Chapter 072. Malnutrition and Nutritional Assessment (Part 5) ppsx

Individuals with the characteristics listed in Table 72-3 are at particular risk for nutritional deficiencies.. On the other hand, if it is widespread in a person who consumes little fru

Chapter 072 Malnutrition and Nutritional Assessment

(Part 5)

Nutritional History

A nutritional history is directed toward identifying underlying mechanisms that put patients at risk for nutritional depletion or excess These mechanisms include inadequate intake, impaired absorption, decreased utilization, increased losses, and increased requirements of nutrients

Individuals with the characteristics listed in Table 72-3 are at particular risk for nutritional deficiencies

Table 72-3 The High-Risk Patient

Underweight (body mass index <18.5) and/or recent loss of ≥10% of usual body weight

Poor intake: anorexia, food avoidance (e.g., psychiatric condition), or NPO status for more than about 5 days

Protracted nutrient losses: malabsorption, enteric fistulae, draining abscesses or wounds, renal dialysis

Hypermetabolic states: sepsis, protracted fever, extensive trauma or burns

Alcohol abuse or use of drugs with antinutrient or catabolic properties: steroids, antimetabolites (e.g., methotrexate), immunosuppressants, antitumor agents

Impoverishment, isolation, advanced age

Physical Examination

Physical findings that suggest vitamin, mineral, and protein-energy deficiencies and excesses are outlined in Table 72-4 Most of the physical findings are not specific for individual nutrient deficiencies, and they must be integrated

with the historic, anthropometric, and laboratory findings For example, the finding of follicular hyperkeratosis on the back of the arms is a fairly common, normal finding On the other hand, if it is widespread in a person who consumes little fruit and vegetables and smokes regularly (increasing ascorbic acid requirements), vitamin C deficiency is likely Similarly, easily pluckable hair may

be a consequence of chemotherapy, but in a hospitalized patient who has poorly healing surgical wounds and hypoalbuminemia, it suggests kwashiorkor

Table 72-4 Physical Findings of Nutritional Deficiencies

Deficiencya

Possible Excess

Hair, Nails

Corkscrew hairs and unemerged

coiled hairs

Vitamin C Easily pluckable hair Protein

Flag sign (transverse

depigmentation of hair)

Protein

Sparse hair Protein, biotin,

zinc

Vitamin A

Transverse ridging of nails Protein

Skin

Cellophane appearance Protein

Cracking (flaky paint or crazy

pavement dermatosis)

Protein

Follicular hyperkeratosis Vitamins A, C

Petechiae (especially

perifollicular)

Vitamin C

Purpura Vitamins C, K

Pigmentation, scaling of

sun-exposed areas

Niacin

Poor wound healing, decubitus

ulcers

Protein, vitamin C, zinc

Scaling Vitamin A,

essential fatty acids, biotin

Vitamin A

Yellow pigmentation sparing

sclerae (benign)

Zinc (hyperpigmented)

Carotene

Eyes

Night blindness Vitamin A

Papilledema Vitamin A

Perioral

Angular stomatitis Riboflavin,

pyridoxine, niacin

Cheilosis (dry, cracking,

ulcerated lips)

Riboflavin, pyridoxine, niacin

Oral

Atrophic lingual papillae (slick

tongue)

Riboflavin, niacin, folate, vitamin

B12, protein, iron

Glossitis (scarlet, raw tongue) Riboflavin,

niacin, pyridoxine, folate, vitamin B12

Hypogeusesthesia, hyposmia Zinc

Swollen, retracted, bleeding

gums (if teeth present)

Vitamin C

Bones, Joints

Beading of ribs, epiphyseal

swelling, bowlegs

Vitamin D

Tenderness, subperiosteal

hemorrhage in children

Vitamin C

Neurologic

Confabulation, disorientation Thiamine

(Korsakoff psychosis)

Drowsiness, lethargy, vomiting Vitamin A

Dementia Niacin, vitamin

B12, folate

Headache Vitamin A

Ophthalmoplegia Thiamine,

phosphorus

Peripheral neuropathy (e.g.,

weakness, paresthesias, ataxia, foot drop,

and decreased tendon reflexes, fine

tactile sense, vibratory sense, and

position sense)

Thiamine, pyridoxine, vitamin

B12

Pyridoxine

Tetany Calcium,

magnesium

Other

Edema Protein,

thiamine

Heart failure Thiamine

("wet" beriberi), phosphorus

Hepatomegaly Protein Vitamin A

Parotid enlargement Protein

(consider also bulimia)

Sudden heart failure, death Vitamin C

a

In this table, "protein deficiency" is used to signify kwashiorkor