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Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Nutrition Focused Physical Assessment Clinical Assignment


Before beginning this assignment, read the Academy of Nutrition and Dietetics’ Practice Papers:
1. Scope of Practice for the Registered Dietitian; and,
2. Critical Thinking Skills in Nutrition Assessment and Diagnosis.
3. Review the ASPEN/AND Guidelines for Malnutrition Screening/Diagnosis.

Q: What is the purpose/intent of the Nutrition Focused Physical Assessment?


A: Assessing the characteristics of malnutrition.

From the Academy’s Definition of Terms:

Nutrition Assessment:
A method of identifying and evaluating data needed to make decisions about a nutrition-
related problem/diagnosis.

While the type of data may vary among nutrition settings meeting client or community needs,
the process and intention are the same. When possible, the assessment data is compare to
reliable norms and standards for evaluation. Nutrition Assessment initiates the data collection
process providing the base for Nutrition Diagnosis; Nutritional Recommendations/Care
Plan/Nutrition Intervention, and form the foundation for reassessment in Monitoring and
Evaluation.

Beginner:
Dietetic Intern with supervised practice.

Level of Practice: Competent:


A dietetics practitioner who has just obtained registered dietitian status through the first three
years of practice in a given arena, starting in an employment situation as a professional, and
gains on the job skills as well as tailored continuing education to enhance proficiency and
knowledge.
Education: Completion of supervised practice experiences and is post registration.
Experience: Functions at a professional level using science based application learned in the
education process and seeks additional learning experiences.

At the beginner’s level, “you will identify potential nutrition-related problems by reviewing data
from the patient/client medical charts, which are gathered by the medical team during the physical
examination and comprehensive medical history. You will also look at nursing notes and
assessments, vital signs documentation, rehabilitation therapy (physical, speech, occupational,
respiratory) assessments and progress notes, as well as medication orders, lab test results, measure
of hydration status, anthropometric measurements, food and water intake.” (Litchford, M. (2013)
Putting the Nutrition-Focused Physical Assessment into Practice in Long-Term Care.

Retrieved July 6, 2015 from: http://www.annalsoflongtermcare.com/content/putting-nutrition-


focused-physical-assessment-practice
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

A.) MEDICAL TERMINOLOGY


1. Provide definitions for the following terms that are relevant to location and position of the
anatomical structure
a. Superior – above or upward
b. Inferior – below or downward
c. Anterior – front
d. Posterior – back
e. Ventral – front
f. Dorsal – back
g. Medial – middle
h. Lateral – side
i. Intermediate- between two extremes
j. Internal – inside
k. External – outside
l. Superficial – on the surface
m. Deep – away from the surface
n. Central – in the center
o. Peripheral – away from the center
p. Proximal – the beginning
q. Distal – away from the center
r. Parietal – the walls of a cavity
s. Visceral – internal organs of the body
2. Provide definitions for the following terms that are commonly seen in patient physical
examinations assessments
t. Gowning and gloving – The use of a gown and gloves to prevent or decrease the possibility
of infecting a staff member
u. Inspection – Visual examination noting any abnormalities.
v. Palpation – Hands are used to conduct examination
w. Percussion – Assessment of the internal organs by tapping the area where it is located.
Assessment is determined based on sound from tapping.
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

x. Auscultation – Medical diagnosis is made by listening to the sounds of the heart, lungs, or
other organs through a stethoscope
y. Quadrants – know the acronym and identify which organs are within each quadrant
1) LUQ – left upper quadrant-stomach, pancreas, left lobe of liver, spleen, left kidney
and adrenal gland.
2) RUQ – right upper quadrant-right kidney, adrnal gland, top of pancreas, duodenum,
liver
3) LLQ – left lower quadrant-desending and sigmold colon, left ovary, fallopian tube
4) RLQ – right lower quadrant-ascending colon, right ovary, right ureter, right ovary
z. Vital Signs – Body temp, pulse, rate, respiration rate, blood pressure
aa. HEENT – examination of the head, eyes, ears, nose, and throat
3. List of implements:

INSTRUMENT USES

Stethoscopes listening to internal sounds of the body

Blood Pressure Cuff/Meter measures blood pressure

Scale measures wt

Tongue Depressor depresses tongue to allow for examination of the mouth and
throat

O2 mask/Tubes transfers breathing oxygen to the lungs

Vaporizer use to add hot mist to the air to increase moisture in the air

Nebulizer a breathing machine to treat lung conditions

Positive Pressure Ventilator increases the pts airway pressure to allow air to flow into the
airway unit the ventilator breath is terminated

Cardioverter/Defibrillator tracks heart rate. if the heart rate becomes abnormal or


irregular it will send an electric shock to restore the heart
beat to normal

Dialyser removes waste and excess water from the body for those
who have little to no kidney function
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Canula thin tube inserted into a vein or body cavity to administer


medicine, drain fluid, or insert a surgical tool

Rubber catheter inserted into the bladder to drain urine

Endoscope a flexible tube with a light and camera used to examine the
digestive tract

Balloon Catheter a soft catheter with a balloon to enlarge a narow opening or


area in the body during a catherization procedure

B) HISTORY AND PHYSICAL


The point of this section is to be familiar in how to read the history and physical
portion of a medical record. Read the following sections and understand the flow
of medical charting, as this will be the flow in most medical records.
I. CHIEF COMPLAINT
The chief complaint states why the patient came to the hospital. It is
normally written in the patient’s own words.

