nutrition assessment: malnutrition and nutrition focused...

Nutrition Assessment: Malnutrition and

Nutrition Focused Physical Examination

Iowa State University Dietetics Internship

Objectives

1. Implement ASPEN / Academy Consensus Statement Guidelines for Identifying and Documenting Adult Malnutrition

2. Perform a nutrition-focused physical examination (NFPE) on self or peer

3. Identify key components of Adult Malnutrition Consensus Statement needed for student education

4. Identify ways to implement of NFPE and malnutrition assessment in practice

Presenter

Presentation Notes

Objectives: At the end of this program, the participant will be able to: 1. Identify etiology-based malnutrition and understand the role of inflammation in malnutrition identification 2. Document moderate to severe malnutrition using standardized characteristics developed by the American Society of Parenteral and Enteral Nutrition (ASPEN) and The Academy of Nutrition and Dietetics 3. Recognize how to perform nutrition-focused physical examination

• ISU has been training interns on NFPE since 2015

• New competencies include NFPE specifically and are required starting June 1 2017.

• Dietetic Internships

– CRDN 3.3

• Conduct nutrition-focused physical exams.

ACEND Competencies

• Sphere 10 Clinical Care

– Competencies and Performance Indicators for RDNs and NDTRs

o 10.2 Implements the Nutrition Care Process to ensure individual health goals are established, monitored and achieved while adhering to the Standards of Practice in Nutrition Care for RDNs

o 10.2 Implements the Nutrition Care Process under the supervision of the RDN while adhering to the Standards of Practice in Nutrition Care for NDTRs.

– Practice Illustrations

o Assess the patient’s nutritional status through nutrition-focused physical exam and available anthropometric data.

https://admin.cdrnet.org/vault/2459/web/files/FINAL-CDR_Competency.pdf

Practice Competencies

This article was jointly published by the Academy and JPEN and online versions of this article can be found at

http://pen.sagepub.com/content/36/3/275 orhttp://www.andjrnl.org/article/S2212-2672(12)00328-0/pdf

Presenter

Presentation Notes

The Consensus Statement was jointly published in the Journal of the Academy of Nutrition and Dietetics and the Journal for Parenteral and Enteral Nutrition. Online versions can be found for free at the url’s listed here: http://pen.sagepub.com/content/36/3/275/

http://pen.sagepub.com/content/36/3/275

http://www.andjrnl.org/article/S2212-2672(12)00328-0/pdf

Albumin and Prealbumin

• Academy of Nutrition and Dietetics, Evidence Analysis Library (2009):

• No correlation between serum albumin and prealbumin in prolonged protein-energy restriction

• No research available to correlate serum albumin or prealbumin with nitrogen balance

– Indicators of inflammation, NOT indicators of nutritional status

– Do not respond to feeding interventions in the setting of inflammation!!

https://www.andeal.org/topic.cfm?cat=4302&evidence_summary_id=251043&highlight=albumin&home=1

Presenter

Presentation Notes

According to the Consensus Statement for Adult Malnutrition, current estimates of the prevalence of adult malnutrition range from 15–60% of hospitalized patients in the US. Until this point, malnutrition screening protocols have varied widely and typically include serum albumin and prealbumin as indicators of malnutrition. The Academy of Nutrition and Dietetics’ Evidence Analysis Library concluded in 2009 that serum albumin and prealbumin do not correlate with weight loss or nitrogen balance. The Consensus Statement suggests albumin and prealbumin do not typically respond to nutritional intervention in the setting of inflammation.


ASPEN – Academy Guidelines

• 6 characteristics to identify malnutrition in all settings, based on inflammatory status1. Weight loss

2. Insufficient energy intake

3. Fat loss

4. Muscle loss

5. Fluid accumulation

6. Diminished functional status

2 or more criteria needed for diagnosis

Presenter

Presentation Notes

No single parameter can diagnose malnutrition. ASPEN and The Academy workgroup developed a set of 6 characteristics recommended for the identification of adult malnutrition in all settings, with 2 or more criteria to be present in order to identify malnutrition. These characteristics include an understanding of the role of the inflammatory response on malnutrition’s incidence, progression, and resolution as well as a look at: weight loss, PO intake, fat loss, muscle loss, fluid accumulation, and functional status

Malnutrition

• Under nutrition occurs along a continuum:– Inadequate PO

– Increased needs

– Impaired absorption

– Altered transport, and/or

– Altered nutrient utilization

Source: White et al, JPEN, 2012 Consensus Statement

Malnutrition = Undernutrition

Presenter

Presentation Notes

Adult undernutrition typically occurs along a continuum of inadequate intake and/or increased requirements, impaired absorption, transport, OR nutrient utilization. Weight loss can and frequently does occur at multiple points along this continuum. Even overweight or obese adults are at risk for malnutrition and benefit from accurate nutrition diagnosis. Individuals may also present with inflammatory, hypermetabolic, and/or hypercatabolic conditions. Inflammation is increasingly identified as an important underlying factor that increases the risk for malnutrition and may contribute to suboptimal response to nutrition intervention and increased risk of mortality.

