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FN 123 > Clinical Assessment > Flashcards

Clinical Assessment Flashcards

1
Q

What is Clinical Assessment?

A
  • estimation of nutritional status on the basis of
  • recording a medical history and conducting a physical examination
  • to detect signs symptoms
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2
Q

What are the uses of Clinical Assessment?

A

• Community nutrition survey
• Clinical medicine (prior to nutrition counseling)

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3
Q

At what stage in the development of nutrition deficiency is the clinical method used?

A

7th - Clinical Symptoms
8th - Anatomical Sign

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4
Q

What are the components of Clinical Assessment?

A
  1. Detailed History (Medical and Dietary)
  2. Thorough physical examination
  3. Interpretation of signs and symptoms associated with malnutrition
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5
Q

What are the components of Medical History?

A
  1. Past and current diagnosus of nutritional consequence
  2. Diagnostic procedures
  3. Surgeries
  4. Chemotherapy and Radiation therapy
  5. History of nutrition-related problems
  6. Existing nutrient deficiencies
  7. Medications and their interactions
  8. Psychosocial history
  9. Signs or symptoms suggestive of vitamin and/or mineral deficiency
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6
Q

What are the types of Medical Record?

A
  1. Source-oriented (SOMR)
  2. Problem-oriented (POMR)
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7
Q

What is an ongoing collection of information that documents a patient’s medical care, considered a legal document, and a complete assessment - history, physical exams, discharge notes, diagnostic & laboratory tests

A

Medical record

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8
Q

What is an SOMR?

A

• Based on source of information - doctor, nurse, RND etc.
• Obtained during the course of health care
• Consists of patient identification data, admission notes, physician’s orders, laboratory reports, medication records, consents, consultations, operating room records, progress notes, and flow sheets

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9
Q

What is a POMR?

A

• Organized according to series of problems identified during the data collection process
• Consists of defined data base, complete problem list, initial care plan, progress notes, flow sheets, and discharge summary

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10
Q

What are the components of a Dietary History?

A
  1. Weight changes
  2. Usual meal pattern
  3. Appetite
  4. Satiety
  5. Discomfort after eating
  6. Chewing/swallowing ability
  7. Likes/ Dislikes
  8. Taste changes/ Aversions
  9. Allergies
  10. Nausea/ Vomiting
  11. Bowel habits
  12. Living conditions
  13. Snack consumption
  14. Vitamin/Mineral supplement use
  15. Alcohol/Drug use
  16. Previous diet restrictions
  17. Surgery/Chronic diseases
  18. Ability to purchase and prepare food
  19. Access to and ability to pay for health care
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11
Q

What is a nutrition-focused physical examination?

A

• a physical exam that RDNs perform to assess nutritional status or evaluate malnutrition.

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12
Q

What are the 4 things RNDs assess during a NFPE?

A
  1. physical health
    2.level of frailty or fitness,
  2. posture, and
  3. body symmetry
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13
Q

What are the limitations of physical examination?

A
  1. Non-specificity of the physical sign
  2. Multiple physical signs
  3. Signs may be two-directional
  4. Examiner inconsistencies
  5. Variation in the pattern of physical signs
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14
Q

What is a SGA?

A

Clinical technique for assessing the nutritional status of a patient based on features of the patient’s history and physical examination

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15
Q

Elements of the Patient’s History as basis for SGA

A

Weight loss
Changes in usual diet
Significant gastrointestinal symptoms
Patient’s functional status

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16
Q

Elements of a Patients PHYSICAL EXAM as basis for SGA

A

• Loss of subcutaneous fat
• Muscle wasting
• Presence of edema or ascites

17
Q

SGA Ranking Class A

A

Recent increased in weight, improvement in appetite

18
Q

SGA Ranking Class B

A

At least 5% weight loss, reduced dietary intake, mild ot moderate loss of subcutaneous fat and muscle wasting

19
Q

SGA Ranking Class C

A

Weight loss >10%, poor dietary intake, severe loss of subcutaneous fat and muscle wasting

20
Q

What is a Mini Nutritional Assessment?