II. HISTORY OF PRESENT ILLNESS


A chronological account of the major problem for which the patient is
seeking medical care. The principal symptoms should be described in the
terms of their:
1.) Location
2.) Quality
3.) Quantity or severity
4.) Timing (i.e. onset, duration, and frequency)
5.) In the setting in which they occur
6.) Factors that have aggravated or relieved them
7.) Associated manifestations and/or significant negatives
The part of the review of systems that pertains to the organ system
involved in the problem for which the patient is seeking medical attention
should be included in the present illness.
III. PAST MEDICAL HISTORY (PHx)
A. Childhood illnesses – measles, rubella, mumps, whooping cough,
chicken pox, rheumatic fever, scarlet fever, polio
B. Immunizations – whether immunizations were complete during
childhood/last tetanus boosters given and if polio, measles, rubella,
mumps vaccinations are up to date. Whether the patient has received
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

any other vaccinations, particularly pneumococcal, hepatitis B,


influenza
C. Adult Illnesses – type of illnesses, the date it occurred, whether
hospitalization was required (if so, where?), and a very brief summary
of the illness
D. Operations – what procedure was done, why it was done, when and
where it was done, and whether or not there were any complications
E. Allergies – to what medications/foods; describe the type of reaction and
how soon it occurs
F. Medications – names of the medications, doses that the patient takes,
how long they have been on the medicines and for what reasons
G. Complimentary Treatments – i.e. massage therapy, acupunctures,
herbal, vitamins, etc.

IV. FAMILY HISTORY


Includes information about parents, siblings, maternal and paternal
grandparents, aunts and uncles. Major diseases of importance:
- Diabetes (DM)
- Hypertension (HTN)
- Ischemic heart disease
- Stroke
- Kidney disease
- Tuberculosis
- Cancer
- Arthritis
- Hematologic disorders
- Mental illness
V. SOCIAL HISTORY
Education, occupation, who the patient lives with, financial situation,
Travel
Cigarette smoking expressed in number of pack years ( = number of packs
smoked per day x number of years that the patient has smoked); if the
patient has quit smoking, note how long ago
Alcohol (what kind of liquor patient drinks, how much is drunk daily, and
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

for how long has this pattern been going on)


Illicit drug use
Sexual history

VI. REVIEW OF SYSTEMS


General: Usual wt., recent wt. change, weakness, fatigue, fever, night sweats,
anorexia, malaise
Skin: Color changes, pruritus, bruising petechiae, infections, rashes, sores,
changes in moles, changes in hair or nails
Head: Headache, head injury
Eyes: Vision, glasses/contact lens, date of last eye examination, pain, redness,
excessive tearing, double vision (diplopia), floaters, loss of any visual fields, hx of
glaucoma or cataracts
Ears: Hearing loss, change in hearing, ringing in ears (tinnitus), ear infections
Nose and Sinuses: Frequent colds, nasal stuffiness, hay fever, nosebleeds, sinus
trouble, obstruction, discharge, pain, change in ability to smell, sneezing, post-
nasal drip, history of nasal polyps
Mouth and Throat: Soreness, dryness, pain, ulcers, sore tongue, bleeding gums,
pyorrhea, teeth (cavities, abscesses, extractions, dentures), sore throat, hoarseness,
history of recurrent sore throats or of strep throat or of rheumatic fever
Neck: Lumps, swollen lymph nodes or glands, goiter, pain
Lymphatics: Swollen lymph nodes in neck, axillae, epitrochlear areas, or inguinal
area
Breasts: Lumps, pain, nipple discharge, self-examination, enlargement in men or
children (gynecomastia)
Pulmonary: Cough (duration, association with sputum production), change in
chronic cough, trouble breathing (dyspnea), wheezing, coughing up blood
(hemoptysis), pain with taking a deep breath (pleuritic chest pain), blue
discoloration of lips or nailbeds (cyanosis), history of exposure to TB, history of a
previous TB skin test and the results if done, recurrent pneumonia, history of
environmental exposure
Cardiovascular: Chest pain (including details), dyspnea, paroxysmal nocturnal
dyspnea (PND; patient will describe shortness of breath that improves when he or
she sits up and dangles feet off the bed), orthopnea (patient has to sleep on pillows
to prevent shortness of breath; quantitate by the number of pillows that the patient
sleeps on), edema, palpitations, hypertension, hx or a murmur, hx of rheumatic
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

