1 / 58

FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY

FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY. NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION SPECIALIST GENERAL SURGICAL OUTPATIENT SERVICES INDIANA UNIVERSITY HOSPITAL APRIL 12, 2012. FUNCTIONAL NUTRITIONAL ASSESSMENT. OBJECTIVES

hao
Download Presentation

FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION SPECIALIST GENERAL SURGICAL OUTPATIENT SERVICES INDIANA UNIVERSITY HOSPITAL APRIL 12, 2012

  2. FUNCTIONAL NUTRITIONAL ASSESSMENT • OBJECTIVES • Following the completion of this presentation the participant will be able to identify: • DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO IDENTIFICATION OF VITAMIN AND MINERAL DEFICIENCIES • SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL DEFICIENCIES • PHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIES

  3. FUNCTIONAL NUTRITION ASSESSMENT • TRADITIONAL NUTRITIONAL ASSESSMENT COMPONENTS INCLUDE: • ANTHROPOMETRIC MEASUREMENTS • MEDICAL HISTORY • SOCIAL HISTORY • MEDICATION HISTORY • DIET HISTORY • PHYSICAL EXAM • SUBJECTIVE STATEMENTS

  4. FUNCTIONAL NUTRITIONAL ASSESSMENT • COMPONENTS OF ANY NUTRITIONAL ASSESSMENT • ALL ARE IMPORTANT PIECES TO THE PUZZLE • ALL HAVE VARYING LEVELS OF IMPORTANCE AND APPLICATION BASED ON THE AREA OF NUTRITION PRACTICE • ALL COMBINE TO PROVIDE A NUTRITIONAL “PICTURE”

  5. FUNCTIONAL NUTRITIONAL ASSESSMENT • WHAT IS IMPORTANT ABOUT THESE COMPONENTS? • DIET HISTORY • SUBJECTIVE SYMPTOMS • PHYSICAL EXAM

  6. FUNCTIONAL NUTRITIONAL ASSESSMENT • USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM TOGETHER CAN IDENTIFY SIGNIFICANT PROBLEMS THAT IMPEDE AN INDIVIDUAL’S FUNCTIONAL CAPACITY. • COMBINATION WILL RESULT IN A HIGH RATE OF IDENTIFICATION OF MICRONUTRIENT DEFICIENCIES • IDENTIFY METHODS FOR IMPROVED OUTCOMES

  7. FUNCTIONAL NUTRITIONAL ASSESSMENT • IMPORTANCE OF USE AND INTEGRATION OF THIS KNOWLEDGE: • PROVIDES A SERVICE TO THE MEDICAL TEAM THAT IS NOT PROVIDED IN ANY OTHER DISCIPLINE. • NUTRITION COMPONENTS OF A PHYSICAL EXAM ARE NOT TAUGHT IN MEDICAL SCHOOLS • IMPROVEMENT IN OUTCOMES: • FOR THE PATIENT • REDUCTION IN INSTITUTIONAL EXPENDITURES

  8. FUNCTIONAL NUTRITIONAL ASSESSMENT • IF YOU ARE ABLE TO IMPROVE OUTCOMES? • PHYSICIANS CHANGE THEIR OPINIONS ABOUT NUTRITION, INCLUDE RD MORE FREQUENTLY • ADMINISTRATION LISTENS • RD JOB SATISFACTION IS WONDERFUL

  9. FUNCTIONAL NUTRITIONAL ASSESSMENT

  10. FUNCTIONAL NUTRITIONAL ASSESSMENT • “WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE HELP? ” • VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU HOSPITAL ON ROUNDS – 3/27/2012 • “WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS SO WE DECIDED THAT WE COULD DO THAT AND STOPPED CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ” • 25 YEAR SURGICAL RN, IU HOSPITAL, 6/2011 • “I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I EVER HAVE IN THE PAST. “ • PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011

  11. FUNCTIONAL NUTRITIONAL ASSESSMENT • “THE MORE INFORMED YOU ARE, THE MORE LIKELY YOU ARE TO BE PERFORMING A NUTRITION FOCUSED PHYSICAL EXAM. THIS REAFFIRMS THE DIETITIAN’S ROLE, AREA OF EXPERTISE AND ADVANCED LEVEL OF PRACTICE” • MP Kelly, 2005

