Physical Assessment to Determine Nutritional Deficiencies Sharolyn tsamoutales, Graduate student Intern Bowling Green State University, 2012

Nutrition-focused Physical assessment During initial patient (pt) evaluation an RD’s assessment can be further enhanced by performing a “head to toe” visual interpretation of a pt’s physical signs and symptoms in determining appropriate Medical Nutrition Therapy. Throughout this process, it is important to exercise thoughtful consideration for pt’s comfort level.

Nutrition-focused Physical assessment Seldom are nutrient deficiencies isolated, multiple deficiencies are most common Physical signs of nutrient deficiencies are typically observed after prolonged diet inadequacy Non-nutritional related symptoms may be observed

Clinical Assessment Consideration of physical observations and interpretation of: Hair - Neurological Eyes - Additional Oral health observations Thyroid gland - Hydration status Nails Skin

Hair Assessment Hair should have a shiny, normal to thick appearance that is not easily plucked. Clinical Findings Potential Deficiency Thinning, sparse, Alopecia Easily plucked, brittle Dry “Corkscrew”, coiled hair Protein, Biotin, Zinc, Essential Fatty Acids (EFA), Iron Zinc, Protein Vitamin A, EFA, Zinc Vitamin C

Hair Images Alopecia Corkscrew

Eye Assessment Eyes should appear bright and clear with healthy membranes and normal movement Clinical Findings Potential Deficiency Nyctalopia, Pale Conjunctiva Ophthalmoplegia Xerophthalmia Fissuring in corners, redness Vitamin A, E Vitamin A, Iron Thiamin (B1), Phosphorus Vitamin A, Protein Riboflavin (B2), Pyridoxine Nyctalopia is night blindness. Pale Conjunctiva presents in the eye lid as a pale, porcelain color. Ophthalmoplegia is paralysis or impaired muscle function of the eye or slowing eye movement. Xerophthalmia is dry eye, with decreased tear secretion.

Eye Images Pale conjunctiva Ophthalmoplegia

Oral health Assessment Mouth should appear free of sores and swelling, with normal pink/red gums and tongue. normal teeth, taste and smell. Clinical Findings Potential Deficiency Cheilosis, Angular stomatitis, or Perlèche Magenta glossitis Pale, Sore tongue Atrophic lingual papillae Riboflavin, Pyridoxine, Niacin, Iron, Zinc Riboflavin Riboflavin, B12, Iron Riboflavin, Niacin, Folate, B12, Protein, Iron Cheilosis, Angular stomatitis, or Perlèche presents as bilateral fissuring and dry scaling of the vermilion surface of the lips and angles of the mouth. Magenta glossitis presents as a deeply red-to-purple, smooth tongue. Atrophic lingual papillae is a condition of the tongue. The small, red, raised area of the tongue is no longer visible and has a thin, shiny, smooth red appearance.

Atrophic lingual papillae Oral Health images Angular stomatitis Atrophic lingual papillae

Oral health Assessment Mouth should appear free of sores and swelling, with normal pink/red gums and tongue. normal teeth, taste and smell. Clinical Findings Potential Deficiency Swollen, retracted, bleeding gums Loose teeth Hypoguesia Hyposmia Vitamin C Zinc Hypoguesia is diminished or cessation of ability to taste. Hyposmia is diminished or cessation of ability to smell.

Swollen, retracted, bleeding gums Oral health Images Swollen, retracted, bleeding gums Loose teeth

Thyroid Gland Assessment Located on the front of the neck flanking the trachea, should not appear enlarged Clincal Findings Potential Deficiency Hypothyroidism, Goiter Iodine The thyroid gland is an endocrine gland made up of two lobes, one on either side of the trachea, joined by a narrow band of tissue. It produces the hormones thyroxine (T4)and triiodothyronine (T3), which require iodine. Iodine deficiency may be related to insufficient dietary intakes or malabsorption. A goiter is visibly enlarged thyroid gland typically due to a deficiency of iodine.