ASPEN – Academy Guidelines

• Accurately diagnose malnutrition in all settings

STEP 1: Determine if inflammation is present

– Weight loss

– Insufficient energy intake

– Fat loss

– Muscle loss

– Fluid accumulation

– Diminished functional status

Presenter

Presentation Notes

Now I’ll take you through the steps to identify malnutrition, using the Consensus Statement, in order to accurately diagnose severe or moderate malnutrition. The first step is to identify if inflammation is present and if it is, to what degree.

Inflammation

Acute inflammation

• Swelling, erythema, hyperthermia, pain, marked elevated C-reactive protein (CRP)

• Purpose: defense, clearance, adaptation, and repair

Chronic inflammation

• Lack of classic signs of inflammation (obesity, diabetes mellitus, cancer, rheumatoid arthritis, cardiovascular disease), minor elevation in CRP

• Purpose: restore homeostasis

*Normal CRP levels: < 1 mg/dLAdapted from: Learn to Diagnose Malnutrition Workshop, Cleveland Clinic, Sandra Austof and Rebecca Wehner 10/31/14

*CRP levels accessed from http://www.webmd.com/a-to-z-guides/c-reactive-protein-crp?page=3

Presenter

Presentation Notes

As you know, inflammation is a protective response by the body to remove harmful stimuli and promote healing. It is induced by pro-inflammatory cytokines such as IL-1, IL-6, TNF and can be categorized as acute or chronic based on severity of response. Acute inflammation contains the classic signs of inflammation including: Swelling, erythema, hyperthermia, pain, and markedly elevated C-Reactive Protein (CRP); chronic inflammation is often seen in conditions such as obesity, diabetes mellitus, cancer, rheumatoid arthritis, cardiovascular disease with a minor elevation in CRP. Normal CRP levels are < 1 mg/dL.

http://www.webmd.com/a-to-z-guides/c-reactive-protein-crp?page=3

Practical Tools To Determine if Inflammation is Present

Diagnosis:– chronic conditions – diabetes, heart failure, arthritis, cancer

– acute illness – itis, sepsis, acute respiratory distress syndrome, severe burns, major surgery

Imaging Studies:– Chest x-ray – pneumonia

– Abdominal/pelvis x-ray – abscess, pancreatitis, obstruction

– GES or SBFT– gastroparesis, dysmotility

– EGD/colonoscopy – IBD, radiation enteritis, strictures

– TEE – vegetations, endocarditisAdapted from: Learn to Diagnose Malnutrition Workshop, Cleveland Clinic, Sandra Austof and Rebecca Wehner 10/31/14

Presenter

Presentation Notes

The next 2 slides provide useful information for the practitioner to determine whether or not inflammation is present, and if it is – whether inflammation is acute or chronic. Inflammation can be determined from a variety of sources, including from the medical diagnosis or a variety of imaging studies such as chest x-rays or scopes. GES = gastric emptying study SBFT = small bowel follow though EGD = esophagogastroduodenoscopy TEE = transesophageal echocardiogram

Practical Tools To Determine if Inflammation is Present

• Vital Signs:– Hyper or Hypo thermia

– Pulse/heart rate > 100 bpm

• Labs reflecting inflammation:– Albumin and prealbumin

– Elevated CRP,

– White blood cell count (both high and low),

– Hyperglycemia

Adapted from: Learn to Diagnose Malnutrition Workshop, Cleveland Clinic, Sandra Austof and Rebecca Wehner 10/31/14

Presenter

Presentation Notes

Vital signs and labs like albumin, prealbumin, C reactive protein, white blood cell count and even markedly increased glucose levels could all reflect a degree of inflammation. This information is typically readily available to the nutrition practitioner.

Yes –Severe

• Acute Disease or Injury-Related Malnutrition

• Short time period

Yes –Mild - Moderate

• Chronic Disease-related malnutrition

• > 3 months

No

• Starvation-related malnutrition

• Extended period of time

Step 1: Determine if inflammation is present

Presenter

Presentation Notes

Step 1: The taskforce determined that the presence of inflammation can help categorize specific types of malnutrition. Acute disease or injury related malnutrition exhibits severe degrees of inflammation over a short time period. Chronic disease-related malnutrition exhibits mild to moderate degrees of inflammation and typically occurs over a period of 3 or more months. Starvation related malnutrition - exhibits no inflammation and occurs over an extended period of time.

