GENERAL SURVEY, VITAL SIGNS, and NUTRITIONAL SCREENING and ASSESSMENT GENERAL SURVEY First moments of the patient

t encounter Patients apparent state of health Patients demeanor Facial affect or expression Grooming Posture and Gait Height and Weight VITAL SIGNS Blood pressure Heart Rate Respiratory Rate Temperature PAIN The fifth vital sign Commonly underdiagnosed Major focus of caring for patients in all health professions. pain is subjective, tenderness is objective Common or Concerning Symptoms: Changes in weight Fatigue and weakness

Fever, chills and night sweats Pain CHANGES IN WEIGHT *weight GAIN may be due HYPOTHYROIDISM, TB, or CANCER to

*weight LOSS may be due to HYPERTHYROIDISM, or due to chrons disease, gastric cancer be due to: a. decreased intake of food due to anorexia,vomiting or insufficient supplies of food b. defective absorption of nutrients from the GIT c. increased metabolic requirements d. loss of nutrients thru urine,feces , skin(like cystic fibrosis). ***Rapid changes in weight, over a few days, suggest changes in body fluids, not tissues. FATIGUE AND WEAKNESS Fatigue non-specific symptom with many causes sense of weariness or loss of energy try to elicit the life circumstances in which it occurs. may require further investigation *fatigue may be also due to DEPRESSION 1 |Page Weight loss may

Weakness different from fatigue Denotes demonstrable loss of muscular power. The General Survey Apparent state of health Level of consciousness Signs of distress Skin color and obvious lesions Dress, grooming, personal hygiene Facial expression Odors of the body and breath Posture,gait and motor activity Height Weight I. Apparent state of Health Try to make this general judgement based on observations o o o Acutely ill or chemically ill Frail Feeble Frail/feeble = CA Pt, Eldery Pt o o fit Pt II. Level of Consciousness 1. Alertness - patient responds fully and appropriately to stimuli. 2. Lethargy - patient appears drowsy but opens the eyes, looks at you, responds to questions, then falls asleep. Robust Vigorous Robust vigorus = healthy &

3. Obtundation (drowsy) - patient opens the eyes, looks at you, responds slowly & somewhat confused. 4. Stupor - patient arouses from sleep only after painful stimuli. 5. Coma - no evident response to external stimuli; unarousable with eyes closed. (accd to doc UY, OGK Hahaha. Only God Knows!) III. Signs of Distress Cardiorespiratory insufficiency: labored cough breathing, wheezing,

Pain: Look for Guarding Behavior -wincing, sweating, protectiveness of a painful part Anxiety: anxious face, movements(Parkinsons), moist palms (Graves Dse) fidgety cold

IV. Skin Color and Obvious Lesions Pallor Cyanosis - * lips (rich in blood and nerve endings) Jaundice membrane Rashes Bruises V. Dress, Hygiene Grooming & Personal * eyes have thin

Excess clothing may reflect cold intolerance of hypothyroidism, may hide skin rash or needle marks, or signal personal lifestyle preferences. Cut out holes or slippers may indicate gout, bunions or other painful conditions. 2 |Page

 Untied laces or slippers may suggest edema. ***Is the patient wearing jewelry? - Copper bracelets - for arthritis ***Note the patients hair, fingernails, use of cosmetics - grown out hair & nail polish estimate of the length of illness ***Is the personal hygiene & grooming appropriate to the patients age, lifestyle, occupation & socio-economic group? - unkept appearance - depression & dementia VI. Facial Expression stare of hyperthroidism immobile face of parkinsonism flat affect of depression decreased eye contact may be cultural, or may suggest anxiety, fear or sadness

Left-sided heart failure - preference for sitting up COPD braced. leaning forward with arms

*** Is the patient restless or quite? How often does he move about? Fast, frequent movements hyperthyroidism Slowed myxedema activity of of