  12. FUNCTIONAL NUTRITIONAL ASSESSMENT • START WITH THE BASICS • A KNOWLEDGE BASE OF HOW TO USE ALL COMPONENTS OF A NUTRITIONAL ASSESSMENT IS ESSENTIAL • DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A FULL ASSESSMENT • NUTRITION PLAN OF CARE THAT IS CONCISE AND CLEAR

  13. FUNCTIONAL NUTRITIONAL ASSESSMENTS • COMMUNICATE • DEVELOP RELATIONSHIPS WITH NURSES, PHARMACISTS, PHYSICIANS, PHYSICIAN ASSISTANTS, PT, OT, SPEECH THERAPIST • INCLUDE THE NURSE IN YOUR SUGGESTED PLAN OF CARE • TAKE THE TIME TO COMMUNICATE

  14. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY • GIVES YOU A CURRENT PICTURE OF THE PATIENT • INCLUDE SUPPLEMENT USE IN THE DIET HISTORY • KNOW THE KEY NUTRIENTS IN FOOD GROUPS • EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR SUFFICIENCY TO HAPPEN • USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS. • WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE SUFFICIENT? • EXAMPLE: RIBOFLAVIN • IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT RIBOFLAVIN IN THE DIET

  15. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY • IMPORTANT FOR THE PATIENT TO UNDERSTAND WHY YOU ASK THE QUESTIONS. REMOVE THE “MORAL” VALUE OF FOOD FROM THE CONVERSATION

  16. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY – • FOCUS TO SPECIFIC POPULATIONS • WOUND HEALING • WIC • LONG TERM CARE • COMPLETE AT ANY POINT IN THE INTERVIEW PROCESS • USE A SIMPLFIED FORM • YOU ARE ONLY LOOKING FOR TRENDS • QUANTIFY WHAT PATIENT STATES

  17. FUNCTIONAL NUTRITIONAL ASSESSMENT • SUBJECTIVE SYMPTOMS • ARE KEY IN HELPING TO IDENTIFY NUTRITIONAL ISSUES RELATED TO VITAMIN AND MINERAL DEFICIENCIES • PATIENT’S GAIN CONFIDENCE IN THE SKILLS OF THE RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED TO NUTRITION. • PATIENT’S ARE YOUR BEST ADVOCATES, ESPECIALLY WHEN RELATIVELY SIMPLE MEASURES IMPROVE THEIR SYMPTOMS AND QUALITY OF LIFE

  18. FUNCTIONAL NUTRITIONAL ASSESSMENT • MOST NUTRIENT DEFICIENCIES HAVE A: • LOOK • SOUND • FEEL SOUND AND FEEL - ARE SUBJECTIVE SYMPTOMS THAT WILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENT USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE YOU SEE THE DEFICIENCIES

  19. FUNCTIONAL NUTRITIONAL ASSESSEMENT EXAMPLES: FATIGUE- VITAMIN C, A, IRON, B12, B COMPLEX BURNING MOUTH: B12, THRUSH, B COMPLEX SHORT TERM MEMORY ISSUES: B12, B1, IRON, IODINE FOOD CRAVINGS: WHAT IS FOOD GROUP CRAVED? CHOCOLATE, SALTY, STARCHY? TIME OF DAY THE FOOD CRAVING OCCURS?

  20. FUNCTIONAL NUTRITIONAL ASSESSMENT NUTRITION PHYSCIAL EXAM STARTING THE PROCESS Routinely check for: - Protein Calorie Malnutrition - Muscle Tissue - Adipose Tissue - Vitamin Deficiencies - Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin, B6 - Mineral Deficiencies - Zinc, Iron, Iodine IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU WILL LIKELY NOT SEE IT.

  21. FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL EXAM – GETTING STARTED • LOOK AT THE AVAILABLE PICTURES OF NUTRIENT DEFICIENCIES • KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR SKIN CHANGES • MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO HELP WITH THIS • YOU WILL HAVE TO DEFEND WHAT YOU ARE DESCRIBING – IT IS JUST PART OF THE PROCESS • LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN LOOK LIKE

  22. FUNCTIONAL NUTRITIONAL ASSESSMENT • PHYSICAL EXAM • TAKE THE NUTRITION TEXT BOOKS LITERALLY • KNOW “TIME TO DEFICIENCY” • DON’T ASK FOR LABS WITHOUT THE DIET HISTORY, SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE MEDICAL TEAM • PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS • THIS IS TO BECOME COMFORTABLE WITH TOUCHING, LOOKING AT SOMEONE ELSE • UNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSIS

