition and Dieteics, Physical Exam-Parameters Useful in
Assessment of Nutritional Status
General Survey of person
Vital Signs - blood pressure, temperature, respirations, pulse
Skin - color changes, pigmentation, lesions,
Hair – color, distribution, texture, loss
Nails
Head and Neck (head, eyes, nose, neck)
Oral Cavity (lips, tongue, mouth, teeth – moisture, swelling, color, lesions, teeth, dentures)
Respiratory System
Cardiovascular system – fluid balance over/under hydration
Abdomen – bowel sounds
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Neurologic system – evaluation of motor, sensory, autonomic, cognitive, behavioral elements
Muscle mass
Fat stores
8. Body Composition
a. Anthropometrics
b. BIA, Bod Pod
c. Calculations using skinfolds measurements
d. DEXA
9. Functional Measurement/performance
a. Hand grip dynamometer
b. Repeat chair to stand
c. Balance testing
d. 8 foot walk
e. other
10. Wounds, drains, port erosions
11. Regional Anatomy (see physical exam references)
12. Introducing yourself, asking permission, explaining what you are going to do, hand washing, sanitation
care for patient and self. Privacy in space, covering patient and modesty
13. Nutrition and Diet History, Medical history and current state (see attachment)
14. Determining Hypothesis*: See figure 2, page 9. Subjective and objective data merged to create a
hypothesis. Dynamic process, confirm findings with another practitioner.
15. Is patient ‘normal’, ‘abnormal’ or ‘nutrition related issues’?
a. Connect findings with other information
b. Communicate and discuss with team
c. Document as part of the nutrition care process and IDNT
i. Some computer systems have developed a formal flow for data reporting
16. Documentation. Ideally in electronic health record documentation flow sheet in structured data.
17. Lifelong learning! Be alert to learning opportunities!
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
McDonald*
Development of a Hypothesis: regarding the connection of nutritional condition and the physical
manifestation of a nutrient or energy deficiency.
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
*MacDonald
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Below are different approaches to figuring out a connection between a patient condition, food
intake/absorption/loss/increased requirements and nutrient deficiency.
Nutrition History Screen
(excerpted from Alpers, et al; Manual of Nutritional Therapeutics 6th ed. Table 4-12, Pg 66)
Mechanism of Deficiency
Inadequate intake
Inadequate absorption
If History of…
Suspect Deficiency of…
Deficiency of all foods, ask about
alcoholism, weight loss, poverty,
dental disease, AIDS, taste changes
lack of fruits, vegetables, grain
Calories, protein, thiamin, niacin,
folate, pyridoxine, riboflavin
meat, dairy products, eggs,
Food idiosyncrasies, allergy
Drugs-antacids, anticonvulsants,
cholestyramine, laxatives,
neomycin, alcohol
Malabsorption, diarrhea, weight
loss, steattorrhea,
AIDS
surgery such as gastrectomy,
resection of small intestine
Increased losses
Increased requirements
Alcohol abuse
Blood loss
Diabetes poorly controlled
Diarrhea
Draining abscesses, wounds
Peritoneal or hemodialysis
Drugs (especially diuretics,
laxatives)
Fever
Increased physiologic demands
(infancy, adolescence, pregnancy,
lactation)
Surgery, trauma, burns, infection
Vitamin C, thiamin, niacin, folate,
dietary fiber
Protein, vitamin B12
Lactose intolerance
Selected vitamins and minerals,
vitamins A, D and K, calories
protein, iron, calcium, magnesium
zinc,
B12
B12, iron
B12 bile salts, if greater than 10 cm
of distal ileum), all others (if
jejunal),
Magnesium, zinc, phosphorus
Iron
Calories
Protein, zinc, electrolytes
Protein
Protein, water soluble vitamins,
zinc
Potassium, magnesium
Calories
Various nutrients
Calories, protein
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Remember Medications! (prescribed, OTC and street drugs)
Drug-Induced Oral Manifestations
(Excerpted from Alpers, et al; Manual of Nutritional Therapeutics 6th ed. Table 4-13, Pg 67-68)
Candidiasis
Contact hypersensitivity
Erythema multiforme
Fixed Drug Eruptions
Gingival Hyperplasia
Hairy/Black Tongue
Intraoral Bleeding, Petechiae, Purpura
Ulcerations, Mucositis, stomatitis, glossitis
Xerostomia
Salivary Gland Enlargement or pain
Signs and Symptoms of Nutritional Deficiency in Adults – Alpers et al., p 70-71, or other nutrition texts
Clinical Manifestations of Nutrient Deficiency States in Adults--Alpers et al., p 71-73, or other nutrition
texts
Figure 4-2 Development of clinical nutritional deficiency with corresponding dietary, biochemical and clinical evaluations. Krause’s Food
th
and the Nutrition Care Process 13 ed. L.Mahan, S. Escott-Stump, J. Ramond p 132.
