Clinical Assessment Flashcards
What is Clinical Assessment?
- estimation of nutritional status on the basis of
- recording a medical history and conducting a physical examination
- to detect signs symptoms
What are the uses of Clinical Assessment?
• Community nutrition survey
• Clinical medicine (prior to nutrition counseling)
At what stage in the development of nutrition deficiency is the clinical method used?
7th - Clinical Symptoms
8th - Anatomical Sign
What are the components of Clinical Assessment?
- Detailed History (Medical and Dietary)
- Thorough physical examination
- Interpretation of signs and symptoms associated with malnutrition
What are the components of Medical History?
- Past and current diagnosus of nutritional consequence
- Diagnostic procedures
- Surgeries
- Chemotherapy and Radiation therapy
- History of nutrition-related problems
- Existing nutrient deficiencies
- Medications and their interactions
- Psychosocial history
- Signs or symptoms suggestive of vitamin and/or mineral deficiency
What are the types of Medical Record?
- Source-oriented (SOMR)
- Problem-oriented (POMR)
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
Medical record
What is an SOMR?
• 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
What is a POMR?
• 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
What are the components of a Dietary History?
- Weight changes
- Usual meal pattern
- Appetite
- Satiety
- Discomfort after eating
- Chewing/swallowing ability
- Likes/ Dislikes
- Taste changes/ Aversions
- Allergies
- Nausea/ Vomiting
- Bowel habits
- Living conditions
- Snack consumption
- Vitamin/Mineral supplement use
- Alcohol/Drug use
- Previous diet restrictions
- Surgery/Chronic diseases
- Ability to purchase and prepare food
- Access to and ability to pay for health care
What is a nutrition-focused physical examination?
• a physical exam that RDNs perform to assess nutritional status or evaluate malnutrition.
What are the 4 things RNDs assess during a NFPE?
- physical health
2.level of frailty or fitness, - posture, and
- body symmetry
What are the limitations of physical examination?
- Non-specificity of the physical sign
- Multiple physical signs
- Signs may be two-directional
- Examiner inconsistencies
- Variation in the pattern of physical signs
What is a SGA?
Clinical technique for assessing the nutritional status of a patient based on features of the patient’s history and physical examination
Elements of the Patient’s History as basis for SGA
Weight loss
Changes in usual diet
Significant gastrointestinal symptoms
Patient’s functional status
Elements of a Patients PHYSICAL EXAM as basis for SGA
• Loss of subcutaneous fat
• Muscle wasting
• Presence of edema or ascites
SGA Ranking Class A
Recent increased in weight, improvement in appetite
SGA Ranking Class B
At least 5% weight loss, reduced dietary intake, mild ot moderate loss of subcutaneous fat and muscle wasting
SGA Ranking Class C
Weight loss >10%, poor dietary intake, severe loss of subcutaneous fat and muscle wasting
What is a Mini Nutritional Assessment?
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
What are signs suggestive of Dietary Obesity?
• Excessive weight in relation to height or other indices
• Excessive skinfolds
• Excessive abdominal girth in relation to chest girth
What are signs suggestive of Undernutrition?
• 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
What are signs suggestive of protein-calorie deficiency disorder?
● 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
What are signs siggestive of VAD?
● Xerosis of the skin
● Follicular hyperkeratosis (Type 1)
● Xerosis conjunctivae
● Keratomalacia
● Bitot’s spot