Nail Assessment Nails should have a smooth appearance free of ridges and discoloration, with a normal, pale, crescent shaped, lunula Clinical Findings Potential Deficiency Koilonychia Longitudinal central ridges Longitudinal nail beading Absent Lunula Brown-gray color Transverse ridging, dry, brittle Iron, Protein Iron, Folic Acid, Protein B complex (B1, 2, 3, 5, 6, 7, 9, 12), Protein Protein, Iron, B12 Protein, EFA Koilonychia; spoon-shaped concave nails indicating an iron and protein deficiency, particularly sulfur-containing amino acids such as cysteine or methionine.

Nail Images Koilonychia Absent lunula. Longitudinal central ridge Longitudinal nail beading

Skin Assessment Skin should appear Normally smooth and free of discoloration Clinical Findings Potential deficiency Purpura Petechiae Pellegra Follicular hyperkeratosis Nasolabial seborrhea, scaling, dry, goose bump Pallor Vitamin C, K, Folic acid Vitamin C, K Niacin, Tryptophan Vitamin A, B, C, E, EFA Vitamin A, Zinc, EFA, Riboflavin, Pyridoxine Iron, B12, Folic acid, Vitamin E Purpura are large bruise discolorations from bleeding under the skin approximately 3–10 mm in size. Petechiae are tiny red, brown, or purple round spots, formed in clusters from bleeding under the skin approximately 1-3 mm insize. It may appear to be a rash and do not loose their color with applied pressure. Follicular hyperkeratosis is a skin condition characterized by excessive development of keratin in hair follicles, resulting in rough, cone-shaped, elevated papules whose openings are often closed with a white plug of sebum. Nasolabial seborrhea is a redness and scaling in the nasolabial creases of the body or “laugh lines” of the face typical of vitamin B deficiency.

Skin Images Purpura Petechiae

Skin Images Nasolabial seborrhea Dry, goose bump

Skin Assessment Skin should appear Normally smooth and free of discoloration Clinical Findings Potential Deficiency Dermatitis Cellophane appearance Desquamation, Pigmentation Zinc, Niacin Protein Niacin, Protein

Desquamation, Pigmentation Skin Images Desquamation, Pigmentation Protein edema

Neurologic Assessment Clinical Findings Potential Deficiency Dementia Confabulation, Beri-beri Peripheral Neuropathy, Paresthesias Thiamin, Vitamin E Niacinamide, B12, Thiamin Thiamin, Pyridoxine, B12 Confabulation is a memory disturbance exhibited in subjects who unintentionally make verbal statements that are inaccurate and historically false. Typically, subjects are confident in their statements despite making contradicting remarks. This is a symptom often seen in patients with Korsakoff’s Syndrome, Alzheimer’s Disease, Schizophrenia, and traumatic brain injuries. Beri-beri is the more extreme manifestation of thiamin deficiency. Paresthesias is a tingling, burning, pricking, or numbness of a person's skin which may be transient or chronic.

Neurologic Images Beri-beri Tetany

Neurologic Assessment Clinical Findings Potential Deficiency Ataxia Tetany Thiamin, Pyridoxine, B12, Vitamin E Thiamin, Niacin, B12, Calcium, Vitamin D, Vitamin E, Magnesium Ataxia is a neurological sign exhibiting a lack of voluntary coordination of muscle movements. Movements such as tendon reflexes, fine tactile and positioning skills. Tetany is a syndrome of sharp flexing motions of the wrist and ankle joints exhibited by muscle twitching, cramps, convulsions, and possible stridor as a result of hyper-excitability of nerves and muscles caused by decreased extracellular ionized calcium.

