{"id":148,"date":"2021-08-14T12:50:14","date_gmt":"2021-08-14T16:50:14","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/dietmods\/?post_type=chapter&p=148"},"modified":"2022-03-06T23:35:27","modified_gmt":"2022-03-07T04:35:27","slug":"pn-assess","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-assess\/","title":{"raw":"Assess","rendered":"Assess"},"content":{"raw":"\"Step\r\n

Gathering Data for An Assessment<\/h1>\r\nBefore asking the patient questions for your assessment, make sure to introduce yourself and set the agenda for the discussion.\r\n\r\nYou may review your patient's chart or obtain information from them directly. You will need to gather information on the following:\r\n
\r\n
    \r\n \t
  1. Clinical Data<\/strong>: past medical history (PMHx), history of presenting illness (HPI), imaging, investigations, pathology, scheduled procedures, consultations, medical orders (medications, infusions), clinical documentation (fluids in and out, bowel movements, drains and tubes, vitals, and documentation of symptoms), medical plan, disposition plan.<\/li>\r\n \t
  2. Anthropometric Data<\/strong>: weight, height, BMI, weight change, % weight change, % usual body weight, physical assessment, subjective global assessment.<\/li>\r\n \t
  3. Nutritional Requirements<\/strong>: energy, protein, and fluid<\/li>\r\n \t
  4. Biochemical Data<\/strong>: laboratory values (blood, urine, feces, sputum, tissue, wounds, drains etc.).<\/li>\r\n \t
  5. Dietary Data<\/strong>: current\/recent hospital diet order(s), current, recent, and baseline intake, dietary restrictions, allergies\/ intolerances, eating behaviours and patterns, calorie counts, supplements, previous nutrition\/dietitian interventions.<\/li>\r\n<\/ol>\r\nThe components reviewed in each section are common considerations but you may need to consider other factors depending on your patient.\r\n\r\n<\/div>\r\n
    \r\n

    Case Study: Meet Poppy<\/h2>\r\n<\/header>\r\n
    \r\n\r\n[caption id=\"attachment_1490\" align=\"aligncenter\" width=\"662\"]\"Poppy Your patient, Poppy[\/caption]\r\n\r\n \r\n\r\nYou are a Registered Dietitian in the Intensive Care Unit (ICU). The patient you are assessing is a 76-year-old female named Poppy.\r\n\r\n<\/div>\r\n<\/div>\r\n

    Assessment Methods<\/h1>\r\n

    Head-to-toe<\/h2>\r\nThe head-to-toe assessment method is used in the intensive care unit.\u00a0 This method could be used in other areas if you encounter an acutely ill or complex patient. You may encounter this terminology when reviewing chart notes of patients who have been transferred from the ICU; therefore it is important to be familiar with it.\r\n
    <\/div>\r\n
    \r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
    Head-to-toe assessment method<\/caption>\r\n
    System<\/th>\r\nConsiderations<\/th>\r\n<\/tr>\r\n
    Neurological (CNS)<\/td>\r\nSAS (sedation agitation scale) score, GCS (Glascow coma scale), Sedation, Paralytics<\/td>\r\n<\/tr>\r\n
    Respiratory (Resp)\r\n\r\n <\/td>\r\nIf vented:<\/strong> type of breathing tube (ETT, type of [pb_glossary id=\"1681\"]trach[\/pb_glossary]), vent settings (FiO2, PEEP, PS\/PC, SaO2), respiratory rate (RR), secretions (type and frequency)\r\n\r\nIf not vented:<\/strong> type of trach, mode of oxygenation (BiPAP, CPAP, Optiflow, face mask, trach mask, nasal prongs (NP)), amount of oxygenation, secretions (type and frequency)<\/td>\r\n<\/tr>\r\n
    Cardiovascular (CVS)<\/td>\r\nIntra-aortic balloon pump (IABP) and settings, heart rate (HR), blood pressure (BP), mean arterial pressure (MAP), IV access and solution<\/td>\r\n<\/tr>\r\n
    Gastrointestinal (GI)<\/td>\r\nAbdomen soft vs. firm, distended, type of feeding tube, NG output mode (suction\/drainage\/clamp) + 24 hour output, feeding formula\/rate, amount of daily protein supplementation, nausea\/vomiting, bowel movements (type and frequency), 24 hour stoma output, labs (lactate, liver function tests (LFT's))<\/td>\r\n<\/tr>\r\n
    Genitourinary (GU)<\/td>\r\nUrine output (mL\/hr, mL\/day), 24hr fluid balance, diuretics, dialysis, labs (urea, creatinine, K, PO4<\/sub>, sodium)<\/td>\r\n<\/tr>\r\n
    Infectious Disease<\/td>\r\nTemperature (max in 24 hr), microbiology result, antibiotics, labs (white blood count (WBC))<\/td>\r\n<\/tr>\r\n
    Physical Assessment<\/td>\r\nGeneralized\/pitting edema, ascites, wounds, lean body mass wasting, [pb_glossary id=\"1682\"]diaphoresis[\/pb_glossary]<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n

