Nutrition Focused Physical Assessment in Dietetic Curriculum & Practice - PowerPoint Presentation

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Nutrition Focused Physical Assessment in Dietetic Curriculum & Practice

Miami University Nutrition ProgramSlide2

WHY Nutrition Focused Physical Assessment?

RDN/NDTRs are required to be more vigilant & proactive

4 of 6 criteria used to diagnose malnutrition pertain to NFPA outcomes

Reimbursement based on clinical outcomes

Recognize insidious effects of malnutrition

.

Boost RDN/NDTRs recognition for professional skills and ability to impact

healthcare

Enhance RDN/NDTRs ability to help prevent, identify and/ or delay outcomes

of malnutrition in multiple care settingsSlide3

Behavioral

Objectives

Identify the components of a NFPA.

List four areas NFPA techniques assess

Identify where NFPA fits into the dietetic scope of practice and day-to-day provision of care activities.Define the four techniques used to conduct a NFPA.Review benefits and suggestions for implementation of NFPA into the Dietetics CurriculumUtilize a simulated case scenario and determine malnutrition diagnosis from a demonstrated head-to-toe NFPA. Slide4

Background

New federal and state guidelines on the

dx

of malnutrition and reimbursement for related care requires dietitians and technicians to more

vigilant and proactive in providing successful interventions.Goal is to prevent or delay, reverse and limit malnutrition in care settings.Slide5

Nutrition Focused

Physical

Assessment…

Is timely and relevant

Brings significant attention to the subject of malnutrition RDN/DTR’s can utilize NFPA to… evaluate nutritional risk determine more effective nutrition interventionsSlide6

Components of

NFPA Examination

(Objective #1)

General Survey

visual physical appearanceVital SignsSkinHairNailsHead & neck:head, eyes, nose, neckOral Cavitylips, tongue, mouth

TeethUpper/lower bodyshoulder, clavicle, arms, scapula, ribs, hands, legsRespiratory systemCardiovascular systemAbdomenNeurologic systemSlide7

What Do NFPA Techniques Assess?(Objective #2)

overt signs of nutritional deficiency

skin integrity

organ functionloss of muscle & subcutaneous fat storesSlide8

Healthcare

Scrutinized based on clinical outcomes

Care plans need to exhibit cost saving measures

AND has requested Council on Future Practice (CFP) to provide guidance & recommendations on the topic of NFPA…… “Moving Forward- A Vision for the Continuum of Dietetic Education, Credentialing and Practice”.Slide9

Published standards that allow currently accredited dietetics programs to assimilate NFPA skill development into coursework.Slide10

Challenges

•RDN/DTR’s in practice may

have not yet been trained in

putting new assessment

guidelines into practice.Healthcare facilities have not adopted new guidelines on malnutrition; therefore have not made significant progress toward training their dietetics staff on NFPA techniques.Slide11

Malnutrition

Diagnosis Guidelines

Developed by AND & American Society for

Parenteral

& Enteral Nutrition (ASPEN).Goal….use guidelines consistently & accurately, to demonstrate the presence of malnutrition.Facilitate the physicians’ ability to recognize and appropriately diagnose malnourished patients.Refer to HandoutSlide12

Guidelines from AND & ASPEN

FOUR

of the

SIX criteria used to generate malnutrition diagnosis pertain to PHYSICAL ASSESSMENT of……….Muscle mass (wasting)Fat mass (loss of subcutaneous fat)Fluid accumulation Hand grip strengthSlide13

Future Dietetics Education Plan with Expected Outcomes

Diagnosis of malnutrition and reimbursement requires RDN/DTR’s to become more

in identifying malnutrition!!!

Vigilant & PROACTIVESlide14

Linking Malnutrition Identifiers with

NCP Terminology

(objective #3)

Assist RDN/DTR’s with visualizing WHY & WHERE NFPA fits into their scope of practice

NCP is a systematic approach to providing high-quality nutrition careNCP provides RD/DTRs with the ADIME four-step process to individualize careRefer to Handout NCP Flowchart Slide15

Vision for Dietetics

Education

Nutrition related problems are best identified through the NCP First element is to gather objective & subjective data to complete a thorough nutrition assessment.NFPA is part of step one of the comprehensive nutrition assessment (NFPA consists of 3 steps)NFPA (step 3 hands on component) often not performed due to lack of education/trainingSlide16

Comprehensive Nutrition Assessment

Client History

Food/Nutrition History

Laboratory/Medical test resultsPhysical measurementsNFPA findings….