Additional Physical Assessments Clinical Findings Potential Deficiency Parotid enlargement Osteomalacia, Rickets Persistant Cough Dyspnea Protein Vitamin D Thiamin Folic Acid, B12, Vitamin E Parotid enlargement is the swelling of the salivary gland. Xerostomia is dryness of the mouth caused by diminished function of the salivary glands. Osteomalacia and Rickets present as pains and muscle weakness due to a deficiency of vitamin D. Fractures are common. Rickets is the name used when it occurs in children and osteomalacia is the term used for adults.

Additional physical image Parotid swelling Osteomalacia, Rickets

Additional Physical Assessments Clinical Findings Potential Deficiency Marasmus Kwashiorker Macronutrients, micronutrients Protein, Iron, Folic Acid, Vitamin C Marasmus is a form of protein-energy malnutrition, not only due to protein deficiency but to prolonged severe caloric deficit. Typically occurring in the first year of life, exhibiting growth retardation and wasting of subcutaneous fat and muscle. Kwashiorker is a protein-energy malnutrition (PEM) produced by severe protein deficiency. Symptoms include retarded growth, changes in skin and hair pigment, edema.

Additional Physical Assessments Marasmus Kwashiorker

Hydration Status Assessment Clinical Physical Findings Underhydration Overhyration Imput < output Decrease in weight Sunken, dry eyes Oliguria, dark urine Sticky salvia, dry membranes Poor skin turgor Cool, pale clammy skin Imput > output Increase in weight Puffy, swollen eyes Light colored urine Moist skin Anasarca, edema Dyspnea, lung crackles

Nutrient specific Symptoms of deficiency Vitamin A Syndromes Nyctalopia - Xeropthalmia Follicular hyperkeratosis Signs and symptoms Poor Vision Corneal ulceration Dry Hair Dry Skin Itchy Skin Weak fingernails

Nutrient specific Symptoms of deficiency Vitamin B1, Thiamin Syndromes Beri-beri Wernicke’s encephalopathy Korsakoff syndrome Signs and symptoms Muscle cramping Hyporeflexia Paresthesia Poor Memory Chest pain Tachycardia Dyspnea

Nutrient specific Symptoms of deficiency Vitamin B2, Riboflavin Related Syndrome Ariboflavinosis, Pellagra Cheilosis Edema Seborrheic dermatitis Growth retardation Signs and Symptoms red, scaly, oily skin rash Mouth sores Swollen tongue Fissures of the mouth and lips Itchy eyes

Nutrient specific Symptoms of deficiency Vitamin B3, Niacin/Nicotinamide Related Syndrome - Pellagra Signs and Symptoms Dermatitis Diarrhea - Depression Dementia Dysphagia/hypersalivation - Abdominal/nausea

Nutrient specific Symptoms of deficiency Vitamin B6,Pyridoxine Related Syndrome -Polyneuropathy Signs and symptoms Numbness, tingling, weakness of the limb Diarrhea Swollen tongue Seizures Nausea - Depression Impaired mental faculties Itchy, red skin rash Vomiting

Nutrient specific Symptoms of deficiency Vitamin B9, Folic Acid/Folate Related Syndrome - Macrocytic anemia Increased risk of heart disease, dementia, and cancer Signs and Symptoms Pallor Depression Diarrhea Swollen tongue Fissures of mouth, lips Dyspnea upon exertion

Nutrient specific Symptoms of deficiency Vitamin B12 Related Syndrome -Neuropathy -Macrocytic Anemia Signs and Symptoms - Pallor Sore, Red, swollen tongue Numbness or tingling in upper & lower limbs progressing to the trunk Dyspnea Depression Memory loss Low energy, weak muscles, light-headedness Increased risk over age 51

Nutrient specific Symptoms of deficiency Vitamin C Related Syndrome - Scurvy Signs and Symptoms - Bleeding gums Loose teeth Halitosis Nosebleed Poor wound healing Purpura Corkscrew hair Anemia Painful joints, muscles Numbness in extremities Skin rash or spots

