Nutrition-focused Physical Examinations in Behavioral Health Treatment Environments Ruth Leyse-Wallace, PhD June 14, 2016 [part one :1-30 ]
Why include a Nutrition-Focused Physical Exam? * Provides evidence to substantiate suspected nutrient inadequacies Suboptimal intake often leads to subclinical Signs/ Symptoms Symptoms of suboptimal nutritional status may be mental/psychological as well as physical Provide justification for lab work requested Provide a unique contribution to mental health care Professional Satisfaction *NFPE
Nutritional Triage : Hx of . . . . . > Family Hx Pernicious anemia, Hemochromatosis, Diabetes, Hypothyroidism, >Diet Hx Food groups, Special diets, Preferences >Supplement Hx Excessive, Recommended, >Medical/Health Hx Needs, Absorption, Excretion, (Bariatric surgery, substance abuse, food allergies/sensitivities), >Medication Hx Absorption, Needs, Excretion, Interactions RuthLeyse-Wallace PhD,RD
How long does it take to become deficient? Depleted states of water-soluble vitamins can develop in just a few weeks Vitamin Depletion time* Vitamin A 1-2 years alpha-Tocopherol 6-1 Pyridoxine 2-6 weeks Riboflavin 2-6 weeks Ascorbic Acid 2-6 weeks Thiamin 1-2 weeks 2 months > Symptoms may be nonspecific: anxiety, nervousness, irritability, depression, insomnia and fatigue, apathy, suspiciousness, emotional instability > Psychological Symptoms of low nutritional status often occur earlier than physical symptoms Haller, Jurg. Biokinetic Parameters of Vitamins A, B-1, B-2, B-6, E. K and Carotene in Humans. Nutritional Neuroscience , p. 229. Harris R. Lieberman, Robin B. Kanarek and Chandron Prasad, editors. CRC Taylor and Francis, New York, 2005. RuthLeyse-Wallace PhD,RD
Factors to Consider in Mental Health setting • Paranoia • Emotional sensitivity to body issues/touching • Diminished mental clarity • Lack of familiarity • Fear of new treatments • Lack of knowledge about nutrition • Lack of knowledge about dietitians
Attention to Process – Introducing the idea • Talk to the subject in a private, familiar, comfortable room • Assure subject knows you are the dietitian • Provide careful, easy-to-understand explanation of how what you eat and poor nutrition can show up as signs on the body • These signs can be seen by careful observation • Ask if they understand • Ask if they are interested in whether they would like to know more about whether this happening to them
Attention to Process - Put subject at ease • Encourage questions • Assure subject that at any time s/he wants to stop, the examination can be discontinued • If subject would prefer, arrange for family member or mental health care staff to sit in on the examination.
Attention to Process – Get Permission • Describe how a nutritional physical exam is conducted – 1) you will be looking closely at different parts of the body where signs might appear; 2) you don’t have to undress 3) it isn’t painful; 4) it doesn’t take very long – (estimate how long) • Show and explain the equipment: tongue blades, lights, scales, calipers, muscle strength, goniometer, small mirror, camera, (whatever you will use) • Explain that you will record what you see so you can tell if it improves; a record may include taking a photograph (some institutions have medical photography labs where photos can be taken if subject is able)
NFPE - Equipment Disposable gloves, tongue depressors Goniometer Jamar Hand dyanmometer Optional: sniff & smell cards Hand-held lighted magnifying glass
Attention to Process – Get permission • Get permission - Ask if it is okay for you to look at their skin, fingernails, hair, mouth, eyes • Get signed permission to take a photograph if you think it will be helpful in tracking her/his progress (outcome) in improving her/his nutrition
Go Forward or Discontinue Assure the subject (or person who accompanies) that you will explain the signs that you might see Many subjects are quite interested in the idea of being able to determine by observation if they have good or poor nutrition. If they aren’t able to agree or participate, suggest that they can re-schedule later if they are ready
Nutrition-focused Examination - Order of Examination Start at the “least invasive” areas: General observations Weight Waist measurement > Fingernails (toenails optional) > Hair > Skin Demonstrate your process by explaining 1) what you are looking at, 2) what you are seeing, and 3) what meaning it might have nutritionally. Record observations as you proceed. Use clinical judgment re: whether to take photographs1) as you proceed, during the examination ,2) as the final part of the examination, or 3)whether you will refer to medical photographer
Start with General Observations Temporal wasting (My mother Clerca Newsom; a supporter of my career; died in 2003) Rickets Ref: Vitamin Manual; A SCOPE Edema, swelling Monograph.TheUpJohn Company, Kalamazoo, MI 1965: p.70, Figure 3A . Gait Source: Rosa Lee Nemir, MD, New York University-Bellevue Girth Medical Center, NY City. Stance
Off to a Good Start Thorough Handwashing – in view (Even though you will wear disposable gloves) >Remove rings; push watches high or remove to wash wrists. >With warm water and soap rub hands vigorously for 10 seconds; wash each wrist, clean under nails. Rinse thoroughly from the wrist down. Dry thoroughly with a disposable towel. >Put on disposable gloves, give general explanation to subject. Reference: Swearingen, Pamela L. and Cheri A. Howard. Photo Atlas of Nursing Procedures . Addison-Wesley, Menlo Park, CA. 1996.