Acute Illness

• Moderate – Severe Inflammation

– Ex: Major infection/sepsis, burns, ARDS, trauma, CHI, major surgery involving major organ

– This is not an inclusive list – must thoroughly assess pt for inflammation


Presenter

Presentation Notes

Some examples of conditions a clinician might see with acute inflammation would be major infection/sepsis, burns, ARDS, trauma, CHI, or major surgery involving major organ. ARDS = acute respiratory distress syndrome CHI = closed head injury

Chronic Illness

• Mild – Moderate Inflammation

– Ex: Organ failure, cancer, RA, CVD, CHF, CF, Celiac disease, IBD, CVA, chronic pancreatitis, DM

– This is not an inclusive list – must thoroughly assess ptfor inflammation


Presenter

Presentation Notes

Some examples of conditions a clinician might see with a chronic etiology would be organ failure, cancer, RA, CVD, CHF, CF, Celiac disease, IBD, CVA, chronic pancreatitis, and DM. RA = rheumatoid arthritis CVD = cardiovascular disease CHF = congestive heart failure CF = cystic fibrosis IBD = irritable bowel disease CVA = cerebrovascular accident DM = diabetes mellitus

Social / Environmental

• Anything that limits access to food

– No inflammation

– Ex: Anorexia nervosa, economic hardship, cognitive or emotional impairment, inability or desire to manage self-care, depression, achalasia, poor oral/dental condition


Presenter

Presentation Notes

Social/environmental or behavioral etiologies of malnutrition would not include inflammation and conditions could include anorexia nervosa, economic hardship, cognitive or emotional impairment, inability or desire to manage self-care, depression, achalasia, poor oral/dental condition.

Step 2: Evaluate Weight Loss

Malnutrition can occur at any BMI– Clients with extreme obesity or extreme underweight may be at increased risk

Acute Illness/Injury Chronic IllnessSocial/

Behavioral/Environmental Circumstances

Is inflammation present?

Yes - Severe Yes – Mild to Moderate No

Severe Moderate Severe Moderate Severe Moderate

Weight Loss

Weight Loss>2% in 1 week>5% in 1 month >7.5% in 3 mos

Weight Loss1-2% in 1 week5% in 1 month 7.5% in 3 mos

Weight Loss>5% in 1 month>7.5% in 3 mos>10% in 6 mos>20% in 12 mos

Weight Loss5% in 1 month7.5% in 3 mos10% in 6 mos20 % in 12 mos

Weight Loss>5% in 1 month>7.5% in 3 mos>10% in 6 mos>20 % in 12 mos



Presenter

Presentation Notes

The second step in identifying malnutrition is to assess for unintentional weight loss. This is routine for dietitians. Listed are the weight loss criteria for each category of malnutrition that are deemed significant. You can use the Malnutrition Pocket Guide provided as a resource to quickly determine if weight loss meets malnutrition criteria. It’s important to remember that malnutrition can occur at any BMI. Weight loss can be masked in clients with a higher BMI, so assessing fat and muscle loss can assist in correctly diagnosing malnutrition that might otherwise be missed.

Step 2: Evaluate Weight LossStep 3: Evaluate PO Intake



Is inflammation present? Yes - Severe Yes – Mild to Moderate No

Severe Moderate Severe Moderate Severe Moderate

Weight Loss - is evaluated in light of other clinical findings including hydration. Weight change over time is reported as a percentage of weight lost from baseline.







Intake Energy Intake< 50% energy intake compared to estimated energy needs for > 5 days

Energy Intake < 75 % energy intake compared to estimated energy needs for > 7 days

Energy Intake< 75% energy intake compared to estimated energy needs for ≥ 1 month

Energy Intake< 75% energy intake compared to estimated energy needs for > 1 month

Energy Intake < 50% energy intake compared to estimated energy needs for > 1 month

Energy Intake < 75% energy intake compared to estimated energy needs for > 3 months

RD/RDN calculates estimated needs and compares to estimated intake

Presenter

Presentation Notes

The third step is to evaluate the client’s energy intake compared to their estimated energy needs over a defined time frame. You can use the Malnutrition Pocket Guide provided as a resource to quickly determine if decline in PO intake meets malnutrition criteria.

Step 2: Evaluate Weight LossStep 4: Physical Assessment



Inflammation Yes - Severe Yes – Mild to Moderate No

Severe Moderate Severe Moderate Severe ModerateWeight Loss - is evaluated in light of other clinical findings including hydration. Weight change over time is reported as a percentage of weight lost from baseline.






Weight Loss5% in 1 month7.5% in 3 mos10% in 6 mos 20 % in 12 mos

Intake - RD obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated needs over time.

Energy Intake< 50% energy intake compared to estimated energy needs for > 5 days



Energy Intake< 75% energy intake compared to estimated energy needs for > 1 month



FAT – loss of subcutaneous fat i.e. orbital, triceps, fat overlying ribcage.

Body FatModerate depletion

Body FatMild depletion

Body FatSevere depletion




MUSCLE – loss of muscle i.e. temples, clavicles, shoulders, scapula, thigh and calf

Muscle MassModerate depletion

Muscle MassMild depletion

Muscle MassSevere depletion




FLUID – general or local fluid accumulation i.e. extremities, ascites or vulvar/scrotal edems

Fluid AccumulationModerate to Severe

Fluid AccumulationMild

Fluid AccumulationSevere




Presenter

Presentation Notes

The fourth step involves performing a nutrition-focused physical examination to evaluate fat, muscle, and fluid status. You can use the Malnutrition Pocket Guide provided as a resource to quickly determine if fat, muscle or fluid status meets malnutrition criteria.