*** How does the patient walk? with comfort self-confidence & good balance limping, falling? IX. Height and Build unusually short or tall? Examples: o Turners Syndrome short web neck o Childhood renal failure Achondroplastic dwarfism hypopituitary dwarfism & lanky, or is there fear of

VII. Odors of Body or Breath give clues: o o important diagnostic

o o

alcoholic breath acetone breath - DKA breath Renal

is the build slender muscular or stocky?

o uremic Failure

Symmetry Bells Palsy (Facial N.), Erbs Palsy (Upper Brachial Plexus) Deformities: Long limbs in proportion to the trunk in hypogonadism & Marfans syndrome.

o hepatic fetor encephalopathy (liver)

o pulmonary infections lung abscess VIII. Posture, Gait, Motor Activity

X. Weight If possible, weigh the patient!!

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Emaciated; slender, plump, obese

Obesity: o Simple obesity- generalized fat distribution

Axillary Temperature: 97.5F - 98.6F Pulse: 80 - 120 Respirations: 20 - 30 Blood Pressure: 92/55 systolic

Pre-schooler:

Cushings Syndrome - Truncal fat with relatively thin limbs Causes of weight loss: malignancy, DM, hyperthyroidism, chronic infection, depression, diuresis, dieting. The Vital Signs Blood pressure Pulse Rate Respiratory Rate Temperature best route for children is RECTAL
(Baka makatulong in the near future, mga normal VS) Adults:

Axillary Temperature: 97.5F - 98.6F Pulse: 70 - 110 Respirations: 16 - 22 Blood Pressure: 95/57 systolic

School Age Child:

Oral Temperature: 97.5F - 98.6F Pulse: 60 - 100 Respirations: 16 - 20 Blood Pressure: 107/64 systolic

Adolescent:

Oral Temperature: 97.5F - 98.6F Pulse: 55 - 90 Respirations: 12 - 20 Blood Pressure: 121/70 systolic

Reference: Expert 10-Minute Physical Examinations, Mosby's

Normal Temperature: Oral (96.8F - 99.5F),

Rectal (97.3F - 100.2F), Tympanic (97.2F - 100.0F) Normal Pulse: 60 - 100 Normal Respirations: 12 - 20 Normal Blood Pressure: 100 - 139/60 89

*** While counting the radial pulse, count the respiratory rate without the patients realizing it. Abnormalities in Rate & Rhythm of Breathing: Normal -16-20 per min. -Up to 44/min in infants Tachypnea - rapid shallow breathing

Newborn:

Axillary Temperature: 97.7F - 99.5F Pulse: 120 - 160 Respirations: 30 - 60 Blood Pressure: 73/55 systolic

- in pleuritic chest pain, restrictive lung disease Hyperpnea - rapid deep breathing

One-year Old:

Axillary Temperature: 97.0F - 99.0F Pulse: 90 - 130 Respirations: 20 - 40 Blood Pressure: 90/56 systolic

Hyperventilation - in exercise, anxiety, metabolic Acidosis (Kussmauls breathing)

Toddler:

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Bradypnea

- slow breathing - in diabetic coma - respiratory depression -increased ICP

- extreme elevation in temperature above 41.1 C (106 F) Hypothermia - abnormally low temp. below ( 35 C (95 F), rectally - Chief cause is exposure to cold Others: - vasoconstriction (alcohol, sepsis) - hypothyroidism - hypoglycemia Causes of fever: - infections - drugs - immune

Cheyne - Stokes Breathing - periods of deep breathing alternate with period of apnea - Normal in children & apnea - Abnormal: Heart failure uremia, and brain damage

Obstructive Breathing - expiration is prolonged becausenarrowed airways increase the resistance to air flow. - in COPD, asthma Ataxic breathing (Biots Breathing) - unpredictable irregularity - shallow or deep breaths & stop for short periods - brain damage at medullary level Sighing Respiration - breathing is punctuated frequent sighs (give paper bag accdg. to Dra. Uy) - seen in hyperventilation syndrome(common cause of dysnea and dizziness) Temperature Fever or pyrexia - elevated body temperature Hyperpyrexia

- trauma disorders - malignancies - infarctions - blood disorders

NUTRITIONAL SCREENING AND ASSESSMENT Nutritional screening Identify the characteristics known to be associated with nutritional problems. Identify patients who are at risk for nutritional deficiencies and the subsequent problems related to these deficiencies.

