Tuesday, 1:00 – 2:30, B6   
          Nutrition Focused Physical Examination: Overview and application 
                            Lola Rosewig 
                         lfreedma@med.umich.edu 
         
        Objectives:   
        Identify advances in clinical assessment and management of selected healthcare issues related to 
        persons with developmental disabilities 
        Notes: 
                                                                                                                                                                                                                                                                                                                                    4/7/2016
                                                                                                                                                                   OVERVIEW                                                                                  HOSPITALMALNUTRITION 
                                                                                                                                                                                                                                                                        IS WIDESPREAD
                                                                                                                                                                                                                                                 • ASPEN(American Societyof Parenteral 
                                                                                                                                             Malnutrition                                                                                          and Enteral Nutrition), Nov 2013, JPEN
                                     NUTRITION-FOCUSED                                                                                                                                                                                              • Multiplestudies findthat approximatelyone in 
                                                                                                                                             Nutrition-Focused Physical Exam                                                                          every three adult patients admittedto a hospital 
                               PHYSICALEXAMINATION:                                                                                                                                                                                                   in the UnitedStatesis sufferingfrommalnutrition
                                      OVERVIEW AND APPLICATION                                                                               DocumentationandApplication
                                                    LOLA ROSEWIG, MPH, RD
                                                       CLINICAL DIETITIAN
                                      UNIVERSITY OF MICHIGAN HEALTH SYSTEM
                                                                                                                                                                                                                                                 Consensus Statement: Academy of Nutrition and Dietetics 
                                        PEDIATRIC MALNUTRITION                                                                           IMPACT OF HOSPITALMALNUTRITION                                                                          andAmerican Society for Parenteral and Enteral
                                                                                                                                                                                                                                                 Nutrition: Characteristics Recommended
                                                                                                                                                                                                                                                 for the Identification and Documentation  of
                                • Reported a prevalenceof6%–51% in                                                                      • Morbidity and Mortality                                                                                Adult Malnutrition (Undernutrition)
                                  hospitalizedchildren.                                                                                    • Developmentofpressureulcers
                                • However,it is well known that a gap exists                                                                                                                                                                     .JaneV. White, PhD,RD, FADA1 ; PeggiGuenter, PhD, RN2;
                                                                                                                                           • Reducedmusclemassà decreasedstrength/                                                               Gordon Jensen, MD, PhD,FASPE     3; Ainsley Malone, MS, RD, CNSC;
                                  betweendiagnosingmalnutritionin                                                                            debilityà risk of falls                                                                             Marsha Schofield, MS,RD5; tbe Academy Malnutrition Work Group;
                                  hospitalizedpatients and actuallycoding                                                                  • Nosocomialinfections                                                                                theA.S.P.E.:S. Malnutrition Task Force; and tbe A.S.P.E.ri. Board of Directors
                                  for it.                                                                                                  • Qualityof life
                                                                                                                                                                                                                                                                 LEADINGTHESCIENCEAND
                                                                                                                                        • Increased length of stay (LOS)                                                                                        I PRACTICEOFCLINICALNUTRITION
                                                                                                                                        • Readmission and Institutionalization
                                                                                                                                        • Cost                                                                                                                                                          AcademyofNutrition
                                Abdelhadi et al. JPEN 2016                                                                                                                                                                                                                                              andDietetics
                                                                                                                                                                                                                                                                                                                                                       1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     4/7/2016
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      u:AoOWGTMCSOCN. . ...
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      MACTICSMCUMCMMLI1"Mtl0ff
                                                                                                                    NOSINGLEPARAMETER IS DEFINITIVE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  I                                                                                                                                NOSINGLEPARAMETER IS DEFINITIVE
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Special Report                                                                                                                                                                                                                                                   ..,........,..............   ..,.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           utrition inCJjnical Practice
                                                                                                                                                         FORADULT MALNUTRITION                                                                                                                                                                                                                                                                                                                                     Consensus Statement oftheAcademy of Nutrition                                                                                                                                                                                          Volume 30Number  I                                                                                                                                                                 FOR PEDIATRIC MALNUTRITION
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          February2015147   161
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   and Dietetics/American Society for Parenteral and                                                                                                                                                                                      C 2014 American Society
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          for Parenteral and Enteral  utrition
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Enteral Nutrition: Indicators Recommended  for the                                                                                                                                                                                     and Academy of utrition and
                                                                                                                   • MUSTMEETATLEAST 2OFTHE6CRITERIAFOR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Dietetics                                                                                                                                                  • Food/NutrientIntake
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Identification  and Documentation of Pediatric                                                                                                                                                                                         [X)(: 10.1177/0884533614557642
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          ncp.sagepub.com
                                                                                                                           DIAGNOSIS:                                                                                                                                                                                                                                                                                                                                                                              Malnutrition (Undernutrition)                                                                                                                                                                                                          hosted at                                                                                                                                                  • AssessmentofEnergyandProteinNeeds
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          online.sagepub.com
                                                                                                                             • Insufficientenergy intake                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ($)SAGE                                                                                                                                                    • GrowthParameters/Anthropometric