Nutrition-Focused Physical Examination



Systemic Approach• General Survey

• Skin

• Nails

• Hair

• Head and neck

– Head

– Eyes

– Nose

– Mouth

– Neck

Nutrition Focused Physical Exam• Upper body

- Clavicles, shoulders- Scapula, deltoids- Ribs, hands

• Lower Body- Quadriceps, calves, feet and

ankles• Respiratory• Cardiac• Abdomen• Neurological• Edema or ascites

Presenter

Presentation Notes

Nutrition-focused physical examination is a systematic approach to inspect the general body as well as specific areas for any nutrition-related changes.

General

• Orbital Region

• Upper Arm

• Thoracic Lumbar

Subcutaneous Fat Loss

Presenter

Presentation Notes

To evaluate subcutaneous fat loss, the criteria focuses on 3 specific areas: orbital or eye region, upper arm, and thoracic lumbar region. To meet criteria for malnutrition, more than one area should reflect loss of subcutaneous fat.

General

Orbital Region:

View patient directly in front

Touch above cheekbone

• Well-nourished

– Slightly bulged fat pads

– Fluid retention may mask loss

• Mild/moderate loss of fat

– Slightly dark circles

– Somewhat hollow look

• Severe loss of fat

– Hollow look, depressions, dark circles or loose skin


Presenter

Presentation Notes

The orbital region is the area surrounding the eye. To evaluate for fat loss you would view the client from the front, and gently palpate above the cheekbone. You can practice on yourself. You should feel a soft pad of fat covering the cheekbone, this represents a well-nourished person. You might notice dark circles or a hollow look in a person with mild-moderate loss of subcutaneous fat. Severe loss of fat in this area would feel like you are touching bone without padding and the area would look hollow as seen in the pictures on this slide.

General

Upper Arm Region:

Arms Bent

Roll skin between fingers

Do not include muscle in pinch

• Well Nourished

– Ample fat tissue between fingers.

• Mild/Moderate fat loss

– Some depth pinch, but not ample.

• Severe fat loss

– Very little space between folds, fingers touch.


Presenter

Presentation Notes

To examine the upper arm region, have the client bend their arm at a 90-degree angle and relax as much as possible. Gently pinch the skin on the triceps area with your thumb and forefinger, rolling the skin so just fat and not muscle is assessed – similar to what is shown in the top photo. A well-nourished person has ample fat tissue between fingers. A person with mild - moderate fat loss has some depth to the pinch, but not ample. A person with severe fat loss has very little space between folds, fingers touch easily while gently pinching the area.

GeneralMid-axillary at the iliac crest (IC)

– Thoracic and lumbar– Ribs– Lower back– Midaxillary line

• Well-Nourished: – Full Chest– Ribs not visible– Slight to no protrusion of IC

• Mild-moderate loss of fat: – Ribs apparent– Some depression between ribs– IC somewhat prominent

• Severe loss of fat: – Depression between ribs apparent– IC very prominent


Presenter

Presentation Notes

The final area to assess loss of fat is the iliac crest region, which involves the thoracic and lumbar area, ribs, lower back and mid-axillary line. A well-nourished person will have a full chest with ribs not visible and slight to no protrusion of iliac crest. A person with mild-moderate fat loss will have apparent ribs, some depression between ribs, and iliac crest somewhat prominent. Severe loss of fat would should depression between ribs and a very prominent iliac crest. The picture below is an extreme example of loss of subcutaneous fat.

General

Regions to examine

• Temple

• Clavicle Bone

• Clavicle and Acromion

• Scapula Bone

• Dorsal Hand

• Patellar

• Anterior thigh

• Posterior calf

Muscle Loss

Presenter

Presentation Notes

To assess for loss of muscle, the practitioner would look at the temple, clavicle, acromion process, scapula, dorsal region, patella, anterior thigh and posterior calf. To meet criteria for malnutrition, more than 2-3 areas should reflect loss of muscle.

GeneralTemporalis Muscle:

View directly from front and have ptturn head to side.

• Well-Nourished: – See/feel well defined muscle

• Mild-moderate muscle loss:– Slight depression

• Severe muscle loss: – Hollowing, scooping, depression

Muscle Loss: Temple

Presenter

Presentation Notes

To assess the temporalis muscle, view the client from the front and have client turn their head to the side. You can practice muscle assessment on yourself. Gently palpate the temple muscle, you should see and feel a firm muscle. A person with mild-moderate muscle loss would have a slight depression that is visible and a person with severe muscle loss would have a visible depression as noted in the lower pictures.

GeneralClavicle Bone Region:

– Look for prominent bone

– Make sure pt.. is not hunched

– Patient arms at side, observe shape

• Well-Nourished: – Clavicle not visible in male

– Visible not prominent in females

– Rounded curves

• Mild-moderate muscle loss:– Visible in males

– Protrusion in females

– AP may protrude

• Severe muscle loss: – Protrusion is prominent

Muscle Loss: Clavicle and Acromion Process

Presenter

Presentation Notes

The clavicle region includes the pectoralis major, deltoid, and trapezius muscles. When assessing the clavicle area ask the client to sit upright with arms at their sides. The clavicle bone is not typically visible in a well-nourished male and might be visible, but not prominent in females. The shoulders should look rounded. Mild-moderate muscle loss would reveal a visible clavicle in males and a protrusion in females. You might start to see squaring or protrusion of the acromion process. With severe muscle loss, both the clavicle and acromion process are visible and protruding. The shoulders will be squared off as shown in the lower picture.

