sharolyn tsamoutales, graduate student intern bowling green state university, 2012 physical...
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S H A R O LY N T S A M O U T A L E S , G R A D U A T E S T U D E N T I N T E R NB O W L I N G G R E E N S T A T E U N I V E R S I T Y , 2 0 1 2
PHYSICAL ASSESSMENT TO DETERMINE NUTRITIONAL
DEFICIENCIES
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NUTRITION-FOCUSED PHYSICAL ASSESSMENT
During initial patient (pt) evaluation an RD’s assessment can be further enhanced by performing a “head to toe” visual interpretation of a pt’s physical signs and symptoms in determining appropriate Medical Nutrition Therapy.
Throughout this process, it is important to exercise thoughtful consideration for pt’s comfort level.
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NUTRITION-FOCUSED PHYSICAL ASSESSMENT
• Seldom are nutrient deficiencies isolated, multiple deficiencies are most common
• Physical signs of nutrient deficiencies are typically observed after prolonged diet inadequacy
• Non-nutritional related symptoms may be observed
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CLINICAL ASSESSMENT
Consideration of physical observations and interpretation of:
- Hair - Neurological- Eyes - Additional - Oral health observations - Thyroid gland - Hydration status- Nails- Skin
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HAIR ASSESSMENTHAIR SHOULD HAVE A SHINY, NORMAL TO THICK APPEARANCE
THAT IS NOT EASILY PLUCKED.
Clinical Findings
• Thinning, sparse, Alopecia
• Easily plucked, brittle• Dry • “Corkscrew”, coiled
hair
Potential Deficiency
• Protein, Biotin, Zinc, Essential Fatty Acids (EFA), Iron• Zinc, Protein• Vitamin A, EFA,
Zinc• Vitamin C
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HAIR IMAGES
Alopecia Corkscrew
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EYE ASSESSMENTEYES SHOULD APPEAR BRIGHT AND CLEAR WITH HEALTHY MEMBRANES
AND NORMAL MOVEMENT
Clinical Findings
• Nyctalopia, • Pale Conjunctiva• Ophthalmoplegia
• Xerophthalmia• Fissuring in corners,
redness
Potential Deficiency
• Vitamin A, E• Vitamin A, Iron• Thiamin (B1),
Phosphorus • Vitamin A, Protein• Riboflavin (B2),
Pyridoxine
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EYE IMAGES
Pale conjunctiva Ophthalmoplegia
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ORAL HEALTH ASSESSMENTMOUTH SHOULD APPEAR FREE OF SORES AND SWELLING, WITH NORMAL
PINK/RED GUMS AND TONGUE. NORMAL TEETH, TASTE AND SMELL.
Clinical Findings
• Cheilosis, Angular stomatitis, or Perlèche• Magenta glossitis• Pale, Sore tongue• Atrophic lingual
papillae
Potential Deficiency
• Riboflavin, Pyridoxine, Niacin, Iron, Zinc • Riboflavin• Riboflavin, B12, Iron• Riboflavin, Niacin,
Folate, B12, Protein, Iron
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ORAL HEALTH IMAGES
Angular stomatitisAtrophic lingual
papillae
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ORAL HEALTH ASSESSMENTMOUTH SHOULD APPEAR FREE OF SORES AND SWELLING, WITH NORMAL
PINK/RED GUMS AND TONGUE. NORMAL TEETH, TASTE AND SMELL.
Clinical Findings
• Swollen, retracted, bleeding gums• Loose teeth• Hypoguesia• Hyposmia
Potential Deficiency
• Vitamin C
• Vitamin C• Zinc• Zinc
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ORAL HEALTH IMAGES
Swollen, retracted, bleeding gums Loose teeth
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THYROID GLAND ASSESSMENTLOCATED ON THE FRONT OF THE NECK FLANKING THE TRACHEA,
SHOULD NOT APPEAR ENLARGED
Clincal Findings
• Hypothyroidism, Goiter
Potential Deficiency
• Iodine
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NAIL ASSESSMENTNAILS SHOULD HAVE A SMOOTH APPEARANCE FREE OF RIDGES AND
DISCOLORATION, WITH A NORMAL, PALE, CRESCENT SHAPED, LUNULA
Clinical Findings
• Koilonychia• Longitudinal central
ridges• Longitudinal nail
beading• Absent Lunula • Brown-gray color• Transverse ridging,
dry, brittle
Potential Deficiency
• Iron, Protein • Iron, Folic Acid,
Protein • B complex (B1, 2, 3,
5, 6, 7, 9, 12), Protein• Protein, Iron, • B12• Protein, EFA
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NAIL IMAGES
Koilonychia Absent lunula.
