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Health Assessment Exam 3
Terms in this set (125)
Who are vulnerable for developing malnutrition?
Infants, children, pregnant women, recent immigrants, low income individuals, hospitalized patients, aging adults
What is the most rapid period of growth?
Birth to 4 months
When should infants double their weight?
By 4 months
When should infants triple their weight?
Why is breastfeeding recommended for full-term infants for the first year of life?
Ideally formulated to promote normal infant growth and development and natural immunity
Advantages to breastfeeding?
Fewer food allergies and intolerances
Reduced likelihood of overfeeding
More cost efficient
Increased mother-infant interaction time
Should you feed infants cows milk?
NO, it can cause GI and kidney problems
Also insufficient source of vitamin C and E and iron
not recommended until > 12 months
Why should children not drink low-fat or skim products before 2 years of age?
Brain size increases very rapidly during this period, as it has reached 50% of adult size by 2 y/o, and full size by 8 y/o
The fat, calories and essential fatty acids are important in brain growth and development
When do girls double body weight?
When do boys double body weight?
Weight gain in pregnancy
25-35 lbs for normal weight
28-40 lbs for underweight
15-25 lbs for overweight
11-20 for obese
Increase in which nutrients are required for pregnant women?
Iron, folate, zinc and overall increase in calories and proteins
What is the purpose of nutrition in adulthood?
It is an important time to preserve health and prevent or delay onset of chronic disease with lifestyle changes, including nutrition
Carries increased cardiac risk and is diagnosed when patient has 3/5 biomarkers:
3) increased fasting blood glucose levels
4) Increased waist circumference (>35 cm women, >40 cm men)
5)Low HDL levels
5 biomarkers of metabolic syndrome
elevated fasting blood glucose
Hyperlipidemia (elevated triglycerides)
Low HDL levels
Increased waist circumference (>35 cm women, >40 cm men)
What is the significance of metabolic syndrome
Patient is at increased risk for cardiac disease
age-related loss of muscle mass
age-related loss of muscle mass in combination with an increase in body fat
Why are immigrants at nutritional risk?
Frequently come from countries with limited food supplies due to poverty, poor sanitation, war, political strife
Nutritional assessment tools
24 hour food recall
What are the problems with 24 hour food recall, food diaries, or food frequency questionnaires?
May not be able to recall the type or amount of food eaten and how frequently
Intake within time frame may be atypical of usual intake
May alter the truth for a variety of reasons
Snack items and use of gravies, sauces, and condiments are often omitted
What is the time frame often used with food diaries
Health related outcomes of childhood and adolescent obesity
Fatty liver disease
What does the nursing student need to know about sarcopenia?
It is a result of decreased physical activity and decrease in protein intake
Resistance training is needed to treat weakened muscles
What is low birth weight attributed to?
Poor gestational nutrition, low maternal weight gain, maternal drug and alcohol use
What is significant about low birth weight?
Lead to birth defects and delayed growth and development
Most common eating disorder across all age groups?
What is binge eating?
eating a large amount of food in a short period of time
What is the purpose of nutritional screening?
Identify individuals at risk of weight loss, inadequate food intake, or recent illness
Provide data for designing a nutrition plan of care that will prevent the development of malnutrition
Establish baseline data for evaluating the efficacy of nutritional care
body mass index (measurement of body fat based on height and weight)
Equation to measure BMI
weight in lbs/(height in inches)^2 X 703
18.5-25 Normal weight
>40 extreme obesity
excess body fat that is placed predominantly within the abdomen and upper body, as opposed to the hips and thighs
most of fat in thighs and hips
Waist circumference/hip circumference
What waist-to-hip circumference is indicative of android obesity?
>1.0 in men; >0.8 in women
What is significant about android obesity?
Increases risk for obesity related disease and cardiovascular disease
Most frequent skinfold thickness test
Triceps skinfold test
Purpose of skinfold thickness measurements
Estimate the body fat stores or the extent of obesity or undernutrition
What TSF standards indicate undernutrition or overnutrition?
+/- 10% standard for the weight
Bioelectrical impedance analysis
Purpose of BIA
measures fat and lean body mass
dual-energy x-ray absorptiometry
Purpose of DEXA
measure fat and lean body mass and bone density
What can produce false high readings of TSF?
Who can you perform TSF on?
Everyone but the aging adult due to the sagging skin, decline in muscle mass, and redistribution of subq fat will give false results
Why would you want to calculate arm span?
When height is difficult to measure, such as with children with scoliosis or cerebral palsy that can't stand straight
Or in aging person with kyphosis
How do you measure arm span?
Measure distance from sternal notch to longest finger on dominant hand X 2.8
What tools can be used to measure body composition or fat?
How frequently do you measure pregnant woman's weight?
Monthly until 30 weeks
Q 2 weeks until last month of pregnancy
Weekly in the last month
When would you consider a pregnant woman at nutritional risk?
If weight is >10% below ideal weight, or > 20% above ideal weight
What is the best way to assess aging adult obesity?
BMI and waist-to-hip ratio
Why do you want to ask about alcohol use in nutritional screening?
Alcohol is empty calories and can block absorption of some nutrients
Inadequate protein and inadequate calorie intake, possibly from prolonged starvation
Get the starved appearance
Inadequate anthropometric measurements but adequate visceral protein levels
Common causes of marasmus
Anorexia, bowel obstruction, cancer cachexia, chronic illness
A diet that is high in calories but little protein, resulting in decreased protein levels in blood but adequate anthropometric measures
Have well-nourished appearance but edematous
Scorbutic gums are a result in which deficiency?
Vitamin C as a result of scurvy
Rickets is a sign of which nutrient deficiency?