A

Designed to provide primary care professionals with a single tool to efficiently identify elderly patients and nutritionally at-risk individuals who may subsequently need a more extensive nutritional assessment

Effective for screening hospitalized elderly and those requiring surgery

21
Q

What are signs suggestive of Dietary Obesity?

A

• Excessive weight in relation to height or other indices
• Excessive skinfolds
• Excessive abdominal girth in relation to chest girth

22
Q

What are signs suggestive of Undernutrition?

A

• Lethargy, mental and physical (starvation)
• Low weight in relation to height or other skeletal indices
• Diminished skinfolds
• Exaggerated skeletal prominences
• Loss of elasticity of the skin

23
Q

What are signs suggestive of protein-calorie deficiency disorder?

A

● Edema
● Muscle wasting
● Low body weight
● Psychomotor change
● Dyspigmentation of the hair
● Easy pluckability of hair
● Thin, sparse hair
● Moon-face
● Flaky paint dermatosis
● Diffuse depigmentation of the skin

24
Q

What are signs siggestive of VAD?

A

● Xerosis of the skin
● Follicular hyperkeratosis (Type 1)
● Xerosis conjunctivae
● Keratomalacia
● Bitot’s spot

25
Q

What are signs suggestive if Iron Deficiency?

A

● Pallor of mucous membranes
● Koilonychia
● Atropic lingual papillae

26
Q

What are signs suggestive of Iodine Deficiency?

A

• thyroid enlargement

27
Q

What are signs suggestiv of Riboflavin Deficiency?

A

● Angular stomatitis (or angular scars)
● Cheilosis
● Magenta tongue
● Central atrophy of lingual papillae
● Naso-labial dyssebacea
● Angular palpebritis
● Scrotal and vulval dermatosis
● Corneal vascularization

28
Q

What are signs suggestive of Thiamin Deficiency?

A

● Loss of ankle jerks
● Loss of knee jerks
● Sensory loss and motor weakness
● Calf-muscle tenderness
● Cardiovascular dysfunction
● Edema

29
Q

What are signs suggestive of Niacin Deficiency?

A

● Pellagrous dermatosis
● Scarlet and raw tongue
● Tongue fissuring
● Atrophic lingual papillae
● Malar and supraorbital pigmentation

30
Q

What are signs suggestive of Vit C Deficiency?

A

● Spongy and bleeding gums
● Follicular hyperkeratosis (Type 2)
● Petechiae
● Ecchymoses
● Intramuscular or subperiosteal hematoma
● Epiphyseal enlargement (painful)

31
Q

What are signs suggeative of Vit D Deficiency?

A

Active rickets (in young children)
● Epiphyseal enlargement (>6 months, painless)
● Beading of ribs
● Craniotabes (<1 year)
● Muscular hypotonia

Healed rickets (in children or adults)
● Frontal and parietal bossing
● knock-knees or bow-legs
● Deformities of the thorax

Osteomalacia (in adults)
● Local or generalized skeletal deformities

32
Q

What are the differences between acute PEM and Chronic PEM?

A

Acute PEM
• Caused by recent severe food restriction
• Characterized in children by thinness for height

Chronic PEM
• Caused by long-term food deprivation
• Characterized in children by short height for age

33
Q

What is Kwashiorkor?

A

• Results from protein deficiency and is commonly precipitated by an illness or infection

34
Q

What is Maramus?

A

• Results from severe deprivation, or impaired absorption of energy, protein, vitamins, and minerals

35
Q

Differentiate Marasmus and Kwashiorkor

A

see notes

36
Q

Explain Clinical and Subclinical VAD

A

Clinical
• Detected physical signs and symptoms by examiner and patient, respectively

Subclinical
• Absence of clinical evidence of disease
• Subject has no complaints of being ill
• Examiner unable to elicit any physical signs of disease

37
Q

Explain the stages of VAD

A

Subclinical
• Reducing stores
• Lowering serum level
• Metaplasia

Clinical
• Xerophthalmia
- non-binding
- binding

FN 123 (3 decks)

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