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                1                                                                                                   3
                                                                                                                             • Weight loss                                                                                                                                                                                                                                                                                                                                                                         Patricia Becker, MS, RD,CSP,LDN, CNSC ;Liesje Nieman Carney, RD, CSP,LDN ;                                                                                                                                                                                                                                                                                                                                Measurements:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2                                                                                              4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Mark R.Corkins,MD, CNSC,FAAP ; Jessica Monczka, RD, LDN, CNSC ;
                                                                                                                             • Loss of musclemass                                                                                                                                                                                                                                                                                                                                                                  Elizabeth Smith, RD,LDN, CNSC3  Susan E.Smith, RD, CSP,LD5;
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ;                                                                                                                                                                                                                                                                                                                                          • Percentiles/z-scores
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   6                                                                                                   7
                                                                                                                             • Loss of subcutaneous fat                                                                                                                                                                                                                                                                                                                                                            BonnieA. Spear,PhD,RDN,LD ; Jane V. White, PhD,RD,LDN, FAND ; Academy of                                                                                                                                                                                                                                                                                                                                     • Weightforage
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Nutrition and Dietetics; andAmerican Societyfor Parenteral and Enteral Nutrition
                                                                                                                             • Localized or generalizedfluid accumulation (that may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             • Height/length for age
                                                                                                                                      sometimesmaskweightloss)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • BMI/weight-for-lengthfor age
                                                                                                                             • Diminishedfunctional status as measuredby hand-grip                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   • WeightGainVelocity
                                                                                                                                      strength                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       • Mid-UpperArm Circumference(MUAC)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ....._l_,         'ool©=Michigan'sInalnutrition diagnostic tool                                                                                                                                                                                                                                                                                                                        • HandgripStrength
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     • Nutrition-FocusedPhysicalFindings
                                                                                                      White et al. 2012
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     NUTRITION CARE PROCESS                                                                                                                                                                                                                                                                                                                                                                                   NUTRITIONASSESSMENT
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Nutrition
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Assessment                                                                                                                                                                                                                                                                                                                                                                                                Biochemical 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Food/Nutrition-                                                                                             Data, Medical                                                                                                   Anthropometric 
                                                                                                                                                             NUTRITION-FOCUSED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 RelatedHistory                                                                                                             Tests and                                                                                          Measurements
                                                                                                                                                                                     PHYSICALEXAM                                                                                                                                                                                                                                                                                                                                                  Monitoring &                                                                                                                                 Nutrition                                                                                                                                                                                                                                                                                                                           Procedures
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Evaluation                                                                                                                      Diagnosis                                                                                                                                                                                                                                                                                Nutrition-
                                                                                                                                                       PART OF THE NUTRITION CARE PROCESS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Focused                                                                                        ClientHistory
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Physical 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Nutrition                                                                                                                                                                                                                                                                                                                                             Findings
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Intervention
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                                                                                                                                                                                                                  4/7/2016
                    NUTRITION-FOCUSED PHYSICALEXAM                                               OVERALLAPPEARANCE/                                                  OVERALLAPPEARANCE/
                                                                                                     FIRST IMPRESSIONS                                                   FIRST IMPRESSIONS
                    GETTINGSTARTED:                                                     • The NFPE begins with a general                                   ✓ Body positioning(musclecontractures,paralysis)
                    • Prepare for patient interaction                                    observation of the patient.                                       ✓ Body Language
                    • Standard and universalprecautions                                 • First impression and physical                                    ✓ Body habitus
                                                                                         characteristicsto note during interview:                          ✓ Amputations
                    • Physical exam techniques:                                          üWhatistheapparentstateofhealth?
                      • Inspection—closeobservation                                       üWhatisthelevelofconsciousness?                                  ✓ Ability to communicate
                      • Palpation—tactileexamination                                      üDoesthepatientshowsignsofphysicaldistress?                      ✓ Affect
                      • Percussion—elicita soundwave                                      üHow isthe patient dressed?
                      • Auscultation—listeningto body sounds                              üDoyouseeanyobvioussignsofnutrientdeficiencies?
                                                                                          üIs thereany involuntarymovementsor signsofparalysis?
                                                                                      Litchford, 2013                                                     Litchford, 2013
                        ASSESSING FOR MUSCLELOSS                                            ASSESSING FOR MUSCLELOSS                                            ASSESSING FOR MUSCLELOSS
                     • Regions to assess:                                             Temporalis                                                          Clavicular region:
                        • Upper body:                                                                                                                     Pectoralismajor, deltoid, 
                        • Temple                                                                                                                          trapeziusmuscles
                        • Collarbone
                        • Shoulder
                        • Shoulder blade
                        • Hand
                        • Lower body:
                        • Thigh/knee
                        • Calf
                                                                                      Image: Litchford 2013
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