    Subjective Global Assessment<\/h2>\r\nAnother important assessment strategy is to physically evaluate your patient for signs and symptoms of malnutrition.\r\n\r\nAccording to the\u00a0<\/span>Canadian Malnutrition Task Force<\/a>:\r\n
    Subjective global assessment (SGA) is the gold standard for diagnosing malnutrition. SGA is a simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition care. The assessment includes taking a history of recent intake, weight change, gastrointestinal symptoms and a clinical evaluation.<\/blockquote>\r\nThe SGA provides guidance on how to complete a physical examination by using a head-to-toe method for the assessment of muscle wasting, subcutaneous fat and fluid retention.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
    SGA guidance for assessment of Muscle Wasting\r\nSource: Canadian Malnutrition Task Force SGA Form (PDF)<\/a>\r\n[**] Note: in the elderly, this may reflect aging, not malnutrition.<\/caption>\r\n
    Physical Examination<\/th>\r\nNormal<\/th>\r\nModerate<\/th>\r\nSevere<\/th>\r\n<\/tr>\r\n
    Temple<\/th>\r\nWell-defined muscle<\/td>\r\nSlight depression<\/td>\r\nHollowing, depression<\/td>\r\n<\/tr>\r\n
    Clavicle<\/th>\r\nNot visible in males, may be visible but not prominent in females<\/td>\r\nSome protrusion; may not be all the way along<\/td>\r\nProtruding\/prominent bone<\/td>\r\n<\/tr>\r\n
    Shoulder<\/th>\r\nRounded<\/td>\r\nNo square look, [pb_glossary id=\"1683\"]acromion process[\/pb_glossary] process may protrude slightly<\/td>\r\nSquare look, bone prominent<\/td>\r\n<\/tr>\r\n
    Scapula\/ribs<\/th>\r\nBones not prominent<\/td>\r\nMild depression or bone may show slightly<\/td>\r\nBone prominent, significant depressions<\/td>\r\n<\/tr>\r\n
    Quadriceps<\/th>\r\nWell defined<\/td>\r\nDepression\/ atrophy medially<\/td>\r\nProminent knee, severe depression medially<\/td>\r\n<\/tr>\r\n
    Interosseous muscle between thumb and forefinger (back of hand)**<\/th>\r\nMuscle protrudes, could be flat in females<\/td>\r\nSlightly depressed<\/td>\r\nFlat or depressed area<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n[caption id=\"attachment_1278\" align=\"aligncenter\" width=\"506\"]\"The The interosseous muscle is depressed in a patient with muscle wasting. Photo by Juniper Publishers<\/a> is licensed under a Creative Commons Attribution 4.0<\/a> International License[\/caption]\r\n\r\n\r\n\r\n\r\n\r\n
    SGA guidance for assessment of Subcutaneous Fat\r\nSource: Canadian Malnutrition Task Force SGA Form<\/caption>\r\n
    Physical Examination<\/th>\r\nNormal<\/th>\r\nModerate<\/th>\r\nSevere<\/th>\r\n<\/tr>\r\n
    Under the eyes<\/th>\r\nSlightly bulging area.<\/td>\r\nSomewhat hollow look, slightly dark circles.<\/td>\r\nHollowed look, depression, dark circles.<\/td>\r\n<\/tr>\r\n
    Triceps<\/th>\r\nLarge space between fingers.<\/td>\r\nSome depth to fat tissues, but not ample. Loose fitting skin.<\/td>\r\nVery little space between fingers or finger touch.<\/td>\r\n<\/tr>\r\n
    Ribs, lower back, sides of trunk<\/th>\r\nChest is full, ribs do not show. Slight to no protrusion of the [pb_glossary id=\"1664\"]iliac crest[\/pb_glossary].<\/td>\r\nRibs obvious, but indentations are not marked. Iliac crest somewhat prominent.<\/td>\r\nIndentation between ribs obvious. Iliac crest very prominent.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n[caption id=\"attachment_1279\" align=\"aligncenter\" width=\"339\"]\"Hollow, Hollow, dark circles under the eyes. Photo by Serdar G.<\/a>, CC0<\/a>, via Wikimedia Commons[\/caption]\r\n\r\n\r\n\r\n\r\n
    SGA guidance for assessment of Fluid Retention\r\nSource: Canadian Malnutrition Task Force SGA Form<\/caption>\r\n
    Physical Examination<\/th>\r\nNormal<\/th>\r\nModerate<\/th>\r\nSevere<\/th>\r\n<\/tr>\r\n
    Edema<\/th>\r\nNone<\/td>\r\nPitting edema of extremities \/ pitting to the knees, possible [pb_glossary id=\"1665\"]sacral[\/pb_glossary] edema if bedridden<\/td>\r\nPitting beyond knees, sacral edema if bedridden, may also have generalized edema<\/td>\r\n<\/tr>\r\n
    Ascites<\/th>\r\nAbsent<\/td>\r\nPresent (may only be present on imaging)<\/td>\r\nPresent (may only be present on imaging)<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