General

Scapular bone region:

• Trapezius

• Supraspinatus

• Infraspinatus

Muscle Loss: Scapula

Infraspinatus

Supraspinatus

Presenter

Presentation Notes

The scapular region includes the trapezius, supraspinatus and infraspinatus muscles

GeneralScapula Bone Region:Pt. extend hands straight out

Push against solid surface

• Well-Nourished:– Bones not prominent

– No significant depressions

• Mild-moderate muscle loss: – Mild depression

– Bone may show slightly

• Severe muscle loss: – Prominent bones

– Depressions between ribs, scapula or shoulder/spine

Muscle Loss: Scapula

Presenter

Presentation Notes

To evaluate this area, have the client extend one hand straight out and push against a solid surface. Your clipboard can work well in a clinical setting. A well-nourished person will have no significant depressions in the area above and below the scapula bone. A person with mild-moderate muscle loss will have mild depressions with the scapula showing slightly. Severe muscle loss would exhibit prominent depressions between ribs, scapula or shoulder/spine as seen in the bottom picture.

GeneralDorsal Hand Region:

– Look at: thumb side of hand

pads of thumb when tip of forefinger and thumb touch

• Well-Nourished:

– Bulges or could be flat

• Mild-moderate muscle loss:

– Slightly depressed

• Severe muscle loss:

– Depressed area between thumb and forefinger

Muscle Loss: Dorsal Hand

Presenter

Presentation Notes

See handout for list of muTo evaluate the interosseous muscle, have the client squeeze the thumb to the side of the finger as shown in the bottom left slide or make the OK sign as shown in the bottom right slide. Muscle should be bulging or visible. Slight to severely depressed findings reflect loss of muscle in this area. scles in each region

GeneralPatellar Region:

Sit with leg propped up, bent at knee

• Well-Nourished:

– Muscle protrudes

– Bones not prominent

• Mild-moderate muscle loss:

– Knee cap is visible but still rounded

• Severe muscle loss:

– Bones prominent, squared

– Little sign of muscle around knee

Muscle Loss: Patellar Region

Presenter

Presentation Notes

The patellar region includes the quadriceps muscle, which also surrounds the knee area. To assess, have the client bend their knee as shown in the top photo. A well-nourished patellar region has muscle that protrudes and knee bone is not prominent. Mild-moderate muscle loss is present when the knee cap is visible but still rounded and severe muscle loss is present when the knee bones are prominent, squared with little sign of muscle around knee.

GeneralPosterior Calf Region:

• Grasp the calf muscle to determine the amount of tissue

• Well-Nourished:– Well-developed bulb of muscle

• Mild-moderate muscle loss:– Not well developed

• Severe muscle loss: – Thin

– Minimal to no definitions.

Muscle Loss: Posterior Calf

Presenter

Presentation Notes

The posterior calf region includes the gastrocnemius muscle. To assess this area, gently grasp the calf muscle to determine the amount and quality of the muscle present. A well-nourished area has a well-developed bulb of muscle that is firm in texture. Mild-moderate muscle loss would present as a small bulb of muscle with a somewhat spongy quality. Severe muscle loss is present when the calf is thin, under developed and spongy in texture.

• Edema and/or Ascites

– Excess fluid in within cellular tissue or body cavities

– Asses for edema in:

o Feet, ankles, and sacrum

o Note moist and puffy eyes

– Sign of inflammation and/or loss of plasma protein

o Rule out other causes of edema, look for symmetry

o Impacts weight gain or weight loss history

Fluid Accumulation

Presenter

Presentation Notes

Other causes of fluid accumulation- obstruction of lymphatic circulation, pregnancy, heart failure, kidney disease

Fluid Accumulation

Mild-Moderate Malnutriton Severe

Malnutrition

Presenter

Presentation Notes

Edema may be staged at 0-4 depending on length of time and depth of the pit. Encourage interns to review chart and nursing notes or ask nurse about edema if possible

Micronutrient Assessment

Exam Areas: Description: Potential Deficiency:

Skin Observe skin color, uniformity, texture, turgor

Pallor: iron, folate, B12Lesions, pigmentationDermatitis: EFA, zinc, niacin, riboflavinPellagrous dermatitis: Niacin or tryptophan deficiencyFlaky pain dermatitis: Protein deficiencyPoor wound healing, pressure ulcers: zinc, vitamin C, and/or protein deficiencyDry scaly texture: vitamin A, EFASmall lumps/nodules on elbows/eyelids: hypercholesterolemiaHyperkeratosis: vitamin A, vitamin CMoisture, turgor: poor skin turgor, tenting = dehydration

Nails Observe shape, color, angle contour, lesionsKoilonychia (spoon shape): ironLackluster, dull, or transverse ridge: proteinMottled, poor blanching: vitamin A or C