Nutrient specific Symptoms of deficiency Vitamin D Related Syndrome - Osteomalacia Rickets Signs and Symptoms Tingling, numbness, burning of lips, tongue, hands Weak bones Bone protusions Bone pain Bowing in legs Muscle weakness Muscle pain

Nutrient specific Symptoms of deficiency Vitamin E Related Syndrome Hemolytic anemia Neurologic problems Signs and Symptoms Pallor Demetia Night blindness Dyspnea Ataxia Tetany Muscle weakness Follicular hyperkeratosis

Nutrient specific Symptoms of deficiency Vitamin K Related Syndrome Bleeding disorders Birth Defects Signs and Symptoms Purpura Petechiae Nosebleeds Menorrhagia Poor wound clotting Gastrointestinal bleeding

Nutrient specific Symptoms of deficiency Iron Related Syndrome Pica Restless Led Syndrome Signs and Symptoms - Fatigue - Alopecia - Pale Conjunctiva Pale, Sore tongue Atrophic lingual papillae Koilonychia Longitudinal central ridges Absent Lunula in nail Pallor Cold extremities Pica is a condition in which a patient exhibits an extreme craving for the consumption of unusual non-food items, such as a craving for paint, cement, sand, or starch. Compulsive ice consumption is known to be one of the leading signs and symptoms of iron deficiency. Restless Leg Syndrome (RLS), as the name suggests, patient’s have a strong urge to move their legs. This urge to move often occurs with strange and unpleasant feelings in the legs, resulting in difficulty with sleeping.

References 1.Seshadri D, De D. Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol [serial online] 2012 [cited 2012 Jun 23];78:237-41. Available from: http://www.ijdvl.com/text.asp?2012/78/3/237/95437 2.R W Vilter, and J J Will. Nutrition and Nutritional Deficiency Diseases Annual Review of Medicine Vol. 9: 191-208 (Volume publication date February 1958) DOI: 10.1146/annurev.me.09.020158.001203 3. Centers for Disease Control and Prevention (CDC). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children During the Domestic Medical Screening Examination http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html 4. Peggy K.Yen, RD,MPH. Nutritional Anemia. Geriatric Nursing 2000 • Volume 21 • Number 2, pg 111-112. 5.Paillaud, Elena1; Merlier, Isabelle1; Dupeyron, Catherine. Oral candidiasis and nutritional deficiencies in elderly hospitalized patients. British Journal of Nutrition, Volume 92, issue 5 (November 1, 2004), p. 861-867 6.Collinsworth, Reatha. Determining nutritional status of the elderly surgical patient: Steps in the assessment process. AORN Journal, Volume 54, issue 3 (September, 1991), p. 622-628,630-631 7 Stotts, Nancy, RN. Nutritional Assessment before Surgery. AORN Journal, February 1982, Vol35, No 2 207-214. 8. Miller, Stanley J, MD. Nutritional Deficiency and the Skin. Journal of the American Academy of Dermatology. Volume 21 , issue 1 (July, 1989), p. 1-30 9. Sinn, N. Physical fatty acid deficiency signs in children with ADHD symptoms. Prostaglandins, Leukotrienes & Essential Fatty Acids, Volume 77, issue 2 (August, 2007), p. 109-115. 10. CDC Report: Why Vitamin B12 Deficiency Should Be on Your Radar Screen. A Continuing Education Update Course WB1349. http://www.cdc.gov/ncbddd/b12/documents/b12-030910.pdf http://www.cdc.gov/ncbddd/b12/cases.html 11.Charney P. PhD RD, Malone A. MS RD CNSD. ADA Pocket Guide to Nutrition Assessment. Second edition. pgs 40-61. 12. Academy of Nutrition and Dietetics Nutrition Care Manual https://elearning.bgsu.edu/webapps/portal/frameset.jsp?tab_id=_2_1&url=%2fwebapps%2fblackboard%2fexecute%2flauncher%3ftype%3dCourse%26id%3d_15729_1%26url%3d