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Health Assessment Week 3
Nutrition and Integumentary
57
Nursing
Undergraduate 3
02/09/2013

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Cards

Term
What could cause weight loss?
Definition
-Anorexia
-Dysphagia
-Vomiting or Diarrhea
-Inability to absorb nutrients from GI tract
-Increased metabolic needs
-Food allergies
-Problems chewing
-Peer pressure
Term
What do you ask about during a nutritional ROS?
Definition
Ask about weight changes, fatigue, allergies, or problems in GI
Term
What should you ask about regarding health patterns and nutrition?
Definition
Ask about nutrition and exercise patterns
Term
What are some common or concerning symptoms related to nutrition?
Definition
-Changes in weight (unintended)
-Anorexia
-Changes in sense of taste or smell
-Difficulty chewing and swallowing
Term
A detailed nutrition history includes:
Definition
1. Food pattern
2. Personal food preferences
3. Food preparation
4. Finances
5. Accessibility
6. Patient health
7. Exercise Pattern
8. Body Image
9. Family health
10. Family dietary problems
Term
What are some ways you can do a nutrition screening?
Definition
-Admission nutrition screening tool
-24-hour diet recall
-Food frequency questionnaire
-Food diaries
-Direct observation
Term
What are the types of equipment you need to for a nutrition-related physical exam?
Definition
-Skinfold calipers
-Measurement tape
-Nutrition assessment form
Term
What is skinfold thickness exam?
Definition
Technique of measurement in which you repeat three measurements and then take an average
Term
BMI
Definition
Body mass index = weight in kg divided by height (m)2 or weight in lbs divided by height (in)2 x 703
Term
What are some signs of dehydration?
Definition
-Tachychardia
-Weak pulse
-Turgor on abdomen
Term
What should you look for during cardiovascular and peripheral vascular exam r/t nutrition?
Definition
-Measure pulse rate and amplitude
-Inspect arms and legs for edema (protein deficiency)
-Petechiae and ecchymoses (lack of vitamin A)
Term
What should you look for during HEENT exam r/t nutrition?
Definition
-Note dark circles under eyes
-Inspect mucus membranes for dryness, color, and intactness
-Enlarged thyroid gland
Term
What should you look for during GI exam r/t nutrition?
Definition
-Distension and ascites (protein deficiency)
-Turgor on abdomen (dehydration)
-Measure waist circumference (measure of central body fat)
Term
What should you look for during MSK exam r/t nutrition?
Definition
-Muscle wasting and flaccidity (protein deficiency)
-Bone pain and bowing of legs (lack of vitamin D)
Term
What should you look for during Neurologic exam r/t nutrition?
Definition
-Changes in mental status, irritability, inability to concentrate, paresthesias (dehydration and lack of vitamins)
Term
What are some signs of protein deficiency?
Definition
-Edema in arms and legs
-Distension/ascites of abdomen
-Muscle wasting and flaccidity
Term
What are the measurements of BMI?
Definition
Underweight: <18.5
Normal: 18.5-24.9
Overweight: 25.0-29.9
Obesity I: 30.0-34.9
Obesity II: 35.0-39.9
Extreme Obesity III: >40
Term
What laboratory studies are important in nutritional assessment?
Definition
-Hemoglobin
-Hematocrit
-Cholesterol
-Triglycerides
-Total Lymphocyte count
-Skin Testing
-Serum Proteins
-Nitrogen balance
-Creatinine-height index
Term
Marasmus
Definition
Protein-calorie malnutrition
Term
Kwashiorkor
Definition
protein malnutrition
Term
Abnormal findings caused by nutritional deficiencies
Definition
-Scorbutic gum: Vit C deficiency
-Follicular hyperkeratosis: Vit A deficiency
-Bitot's Spots: Vit A deficiency
-Rickets - Vit D, Calcium deficient
Term
How would you write a chief complaint for an Adult Health History?
Definition
Make every attempt to quote the patient's own words
Term
What is the difference between signs and symptoms?
Definition
Signs = Objective; Symptoms = Subjective
Term
What are the 7 components of a Comprehensive Adult Health History?
Definition
1. Identifying data and source of history
2. Chief Complaints
3. Past History
4. Family History
5. Review of Systems
6. Health Patterns
7. History of present illness
Term
CAGE
Definition
Cutting down, Annoyance if criticized, Guilty feelings, Eye-openers (2 or more of these suggest misuse)
Term
What are ways to approach sensitive topics that call for specific approaches?
Definition
1. Be nonjudgemental
2. Explain why you need to know certain info
3. Find opening questions
4. Consciously acknowledge whatever discomfort you're feeling
Term
What are signs of abuse?