Scalp/Hair Observe shape and symmetry of scalp; masses; hair distribution, color, textureDull, lackluster, thin, sparse, or depigmented bands of color: protein, iron, zinc or EFAEasily pluckable: protein

Face Shape and symmetry Moon face, bilateral temporal wasting: PEM

Eyes Ask about night blindness, observe for Bitot’s spots, observe skin color and textureNight blindness, Bitot’s spots: Vitamin ACracked and reddened corners of eye brows, lids: riboflavin or niacin deficiency

Nose Observe shape, septum, nares, mucosa, discharge Skin scaly, greasy, with gray or yellowish material around nares (nasolabial seborrhea): riboflavin or pyridoxine deficiency

Lips Color, temperature, cracking, lesions, symmetryBilateral cracks, redness of lips (angular stomatitis): riboflavin, niacin, and/or pyridoxine deficiencyVertical cracks of lips (cheilosis): riboflavin or niacin deficiency

Mouth Observe color, texture, lesions, integrity, moisturePallor: iron, B12 or folate deficiency; Dry: dehydrationCracking: vitamin C deficiencyGeneral inflammation: vitamin B complex, vitamin C, iron

Tongue Observe color, texture, moisture, lesionsMagenta color: riboflavin deficiency; Beefy red color: niacin, folate, riboflavin, ironSmooth, slick, loss of papillae: folate, niacin, iron, riboflavin, B12Distorted taste (dysgeusia), diminished taste (hypogeusia)

Teeth Observe state of repair, missing, denture fitInfluence ability to chew; caries-tooth decay; enamel erosion associated with bulimiaBleeding gums: vitamin C

Gums Lesions, integrity, moisture, colorSpongy, bleeding, receding: vitamin C deficiency, Dry: dehydration,Pale: iron deficiency

Adapted from Cleveland Clinic Center for Human Nutrition, Digestive Diseases Institute and Charney P et al, Practice Paper of the Academy of Nutrition and

Dietetics: Critical Thinking Skills in Nutrition Assessment and Diagnosis. JAND. 2013;113(11):1545.

Information about observations and potential deficiencies in handout provided:

Presenter

Presentation Notes

Micronutrient assessment is not included in the malnutrition criteria, however, we do address how to conduct a nutrition-focused physical examination for micronutrient deficiencies when teaching interns. This is an opportunity for interns to review knowledge related to vitamin and minerals, including fat-soluble and water soluble vitamins and names/numbers of the B vitamins. Interns are also challenged to think critically and evaluate physical symptoms in light of current condition/diagnosis, intake history (including food, medication and supplements). Most common micronutrient deficiencies noted in a physical exam are iron and zinc and Vitamins A and K, and B vitamins. Other non-nutritive causes of signs and symptoms are also reviewed. Interns are not encouraged to diagnose micronutrient deficiencies on observations alone but rather to use these as clues to uncover potential issues and develop an appropriate nutrition intervention and recommendations.

• Interns are challenged to:

– Think critically and evaluate physical symptoms in light of current condition and intake history.

– Recognize common micronutrient deficiencies noted in a physical exam.

– Consider non-nutritive causes of clinical observations in of the head-to-toe exam.

– Use NFPE to develop appropriate nutrition recommendations.


Presenter

Presentation Notes

Interns are also challenged to think critically and evaluate physical symptoms in light of current condition/diagnosis, intake history (including food, medication and supplements). Most common micronutrient deficiencies noted in a physical exam are iron and zinc and Vitamins A and K, and B vitamins. Other non-nutritive causes of signs and symptoms are also reviewed. Interns are not encouraged to diagnose micronutrient deficiencies on observations alone but rather to use these as clues to uncover potential issues and develop an appropriate nutrition intervention and recommendations.

• Scalp and Hair

– Observe shape and symmetry of scalp, masses, hair distribution, color and texture

o Protein, iron, zinc, essential fatty acids

• Eyes

– Bitot’s spots, night blindness

o Vitamin A

• Nose

– Observe shape and presence of mucosa or discharge


Presenter

Presentation Notes

Consider other reasons for hair loss- medications/chemotherapy, hormones/pregnancy and stress Consider vitamin A deficiency in patients with malabsorption (CF and inflammatory Bowel disease) rather than poor intake alone

• Mouth

– Observe color, moisture, lesions

– Ask about taste

– Lips, tongue, teeth, gums

o B vitamins, iron

• Nails

– Observe shape, color, contour, and lesions

o Protein, iron, vitamins A or C


Presenter

Presentation Notes

It can be difficult to pinpoint specific B vitamin deficiency based on NFPE alone, need to consider other factors including diet and medical conditions. Review conditions that may lead to B12 deficiency including age/elderly, vegan diet, alcohol abuse and bariatric surgery Discuss how the cause of physical abnormalities may not be diet-related, may be disease related but still may require nutrition intervention to improve. Stress importance of understanding how different conditions may impact absorption or increase the about of micronutrients required. Excellent article with table describing nail abnormalities and associated nutritional deficiencies in the August 2016 volume of the Support Line from the Dietitians in Nutrition Support Dietetic Practice group.

