Week 9 Flashcards
(27 cards)
WEEK 9
Screening in Clinical Assessment
What is a clinical assessment?
may include =
=
- Medical history and client (pt) characteristics
- Results of medical tests, procedures and monitoring (x-rays, ultrasounds, surgical reports, procedural reports)
- Results of screen questionnaires
- Physical examination - signs and symptoms of disease/condition
- Physical activity assessment
- Activities of daily living
[Medical Record - where you find medical, surgery, diet history of pt - important to determine path of intervention and how to prioritize treatments etc]
-
-
-
-
- Previous medical conditions and medications
- Family history
- Patient characteristics (age, sex, socioeconomic status (SES), employment etc
- Current medical condition and medications
- Nutrition-related history
(prior intake/period of poor intake, allergies/dietary restrictions, GI symptoms, Period of diarrhea/malabsorption)
Medical (client/patient) history in practice
Where do you get this info?
-
( )
-
( )
-
( )
** Common medications and potential effects on nutrient status ** Slide 5
- Medical charts
(History of disease, family history of disease, present illness symptoms, meds, heights, weights, functional tests (spirometry), SES, family dynamics - Team meetings
(for updates, changes to patient status) - Asking the patient
(changes in taste, appetite, food preferences, dentures)
Medical (participant) history in research (aka demographics)
–>
-
-
–>
-
-
- Why is this important for clinical situations?
( ) - Sometimes collected for research - why?
( )
–> use validated questionnaires
- collect information so that comparing to other studies is easy
- also, it allows breakdown of findings into meaningful groups of respondents with specific characteristics
–> Sensitive information often collected at the end of a survey
- Sensitive Q’s, such as Q’s about income, drug use or sexual activity, should be put at the end of the survey
- Establish trust before asking questions that might embarrass respondents
- X-rays, ultrasounds, surgical reports, procedural reports, wound healing, stent placement etc
- Why is this important for clinical situations?
(provide additional and more relevant information for a better diagnosis and assessment of the patient’s status versus the routine examination) - Sometimes collected for research - why?
(add to the accuracy of data collected from the pt medical record, which may ultimately correlate with the analytical outcomes of the study)
Problem with physical signs and symptoms:
- setting the stage for nutrition screening - slide 12/13 *
- purpose?
- results are used for?
: can’t say a symptom is from one thing in particular - could be many things
Ex: if there is wasting - need to do more testing to figure out if its protein, energy or other nutrient deficiency
- Full nutrition assessments are time consuming and are not needed by all patients
- The purpose of nutrition screening is to identify those at nutritional risk
- Results are used for:
(triaging systems / determining type and standards of care needed)
SCREENING TOOLS
–> Nutr screening tools contain…
-
-
STAMP: Screening tool for the assessment of malnutrition in paediatrics
—> … contain measures or Q’s based on known nutritional risk factors
- items on the screening tool depend on the population and settling it was designed for
- may include dietary, anthro, clinical and biochemical risk factors
What makes a good screening tool?
–> Good screening tools:
-
-
-
-
-
SENSITIVITY and SPECIFICITY
–> High sensitivity:
–> High specificity:
- are simple and quick to complete, using routinely collected data
- can be completed by the patient/client or proxy or another health professional
- facilitate early intervention
- are cost-effective
- have good sensitivity and specificity
: sensitive enough to pick up small changes in nutr risk
- correctly identifies those at risk
EX: 100% sensitive malnutrition tool -> no malnourished persons are classified as ‘well’
- Ideally no false negatives (someone who is having nutr prob but defined as ‘well’)
: specific enough to identify the nutritional risk in question rather than other problems
- correctly identifies those not at risk
EX: 100% specific malnutrition tool - no well-nourished individuals classified as ‘ill’
- Ideally no false positives
Slide 21 - Sensitivity / Specificity
Table - KNOW it + equations
* Sensitivity = TP / (TP + FN)
Specificity = TN / (FP + TN)
Predictive value (V) = (TP + TN) / (TP + FP + TN + FN)
The higher above 50%-70% is the better predictive value (moderate is 50-70)
Sensitivity = 90 / (90 + 80) = 53%
Specificity = 85 / (70 + 85) = 55%
Predictive Values (how well will the tool classify into correct stage etc) = 54%
CONSENSUS = this tool has lower sensi/spec (want 50-70 +) therefore relatively low predictive value
Sensitivity and Specificity
–> Ethics of screening
-
[What are the consequences of false negatives and false positives?]