Definition
-Unexplained abuse
-Delayed getting treatment for trauma
-Past history of repeated injuries or "accidents"
-Person close to pt. has history of alcohol and drug abuse
-Partner tries to dominate interview or will not leave room
Term
What are the 7 critical attributes for symptom analysis?
Definition
OLDCART
Onset
Location
Duration
Characteristic Symptoms
Associated Manisfestations
Relieving/Aggravating factors
Treatments tried
Term
Genogram
Definition
Pictorial display of a person's family relations and medical history
Term
Review of Systems
Definition
-Address each body system, from head to toe
-Most questions pertain to symptoms
-May uncover problems patient has overlooked
-Do not use medical terms, use plain English
Term
What do you ask about when discussing Health Patterns?
Definition
Self-perception/self-concept
Value-Belief
Activity-exercise
Sleep-rest
Nutrition
Role-relationship
Coping-stress-tolerance
Term
How should you discuss a patient's mental health history?
Definition
-Be aware of cultural constructs
-Be sensitive to mood changes or symptoms of possible depression
-Aks open-ended questions initially, then move to more specific
-If patient seems depressed, ask about thoughts of suicide
Term
What are the functions of skin?
Definition
1. Protection
2. Temperature Regulation
3. Perception
4. Absorption and excretion
5. Synthesizes vitamin D
6. Identification
Term
Why do we do a skin assessment?
Definition
Look for lesions and underlying systemic disease or disorders
Term
What are the 2 kinds of cyanosis?
Definition
1. Central: oxygen level in arterial blood is low
2. Peripheral: Oxygen level is normal, cutaneous blood flow decreases and slows and tissues extract more oxygen than usual from blood flow
Term
What are the 2 types of hair?
Definition
1. Vellus hair: short, fine, inconspicuous, relatively unpigmented
2. Terminal hair: coarser, thicker, more conspicuous, pigmented
Term
What are we trying to identify when taking an integumentary history?
Definition
1. Diseases of the skin
2. Systemic diseases that have skin manisfestations
3. Physical abuse
4. Risk for pressure ulcer formation
5. Risk for skin cancer
6. Need for health promotion education regarding skin
Term
What are common or concerning symptoms when taking an integumentary history?
Definition
-Rash
-Nonhealing lesions
-Moles
-Lesions
-Bruising (ecchymosis)
-Hair loss
Term
What are some external variables that can influence skin color?
Definition
-Emotional states
-Temperature
-Cigarette smoking
-Prolonged elevation/dependent position of extremities
-Prolonged inactivity
Term
What do we look at when doing a physical examination of the skin?
Definition
1. Color
2. Moisture
3. Vascularity
4. Temperature
5. Texture
6. Mobility or turgor
7. Lesions
8. Nails
9. Hair
Term
What are the two types of edema?
Definition
1. Pitting: interstitial fluid mobile
- pitting edema scale 1-4
2. Nonpitting: local infection or trauma; brawny edema
Term
What should you note when you examine a skin lesion?
Definition
1. Color
2. Elevation or flat; and texture
3. Pattern or shape
4. Size
5. Location and distribution on body (generalized v. localized)
6. Exudate (wet or dry, color, consistency)
7. Bleeding from lesion
Term
What are the different lesion patterns of arrangement?
Definition
-Discrete
-Annular or circular
-Grouped or clustered
-Linear
-Gyrate or snakelike
-Confluent or run together
-Target or Iris
-Nerve root distribution or dermatomal
Term
What are the 3 degrees of a burn?
Definition
1st Degree: red, painful, blanches with pressure, no blistering
2nd Degree: blisters, redness, pain, raw surfaces (partial thickness or to dermis layer)
3rd degree: skin white or charred, not painful (full thickness, all skin elements destroyed)
Term
Macule
Definition
small flat spot, up to 1.0cm
Term
Patch
Definition
flat spot 1.0cm or larger
Term
Plaque
Definition
elevated superficial lesion 1.0cm or larger
Term
Papule
Definition
elevated spot, up to 1.0cm
Term
Nodule
Definition
marble-like lesion larger the 0.5cm, often deeper and firmer than papule
Term
Cyst
Definition
Nodule filled with expressible material, either liquid or semisolid
Term
Wheal
Definition
Somewhat irregular, relatively transcient, superficial area of localized skin edema
Term
Vesicle
Definition
Up to 1.0cm, filled with serous fluid
Term
Bulla
Definition
1.0cm or larger, filled with serous fluid
Term
Scale
Definition
Thin flake of dead exfoliated epidermis
Term
Crust
Definition
Dried residue of skin exudates such as serum, pus, or blood
Term
Lichenification
Definition
visible and palpable thickening of the epidermis and roughening of the skin wih tincreased visibility of normal skin furrows
Term
Erosion
Definition
Nonscarring loss of superficial epidermis, surface is moist but does not bleed
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