SHAROLYN TSAMOUTALES, GRADUATE STUDENT INTERN BOWLING GREEN STATE UNIVERSITY, 2012 PHYSICAL ASSESSMENT TO DETERMINE NUTRITIONAL DEFICIENCIES

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

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.

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

CLINICAL ASSESSMENT

Consideration of physical observations and interpretation of:

- Hair - Neurological- Eyes - Additional - Oral health observations - Thyroid gland - Hydration status- Nails- Skin

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

HAIR IMAGES

Alopecia Corkscrew

EYE ASSESSMENTEYES SHOULD APPEAR BRIGHT AND CLEAR WITH HEALTHY MEMBRANES

AND NORMAL MOVEMENT

Clinical Findings

• Nyctalopia, • Pale Conjunctiva• Ophthalmoplegia

• Xerophthalmia• Fissuring in corners,

redness


• Vitamin A, E• Vitamin A, Iron• Thiamin (B1),

Phosphorus • Vitamin A, Protein• Riboflavin (B2),

Pyridoxine

EYE IMAGES

Pale conjunctiva Ophthalmoplegia

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


• Riboflavin, Pyridoxine, Niacin, Iron, Zinc • Riboflavin• Riboflavin, B12, Iron• Riboflavin, Niacin,

Folate, B12, Protein, Iron

ORAL HEALTH IMAGES

Angular stomatitisAtrophic lingual

papillae

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


• Vitamin C

• Vitamin C• Zinc• Zinc

ORAL HEALTH IMAGES

Swollen, retracted, bleeding gums Loose teeth

THYROID GLAND ASSESSMENTLOCATED ON THE FRONT OF THE NECK FLANKING THE TRACHEA,

SHOULD NOT APPEAR ENLARGED

Clincal Findings

• Hypothyroidism, Goiter


• Iodine

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


• Iron, Protein • Iron, Folic Acid,

Protein • B complex (B1, 2, 3,

5, 6, 7, 9, 12), Protein• Protein, Iron, • B12• Protein, EFA

NAIL IMAGES

Koilonychia Absent lunula.

Longitudinal central ridge Longitudinal nail beading

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

SKIN IMAGES

Purpura Petechiae

SKIN IMAGES

Nasolabial seborrhea Dry, goose bump

SKIN ASSESSMENTSKIN SHOULD APPEAR NORMALLY SMOOTH AND FREE OF DISCOLORATION

Clinical Findings

• Dermatitis• Cellophane

appearance• Desquamation,

Pigmentation


• Zinc, Niacin• Protein

• Niacin, Protein

SKIN IMAGES

Desquamation, Pigmentation

Protein edema

NEUROLOGIC ASSESSMENT

Clinical Findings

• Dementia

• Confabulation, Beri-beri• Peripheral

Neuropathy, Paresthesias


• Thiamin, Vitamin E Niacinamide, B12, • Thiamin

• Thiamin, Pyridoxine, B12

NEUROLOGIC IMAGES

Beri-beri Tetany

NEUROLOGIC ASSESSMENT

Clinical Findings

• Ataxia

• Tetany


• Thiamin, Pyridoxine, B12, Vitamin E• Thiamin, Niacin,

B12, Calcium, Vitamin D, Vitamin E, Magnesium

ADDITIONAL PHYSICAL ASSESSMENTS

Clinical Findings

• Parotid enlargement• Osteomalacia,

Rickets• Persistant Cough• Dyspnea


• Protein

• Vitamin D

• Thiamin• Folic Acid, B12, Vitamin E

ADDITIONAL PHYSICAL IMAGE

• Parotid swelling • Osteomalacia, Rickets


Clinical Findings

• Marasmus

• Kwashiorker


• Macronutrients, micronutrients• Protein, Iron, Folic

Acid, Vitamin C


Marasmus Kwashiorker

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

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


Vitamin B1, ThiaminSyndromes- Beri-beri- Wernicke’s

encephalopathy- Korsakoff

syndrome

Signs and symptoms- Muscle cramping - Hyporeflexia- Paresthesia- Poor Memory- Chest pain- Tachycardia- Dyspnea


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


Vitamin B3, Niacin/NicotinamideRelated Syndrome- Pellagra

Signs and Symptoms- Dermatitis- Diarrhea- Depression- Dementia- Dysphagia/

hypersalivation- Abdominal/nausea


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


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


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


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


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


Vitamin ERelated Syndrome- Hemolytic anemia- Neurologic problems

Signs and Symptoms- Pallor- Demetia- Night blindness- Dyspnea- Ataxia- Tetany- Muscle weakness- Follicular

hyperkeratosis


Vitamin KRelated Syndrome- Bleeding disorders- Birth Defects

Signs and Symptoms- Purpura- Petechiae- Nosebleeds- Menorrhagia- Poor wound

clotting- Gastrointestinal

bleeding


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

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

http://www.cdc.gov/ncbddd/b12/cases.html

http://www.cdc.gov/ncbddd/b12/cases.html

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SHAROLYN TSAMOUTALES, GRADUATE STUDENT INTERN BOWLING GREEN STATE UNIVERSITY, 2012 PHYSICAL ASSESSMENT TO DETERMINE NUTRITIONAL DEFICIENCIES