  23. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C/ASCORBIC ACID • DISEASE: SCURVY • PRIMARY ROLES IN THE BODY • ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS OF NOREPINEPHRINE • REGENERATION OF VITAMIN E • COLLAGEN SYNTHESIS • CARNITINE SYNTHESIS • HISTIDINE SYNTHESIS • ADRENAL STEROID SYNTHESIS • FUNCTIONS IN TYROSINE AND FOLATE METABOLISM

  24. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEFICIENCY IDENTIFIED • NHANES, 1994 • 10-14% • NHANES, 2003-2004 • 7.1% - SMOKERS AND LOWER INCOME AT SIGNIFICANT RISK

  25. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEPLETION • GENERAL OUTPATIENT POPULATION • 6% OF GENERAL POPULATION • 51% OF DIABETIC POPULATION • 40% OF CARDIAC/HLD PATIENTS • Journal of American College of Nutrition; 1998

  26. FUNCTIONAL NUTRITIONAL ASSESSMENT • RENAL FAILURE ON RRT • 20-25% RATE OF VITAMIN C DEFICIENCY • HOSPITALIZED PATIENTS • MULTIPLE SINGLE CASE REPORTS • SURGICAL OUTPATIENT POPULATION AT IU: • SCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RD • ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC STATUS, NOT ALWAYS POST SURGICAL OR HIGHER RISK CATEGORIES

  27. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEFICIENCY • DIET HISTORY • FRUITS AND VEGETABLES • NEED TO BE SPECIFIC • FORTIFIED FOODS -CEREALS, JUICES, DRINKS, PROTEIN BARS • SOUR CANDIES

  28. FUNCTIONAL NUTRITIONAL ASSESSMENT • SUBJECTIVE SYMPTOMS OF SCURVY • FATIGUE • LOWER EXTREMITY PAIN • ARTHRALGIAS • MYALGIAS • LASSITUDE • DEPRESSED MOOD/DEPRESSION • EASILY BRUISED • BLEEDING TENDER GUMS • DIARRHEA • TOBACCO USE

  29. FUNCTIONAL NUTRITIONAL ASSESSMENT • HOW DO YOU CORRELATE THE SUBJECTIVE SYMPTOMS WITH THE FUNCTION OF VITAMIN C IN THE BODY? • ASK THIS QUESTION WITH EACH FUNCTION OF THE NUTRIENT • EXAMPLE: FATIGUE WITH SCURVY • BLOOD LOSS FROM CAPILLARY BLOOD LOSS WITH LOSS OF COLLEGEN SYNTHESIS; • UNABLE TO SYNTHESIZE CARNITINE • DECREASED ADRENAL HORMONE SYNTHESIS

  30. FUNCTIONAL NUTRITIONAL ASSESSMENT • PHYSICAL ASSESSMENT • FOLLICULAR PETECHIEA • EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY CONTINUES • CAN BE MASKED BY VITAMIN A HYPERKERATOSIS • EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER APPEARANCE • BRUISING/PURPURA • EARLY AND ONGOING • PEDAL EDEMA • LATER, NON RESPONSIVE TO DIURETICS • OFTEN SEEN WITH LOWER EXTREMITY CELLULITIS • JOINT SWELLING • USUALLY MID TO LATE MANIFESTATION

  31. FUNCTIONAL NUTRITIONAL ASSESSMENT

  32. FUNCTIONAL NUTRITIONAL ASSESSMENT • PURPURA

  33. FUNCTIONAL NUTRITIONAL ASSESSMENT • FOLLICULAR PETECHIEA • SWAN HAIR • DX: WOUND HEALING FAILURE

  34. FUNCTIONAL NUTRITIONAL ASSESSMENT • SERUM VITAMIN C LEVEL: UNABLE TO BE MEASURED • DX: SEVERE MALNUTRITION WITH H/O R-N-Y 25 YEARS PRIOR; • HAD NOT BEEN ABLE TO WALK FOR 6 MONTHS DUE TO SCURVY

  35. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • NHANES III –35-45% RATE OF DEFICIENT INTAKE IN INDIVIDUALS >60 YEARS OF AGE • DEFICIENCY RATE OF 20-25% AFTER ADJUSTING FOR SUPPLEMENT INTAKE

  36. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • HIGHER RISK POPULATIONS • > 50 YEARS OF AGE • GASTROINTESTINAL DISEASES • MALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBD • LIVER DISEASE • ALCOHOLICS • HIV/AIDS • SICKLE CELL DISEASE • DIABETES • PREGNANCY • VEGETARIANS • FOOD INSUFFICIENT POPULATIONS • EATING DISORDERS • USE OF GASTRIC ACID REDUCTION MEDICATIONS