• Skin

– Observe turgor and moisture

o Dehydration

– Observe color and texture

o Iron, folate, B12

o Protein, vitamin A, essential fatty acids

– Check for wounds and ulcers

o Zinc, vitamin C, protein


Presenter

Presentation Notes

Skin is the body’s largest organ and is constantly turning over. It reflects developing vitamin and mineral deficiencies as well as hydration status Poor skin turgor is a sign of dehydration (skins sticks together after being pulled up and released), other sign can confirm dehydration look at weight, urine output, dry eyes and mouth, vitals and labs Nursing will stage wounds- it is important to review notes and look for this or discuss with nursing

Poll the Audience

• Discuss common disease conditions that result in clinical signs of micronutrient deficiency.

• Share examples of interesting cases of micronutrient deficiencies seen in practice.

• How can preceptors help students or interns learn about micronutrient deficiencies?

Micronutrient Discussion

Functional Assessment



Inflammation Yes - Severe Yes – Mild to Moderate No

Severe Moderate Severe Moderate Severe ModerateWeight Loss - is evaluated in light of other clinical findings including hydration. Weight change over time is reported as a percentage of weight lost from baseline.






Weight Loss5% in 1 month7.5% in 3 mos10% in 6 mos 20 % in 12 mos

Intake - RD obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated needs over time.

Energy Intake< 50% energy intake compared to estimated energy needs for >5 days



Energy Intake< 75% energy intake compared to estimated energy needs for >1 month



Physical Assessment – loss of subcutaneous fat i.e. orbital, triceps, fat overlying ribcage.

Body FatModerate depletion






Physical Assessment – loss of muscle i.e. temples, clavicles, shoulders, scapula, thigh and calf

Muscle MassModerate depletion






Physical Assessment – general or local fluid accumulation i.e. extremities, ascites or vulvar/scrotal edems

Fluid AccumulationModerate to Severe






Functional Assessment Reduced Grip Strength Not recommended in Intensive Care Setting

Reduced Grip Strength Measurably reduced for age and gender

Reduced Grip Strength Not applicable

Reduced Grip Strength Measurably reduced for age and gender

Reduced Grip Strength Not applicable

White J et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) JPEN 2012;36(1):275-283.

Step 5: Functional Assessment

Presenter

Presentation Notes

The fifth step in accurately identifying malnutrition is evaluating the client’s functional status using handgrip strength. You can use the Malnutrition Pocket Guide provided as a resource to quickly determine if functional status meets malnutrition criteria. It is most helpful in determining severe chronic malnutrition and severe environmental malnutrition (check on best way to say this)

Functional Assessment

• Functional Markers:

– Currently limited to assessment of hand-grip strength using dynamometer

– May expand as performance measures are validated

– Not appropriate in intensive care setting

– Facility may develop own functional assessment standards

– Assess for decrease in activities of daily living in collaboration with other health professionals

Presenter

Presentation Notes

Measuring grip strength is not appropriate in all settings and characteristics used to measure functional status will expand in the future as more performance measures are validated. And specific facility’s may develop their own measures of functional status assessment. Asking about decrease in physical activity may further support muscle loss if noted in physical exam Encourage interns to review notes from nursing, therapists and social workers or discuss any problems with other health professionals

• Key points

– Consider the big picture for the patient, use micronutrient assessment to support request for labs or nutrition recommendations

– Review patient chart for clues and ask relevant questions

– Collaborate with the health care team including nurses, therapists and social workers

Fluid, Micronutrient and Functional Assessment

VideoNFPE Video

• Severe – 2 criteria met in severe column

• Moderate - 2 criteria met in moderate and/or severe column

• No criteria for mild at this time

Malnutrition Severity

Presenter

Presentation Notes

Once you have evaluated all 6 characteristics, it’s time to determine whether or not the client meets malnutrition criteria. If 2 characteristics are met in the severe column, the patient can be identified as severely malnourished. If 2 characteristics are met in the severe and/or moderate column, the patient can be identified as moderately malnourished. These standards do not include identification of mild malnutrition at this time.

ExampleAcute Illness

Presenter

Presentation Notes

Let’s practice using the standards. In this example of an acute illness or injury, the client has had moderate weight loss, severely restricted energy intake and mild fluid accumulation. Are you able to identify severe or moderate malnutrition? 3 criteria are present, but only one criterion in the severe category – so we are able to document moderate malnutrition.

ExampleAcute Illness

Presenter

Presentation Notes

In this example, the client has not had weight loss, has severely restricted energy intake and severely depleted body fat with moderate loss of muscle mass and mild fluid accumulation. 4 criteria are present, with 2 characteristics are identified in both the severe and moderate categories. So we would document severe malnutrition.

Summary


Step 3: Evaluate PO Intake

Step 1: Determine if inflammation is present

Step 4: Physical Assessment (Fat, Muscle, Fluid, Micro)

Step 5: Functional Assessment

Develop clinical judgment, consider all factors, Re-assess often, can change over time!!