- Need to use a valid tool that identifies those truly at risk with acceptable levels of sensitivity and specificity
[- can mis-categorize patients / leading to wrong treatments]
TYPES of screening tools
Subjective Global Assessment (SGA)
–> SGA
-
-
The SGA tool
-
-
-
Components:
–> Patient history
-
-
-
-
–> Physical Exam
-
-
-
SGA
- Most commonly used screening tool in clinical care
- Malnutrition screening tool in hospitals
The SGA tool
- SGA was developed by researchers and clinicians in TO as a way to assess malnutrition without doing precise body composition analysis
- Correlates well with objective anthro, biochem and immunological parameters
- Good inter-rater reliability (good degree of agreement among raters)
–> Pt history
- Wt loss in the past 6 months & change in past 2 weeks (net wt loss)
- Change in dietary intake in the past 2 weeks
- GI symptoms occurring on a daily basis in the past 2 weeks (ie. anorexia, nausea, vomiting, diarrhea)
- Functional capacity/ energy level (normal to bedridden)
- Disease and its relation to nutrition requirements (metabolic stress)
–> Phys exam
- Loss of subcutaneous fat
- Muscle Wasting
- Peripheral or sacral edema
- Ascites
Con’d
Classifications
SGA Grade
A
B
C
Uses of SGA
- SGA 1st used to…
- SGA can be used to assess…
( )
- SGA has become widely used and modified for particular pt populations - published literature demonstrates SGA as a valid tool for the nutritional diagnosis of hospitalized clinical and surgical pts
-
-
A - well nourished
B - suspected of being malnourished
C - severely malnourished
- … to assess surgical patients - malnutrition is associated with length of hospital stay and complications post-surgery
- … assess risk for refeeding syndrome - can then determine appropriate rates for starting and advancing tube feeds
(close monitoring of phosphate, potassium and magnesium levels when refeeding malnourished pts (particularly SGA Grade C)) - Poor sensitivity to detect changes in nutrition status over a short hospital stay
- Not validated yet in obese populations
- Difficult to use for patients in intensive care units (ICU)
(Hard to get an accurate history if the patient is intubated / typically pts in ICU were previously healthy and suddenly became ill/injured)
Nutritional screening in children
Nutri-eSTEP
-
- variables included:
read off slides past slide 40
- designed to identify children with undernutrition AND overnutrition
- : 17 Q’s - slide 38/39
Nutrition Screening in Older Adults
= Mini-Nutritional Assessment
- has been validated for use in hospital, community and long term care settings
6 items in the MNA -
Screening score max is 14 points
- 12-14 = normal nutr status
8-11 = at risk of malnutrition
0-7 = malnourished
Validity:
Full MNA - sensitivity = 96% / spec =98%
MNA - sensitivity 98% / spec 100%
- decline in food intake over past 3 mon
- wt loss during the past 3 mon
- mobility
- psychological stress or acute disease in past 3 mon
- neurological problems (ie dementia or depression)
- BMI or calf circumference
Screening for swallowing problems
The TOR-BSST (Toronto Bedside Swallowing Screening Test) tool
- Screens patients for swallowing difficulties
- Usually administered by nurses or other trained professionals
- Used to determine if thorough swallowing assessment is needed
-
-
-
What this means for the RD
-
-
-
- see if pt coughs while swallowing water
- listen to the voice quality before and after swallowing water
- Observe movement of the tongue
- Pharyngeal sensation
- Thickened diet may be needed while swallowing assessment is completed
- Some RD’s conduct more thorough swallowing assessments
- Watch for results of the swallowing assessment to determine patient’s, long-term needs
Screening for Dementia
Mini-Mental State Examination (MMSE)
-
-
-
Usually administered by nurses or occupational therapists
-
Consists of 11 Q’s: slide 52-56
- Commonly used to assess geriatric patients
- Quick to administer
- Gives a good idea of mental capacity
- Assess their ability to feed themselves
- Assess the need for a family member’s help
WEEK 9
Medical History and Physical Exams in Clinical Assessment
Signs and symptoms of nutrient deficiencies/toxicities:
- What can you look at?