fever, syncope or near syncope, pain in posterior calves with walking


(claudication), varicosities, thrombophlebitis, history of an abnormal EKG.
Gastrointestinal: Trouble swallow (dysphagia), pain with swallowing
(odynophagia) n/v/d, hematemesis, food intolerance, indigestion, heartburn,
change in appetite, early satiety, formed vs loose bowel movements, changes in
bowel pattern, rectal bleeding, melena, constipation, abdominal pain, excessive
belching or passing of gas, hemorrhoids, jaundice, liver or gallbladder problems,
hepatitis
Urinary: Blood in urine (hematuria), dysuria, frequency, suprapubic pain,
costovertebral angle (CVA), tenderness, frequent urination at night (nocturia),
polyuria, stones, inguinal pain, trouble initiating urinary stream, incontinence, UTI
Genital tract (male): Penile discharge, lesions, STD, testicular pain, testicular
swelling, scrotal mass, infertility, impotence, change in libido, sexual difficulties,
hernias
Genital tract (female): Age of menarche, last menstrual period, cycle (number of
days; how much bleeding. Intermenstrual bleeding, postictal bleeding,
dyspareunia, vaginal discharge, pruritus, contraceptive use, STD, last pap smear
and results, age at menopause, postmenopausal bleeding, infertility, change in
libido, sexual difficulty, pregnancies
Musculoskeletal: Joint pains or stiffness, arthritis, gout, backache, joint swelling
or tenderness or effusion, limitation of motion, lack of grip, history of fractures,
muscular wasting
Neurologic: Fainting, blackouts, seizures, paralysis, local weakness, numbness,
tingling, tremors, memory changes headaches, vertigo or dizziness, muscle
atrophy
Psychiatric: Anxiety, nightmares, nervousness, irritability depression insomnia,
hypersomnia, phobias, tension, suicidal ideation, criminal or other sociopathic
behavior should be pursued
Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating or
flushing, diabetes, excessive thirst or hunger or urination
Hematologic: Anemia, easy bruising or bleeding, past transfusions and reactions
VII. PHYSICAL EXAMINATIONS
1. Vital signs
2. General appearance
3. Skin
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

4. HEENT
5. Neck
6. Nodes
7. Breasts
8. Chest
9. Heart
10. Abdomen
11. Back/spine
12. Extremities, including exam of pulses
13. Genitalia
14. Rectal
15. Neurologic
a. Mental status
b. Cranial nerves
c. Motor
d. Sensory
e. Cerebellar; posterior column
f. Reflexes
1. Vital signs: Blood pressure: right and left arms; supine and standing; Pulse:
including comments about whether regular vs. irregular respirations; temperature,
anthropometrics (height measured or stated; weight measured standing/bed scale
or stated)
2. General appearance: Should describe whether the patient appears acutely ill or
not, whether the patient is oriented (to time, place, and person)
3. Skin: Texture (dry, supple, moist, etc.) turgor, rash, skin lesion (describe
including location and size if present, icterus, pallor, edema, cyanosis
4. HEENT:
Head: Skull (normocephalic, atraumatic, any deformities), scalp, hair,
distribution
Eyes: Lids (any ptosis?), sclera (any icterus, muddy appearance), conjunctivae
(pale, injected red), cornea (opacified), pupils (PERRLA – Pupils Equal, Round,
React to Light and Accomodation), light reflex (both direct and consensual),
visal acuity, fundoscopic exam (includes description of optic disc, retinal vessels
retinal lesions)
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Ears: External auditory canal and tympanic membranes


