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Two Techniques used:

1. Inspection: involves searching for physical sign by observing the patient

2. Palpation: involves using the sense of touch to evaluate the patient

Nutrition Focused Physical Exam

Bilateral Muscle Wasting - Upper Body

Clavicle Region/Shoulder and Deltoid Muscle Wasting

Temple Region - Temporalis Muscle

-looking for scooping or hollowing of temporal region

-Example: if patient turned face to side and you poured water some of the water would catch in the hollowing area - severe

-looking for prominence of the clavicle and squaring of shoulders (indicates malnourishment)

-Normal: clavicle bone should be visible, with no area of depression behind the bone - nice curvature and roundness from neck to shoulders and down arm

-Mild-Moderate: depression behind the clavicle bone - acromion process may protrude slightly and slightly squared off but some curvature

-Severe: clavicle bone significantly protruded and area behind bone more depressed - bones clearly prominent and visible beneath the skin, very square

and assessing malnutrition

Interosseous Muscle - Dorsal Hand

Scapular Bone Region - Trapezius, Supraspinus, Infraspinus Muscles (back)

-look for prominent bone or areas of depression between bones

-Normal: scapula and other bones in area are not prominent and no areas of depression between bones

-Mild-Moderate: area around the should blade is mildly depressed and the bones may protrude slightly

-Severe: bones are clearly prominent and visible beneath the skin, depression can be seen along the scapula and spine

-combine thumb and for finger together and apply pressure

-Normal: bulge; in females it may appear almost flat

-Mild-Moderate: may appear flat or slightly depressed

-Severe: area between thumb and for finger will appear very depressed

Subcutaneous Fat Loss Areas

-to observe and feel for areas where adipose or fatty tissue is normally present

Anterior Lower Ribs

Orbital Fat Pad Region

-only observation; examine ribs for loss of fullness or loose skin, the ribs should not be apparent

-Normal: normal ribs with fullness and taught skin

-Mild-Moderate: loss of fullness with lose skin and outline of rib cage is apparent

-Severe: well defined rib cage and can see depression between the ribs

-observing the area under the eye, remember that is this something you can view when you first come in contact with the patient

-Normal: OFP should appear slightly bulged

-Mild-Moderate: OFP appear with slightly dark circles underneath the eyes, and have hollow appearance

-Severe: appear to have dark circles underneath eyes; skin around the eyes will appear loos, and the eyes will appear depressed with a more prominent hallow look

Triceps and Biceps

-to assess have patient make a 90 degree angle and take your thumb and for finger and make a slight pinch of skin above bicep (be careful not to grab the muscle)

-Normal: exhibit ample fat tissue between folds of skin

-Mild-Moderate: fingers will almost touch when palpating the skin, there will be some depth to pinch

-Severe: little space between skin folds; your fingers will touch

Nutrition Focused Physical Exam

Lower Body Muscle Loss - Less sensitive to change

Anterior Thigh Region

Posterior Calf Region - Gastrocnemius Muscle

-assess when they are in the sitting position; looking for areas of depression along the inner thigh region and for thick appearance of the upper leg, which indicates wasting of thigh muscle

-Normal: quadriceps muscles well-rounded

-Mild-Moderate: area of depression along inner thigh, upper leg appears thin

-Severe: significant depression inner thigh and upper leg appears obviously thin

-client lie down, and bend knee allow access to muscles of the calve - pay special attention to muscle definition and tone

-Normal: calve appears round with well developed bulb

-Mild-Moderate: muscle neither well developed nor well defined, easily compressible upon papation

-Severe: lower leg is thin and minimal muscle definition

Patellar Region - Knee

-Look and assess muscle or fat stores on patient (due to weight loss)

-Some tips to remember:

-always ask for a patients permission

-upper body is more susceptible to muscle loss

-muscle loss related to inactivity or bed rest is more prominent in the pelvis and upper legs

-bilateral muscle wasting is more clinically significant than subcutaneous fat loss

-Think of your grandparents or someone older that you know or have seen in your rotations; think of their physical features as we go through what to look for in a physical exam

-inspect and palpate the muscles around the knee (vatus lateralis and vastus medialis); observe and feel for areas of depression on both sides of the patella and prominence of patella

-Normal: patella not prominent, and muscles around knee are visible

-Mild-Moderate: patella slightly prominent; muscles are less obviouss and feel slightly depressed when palpated

-Severe: patella is very prominent, area around knee cap is depressed; muscles are absent

-if you don't see muscle wasting in the upper body, than you should not expect to see it on the lower body

So in closing a physical exam can help us diagnosis malnutrition in our patients.

-Must meet two criteria to meet the definition of malnutrition

-Can either be non-severe (moderate) or severe

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