-conduct steps 1-3 (refer to handout) Slide17

NFPA Steps 1

Conduct general survey of patient’s appearance

often described as “appears

cachetic” or “very frail & thin”Compare findings with available patient data from medical records and other sourcesSlide18

NFPA Step 2

Evaluate resident’s body

habitus

and compare body mass index and weight changes to findings

Consider whether the individual’s reported appetite and BMI are consistent with the visual assessment of the individual’s body habitusSlide19

Perform hands on physical assessment, focusing on evaluation of body systems, skin, hair, nails, eyes, oral cavity, upper/ lower body noting signs of nutrient deficiencies or excesses

NFPA Step 3Slide20

Approaching the Patient

Introduce

yourself to the

patient/resident. Greet patient warmly and explain the purpose of your visit.

Consider using the 10/4 rule: stop 10 feet from the bed while making eye contact and smile, then approach to within 4 feet. Make sure to acknowledge other health care professionals and visitors in the room.Remove distractions (wait for health care professionals to complete their duties and ask permission to turn off television)4) Ask the patient for permission to examine them.Wash/dry hands thoroughly--don gloves.During exam, ask the patient questions to get a better idea of their nutritional status.

7) Use standard precautions to prevent disease transmission.Slide21

Using NFPA

Connects the dots to a physician and a malnutrition diagnosis

Enhances ability to prevent, identify and/or delay outcomes of malnutrition in multiple care settings.Slide22

Goal for Nutrition Assessment

Incorporate more physical

assessment training into

the dietetics curriculum.

Provide hands-on training for students to gain the self-assurance and skills set necessary to perform NFPA as part of the NCP.Slide23

Benefits

Cutting-edge educational experiences.

Increased recognition of the RDN/DTRs in the functioning of the health care team.

Team experiences/ collaboration for students.

Novice level NFPA skills prior to starting entry-level practice. Slide24

Suggestions for Implementation

Students will ….

Engage in and incorporate NFPA into existing MNT courses

Utilize resources already presentStudents will perform NFPA in class Students

willl reflect on NFPA experienceStudents will obtain training in classroom Slide25

Student Training

Obtain Certificate of Training in Adult Malnutrition through the Abbott Nutrition Health Institute (ANHI) website.

Allows students to obtain a uniform understanding of the NFPA process

Internet based courses from the ANHISlide26

Suggestions

continued….

Students will….

Reach out to preceptors

as content/training experts Collaborate with students to infuse hands-on nutrition focused physical exam education Slide27

Implementation NFPA Training

Demonstration/simulation lecture in each of the following subjects

Body Composition

Anthropometric Indices

Vital Sign Measurement/Biochemical NFPA Head-to-ToeSlide28

Body Composition

Bod

Pod

Bioelectrical Impedance

Skinfold AnalysisSlide29

Anthropometric Indices

Height

Body weight

Waist circumference

Arm spanKnee heightSlide30

Vital Sign Measurement/Biochemical

Temperature

Pulse

Blood pressure

RespirationBowel SoundsFinger stick blood sugarSlide31

Bowel Sounds

Auscultation

Listening to sounds with a stethoscope to assess bowel motility

Bowel sounds produced with air and fluid movement through the small intestine

Typany: High pitched drum like sound. Represents the presence of air.Slide32

Bowel Sounds-Auscultation

Normal bowl sounds are high-pitched gurgle and occur from 5 to 35 x /minute

Hyperactive are loud, high-pitched, rushing and tinkling sounds

Hypoactive are quieter and are heard less frequently , only every 15 to 20 seconds (4x/min)

Hypoactive or absent-symptoms of a paralytic ileus or peritonitisSlide33

NFPA

Getting Started

Head-to Toe

(Step 3)Follows review of patient’s medical and social history, laboratory results, and a nutrition history interviewReview of each body system vs focus on a specific systemSlide34

Components of

Head-to-Toe

skin

hair

nails eyes oral cavity (lips, gums, tongue)upper body (arm, shoulder, clavicle, hands)lower body (quadriceps, knee, calf)Slide35

Four Techniques

(objective #4)

Inspection

Palpation

PercussionAuscultation Most common used for Head-to Toe assessment are inspection & palpationSlide36

Inspection

Visual observation of color, shape, texture & size.Slide37

Palpation

Use of touch to examine location, texture, size, temperature, tenderness, and mobility.