Nose: Nasal septum and whether turbinates are enlarged or reddened, sinus
tenderness to palpation and percussion
Throat: Lips, tongue, teeth, gums, oral mucosa, breath odor.
5. Neck: Supple (mobile), thyroid (palpable, modules or masses, tender), trachea
(midline, stridor over it), carotids (volume, upstroke, bruits), jugular venous
distention)
6. Nodes: Submandibular, submental, pre- and post- auricular, occipital, anterior
and posterior cervical triangles, supraclavicular (those nodes should all be checked
during the HEENT and Neck exams)
7. Breasts: Inspection and palpation, for masses, discharge, or tenderness
8. Chest: Inspection: for symmetry of respiration excursions; for deformities
Palpation: for fremitus
Percussion: for resonance, hyperresonance, or dullness
Auscultation: for normal breath sounds, crackles, wheezes, rhonchi, rubs
9. Heart: Inspection: abnormal outward pulsations
Palpation: for lifts, heaves, shocks, murmurs
Auscultation: rate, rhythm, heart sounds, murmurs, gallops, rubs, clicks
10. Abdomen: Inspection: size, contour, scars, abnormal venous patterns
Auscultation: bowel sounds, bruits
Percussion: Tympany, shifting dullness, fluid wave, liver size
Palpation: tenderness, liver, spleen, masses, aortic pulsations, hernia
11. Back/spine: mobility, curvature, posture, tenderness, CVA tenderness
12. Extremities: Upper and lower: symmetry, moisture, nails, cyanosis, clubbing,
edema, tremor. Joints: swelling, deformities, tenderness, warmth, erythema,
effusions, range of movement (MAE x 4). Pulses: Carotids (may be listed in this
section or under Neck), brachial, radial, femoral, popliteal, dorsalis pedis, posterior
tibial
13. Genitalia: Male – distribution and amount of pubic hair, penile lesions or
discharge, circumcised, scrotum, testes for masses or tenderness, epididymis,
inguinal canal
Female – distribution and amount of public hair, external genitalia for
lesions, discharge, or evidence of inflammation vagina, cervix, uterus and adnexae,
rectovaginal
14. Rectal: External lesions hemorrhoids, fissures, fistulae, sphincter tone, prostate
for size and masses and tenderness, masses, stool (color, consistency, occult blood)
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

15. Neurological:
Mental status – level of consciousness, behavior, attention and concentration,
language, memory, abstract reasoning, alert, lethargic, non-responsive, oriented x 3
(a&o x 3 – alert and orientated to person, place, &time)
Cranial nerves – II-XII are listed and checked
Motor – gait (regular, toe, heel, tandem), balance, involuntary movements,
(fasciculation, tremor, chorea, posturing), limb tone (spasticity rigidity, flaccidity),
contracture, strength, muscle bulk (atrophy, hypertrophy), muscle tenderness
Sensory – pinprick, light touch, graphesthesia, sterognosis, double simulation
touch
Cerebellar – gait for ataxia, finger to nose, heel to shin, rapid alternating
movements; standing with feet together and eyes open
Posterior column – vibratory sensation, position sense
Reflexes – deep tendon reflexes: biceps, triceps, knee jerk
VIII. PROBLEM LIST
This is simply a list of all abnormal findings from the history and physical exam.
Related problems may be grouped together (i.e. shortness of breath (SOB),
tachypnea, and abnormal lung exam could be all listed as part of the same
problem). The list should be organized such that the most serious problems are
listed first.
IX. DIFFERENTIAL DIAGNOSIS
A list of disease that the physician can explain the major problems identified on
the problem list. They should be organized such that the most likely diagnoses are
listed first. It is typical to account for as many problems as possible with a single
diagnosis.
X. LABORATORY DATA
A list of abnormal laboratory data will be provided related to the problem list.
Normally it will include BMP (basic metabolic panels) WBC, RBC, sodium,
potassium, chloride, CO2, BUN, creatinine, glucose, calcium, liver enzymes
(ALT/AST), alkaline phosphate
XI. DIAGNOSTIC STUDIES
Depending on the chief complaint and history of present illness, diagnostic studies
will be performed and notes of the physician conducting the studies will be
provided. Diagnostic studies includes but not limited to: CT, U/S (ultrasound), X-
ray, MRI, PET scan, etc.
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

XII. ASSESSMENT AND PLAN


This is where the physician includes their SOAP notes and plan. The physician
will summarize the subjective/objective data of the patient, the major assessments
completed and the plan including medications, labs to be monitored, and further
procedures to be made.
C) BIOCHEMICAL DATA
1. List the specific labs drawn for each of the following panels, and indicate if they have a
relationship to nutrition.
a. Basic metabolic panel (BMP) – Glucose, calcium, sodium, potassium, CO2, Chloride,
BUN, creatinine. There is a relationship to nutrition
b. Comprehensive metabolic panel (CMP) – glucose, calcium, albumin, total protein, sodium,
potassium, co2, chloride, BUN, creatinine, ALP, ALT, ASt, Bilirubin. There is a
relationship to nutrition
c. Complete blood count (CBC) – white blood cell count, white blood cell differential, red
blood cell count, hemoglobin, hematocrit, platelet count. There is not a relationship to
nutrition
d. Electrolyte panel – sodium, potassium, chloride, bicarbonate. There is a relationship to
nutrition
e. Hemodialysis Profile – creatinine, GFR, sodium, potassium, calcium, phosphorous. There
is a relationship to nutrition
f. Lipid Panel – total cholesterol, HDL, LDL, triglycerides, VLDL, nonHDL.There is a
relationship to nutrition
g. Toxicology Screen (urine) – amphetamine, methamphetamine, bariturates,
benzodiazepines, marijuana, cocaine, methadone, opiates, PCP. There is not a relationship
to nutrition
labtestsonline.org
Label the basic metabolic and CBC panel (shorthand) lab skeleton/fish bones