Nutritional assessment the process of collecting and assessing data about clinical conditions, diet, body composition, and biochemical data, in order to identify patients with poor nutritional status and develop an appropriate nutrition therapy plan

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Classify patients by nutritional state: well-nourished and malnourished

extensive trauma or burns

Screening and assessment have a similar goal to identify malnourished patients and those at risk for malnutrition Compile information that is used to establish an appropriate treatment plan, including nutrition therapy. Avoid negative consequences such as: Complications Poor treatment results Physiological problems Increased healthcare costs

Alcohol abuse or use of drugs with anti nutrient or catabolic properties: steroids, antitumor agents Impoverishment, isolation, advanced age

The diagnosis of nutritional status cannot be made on observation alone. Loss of subcutaneous muscle mass fat and

The screening and assessment processes difference: Type and scope of information obtained Training, skills and technical expertise of staff who collects the information Time required to complete the process Cost of the process

- Even with evidence such as this, it is important to conduct the clinical interview and physical exam to make an accurate nutritional diagnosis. Methods use to assess nutritional status: Clinical assessment, body composition tests biochemical data.

High Risk Patients Underweight (BMI<18.5) and/weight loss of >10% of usual body weight Poor intake: anorexia, food avoidance or NPO status for more than 5 days Protracted nutrient losses: malabsorption, enteric fistulae, draining abscesses or wounds, renal dialysis Hypermetabolic states: Sepsis protracted fever

NUTRITIONAL SCREENING The first step in the process is to screen patients according to their nutritional risk. Screening tools can be quite simple and quick to administer. Involuntary increase or decrease in weight > 10% of usual weight over 6 months or > 5% of usual weight over 1 month Inadequate oral intake

NUTRITIONAL ASSESSMENT Patients who are at nutritional risk require a more detailed assessment.

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The nutritional assessment is the process of collecting, assessing, and interpreting three classes of data: Body composition from anthropometric measurements Note: Both biochemical data and body composition measurements are subject to interference from a number of factors and therefore should not be used alone. Ideally, all three components should be evaluated before malnutrition is diagnosed. NUTRITIONAL HISTORY PHYSICAL EXAMINATION ANTHROPOMETRICS LABORATORY STUDIES Biochemical data Clinical assessment

Weight and height, which can generally be expressed as Body Mass Index (BMI)

Triceps or subscapular skin fold thickness, which is used to measure fat mass.

Mid-arm muscle circumference (MAMC) and mid-arm muscle area (MAMA), used to measure muscle mass.

Subjective Global Assessment (SGA)

-allows physicians to utilize available clinical data to assess a patients nutritional status.

Some institutions have the technical resources and trained staff to take other measurements, such as bioelectric impedance, underwater weighing, tomography, total-body potassium, and ultrasound.

Nutritional Assessment: 1. Body Composition Parameter

Anthropometrics Provide information on body mass and fat reserves. Most commonly used measurements: 1. Body weight 2. Height

-often measured by anthropometric techniques.