Nutrition-focused Examination - Order of Examination Fingernails Hair Skin Continue with other areas: Mouth Eyes Neurological
Examination of the Nails Normal: firm, pink, smooth, uniform bilaterally, any changes not injury-related, free edge, nail plate; lunula, cuticle Note: Color: pale, white lines or spots; white, gray, bluish or yellow coloration Splinter hemorrhages under nail, (vertical red/reddish-brown fine lines) Texture: lines, ridges, (vertical or horizontal) Shape: spoon-shaped, clubbing
Examination of the Nails
Splinter hemorrhages-Scurvy RuthLeyse-Wallace PhD,RD
Koilonychia – iron deficiency An extreme case RuthLeyse-Wallace PhD,RD
Nail images online: collection by Mark Williams, MD http://www.medscape.com/viewprogram/8996_pnt Medscape program 8996 Mees lines – acute illness, Terry’s nails – renal, liver Heavy metal toxicity, chemotherapy See also: webinar supplementary material See also NEJM Image challenges – regular feature See also: http://www.webmd.com/skin-problems-and- treatments/muehrke-lines-of-the-fingernails
Examination of the Hair Normal: Shiny, not easily plucked; rule out effects of hair treatments Note: Color: Flag sign or other horizontal change of color or texture Texture: dry, dull, sparse Pluckability: painless release of 4-6 hairs from a gentle pull on ~one square inch of scalp hair at the occipital ridge
Examination of the Hair RuthLeyse-Wallace PhD,RD
Examination of the Hair Outer third of eyebrows missing: Thyroid Hair Loss: protein, iron, zinc, EFA, medications RuthLeyse-Wallace PhD,RD
Examination of the Skin Normal: Smooth, absence of rashes, redness, swelling, light or dark spotting Note: Color: changes in color: pallor, reddening, light or dark coloration, yellow tinge, Bruising (ecchymosis) pin- size hemorrhages surrounding hair follicles, (petechiae) Texture: dry, flaky, rough (sandpaper feel), keratin plugs surrounding follicles, Lack of subcutaneous fat, fine wrinkling, delayed response to tenting test (dehydration) Bodily Hair: texture (lanugo), quantity ( PCOS), coiled, cork-screw hairs Glands: Enlargement of thyroid or parotid glands
Carotenemia - (compare skin tone of mother & baby) http://dermatlas.med.jhmi.edu/derm/indexDisplay.cf m?ImageID=-2124046147 RuthLeyse-Wallace PhD,RD
Examination of the Skin Redness around follicle: scurvy RuthLeyse-Wallace PhD,RD
Examination of the Skin Vitamin A deficiency Hyperfollicular keratosis Vitamin Manual. A Scope Monograph. The UpJohn Company, Kalamazoo, MI. 1965. p. 15 RuthLeyse-Wallace PhD,RD
Examination of the Skin Skin discoloration/bruising caused by Scurvy - Vitamin C deficiency Petechiae, Purpura and Ecchymosesrefer to bleeding that occurs in the skin. “ Petechiae" refers to smaller lesions. "Purpura" and "ecchymoses" are terms that refer to larger lesions. Petechiae, ecchymoses, and purpura do not blanch when pressed. RuthLeyse-Wallace PhD,RD
Examination of the Skin Acanthosis nigricans: a skin disorder in which there is darker, thick, velvety skin in body folds and creases May be present in patients with diabetes RuthLeyse-Wallace PhD,RD
Due to the number of images and formatting this file was divided into two sections for sending by email: End of Part One : Continue to Part two: Nutrition-focused Physical Examinations in Behavioral Health Treatment Environments Ruth Leyse-Wallace, PhD June 14, 2016
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