BUN
Na+ Cl-
Glucose

K+ HCO3- Creatinine

Hgb

WBC Plts
Hct
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

1. How do the BMP labs relate to nutrition status?

LAB PRIMARY ABOVE NORMAL BELOW NORMAL


VALUES FUNCTIONS RANGE RANGE
Red blood cell RBC contains ● Congenital heart ● Anemia
hemoglobin that permit disease
(RBC) the transport and ● Cancers (lymphoma,
exchange of O2 and ● Erythrocytosis myeloma, leukemia,
CO2 to the tissues, thus ● COPD lymphoma)
without it can impact a ● Cirrhosis
cascade of healing by ● Severe dehydration
reduce the body’s (diarrhea, burns) ● Dietary deficiency:
normal cellular iron, vit B12
response to close the ● Fluid overload
wound (edema)
● Hemorrhage
● Pregnancy
● Renal disease
● Rheumatoid

White Blood Cells of the immune Indication of disease Deficiency would be


Cells (WBC) system that protect Leukemia indicative of an
the body against autoimmune condition
infectious disease and Bone marrow disease that may cause WBC to
foreign invaders. be killed or depleted

Mean Cell Average volume Alcoholism & B12 iron deficiency &
Volume (MCV) of red blood cells deficiency anemia

Mean Cell Average size of Macrocytic anemia Microcytic anemia, iron


Hemoglobin hemoglobin in one Pt may be living a very deficiency, internal
(MCH) red blood cells high altitudes and may be bleeding
a chronic smoker.
Infection High state of stress
Neutrophils White blood cells
inflammation Smoking
that appear Medicine/drugs
immediately
following the onset
of infection
Lymphocytosis Lymphocytopenia
Lymphocytes B cells and T cells
Malnutrition
Remove antigens Inherited disorder
from the body
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

smoking Aplastic anemia


Hemoglobin Iron containing
lives at high altitudes Cancer
(Hgb) protein in the blood COPD Cirrhosis
Transports oxygen to Congenital heart disease Hypothyroidism
body tissues Emphysema Iron deficiency anemia
Chronic kidney disease
Amount of red blood dehydration Anemia
Hematocrit
cells in the total blood Polycythemia vera Excess wbc
(Hct) count Lung or heart disease Vitamin and mineral
deficiencies
blood loss
glucose levels are used Increased carb intake Dumping syndrome
Glucose
to determine how much Lower physical activity
(fasting) glucose is present in Hormonal fluctuations
the blood and is
indicative of
prediabetes or diabetes
Average blood sugar anemia Surgery
Hemoglobin
level for the past 2-3
A1c (A1c) months Heavy menstrual cycle

Blood cell protein that HFE mutation Low iron stores


Ferritin
contains iron Liver disease Iron deficiency
Rheumatoid arthritis
Inflammation
hyperthyroidism
Iron bound to a protein Iron deficiency hemochromatosis
Transferrin
Pregnancy Anemia resulting from
Oral contraceptive excess iron
indicative of abnormal Dehydration Excess sodium loss
Na
sodium levels Cushing syndrome Excessive water
consumption
indicative of abnormal Kidney disease diarrhea
K
potassium levels Addison disease Vomiting
Tissue injury Conn syndrome
Infection Acetaminophen overdose
Diabetes
dehydration
Indicative of Kidney failure Hypercalcemia
Phosphorous
phosphorus imbalances Liver disease Excessive use of diuretics
Hypoparathyroidism Malnutrition
Increased intake of a Alcoholism
phosphate supplement Burns
Diabetic ketoacidosis
Alk Phos. (ALP) Indicator of liver Damaged liver May be seen after a blood
disease or bone Condition causing increase transfusion
disorder bone cell activity
Indication of overall chronic inflammation Liver disorder
Total Protein
health infection Kidney disorder
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Indication of overall dehydration Infection


Albumin
health Burns
Surgery
Chronic illness
Cancer
Diabetes
Hypothyroidism
Carcinoid syndrome
Indication of overall Malnutrition
Pre-Albumin
health and protein- Chronic illness
calorie malnutrition Inflammation
Trauma
Liver disease
Indication of Indicates inflammation but inflammation or infection
C-reactive
inflammation not the location of it is decreasing
protein (CRP)
Indicative of High risk of heart disease Low risk of heart disease
Total
developing heart
Cholesterol (TC) disease
Screens for unhealthy HDL-low risk of heart HDL-high risk of heart
HDL/LDL
levels of lipids disease disease
Cholesterol LDL-high risk of heart LDL-low risk of heart
disease disease