Longitudinal central ridge Longitudinal nail beading
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SKIN ASSESSMENTSKIN SHOULD APPEAR NORMALLY SMOOTH AND FREE OF DISCOLORATION
Clinical Findings
• Purpura• Petechiae• Pellegra• Follicular
hyperkeratosis• Nasolabial seborrhea,
scaling, dry, goose bump• Pallor
Potential deficiency
• Vitamin C, K, Folic acid• Vitamin C, K• Niacin, Tryptophan• Vitamin A, B, C, E, EFA• Vitamin A, Zinc, EFA,
Riboflavin, Pyridoxine
• Iron, B12, Folic acid, Vitamin E
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SKIN IMAGES
Purpura Petechiae
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SKIN IMAGES
Nasolabial seborrhea Dry, goose bump
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SKIN ASSESSMENTSKIN SHOULD APPEAR NORMALLY SMOOTH AND FREE OF DISCOLORATION
Clinical Findings
• Dermatitis• Cellophane
appearance• Desquamation,
Pigmentation
Potential Deficiency
• Zinc, Niacin• Protein
• Niacin, Protein
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SKIN IMAGES
Desquamation, Pigmentation
Protein edema
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NEUROLOGIC ASSESSMENT
Clinical Findings
• Dementia
• Confabulation, Beri-beri• Peripheral
Neuropathy, Paresthesias
Potential Deficiency
• Thiamin, Vitamin E Niacinamide, B12, • Thiamin
• Thiamin, Pyridoxine, B12
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NEUROLOGIC IMAGES
Beri-beri Tetany
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NEUROLOGIC ASSESSMENT
Clinical Findings
• Ataxia
• Tetany
Potential Deficiency
• Thiamin, Pyridoxine, B12, Vitamin E• Thiamin, Niacin,
B12, Calcium, Vitamin D, Vitamin E, Magnesium
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ADDITIONAL PHYSICAL ASSESSMENTS
Clinical Findings
• Parotid enlargement• Osteomalacia,
Rickets• Persistant Cough• Dyspnea
Potential Deficiency
• Protein
• Vitamin D
• Thiamin• Folic Acid, B12, Vitamin E
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ADDITIONAL PHYSICAL IMAGE
• Parotid swelling • Osteomalacia, Rickets
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ADDITIONAL PHYSICAL ASSESSMENTS
Clinical Findings
• Marasmus
• Kwashiorker
Potential Deficiency
• Macronutrients, micronutrients• Protein, Iron, Folic
Acid, Vitamin C
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ADDITIONAL PHYSICAL ASSESSMENTS
Marasmus Kwashiorker
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HYDRATION STATUS ASSESSMENTCLINICAL PHYSICAL FINDINGS
Underhydration
• Imput < output• Decrease in weight• Sunken, dry eyes• Oliguria, dark urine• Sticky salvia, dry
membranes• Poor skin turgor• Cool, pale clammy
skin
Overhyration
• Imput > output• Increase in weight• Puffy, swollen eyes• Light colored urine• Moist skin• Anasarca, edema• Dyspnea, lung
crackles
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin A Syndromes- Nyctalopia- Xeropthalmia- Follicular
hyperkeratosis
Signs and symptoms- Poor Vision- Corneal ulceration- Dry Hair- Dry Skin- Itchy Skin- Weak fingernails
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B1, ThiaminSyndromes- Beri-beri- Wernicke’s
encephalopathy- Korsakoff
syndrome
Signs and symptoms- Muscle cramping - Hyporeflexia- Paresthesia- Poor Memory- Chest pain- Tachycardia- Dyspnea
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B2, RiboflavinRelated Syndrome- Ariboflavinosis, Pellagra - Cheilosis- Edema - Seborrheic
dermatitis- Growth retardation
Signs and Symptoms- red, scaly, oily skin
rash- Mouth sores- Swollen tongue- Fissures of the
mouth and lips- Itchy eyes
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B3, Niacin/NicotinamideRelated Syndrome- Pellagra
Signs and Symptoms- Dermatitis- Diarrhea- Depression- Dementia- Dysphagia/
hypersalivation- Abdominal/nausea
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B6,PyridoxineRelated Syndrome-Polyneuropathy
Signs and symptoms
- Numbness, tingling, weakness of the limb- Diarrhea- Swollen tongue- Seizures- Nausea
- Depression- Impaired mental
faculties- Itchy, red skin rash- Vomiting
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B9, Folic Acid/FolateRelated Syndrome
