Chapter 072. Malnutrition and Nutritional Assessment (Part 5) ppsx
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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), immunosuppr
essants, 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
Clinical Findings Possible
Deficiency
a
Possible
Excess
Hair, Nails
Corkscrew hairs and une
merged
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
B
12
, protein, iron
Glossitis (scarlet, raw tongue) Riboflavin,
niacin, pyridoxine,
folate, vitamin B
12
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
B
12
, 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, vi
tamin
B
12
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