Indicative of High risk of heart disease Low risk of heart disease


Triglycerides
developing heart
(TG) disease
D.) VITAMINS AND MINERALS
VITAMIN/ INDICATION EFFICACY
MINERAL
VITAMIN A eyes (night vision), Deficiency: night blindness; reduced hair
skin, hair, bones, growth in children, loss of appetite, dry
teeth, immune skin, lowered resistance to infection, dry
system, liver, eyes
reproductive organs, Overdose: headaches, blurred vision,
pregnancy & fatigue, diarrhea, irregular periods, joint
lactation and bone pain, cracked skin, rash, loss of
hair, vomiting, liver damages
Indication of bone Deficiency: kidney disease, increased risk of
VITAMIN D weakness, bone cancer.
malformation, Excess: excessive intake of supplements,
abnormal metabolism excess parathyroid hormone
of calcium
Increases the immune Deficiency: anemia
VITAMIN E response to infection Excess: adverse drug/medicine interaction
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Increase blood Deficiency: malnutrition, crohn’s disease,


VITAMIN K coagulation Excess: abdominal pain, diarrhea, fatigue,
headaches
Provides nutrients for Deficiency: Beriberi disease, edema
THIAMINE (B1) the nervous system Excess:
Helps metabolize Deficiency: signs will appear on the skin: dry
RIBOFLAVIN (B2) carbs, fats, and lipids patches, cracks around the mouth
Excess:
Helps the body to Deficiency: pellagra, stomach pains,
NIACIN (B3) break down carbs, headaches, fatigue
proteins and fats to Excess: signs will appear on the skin: dry
use for energy to carry patches, cracks around the mouth
out mechanisms in the
body
Very important for Deficiency: abdominal cramps, fatigue,
PANTOTHENIC ACID carrying out metabolic insomnia
(B5) mechanisms in the Excess:
body
Hormonal regulation, Deficiency: nausea, vomiting, anemia
VITAMIN B6 immune system Excess: nerve damage
(PYRIDOXINE) support
Upregulates the Deficiency: anemia
VITAMIN B12 production of red Excess:
(CYANOCOBALAMIN) blood cells within the
body
Metabolizes, carbs, Deficiency: dry patches on skin
BIOTIN (B7) proteins and fats Excess:

Helps the body to Deficiency: anemia


FOLIC ACID break down and Excess: seizures and can make it more
(FOLATE/FOLACIN synthesize amino difficult to identify a b12 deficiency
B9) acids and
regenerate/build new
cells
Plays an important Deficiency: scurvy
VITAMIN C role in helping the Excess: diarrhea
liver and the body
detox
Increase bone growth Deficiency: causes deterioration or thinning
CALCIUM and development bones
Excess: constipation and impaired kidney
function

Plays a key role in the Deficiency: anemia


IRON formation and Excess: toxicity
production of red
blood cells
Plays a key role in Deficiency: nausea, vomiting, decreased or
MAGNESIUM producing energy for abnormal apetite
the body to use for Excess:
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

energy and metabolic


functions
Plays a key role in the Deficiency:
MAGANESE synthesis of energy Excess: neurological effects
and protein
Plays an intricate role Deficiency: may cause seizures
PHOSPHOROUS with calcium to build Excess: toxicity complications
strong bones
Plays an important Deficiency: weakness, numbness, fatigue,
POTASSIUM role of the production muscle cramps
of energy that the Excess:
body can use to carry
out metabolic and
cellular functions
Plays an intricate role Deficiency: changes in appetite and diet
ZINC in digestion and Excess: digestive complications
metabolism
E.) NFPA-RELATED DISEASES AND CONDITIONS (FOLLOW FROM
HEENT)
For each of the following nutrition focused physical assessment-related diseases and conditions:
a. Define the disease or condition and it’s cause
b. Identify the common physical findings/symptoms/common lab/tests done for diagnostics
c. State the possible nutrition intervention/nutrient deficiency (if there are any, if not, state
it’s significance in nutrition focused physical assessment)
HAIR
Hirsutism –
A. Definition: unwanted hair growth on a womans face, chest, and back
B. Physical Findings: There is unwanted hair growth on a womans body. The hair is usually
coarse. Tests that measure hormones in the body can test for hirsutismokdksd
C. Nutrition Intervention/Deficiency: oral contraceptives, anti-androgens, tropical cream,
electrolysis, laser therapy
Lanugo –
A. Definition: soft downy hair
B. Physical Findings: generally, on baby’s
C. Nutrition Intervention/Deficiency: the underlying cause should be treated.
MOUTH/ORAL CAVITY
Glossitis –
A. Definition: inflammation of the tongue
B. Physical Findings: Tongues swells and develops a smooth surface
C. Nutrition Intervention/Deficiency: Pt is most likely deficient in iron, folate, vitamin b12
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Cheilosis –
A. Definition: inflammation and cracks in the corner of the mouth
B. Physical Findings: doesn’t usually require any labs or images to diagnose it.
C. Nutrition Intervention/Deficiency: pt is most likely deficient in B2
Thrush –
A. Definition: Candida albicans accumulates on the lining of the tongue
B. Physical Findings: creamy white lesions on the tongue or cheeks.
C. Nutrition Intervention/Deficiency: Pt may be deficient in iron, folic acid, or B12
EYES
Orbital Fat Pads –
A. Definition: fat pads in the eye that provide support to the eyeball
B. Physical Findings: the eyes look very sunken in.
C. Nutrition Intervention/Deficiency: Abnormal hormones can cause the eyese to look like
they’re bulging out of the sockets
Bitot’s spots –
A. Definition: white or gray triangular deposits on the bulbar conjunctiva next to the lateral
portion of the cornea
B. Physical Findings: It can be confirmed by a specialist or an ophthalmologist. Can be
determined by measuring retinol and blood serum retinol.
C. Nutrition Intervention/ Deficiency: sign of vitamin A deficiency
NAILS
Koilonychias –
A. Definition: abnormally thin nails
B. Physical Findings: nails grow in a way that looks like a ski jump
C. Nutrition Intervention/ Deficiency: Sign of iron deficiency and anemia
Beau’s Lines –
A. Definition: deeply grooved nails from side to side on fingernails and toe nails
B. Physical Findings: grooved lines that cause deep depressions on the nails
C. Nutrition Intervention/ Deficiency: may be the result of injury to the nails or treatment
to a disease like radiation (chemotherapy)
SKIN
Pallor –
A. Definition: pale skin due to decreased oxyhemoglobin levels
B. Physical Findings: the skin on the palms of the hands and the face are pale
C. Nutrition Intervention/ Deficiency: can be caused by high amounts of stress or low
amounts of oxyhaemoglobin.
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