Presenter

Presentation Notes

In summary, there are 5 main steps to identifying and documenting adult malnutrition in all adult settings, starting with identifying if inflammation is present and if so – whether it is severe or mild-moderate. The second step is evaluating weight loss and the third step is evaluating PO intake. The fourth step is conducting a nutrition-focused physical examination, which includes assessing fat, muscle, fluid and micronutrient status. The final step is to evaluate functional status. Using these characteristics to identify malnutrition does take time and practice. It’s important to keep the “big picture” view of the patient in mind and to continually reassess the patient as nutritional status can change very rapidly.

Benefits and Challenges

• Brainstorm benefits of implementing malnutrition identification and NFPE

• Share challenges experienced and ideas/how overcame

Practice Case

Discussion

• Identify ways to implement of NFPE and malnutrition assessment in your practice

• Share ideas of how you’ve incorporated NFPE in your setting

• Identify tips for teaching student/interns about NFPE

References • White J et al. Consensus Statement: Academy of Nutrition and Dietetics

and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) JPEN 2012;36(1):275-283.

• Academy of Nutrition and Dietetics, Evidence Analysis Library. NSCR: Serum Proteins (2009): https://www.andeal.org/topic.cfm?cat=4302&evidence_summary_id=251043&highlight=albumin&home=1

• Learn to Diagnose Malnutrition Workshop, Cleveland Clinic, Presentation by Sandra Austof and Rebecca Wehner 10/31/14

• Pogatshnik, C., Hamilton, C. Nutrition-focused Physical Examination: skin, nails, hair, eyes, and oral cavity. Support Line. 2011;33(2):7-13.

• Klide, K. Nitzsche, L. Nutrition-focused Physical Examination: A Head-to-Toe Approach with a Focus on Micronutrient Deficiencies. Support Line 2016;38(4);3-8.


• Journal of the Academy of Nutrition and Dietetics, May 2016: http://www.andjrnl.org/

• ASPEN Malnutrition Toolkit: https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Malnutrition_Toolkit/

• Eatright Store: Nutrition Focused Physical Exam Pocket Guide ($10 for members)

• Academy NFPE Hands-on Training Workshop: http://www.eatrightpro.org/resource/career/professional-development/face-to-face-learning/nfpe-workshop

• Cleveland Clinic, Learn to Diagnose Malnutrition: http://www.clevelandclinicmeded.com/live/courses/malnutrition/

• Certificate of Training in Adult Malnutrition (Abbott Nutrition Health Institute) http://anhi.org/malnutrition-ce

• Alliance to Advance Patient Nutrition: http://malnutrition.com/

• Nutrition 411: The Physical Assessment Revisited: Inclusion of the Nutrition-Focused Physican Exam: http://www.o-wm.com/content/physical-assessment-revisited-inclusion-nutrition-focused-physical-exam

Resources

Presenter

Presentation Notes

Additional malnutrition resources can be found in the May 2016 edition of the Journal of the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition’s Malnutrition Toolkit, Eatright.org Store has an inexpensive NFPE pocket guide for members, hands-on training from the Academy or Cleveland Clinic, and Training in Adult Malnutrition from Abbott Nutrition Health Institute.

http://www.andjrnl.org/

https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Malnutrition_Toolkit/

http://www.eatrightpro.org/resource/career/professional-development/face-to-face-learning/nfpe-workshop

http://www.clevelandclinicmeded.com/live/courses/malnutrition/

http://anhi.org/malnutrition-ce

http://malnutrition.com/

http://www.o-wm.com/content/physical-assessment-revisited-inclusion-nutrition-focused-physical-exam

Malnutrition Coding Resources• Implementation of Malnutrition Coding: A Success Story by Jennifer S.

Lowry, RD, LD Jill Johnston, MS, RD, LD Michelle Hoppman, RDN, LRD, CDE

– Published in Dietetians in Nutrition Support 12/2015 http://www.destination10.com/docs/2015DecImplementationofMalnutritionCoding-ASuccessStory.pdf

• Nutrition Care Manual, Malnutrition Coding: https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&lv1=144942&ncm_toc_id=144942&ncm_heading=& Accessed 8/31/16.

• Nutrition Care Manual, Clinical Characteristics the RD can obtain and Document to Support a Diagnosis of Malnutrition: https://www.nutritioncaremanual.org/vault/2440/web/files/Client-Ed/NCM/2016/Malnutrition_ClinicalCharacteristics_Diagnosis.pdfAccessed 8/31/16.

• Nutrition in Clinical Practice, Malnutrition Coding 101: Financial Impact and More: http://ncp.sagepub.com/content/28/6/698.short Accessed 9/14/16.

Presenter

Presentation Notes

Here are additional materials specific to coding and billing malnutrition.

http://www.destination10.com/docs/2015DecImplementationofMalnutritionCoding-ASuccessStory.pdf

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&lv1=144942&ncm_toc_id=144942&ncm_heading=&

https://www.nutritioncaremanual.org/vault/2440/web/files/Client-Ed/NCM/2016/Malnutrition_ClinicalCharacteristics_Diagnosis.pdf

http://ncp.sagepub.com/content/28/6/698.short

nutrition assessment: malnutrition and nutrition focused...

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