- Macrocytic anemia- Increased risk of
heart disease, dementia, and cancer
Signs and Symptoms- Pallor- Depression- Diarrhea- Swollen tongue- Fissures of mouth,
lips- Dyspnea upon
exertion
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin B12Related Syndrome
-Neuropathy-Macrocytic AnemiaSigns and Symptoms
- Pallor- Sore, Red, swollen tongue
- Numbness or tingling in upper & lower limbs progressing to the trunk
- Dyspnea- Depression- Memory loss - Low energy, weak
muscles, - light-headedness- Increased risk over age
51
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin CRelated Syndrome- ScurvySigns and Symptoms- Bleeding gums- Loose teeth - Halitosis- Nosebleed
- Poor wound healing- Purpura- Corkscrew hair- Anemia - Painful joints,
muscles- Numbness in
extremities- Skin rash or spots
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin DRelated Syndrome- Osteomalacia- RicketsSigns and Symptoms- Tingling, numbness,
burning of lips, tongue, hands
- Weak bones- Bone protusions- Bone pain- Bowing in legs- Muscle weakness- Muscle pain
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin ERelated Syndrome- Hemolytic anemia- Neurologic problems
Signs and Symptoms- Pallor- Demetia- Night blindness- Dyspnea- Ataxia- Tetany- Muscle weakness- Follicular
hyperkeratosis
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
Vitamin KRelated Syndrome- Bleeding disorders- Birth Defects
Signs and Symptoms- Purpura- Petechiae- Nosebleeds- Menorrhagia- Poor wound
clotting- Gastrointestinal
bleeding
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NUTRIENT SPECIFIC SYMPTOMS OF DEFICIENCY
IronRelated Syndrome- Pica- Restless Led
Syndrome
Signs and Symptoms- Fatigue- Alopecia- Pale Conjunctiva
- Pale, Sore tongue- Atrophic lingual
papillae- Koilonychia- Longitudinal central
ridges- Absent Lunula in nail- Pallor- Cold extremities
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REFERENCES
• 1.Seshadri D, De D. Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol [serial online] 2012 [cited 2012 Jun 23];78:237-41. Available from: http://www.ijdvl.com/text.asp?2012/78/3/237/95437
• 2.R W Vilter, and J J Will. Nutrition and Nutritional Deficiency Diseases• Annual Review of Medicine Vol. 9: 191-208 (Volume publication date February 1958)• DOI: 10.1146/annurev.me.09.020158.001203
• 3. Centers for Disease Control and Prevention (CDC). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children During the Domestic Medical Screening Examination http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html
• 4. Peggy K.Yen, RD,MPH. Nutritional Anemia. Geriatric Nursing 2000 • Volume 21 • Number 2, pg 111-112.
• 5.Paillaud, Elena1; Merlier, Isabelle1; Dupeyron, Catherine. Oral candidiasis and nutritional deficiencies in elderly hospitalized patients. British Journal of Nutrition, Volume 92, issue 5 (November 1, 2004), p. 861-867
• 6.Collinsworth, Reatha. Determining nutritional status of the elderly surgical patient: Steps in the assessment process. AORN Journal, Volume 54, issue 3 (September, 1991), p. 622-628,630-631
• 7 Stotts, Nancy, RN. Nutritional Assessment before Surgery. AORN Journal, February 1982, Vol35, No 2 207-214.
• 8. Miller, Stanley J, MD. Nutritional Deficiency and the Skin. Journal of the American Academy of• Dermatology. Volume 21 , issue 1 (July, 1989), p. 1-30
• 9. Sinn, N. Physical fatty acid deficiency signs in children with ADHD symptoms. Prostaglandins, Leukotrienes & Essential Fatty Acids, Volume 77, issue 2 (August, 2007), p. 109-115.
• 10. CDC Report: Why Vitamin B12 Deficiency Should Be on Your Radar Screen. A Continuing Education Update Course WB1349. http://www.cdc.gov/ncbddd/b12/documents/b12-030910.pdf http://www.cdc.gov/ncbddd/b12/cases.html
• 11.Charney P. PhD RD, Malone A. MS RD CNSD. ADA Pocket Guide to Nutrition Assessment. Second edition. pgs 40-61.
• 12. Academy of Nutrition and Dietetics Nutrition Care Manual • https://elearning.bgsu.edu/webapps/portal/frameset.jsp?tab_id=_2_1&url=%2fwebapps%2fblackboard%2fexecute%2flauncher%3ftype%3dCourse%26id
%3d_15729_1%26url%3d