Among the most common are:

3. Triceps Skinfold(TSF) 4. Mid-arm muscle circumference (MAMC)

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1. Body weight - One of the most useful parameters to follow in patients who are acutely or chronically ill. - Unintentional weight loss during illness often reflects loss of lean body mass,esp. if it is rapid and not caused by diuresis - Reference standard use is body mass index

- established the criteria for defining overweight and obesity Caucasi an overweigh t obese class 1 obese class 2 above 30 above 35 Asian I above 23 above 25

A. ASSESSING OBESITY Body Mass Index Calculated as weight /(height)2, in kg/m2 Evaluates weight relative to height (as taller people are supposed to weigh more)

Asia Pacific International Obesity Task Force -suggests the modification on the criteria for defining obesity to reflect these observations. a. Skinfold Thickness - Useful in estimating body fat stores - 50% of body fat is normally located in the subcutaneous region - Also permits discrimination of fat mass and muscle mass - Generally representative of the bodys overall fat level - <3mm thickness suggests virtually complete exhaustion of fat stores 2. Mid-arm muscle circumference(MAMC) - Often used to estimate skeletal muscle mass. - calculated as: MAMC (cm) = upper arm circum (cm) {0.314 x TSF(mm)} Responding to the BMI If the BMI is above 25, assess the patient for additional risk factors:

Replaced percentage ideal body weight as criterion for assessing obesity Correlates significantly with body fat, morbidity, and mortality

BODY MASS INDEX (BMI) CHART OBESITY: NIH & WHO CRITERIA Classificati on Under weight Normal weight Overweight Obesity Class 1 Obesity Class 2 Obesity Class 3 NIH/WHO and NIH <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 A/PIOT F <18.5 18.522.9 23.024.9 25.029.9 30 34.9 >35

A/PIOTF Criteria

- hypertension 8 |Page

- high LDL-C - low HDL-C - high triglycerides - high blood glucose - family history of premature heart disease - physical inactivity - cigarette smoking Patients with a BMI over 25 and 2 or more risk factors should pursue weight loss, especially if the waist circumference is elevated.

Total lymphocyte count cell/mm3 Serum transferring <140 mg/dL Serum prealbumin < 17 mg/dL

< 1500

LDL, HDL, TG dyslipide mia factors

Total iron-binding capacity < 250 mcg/dL Serum cholesterol < 150 mg/dL parameters

Several biochemical should be assessed:

General Guidelines in Losing Weight 10% weight reduction over 6 mos or a decrease of 300 to 500 kcal/day, for people with BMIs between 27 and 35. A weight loss goal of to 1 pound per week because more rapid weight loss does not lead to better results at 1 year. Low-caloric diets of 800-1500 kcal per day are recommended. Interventions combining nutrition education, diet and moderate exercise with behavioral strategies are most likely to succeed. Role of moderate physical activity: - It enhances maintenance of weight - Increases cardiorespiratory fitness - May decrease abdominal fat Nutritional Assessment: 1. Biochemical Parameters Serum albumin < 3.5 g/dL

Serum albumin, which has a long half-life of 21 days. Values below 3.5 g/dL indicate risk of malnutrition. Total lymphocyte count. Less than 1,500 cells per cubic millimeter indicate risk of malnutrition. Serum transferrin, which has a half-life of 7 days. Any patient whose numbers are below 140 mg/dL is at risk. Serum pre-albumin (transthyretin), with a half-life of 3 days. Numbers below 17 mg/dL indicate risk of malnutrition. Total iron-binding capacity is normally between 250 and 450 mcg/dL. Serum cholesterol levels less than 150 mg/dL indicate increased risk.

Nutritional Parameters: 2. Change Per Type of Malnutrition This slide indicates that anthropometric and biochemical parameters 9 |Page

can decrease or remain unchanged depending on the type of malnutrition. For example: Acute malnutrition Decreases in albumin, lymphocyte count, and immune functions Chronic malnutrition - Decreases in body weight and mid-arm circumference Subjective Global Assessment (SGA) - Clinical assessment tool - Simple to administer (trained personnel) - Provide clinicians nutritional diagnosis it provides to be an accurate predictor of which patients are at increased risk for developing complications such as infection or poor wound healing. SGA CLINICAL HISTORY 1. Weight Changes Over the last six months During the past two weeks Percentage of that loss is calculated because it is important to identify chronic and/or acute losses. change in weight, in addition to the weight itself, should be noted because a thin patient is not necessarily a patient at nutritional risk 2. Dietary Intake type of diet Recent changes in intake. No change Changes