7 things…
[FYI on slide 7]
Signs and symptoms:
–>
-
–>
- Important to know and monitor signs and symptoms of any disease
EX: DM
1 skin, eyes, hair, mouth/teeth/lips, finger nails. nerves. muscles
–> many clinical signs and symptoms are not specific to malnutrition
- they need to be interpreted together with dietary, anthro, and biochem info
–> Clinical S&S of nutrient deficiency tend to develop relatively late in the progression of a deficiency disease
Depletion stages in the development of nutritional deficiency
What is happening? How can you tell?
4 stages…
+ Ex’s [ Depletion stages in the development of nutritional deficiency i.e. iodine deficiency ]
1 Inadequate intake - can tell via dietary assessment
[ inadequate iodine intake ]
2 Declining nutrient stores - can tell via biochemical assessment
[ decreased iodine stores in breast tissues ]
3 Abnormal functions inside the body - can tell via biochemical assessment
[ decreased levels of the thyroid hormone thyroxine, also called T4 ]
4 Physical (outward) signs and symptoms - can tell via anthropometric and clinical assessment
[ signs of goiter ]
Most common clinical signs used by RD’s in Canada
–> Checking for Edema
- sign of:
-
-
- Also common in
-
-
VISUAL - slide 12
Pitting VS non-pitting Edema - slide 13
Edema =
Lymphedema =
:- Protein energy malnutrition
:- Fluid excess in heart failure, kidney disease
- the elderly
- pregnant
Pitting
- indicative of regular edema
Non-pitting
- indicative of lymphedema
Edema = fluid accumulation in the interstitium (located beneath the skin and in the cavities of the body)
- caused by organ malfunctions and metabolic abnormalities including but not limited to kidney disease, heart failure, electrolyte imbalances & PEM
Lymphedema = edema in the extremities (lower legs particularly) caused by damage to the lymphatic system
surgery, radiation, cancer, infection
- the blockage prevents lymphatic fluid from draining well, and the fluid buildup leads to swelling
- commonly associated with recurring infections and hardening and thickening of the skin (fibrosis)
Classical signs of micronutrient deficiencies
–> classical signs of micronutrient deficiencies are not often seen in North American in the general population
-
-
Micronutrient deficiency diseases
–> The 3 deficiency diseases of greatest public health significance:
-
-
-
- non-invasive and low cost
- examiners need to be well trained
- clinical signs are not always sensitive or specific
- Vitamin A
- Iron
- Iodine
Vitamin A
–> Vitamin A deficiency causes:
-
( ) ( )
-
( ) ( )
-
( )
-
( )
- Stages of Eye damage in Vit A deficiency SLIDE 20 *
- Night blindness
(inability to see under low levels of illumination) (earliest sign of Vit A deficiency) - Bitot’s spots
(dryness and foamy accumulations) (Buildup of keratin located superfically in the conjunctiva, which are oval, triangular or irregular in shape) - Xerophthalmia: dryness of the eyes (cornea)
(Inability of the eyes to produce tears) - Keratomalacia: scarring of the cornea
(Normal eye tissue is damaged and replaced by keratinized tissue)
Iron Deficiency
–> Signs of Iron-deficiency anemia:
-
-
-
-
[Iron Deficiency is the most common and widespread nutritional disorder in the world]
VISUALS - slide 23
- Pallor (pale conjunctivae (eyelids), palms, and tongue
- Tiredness
- Headaches
- Breathlessness
Iodine Deficiency
- Severe iodine deficiency causes _____
( )
- The most severe form of iodine deficiency is ____ ( )
VISUAL - slide 27/28/29
- ___ goiter____ (Swelling of the thyroid gland)
- __Cretinism___ (mental and physical disability)
Other micronutrient deficiencies
–> 3 deficiency disorders that are characteristic of emergency affected populations but rarely occur in stable populations:
-
-
-
Vitamin C deficiency
–> Vit C deficiency causes ____
-
-
-
- VISUAL - signs of scurvy - slide 32/33 *
- Vitamin C
- Thiamin
- Niacin
–> causes scurvy
- Minute haemorrhages (bleeding in the skin)
(perifollicular petechiae (small red/purple spots on the skin, causes by a minor bleed from broken capillary blood vessels))
- Ecchymosis (brusing)
- Swollen and bleeding gums
Niacin Deficiency
- Niacin Deficiency causes ____
–>
-
-
-
-
* VISUALS - slide 35/ 26 *
- ____Pellagra___
–> Pellagra is the “ _____ “ - Dermatitis - redness and itching on areas exposed to sunlight
- Diarrhea
- Dementia
- Death