Tips and pads of fingers are used to assess pulsations and tenderness (capillary refill time of nail plate < 3 seconds)

Back of the hand is used to assess temperatureSlide38

Percussion

Tapping of fingers against body surfaces and listening for sounds that reflect solids/fluids/gas.

Percuss

your cheeks while making “chipmunk” cheeksSlide39

Auscultation

Listening to sounds that reflect movement of fluid or air through organs and viscera with stethoscope.Slide40

Head-to-Toe Assessment

Simulated Case Study

Demonstrated AssessmentRefer to Malnutrition Assessment Training

- Handout NPA Steps 1-3Slide41

Hair

Lack of luster, shine, thin, sparse/easily

pluckableSlide42

Loss of Muscle-Temporal WastingSlide43

Loss of Subcutaneous Fat: Orbital Region

View

patient when standing directly in front of them, touch above the

cheekboneInspect for fat loss under and around the eyeSlide44

Eyes Bitot Spots & Pale

ConjuctivaSlide45

Nasolabial

seborrheaSlide46

Mouth/Lips

Angular

Stomatitis/Cheilitis

/Cheilosis-fissuring of the lips, mouth inflammation, and cracks in the skin at the corner of the mouth Slide47

Tongue

Beefy red, magenta, pale, atrophy of taste buds,

mucosa

red and swollen

Nonvisual possible clinical signs and symptoms of the tongue relating to nutritional deficiencies: hypogeusia (reduced acuity of taste sensation) and dysgeusia (alteration in taste sensation) Slide48

Tongue Continued

Glossitis

-inflammation of the tongue, beefy, red, painful, and taste changes often

present

Papillary filiform atrophy-smooth tongueSlide49

Triceps: Loss of Subcutaneous Fat

mild/moderate

: fingers almost touch, some depth to pinchsevere

: very little space between folds, fingers touchSlide50

Arm Assessing Fat loss-

TricepSlide51

Shoulder- Loss of Muscle

acromion

process (highest point of the shoulder) very prominentSlide52

Clavicle-Loss of MuscleSlide53

Hands: Loss of Subcutaneous Fat Interosseous Atrophy

well

nourished: flat/bulges

mild/moderate: slight depressed/flatsevere: depressed between thumb &

forefingerSlide54

Hands

Atrophy first

interosseousSlide55

Hands

Thenar

atrophySlide56

FingernailsNail Blanch Test

capillary refill time of nail plate <3 secondsSlide57

Fingernails(spoon shaped-iron deficiency)Slide58

Fingernails(mottled-vit

A or C deficiency)Slide59

Fingernails(Pale-vit

A or C deficiency)Slide60

Quadriceps/Calf- Muscle WastingSlide61

Knee & Calf WastingSlide62

Head-to-Toe: Skin Assessment

Skin-largest organ in human body (15% of wt)

Epidermis, outermost layer of skin

Dermis, contains richly vascular connective tissueHypodermis, composed of subcutaneous tissue & fatAssessed for temperature,

turgor, color, moisture, edema, rashes, lesions, wounds, ulcers, bruises, and hygiene.Slide63

Skin Assessment- continued

Temperature-should feel cool to slightly warm

Hypersensitive dorsal portion of hand should be used to assess

Skin turgor-hydration status

Positive test for decreased turgor is when the skin on back of hand, forearm, or chest that is gently pinched to form a tent does not spring back rapidly into place when released.Slide64

Skin Assessment: Edema

Most noticeable in feet, ankles, sacrum

1+-indentation about 2mm/indented space fills rapidly

4+-indentation 8 mm/space refills in 2 to 5 minSlide65

Edema Classifications

Severe Malnutrition

Deep to very deep pitting

Depression lasts a short to moderate times (31-60 seconds) Extremity looks swollen (+3-4 )Mild-Moderate MalnutritionMild to moderate pittingIndentation subsides quickly (0-30 seconds)

Slight swelling of extremity (+1-2 )Well NourishedNo sign of fluid accumulationSlide66

EdemaSlide67

Hand Grip Strength

The strongest correlation with muscle mass and nutrition status

Determined using a Dynamometer

Measures the maximum isometric strength of the hand and forearm.Slide68

Summary…. Value of NFPA

Requires RDN/NDTR’s to be more vigilant and proactive

Boosts recognition for professional skills

Brings significant attention to the subject of malnutrition

Connects the dots to a physician and a medical malnutrition diagnosisEnhances ability to prevent, identify, and /or delay outcomes of malnutrition in multiple care settings