    Physical Assessment<\/h2>\r\nIn addition to the head to toe method and the SGA, it is important to go into your patient\u2019s room to evaluate physical signs and symptoms of nutrition deficiencies. It is important to consider evaluating skin integrity, face, mouth, abdomen, temperature and respiration, when possible.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
    Physical signs & symptoms of nutritional deficiencies, by site of the body<\/caption>\r\n
    Site<\/th>\r\nPhysical Examination<\/th>\r\nPotential Nutritional\/ Metabolic Status<\/th>\r\n<\/tr>\r\n
    Skin Integrity<\/th>\r\n\r\n
      \r\n \t
    1. Pallor<\/li>\r\n \t
    2. Dry, scaly skin<\/li>\r\n \t
    3. Dermatitis<\/li>\r\n<\/ol>\r\n<\/td>\r\n
    		\r\n
      \r\n \t
    1. Iron, folate, or B12 deficiency<\/li>\r\n \t
    2. Vitamin A or [pb_glossary id=\"1666\"]EFA[\/pb_glossary] deficiency<\/li>\r\n \t
    3. EFA, zinc, niacin, or riboflavin deficiency<\/li>\r\n<\/ol>\r\n<\/td>\r\n<\/tr>\r\n
    Face<\/th>\r\nMoon face or bilateral temporal wasting<\/td>\r\nProtein- calorie malnutrition<\/td>\r\n<\/tr>\r\n
    Mouth<\/th>\r\nDry, cracked, red lips<\/td>\r\nRiboflavin, niacin, B12 deficiency<\/td>\r\n<\/tr>\r\n
    Abdomen<\/th>\r\nRounded, distended<\/td>\r\nGas, edema, ascites, obesity<\/td>\r\n<\/tr>\r\n
    Temperature<\/th>\r\nIncreased temperature<\/td>\r\nIncreased energy and fluid requirements<\/td>\r\n<\/tr>\r\n
    Respiration<\/th>\r\nIncreased respiratory rate<\/td>\r\nAltered calorie and protein requirements\r\n\r\nEnergy needs may be increased if weaning from ventilator or decreased if chronically ventilator dependent<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
    \r\n

    Clinical Data<\/h1>\r\nClinical data can include, but is not limited to:\r\n