Purpura –
A. Definition: blood vessels burst and blood pools under the skin causing spots
B. Physical Findings: purple and red spots on the body
C. Nutrition Intervention/ Deficiency: The underlying cause related to the hemorrhage
should be treated.
Pellagra –
A. Definition: inflamed skin that can appear as lesions on the body
B. Physical Findings: inflamed skin, diarrhea, and sores in the mouth
C. Nutrition Intervention/ Deficiency: Deficient in B3
Jaundice –
A. Definition: A yellow tint to the skin and eyes
B. Physical Findings: yellow/orange bile tint to the skin and eyes of pts
C. Nutrition Intervention/Deficiency: Can be caused by liver disease or excess lysis of red
blood cells
Acanthosis Nigricans –
A. Definition :a skin condition
B. Physical Findings: dark and velvety discoloration in body folds and creases
C. Nutrition Intervention/ Deficiency: Most common in pts with diabetes, overweight, or
obese.
Cyanosis –
A. Definition: blush discoloration on the skin and mucous membranes as a result of excess
concentration of deoxyhemoglobin in the blood as a result of deoxygenation
B. Physical Findings: most prevalent in the mucous of dark skin toned people and on the
skin of lighter skin toned people.
C. Nutrition Intervention/ Deficiency: Can cause lung and heart condition if the oxygen
levels continue to dramatically decrease.
NECK/THYROID
Goiter –
A. Definition: abnormal enlargement of the thyroid gland
B. Physical Findings: pt may develop large thyroid nots that don’t function properly.
C. Nutrition Intervention/ Deficiency: The underlying cause of the condition should be
treated
SKELETAL
Osteoporosis –
A. Definition: brittle bones
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

B. Physical Findings: Any magnitude of stress can cause fractures or other complications
within the bones
C. Nutrition Intervention/Deficiency: Pt may be deficient in Vitamin D
Rickets –
A. Definition: softening and weakening of bones
B. Physical Findings: bowed legs
C. Nutrition Intervention/Deficiency: Pt may be deficient in vitamin D and calcium
Scurvy –
A. Definition: swollen and bloody gums
B. Physical Findings: Pt may be weak, tired, and have a loss of appetite
C. Nutrition Intervention/Deficiency: Pt is most likely deficient in Vitamin C

F.) MALNUTRITION
Read the following article to help you answer the following questions:
http://www.andjrnl.org/article/s2212-2672(12)00328-0/pdf
1. List four reasons why malnutrition is a problem.
a. It provides less resources to allow the body to perform its functions
b. It decreases the quality of life
c. It impairs the pts ability to function through day to day activities
d. It can be very timely and costly to make lifestyle changes to accommodate the
malnutrition

2. What is the difference between chronic illness and an acute illness?


a. A disease that last 3 months or longer is considered chronic. An acute condition can be
severe and random/sudden.

3. Discuss the relationship between serum albumin and pre-albumin, weight loss, and
malnutrition.
a. Previously serum albumin and prealbumin have been used as indicators of malnutrition
Serum albumin and prealbumin are not included as defining characteristics of
malnutrition because recent research has shown that proteins don’t change in resposnse
to nutrient intake.