  37. FUNCTIONAL NUTRITIONAL ASSESSMENT • FUNCTIONS OF ZINC • NEUROPEPTIDE FORMATION • IMMUNE FUNCTION • CATALYTIC ROLE • ~ 100 ZINC DEPENDANT ENZYMES • EXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASE • REGULATORY ROLE • REGULATION OF GENE EXPRESSION • STRUCTURAL ROLE • ZINC FINGER, STABILIZES THE STRUCTURE • LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION • HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC • ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS • CELL SIGNALING • HORMONE RELEASE • NERVE IMPULSE INNERVATION • APOTOSIS

  38. FUNCTIONAL NUTRITIONAL ASSESSMENT • FUNCTIONS OF ZINC • STRUCTURAL ROLE • ZINC FINGER, STABILIZES THE STRUCTURE • LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION • HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC • ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS • CELL SIGNALING • HORMONE RELEASE • NERVE IMPULSE INNERVATION • CELLULAR APOTOSIS

  39. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • ASK THE QUESTION: • HOW DOES EACH FUNCTION DIFFER IF ZINC DEFICIENCY EXISTS? • HOW DOES IT LOOK? • HOW DOES IT SOUND?

  40. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • EXAMPLE: IMMUNE FUNCTION • INCREASED CIRCULATING CORTICOIDSTEROIDS • DECREASED LYMPHOCYTES • THYMIC ATROPHY • INDIVIDUAL REFERRED TO YOU BECAUSE OF DESIRE TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE LEVELS; ABDOMINAL OBESITY; FREQUENT INFECTIONS • HOW WOULD THE PHYSICAL EXAM HELP?

  41. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • EXAMPLE: GYNOMASTICA, MALE • DECREASED TESTOSTERONE SYNTHESIS WITH INCREASED ESTROGEN SYNTHESIS • COMPLAINT EXAMPLE: “I CAN’T LOSE WEIGHT OR BUILD MUSCLE.”

  42. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • DIET HISTORY • VEGETARIAN W/O USE OF LEAVENED GRAINS • ELIMINATION OF ZINC RICH FOODS FROM DIET (CRUSTATIONS/BEEF/PORK) • INFREQUENT USE OF BEAN, LEGUME, NUT FAMILY • HIGH INTAKE OF PHYTATES AND DAIRY

  43. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • SUBJECTIVE SYMPTOMS • BLAND TASTE CHANGES • EARLY SATIETY • ANOREXIA/NO INTEREST IN FOOD • LIGHT ADAPTATION ISSUES • DIARRHEA • HAIR LOSS • NIGHT BLINDNESS • DEPRESSION, WITH INADEQUATE RESPONSE TO MEDICATION • ACUTE ONSET? LOOK FOR PRECIPITATING EVENT

  44. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • PHYSICAL EXAM • DRY FLAKY SKIN- LOWER EXTREMITIES • NASOLABIAL SEBORRHEA • DRY, REDDENED KNUCKLES • LEUKONYCHIA • MALE GYNOMASTICA • HAIR LOSS • ECCHYMOSIS • FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN, POOR PROTEIN SYNTHESIS

  45. FUNCTIONAL NUTRITIIONAL ASSESSMENT • DRY RED KNUCKLES

  46. FUNCTIONAL NUTRITIONAL ASSESSMENT • LEUKONYCHIA

  47. FUNCTIONAL NUTRITIONAL ASSESSMENT • SEVERE ZINC DEFICIENCY

  48. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY • 56 YR OLD FEMALE WITH HISTORY OF BREAST CANCER • 3 MONTHS OUT OF TREATMENT • FAILURE TO THRIVE • NO DISEASE RECURRENCE

  49. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY 1 • MEDICAL HISTORY • HTN • BREAST CANCER • HYPOTHYROID • SOCIAL HISTORY • SINGLE, LIVES ALONE • CHILDREN LIVING WITH HER CURRENTLY DUE TO HER INABILITY TO CARE FOR HERSELF • WHEEL CHAIR BOUND

  50. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY 1 • ANTHROPOMETRICS • BMI: 32 • CBW: STABLE • DIET HISTORY • DRINKS ONE STEAK AND SHAKE MILKSHAKE PER DAY • OCCASIONALLY EATS A FEW BITES OF SOUP

More Related