improve your hands-on nutrition physical exam skills annual meeting/kurtz.pdfsubcutaneous#fat#loss#...
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![Page 1: Improve your Hands-On Nutrition Physical Exam Skills annual meeting/kurtz.pdfSubcutaneous#Fat#Loss# Triceps# Ribs&Chest# Orbital## Loss*of*Subcutaneous*Fat* Orbital Fat pad “hollow](https://reader034.vdocuments.us/reader034/viewer/2022050200/5f53db7d24d1d5128d70f7e9/html5/thumbnails/1.jpg)
Julie Kurtz, MS, RD, CDE, CNIS
AZDA Conference June 10, 2011
Improve your Hands-On Nutrition Physical Exam Skills:
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Objec&ves: Demonstrate (practice) the basic nutrition physical assessment skills to include the following:
a) Loss of subcutaneous fat
b) Bilateral muscle wasting
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v Inspection Critical observation of color, shape, texture, size. Uses the senses of sight, smell, and hearing. Most frequently used.
v Palpation Tactile exam to feel pulsations and vibrations, assess body structures (including texture, size, temperature, tenderness and mobility.
v Percussion Assessment of “sounds” to determine body organs’
borders, shape and position.
Basic Nutri&on-‐Focused Physical Examina&on Techniques
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Subcutaneous Fat Loss
Triceps
Ribs & Chest
Orbital
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Loss of Subcutaneous Fat
Orbital Fat pad “hollow eye”
Prominent brow bone
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Subcutaneous Fat loss
Orbital fat pads Technique: Inspection Inspect for loss of bulge under eye (fat pad); characterized by hollow eye v Well-‐nourished – Slightly bulged fat pad Significant findings: v Mild-‐Moderate fat loss– Dark circles, somewhat hollow
v Severe fat loss– pronounced, hollow, depressed, dark circles, loose skin
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Lets quiz your skills? Orbital Fat Pad Well-‐Nourished? Mild-‐Moderate? Severe?
#1
#2
#3
#4
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Subcutaneous Fat loss Triceps
Posterior view
Triceps area on arm most identified with fat loss
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Subcutaneous Fat loss
Triceps Technique: Palpation Palpate (pinch skin) between thumb and forefinger over the
back of the upper arm over the tricep muscle
v Well-‐nourished – Ample fat tissue between folds of skin Significant Findings v Mild-‐Moderate fat loss– Fingers almost touch, some depth to pinch
v Severe fat loss– Very little space between folds or fingers touching
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Lets quiz your skills Triceps Well-‐Nourished?
Mild-‐Moderate? Severe?
#1 #2 #3
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Loss of Subcutaneous Fat Chest/Lower Ribs
� Technique: Inspection
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Subcutaneous Fat Loss Chest/Lower Ribs
Observe the mid-‐axillary line at the costal margin or lower ribs; observe for loss of fullness or loose skin;
v Well-‐nourished -‐ > ample fat tissue; chest wall should not be visible nor should ribs be visible
Significant findings: v Mild-‐Moderate fat loss: loose skin – somewhat apparent ribs
v Severe – Skin is stretched; prominent well-‐defined ribs
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Lets quiz your skills – Chest/Ribs Well-Nourished?
Mild-Moderate? Severe?
#1
#2
#3
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Temporal Muscle
Wasting Shoulder
Scapula
Interosseous
Calf Knee
Pectoral
Deltoid
Quads
Clavicle
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Bi-‐lateral Muscle was&ng v Includes: muscle volume, tone, function and gender
v Upper body more susceptible to muscle loss, independent of functional status
v Muscle loss from inactivity or bedrest is most prominent in the pelvis and upper leg
v Muscle wasting determined by palpation for volume and tone; flat areas or hollow area where muscle should be; prominence of bones
v Neurological deficits (that may present with unilateral wasting); may produce false-‐positive findings
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Bi-‐lateral Muscle Was&ng
Temporal Wasting
Prominent brow bone
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Bi-‐Lateral Muscle Was&ng Temple
Observe patient straight on; turn head from side to side; look for prominence of brow bone; scooping or hollowing indicated wasting of temporalis muscle
v Well-‐nourished -‐ > can observe well-‐defined muscle Significant Malnutrition Findings: v Mild-‐Moderate -‐> slight depression of temporalis muscle
v Severe – Hollowing, scooping depression
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Lets quiz your skills Temporal Was&ng
Well-Nourished? Mild-Moderate? Severe fat wasting?
#2 #3 #1
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Upper Body Muscle Wasting
Deltoid, Shoulder, Pectoris, Clavicle
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Upper Body Muscle Was&ng Clavicle
Observe pectoral and deltoid muscle and look for prominent protruding of bone; protrusion of bone indicates wasting of pectoral and deltoid muscles v Well-‐nourished -‐ > Clavicle bone not prominent in men but visible in women
Significant Malnutrition Findings: v Mild-‐Moderate -‐> some protrusion of clavicle v Severe –> Protruding/prominent bone
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Upper Body Was&ng -‐ Shoulders Observe patient straight on with arms at side looking for squaring of shoulders; loss of roundness at junction of shoulder and neck; and shoulder and arm (significance loss of deltoid muscle) Well-‐nourished -‐> Rounded, curves at the junction of shoulder and neck; shoulder and arm Significant Malnutrition Findings: v Mild-‐Moderate -‐> some protrusion of acromion process
v Severe –> Protruding or prominent bone “squaring of shoulder”
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Lets quiz your skills – Upper Body Muscle was&ng
Well-Nourished? Mild-Moderate ? Severe Wasting?
#4
#3 #2 #1
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Bilateral Muscle Was&ng Interosseous Muscle
Interosseous Muscles
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Interosseous Muscle
Observe interosseous muscle between thumb and forefinger with palm down (back of hand). Have patient
press thumb and forefinger back and forth with pressure to inspect muscle
v Well-‐nourished – may bulge in male and be flat/bulge in female
Significant Malnutrition Findings: v Mild-‐Moderate -‐ Slightly depressed or flat v Severe – flat or depressed area between thumb and forefinger
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]
Lets quiz your skills – Interosseous Muscle Was&ng
Well-Nourished? Mild-Moderate? Severe?
#1
#2
#3
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Considera&ons in Prac&ce � Acquiring the skills
� Education � Physical Examination Techniques and Procedures � General Survey � SGA
� Video’s � Formal learning -‐ Seminar/Workshops for guided practice experience
� Literature � Informal learning -‐ volunteer to work with other professionals that practice SGA or physical examination skills
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References � McCann, Linda (1995), Subjective Global Assessment. NKF Spring Clincial Nephrology Meeting, Dallas, TX April, 17-‐20, 1997.
� http://healthlinks.washington.edu/nutrition/section9.html#b
� Lee Robert and Nieman David. Nutritional assessment 5th edition. New York, NY: Mc Graw Hill, 2010.
� McDonald, Jane. The Canadian Dietetic Association: A Pocket Guide to Physical Examination and Nutritional Assessment Toronto, Canada: W. B. Saunders. 1994
� Photos used with permission of patient