Duration Type: Inadequate conventional diet Total liquid diet

Clear liquid diet (hypocaloric) Fasting

***Special emphasis on 3 (persist for more than 15 days.) Gastrointestinal Symptoms Nausea, Vomiting Diarrhea Anorexia

4. Functional Capacity Dysfunction Duration Type Decreasefunction: ambulatory bedridden

5. Illness and Nutritional Requirements - Records the patients primary diagnosis and indicates what kind of nutritional impact the disease or condition is likely to have on the patient. (79% of hospitalized medical patients are associated with nutritional risk). Acute diseases and conditions that can adversely affect a patients nutritional status include major trauma, surgery, and serious infections. 6. Physical Exam

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- Focuses on physical factors that can affect a patients dietary intake and nutritional status. - Loss of subcutaneous fat is assessed by observing the intercostal region and zygozomatic processes. -Muscle loss can best be seen in quadriceps and deltoid muscles and the presence of edema should also be noted. Other signs and symptoms associated with nutrient deficiencies are: Problems with teeth, gums or mouth Difficulty chewing or swallowing Angular stomatitis Fractures or bone pain Glossitis Skin alterations

Well-nourished Moderately malnourished or suspected malnutrition Severely malnourished

SAMPLES: Mrs.Joy Maligaya is a young,healthylooking woman,well-groomed, fit and cheerful.Height is 54,weight 135 lbs,BMI 24,BP 120/80, HR 72 and regular,RR16, temperature 37.2 degrees Celsius. Mr. Hapo is an elderly male who looks pale and chronically ill.He is alert,with good eye contact but unable to speak more than 2-3 words at a time because of shortness of breath. He has intercostal muscle retractions when breathing and sits upright in bed. He is thin, with diffuse muscle wasting.Height is 62,weight 175 lbs,BP 160/90 R arm,HR 108 and irregular,RR 32 and labored, temperature 38.9 degrees Celsius.

Subjective Global Assessment: Diagnosis

Subjective Global Assessment of Nutritional Status

A. History
1. Weight change Overall loss in past 6 months: ________ kg Change in past 2 weeks: Percent loss ________ no change decrease

increase

2. Dietary intake change relative to normal No change ________ Change: duration ________ weeks ___ ____ months

Type: sub-optimal solid diet ________ full liquid diet ________ hypocaloric liquid diet _______ starvation 3. Gastrointestinal symptoms (persisting more than 2 weeks) None Nausea ________ Vomiting Diarrhea ________ Anorexia _______

4. Functional capacity No dysfunction ___________ Dysfunction: duration _______ weeks _______ months ambulatory _________ bedridden _________

Type: working sub-optimally ________

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5. Disease and its relationship to nutritional requirements Primary diagnosis: ____________________________ Metabolic demand / Stress: none ________ low ________ moderate ________ high ________

B. Physical Examination
(for each specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe) Loss of subcutaneous fat (triceps, chest) ______________ Muscle wasting (quadriceps, deltoids) _________________ Ankle edema ________ Sacral edema ________ Ascites ________

C. Subjective Global Assessment Rating

Well nourished A Moderately (or suspected) of being) malnourished B Severely malnourished C

Do not fear, for I am with you; do not anxiously look about you, for I am your God. I will strengthen you, surely I will help you, surely I will uphold you with My righteous right hand. Isaiah 41:10
Hello Batchmates! Goodluck sa ating lahat. Focus lang, kaya natin yan Gaya nga ng sabi ni Buddha,

"Do not dwell in the past; do not dream of the future, concentrate the mind on the present moment." Hi nga pala sa mga friends naming 33, hahaha. Pati na rin sa Med Dance Family. Thanks po. Goodluck 2014!

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