4. What is the relationship between malnutrition and the inflammatory response?


a. Elevated CRP (C-reactive protein), white blood cell count, and blood glucose levels
can be used as indicators of inflammation. A CRP of >10 mg/dL can be indicator of
stress and can impair the production of prealbumin.
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

5. List six characteristics that are required for the diagnosis of malnutrition. How many of these
must be present to confirm the diagnosis of malnutrition?
a. Insufficient energy intake
b. Weight loss
c. Loss of muscle mass
d. Loss of subcutaneous fat
e. Localized or generalized fluid accumulation
f. Diminished functional status assessed by handgrip strength

6. Clinical judgement is required in assessing adults for malnutrition. Provide an example of a


patient for whom malnutrition is not consistently appropriate diagnosis.
a. Malnutrition may not be appropriate for adolescents who don’t present with any
medical conditions and have access to foods that are of nutritional value.

7. Patients with severe acute illness or injury (i.e. Extreme metabolic stress) can develop
malnutrition. List 3 contributing factors.
a. High levels of stress
b. Socioeconomic status (access to healthcare & quality food)
c. Preexisting illnesses or a combination of medical complications

8. Complete the following table on assessing adult patients for malnutrition.

Category Parameter/s to measure or In the Nutrition Care Pocess,


assess this would be part of:

Medical history & clinical Pt history related to current Nutrition assessment


diagnosis illness and symptoms. Causes
related to the malnutrition
Physical exam should be Nutrition assessment
Physical exam / clinical signs
conducted and findings of body
fat, muscle mass, reduced grip
strength, and fluid accumulation
should be noted.
The pts ht, wt, BMI, and other Nutrition assessment
Anthropometric data
measurements should be
measured.
The pts CRP, BUN, serum Nutrition assessment
Laboratory data
albumin, prealbunim, and Hgb
A1C should also be measured.
The pt’s 24 hr diet recall should Nutrition assessment
Food/nutrient intake
be conducted and when
appropriate they should be
interviewed about how they are
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

doing with following the plan


they have set.
The handgrip strength test is an Nutrition assessment
Functional assessment
indicator of a decrease in
function.

G.) FEEDING TUBES AND PLACEMENTS


TERMINOLOGY
Provide definitions to terminology frequently used to describe enteral/parenteral feedings
a. Flush – The feeding tube is flushed with water in between feedings and medication
administration
b. Bolus feed –a syringe is used deliver formula through the feeding tube.
c. Continuous feed – food is administered through a pump over 8-24 hours
d. Cyclic/Intermittent feeding –A feeding pump is used in less than 24 hours.
e. Vent/venting – it lets the air out of the stomach with a feeding tube with a 60 ml syringe
f. Tolerance/intolerance – Intolerance is stomach cramps, bloating, and when people feel sick
while on tube feeding
g. Motility/dysmotility – motility is food traveling along the gi tract. Dysmotility is when the
food isn’t moving along the gi tract
h. Stoma – a surgical incision
i. PEG – an endoscopic medical procedure where the PEG tube is passed into the pts stomach
through the abdominal wall

TYPE PLACEMENT PROS CONS


NG Nasogastric – Tubes enters the ● Placed non-surgically ● Needs to be
body through the nose and run changed every 1-3
down the esophagus into the ● Easily taught to weeks
stomach. change/use
● Good for short-term ● For children, it
Typically used for patients can be easily
with normal emptying of tube feeding
pulled out
gastric and duodenal contents. ● Large reservoir ● Can cause
capacity of stomach
congestion in the
● Can give bolus feeds nose and eye
without a need for a (oseophageal
pump reflux and/or
pulmonary
aspiration)
● Can cause reflux
Nutrition Focused Physical Assessment Clinical Assignment Due: September 25, 2017

● Most visible
ND Goes through the stomach and Decreased aspiration. Feedings are one very
end in the first portion of the Generally used for kids or slowly and the tubes
small intestine short term tube feeding can move/become
for adults displaced.
Decreased aspiration. This form of tube
NJ Goes through the stomach and
feeding can become
end in the second portion of clogged with food and it
the small intestine can move/become
displaced.
Placed through the abdominal Pt doesn’t have to There is an increased
PEG/G- wall and into the stomach undergo surgery for the risk of aspiration.
TUBE tube to be placed.
Placed into the child’s stomach Decreased aspiration. Pt is most likely placed
GJ and small intestine on continuous feeding.
Placed through the skin and into Decreased aspiration. Pt must undergo surgery
J the small intestine to have the tube placed.
Placed into a vein through a PICC It doesn’t take long for the The tube will most
TPN line or a central line procedure to place the tube likely get clogged
because it is so small.
1.) What determines where feeding tubes are placed?
a. It is dependent on a mixture of things, but primarily on the pts age, the
state of their condition, and the functionality of their organs.

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