Vitamin D and calcium
Foamy plaques of the cornea that are a sign of vitamin A deficiency
Niacin (B3) deficiency characterized by pigmented keratotic scaling lesions
Especially prominent in areas that are exposed to a lot of sun
Vitamin A deficiency associated with dry, bumpy skin
Beefy red-colored tongue is a result of which deficiency?
Vitamin B-complex deficiency
Normal characteristics of nails
Slightly curved or flat
Smooth and regular and rounded consistency without splitting or brittle
Nail edges are smooth, rounded, and clean (adequate self care)
Nail plate is translucent with pink bed
Capillary refill <3 seconds indicating peripheral circulation
When does clubbing of the nails occur?
Congenital cyanotic heart disease, lung cancer, pulmonary diseases
Due to chronic hypoxemia
Characteristics of clubbing
early clubbing--angle flattens to 180 degrees
Then nail becomes convex like ET fingers
Nail base is spongy on palpation
What does capillary refill indicate?
Mask of pregnancy
Irregular brown patch of hyperpigmentation on face
Due to pregnancy or oral contraceptives, and disappears after birth or d/c birth control
Common in pregnancy due to increased estrogen that may resolve after childbirth
More than 5 occur with significant liver disease when it cannot metabolize the estrogen
Why are infants at increased risk for fluid loss?
Why is temperature regulation ineffective in infants?
Arrector pilli mm. don't contract and can't shiver and they have an inefficient subcutaneous layer, meaning they don't respond well to the cold
Eccrine glands (dilute saline that secretes as sweat to cool body off) don't respond to hat until 3 months old, but only works minimally from that point and into childhood, so don't respond well to heat
Waxy or "cheesy" white substance found coating the skin of newborn humans
Where do you test mobility in adult? infant?
underneath clavicle in the adult
Abdomen in infant
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn.
Why does jaundice appear 3-4 days after birth?
Bc the infant has an increased in numbers of RBC that hemolyze after birth, which increases bilirubin
Due to birth trauma
What if baby has jaundice on day 1?
indicates hemolytic disease
What if baby has jaundice 2 weeks of age?
indicates biliary tract obstruction
What does loss of subcutaneous fat indicate in a baby?
Prematurity or malnutrition
seborrheic dermatitis in infants
Scaly, crusted scalp
small raised white spots on nose, chin, and forehead of infant caused by sebum occluding opening of follicles
Normal and resolves spontaneously
Common vascular birthmark
flat, irregular shaped red or pink patch found on the forehead, eyelid, or upper lip
Most common on back of neck
Fades within first year
What is special about newborn's nail beds?
Cyanotic for first few hours of life, but then turn pink
common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns
Blue/black to purple macular area at the sacrum or buttocks but sometimes on abdomen, thighs, shoulders or arms
Generally fades in 1st year
Cafe au lait spot
large round or oval patch of light brown pigmentation which is usually present at birth
Harlequin color change
Baby is in side lying position where lower half of body turns red, and the uppere half blanches with a distinct demarcation line down the middle
common rash in first 3-4 days of life
Tiny punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks
No treatment needed
What are two temporary cyanotic conditions that may occur with newborns and infants
bluish color around lips, hands, and fingernails, feet and toenails that may last for a few hours and disappear without warning
What would generalized cyanosis in infants indicate? Especially during feeding?
Congenital heart disease (Tetrology of Fallot's specifically)
Transient mottling in the trunk and extremities in response to cooler room temps
Where would you see persistent or pronounced cutis marmorata?
Down syndrome or prematurity
When can babies starting prespiring?
After 1 month
What happens to turgor in the aging adult?
Decreases turgor due to decreasing elasticity of the skin
Skin starts to sag so does tent easily
Liver spots--clusters of melanocytes that appear after extensive sun exposure
Cyanosis in dark skin
only severe cyanosis is apparent in skin
Check conjunctivae, oral mucosa, nail beds
Dark but dull and lifeless
Color of skin and mucosa with carbon monoxide poisoning
Cherry red color
Pallor in dark skin
Yellow/brown in brown skin
black skin appears ashen gray
Overall skin loses its healthy glow and you want to check thee areas with least pigmentation
flat, circumscribed color change on the skin that is <1 cm in diameter
Macules that are larger than 1 cm
Superficial thickening of epidermis
Solid, elevated, circumscribed <1 cm diameter
I.e. elevated mole (nevus)
Papules coalesce to form surface elevation >1cm
Plateaulike, disk-shaped lesion
Solid, elevated, hard or soft, larger than 1 cm
May extend into the dermis
superficial, raised, transient, erythematous
Slightly irregular due to edema
I.e. mosquito bite
Blister < 1cm
Blister > 1cm
encapsulated fluid filled cavity in the dermis or subcutaneous layer, tensely elevating skin
turbid fluid (pus) in the cavity
Begins in center and spreads to periphery
lesions that run together
example of confluent lesions
Example of annular lesions
distinct individual lesions that remain separate
examples of discrete lesions
skin tags or acne
twisted coiled spiral snakelike
clusters of lesions
example of grouped lesions
vesicles (blisters <1 cm) of contact dermatitis
a scratch, streak, line, or stripe
resembles iris of eye, concentric rings of color in lesions
linear arrangement along a unilateral nerve route
annular lesions that grow together
Example of zosteriform lesion
Koplik spots in mouth
bluish white, red based elevations of 1-3 mm that does not blanch
CHARACTERISTIC OF MEASLES
Difference of german measles vs measles?
German measles have neck lymphadenopathy and absence of Koplik spots
Where does the measles rash appear first in measles?
First behind ears, spreads over face, then over neck, trunk, arms, and legs