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
From Nutrition411.com http://www.nutrition411.com/content/vitamin-and-mineral-deficiencies-physicalassessment Accessed 3/12/2015
Vitamin and Mineral Deficiencies: Physical Assessment
This table might prove useful in detecting nutrient deficiencies during a nutrition-focused physical
assessment.
Vitamin or Mineral
Vitamin A
Vitamin D
Vitamin K
Thiamine
Riboflavin
Physical Signs of Deficiency
Hair follicle blockage with a permanent
“goose-bump” appearance
Dry, rough skin
Small, grayish, foamy deposits on the
conjunctiva adjacent to the cornea
Drying of the eyes and mucous membranes
Night blindness
Rickets (children)
Small hemorrhages in the skin or mucous
membranes
Weight loss
Muscular wasting
Sometimes edema (wet beriberi)
Malaise
Mental confusion
Tense calf muscles
Distended neck veins
Jerky movement of eyes
Staggering gait and difficulty walking
Infants may develop cyanosis
Round, swollen (moon) face
Foot and wrist drop
Tearing, burning, and itching of the eyes with
fissuring in the corners of the eyes
Soreness and burning of the lips, mouth, and
tongue with fissuring and/or cracking of the
lips and corners of the mouth
Purple swollen tongue
Seborrhea of the skin in the nasolabial folds,
scrotum, or vulva
Capillary overgrowth around the corneas
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Niacin
Vitamin B6
Folate
Vitamin B12
Vitamin C
Magnesium
Iron
Zinc
Dermatitis or skin eruptions
Dementia
Diarrhea
Tremors
Sore tongue
Skin that is exposed to sunlight will develop
cracks and a scaly form of dermatitis with
pigmentation
Anorexia
Indigestion
May also show signs of riboflavin deficiency
Tongue inflammation
Inflammation of the lining of the mouth
Fissures in the corners of the mouth
Weakness, fatigue, and depression
Pallor
Dermatologic lesions
Lemon-yellow tint to the skin and eyes
Smooth, red, thickened tongue
Impaired wound healing
Edema
Swollen, bleeding, and/or retracted gums or
tooth loss; mottled teeth; enamel erosion
Lethargy and fatigue
Skin lesions
Small red or purplish pinpoint discolorations
on the skin or mucous membranes (petechiae)
Darkened skin around the hair follicles
Corkscrew hair or unemerged, coiled hair
Tremors, muscle spasms, and tetany
Personality changes
Skin pallor
Pale conjuctivia
Fatigue
Thin, concave nails with raised edges
Delayed wound healing
Hair loss
Skin lesions
Eye lesions
Nasolabial seborrhea
Decubitus ulcers
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Malnutrition and Nutrition-Focused Physical Assessment
Terse Scollard MBA RD LD FAND
March 27, 2015
Utah Academy of Nutrition and Dietetics Annual Meeting,
Provo, Utah
Copper
Iodine
Hair and skin depigmentation
Pallor
Goiter
Chromium
Corneal lesions
Reference and recommended reading
Gallagher ML. Intake: the nutrients and their metabolism. In: Mahan LK, Escott-Stump S, Raymond JL. Krause’s
Food and the Nutrition Care Process. 13th ed. St Louis, MO: Elsevier Saunders; 2012:32-128.
Review Date 1/14 G-0890 downloaded from Nutriton411 3/12/2015
Summary:
Scollard Suggested Approach on the Path to Skill:
1. Observe and listen to your patients!
2. Take some of the various overview programs above, read, study. Pick an area or topic. All of it is
too much, and will overwhelm. Plan your learning with one topic/step at a time.
3. Identify your target patient population.
4. Research and study to determine common nutrient and energy deficiencies/excesses
associated with that population and the manifestations of the deficiency (or excess), including
medications that impact nutrition.
5. Target study using suggested references above, and other references on the best techniques
and methods to use for that targeted nutrient issue in your targeted population.
6. Start observations with patient body areas that are exposed, are readily available to see and
that you are comfortable talking about with the patient. Okay to do a little education along the
way and ask questions during the observation.(Hair, hands, nails, neck, back, exposed skin).
7. Get a friend to practice with. Practice introducing self, asking permission of patient, telling the
patient in lay terms what you are doing. “May I look at your fingernails? Sometimes we can see
how someone has been doing nutritionally by looking at fingernails.”
8. Do not need to write a long chart note about your observations. Descriptive phrases satisfy
malnutrition documentation requirements from the regulatory standpoint, and are very
powerful when read in context of the entire nutritional assessment. Use the language on the
document “Parameters Useful in the Assessment of Nutritional Status” (pg 11-13).
9. Be sure to document the connection between physical and functional observations/tests with
food intake/absorption/losses/increased requirements.
Note the Academy continues to work on supporting this aspect of our practice. Stay Tuned!
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