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NUTRITION FOCUSED PHYSICAL EXAM

Assessing Nutrition Status & Malnutrition Risk in the Inpatient Setting

Effects of Malnutrition
Altered mental status Impaired wound healing Decreased immune response Increased infection and pressure ulcer risk Compromised temperature regulation & GI function (ie

nutrient absorption) Longer hospital stay Decreased kidney, heart, lung, liver and cognitive function Altered blood pressure and electrolytes

When to use it at Asante?


No baseline albumin

Non-healing wounds/pressure ulcers


Hospital stay longer than 2 weeks Assess cause of weight change (edema?) Assess urgency of nutrition intervention (risk) Obese patients (protein status) Poor intake prior to admit Steroid usage & immune suppressant drugs Bariatric patients

Physical Assessment Benefits


Improved wound healing

Proactive vs reactive care


Better determination of when to begin nutrition support Shorter hospital stay Outpatient better indication of micronutrient

deficiencies Improves credibility as a health care provider Builds rapport

Hand Hygiene
Wash hands before and after

Use clean gloves with each

patient Proper glove removal

Introduce Yourself & Ask Permission

Questions to ask
History of physical activity If very inactive, baseline muscle mass is lower and risk for malnutrition/muscle wasting is higher Original teeth? Dentures? Oral pain?

Change in taste, dry mouth, mouth sores?


Change in strength - daily acts of living? Weakness?

Recent fractures?
Recent onset of memory problems?

Fluid Status
Look for edema, ankles are a good place to start Check hydration status with hand pinch

Is ascites present?

If skin remains elevated after being released, consider dehydration

Fat Stores eye pad


Along with weight trends depict how long a patient can go without adequate intake and can indicate fat soluble vitamin status, as well as duration of poor intake

How: Touch face just above cheekboneshould feel puffy. Can feel fat between finger and upper cheekbone in well-nourished.

Severe Malnutrition: Hollow look, depressed area, dark circles, very loose skin.

Fat Stores triceps/biceps


How: Arm bent, relaxed. Dont pull muscle as you pinch fatfold. Roll skin between fingers.

Well-nourished: Ample fat stores are present in both places.

Severe malnutrition: Very little or no fat between fingers, skin is like 2 layers of paper.

Muscle Status - Temporal


How: Observe straighton. Have patient turn head to one side. In well-nourished, muscle will be well defined, especially if patient chews. May see some depletion with aging.
Severe Malnutrition: Slight to severe depression, hollow. Family members may comment on weight loss.

Muscle Status Interosseous


How: Have patient make circle with thumb and index finger. This muscle is the bottom edge of that circle (above the skin flap). In well-nourished, the bottom of this circle protrudes or may be flat in women

Severe Malnutrition: Very depressed area between thumb and index finger.

Muscle Status Shoulder & Clavicle


Shoulder
How: Examine with arms relaxed at sides. Joints should be rounded with curves at junction of shoulder and arm or neck. Malnutrition is severe if shoulderarm joint looks boxy, with bones easily seen.

Clavicle
How: Look for prominent bone. In wellnourished, the clavicle bone is not visible (men) or only faintly seen (women). Malnutrition is severe if the bone is protruding and very prominent.

Muscle Status Shoulder Blade & Knee


Shoulder Blade
How: Look for prominent bones. Have patient push hands against solid object. Malnutrition is severe if bony edges clearly defined, prominent and visible with significant depressions.

Knee (the lower body is slower to change)


How: Have patient sit with leg propped on low stool or pillow. Knee should be rounded, with bones not obvious or prominent. Severe if bones are very prominent.

Malnutrition Protein Status


Other things to look for:
Visible ribs
Very thin arms with absent muscle Very small legs with absent calf muscle Slow reaction time

Confusion
Slow wound healing Swelling and impaired joint mobility of upper

extremities Skin folds on buttock Any empty looking skin

Malnutrition - Nails, Hair & Skin


Possible indications of malnutrition/protein deficiency:
Hair: Lack of shine/luster, thin, easily pluck-able *Alternating bands of light and dark in hair in children

Skin: Dry with fine lines, shedding and/or scaly skin

Nails: Dull, brittle, ridged, or horizontal lines (nails take 5 months to grow out)

Considerations
Always look at the whole picture Make assessments based on

multiple signs/symptoms Medication side effects Effects of disease/illness Frame size Variations between races, gender and individuals

Obesity: Lack of physical activity (muscle mass) can actually put obese individuals at a higher risk for protein deficiency when intake is inadequate. Physical exams can be more difficult but it is important to consider muscle stores are depleted faster in obese individuals

Considerations in the Elderly


We see some signs of malnutrition so frequently that we often dont notice them. However, what we consider normal in the aging population may actually be a sign of malnutrition.

THANK YOU!
Lindsey Patterson 719-248-7299 Chelsea Small 541-944-5442