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Nursing 20G - Health Assessment And Physical Examination > 2) Height And Weight > Flashcards

2) Height And Weight Flashcards

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1
Q

Why are height and weight important measures?

A
  • Reflect general level of health
  • Routine for health screenings and clinical visits
  • Assess growth/development in infants and children
  • Help identify nutritional issues in older adults
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2
Q

Why monitor trends in height and weight?

A
  • Changes can indicate health problems
  • Downward trend in frail elderly signals reduced nutritional reserves
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3
Q

What should be assessed regarding weight changes?

A
  • Ask patient about current height and weight
  • Assess for recent gains or losses
  • Weight gain of 2.3 kg in a day indicates fluid retention
  • Loss of >5% in 1 month or >10% in 6 months is significant
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4
Q

What helps explain weight changes?

A
  • Nursing history can identify possible causes
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5
Q

What is the purpose of BMI tables?

A
  • Help determine normal expected weight range for a patient’s height
  • Locate intersection of height and weight to find BMI
  • Assess health risk using BMI categories
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6
Q

How is waist circumference used with BMI for adults?

A
  • Measures health risk associated with obesity
  • Measured midway between costal margin and iliac crest
  • Taken at end of expiration, snug but not compressing tissue
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7
Q

Why is consistent weighing technique important?

A
  • Allows objective comparison of weights over time
  • Providers base decisions on weight changes (dosing, lifts, positioning)
  • Should be same time, scale, and clothing each time
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8
Q

What are advantages of electronic scales?

A
  • Most reliable and commonly used
  • Automatically calibrated each use
  • Display weight digitally within seconds
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9
Q

How are weights obtained for non-ambulatory patients?

A
  • Stretcher/chair scales with hydraulic lift measure weight
  • Patient transferred onto scale, lifted above bed
  • Weight shown on balance beam or digital display
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10
Q

What are proper techniques for weighing infants?

A
  • Use baskets or platform scales
  • Remove clothing, weigh in dry diaper (adjust for diaper weight)
  • Keep room warm, use cloth/paper on scale to prevent contamination
  • Hold hand above to prevent falls
  • Measure in grams
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11
Q

What should be assessed about weight changes?

A
  • Total weight lost or gained
  • Compare to usual weight
  • Note if loss was gradual, sudden, desired or undesired
  • Determines severity and if related to disease, eating pattern, or pregnancy
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12
Q

For desired weight loss, what should be asked?

A
  • Eating habits
  • Diet plan followed
  • Food preparation
  • Calorie intake
  • Appetite
  • Exercise pattern
  • Support group participation
  • Weight goal
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13
Q

For undesired weight loss, what should be asked?

A
  • Anorexia
  • Vomiting
  • Diarrhea
  • Thirst
  • Frequent urination
  • Changes in lifestyle, activity, stress, alcohol intake
  • Focuses on conditions causing weight loss like GI issues
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14
Q

What social/lifestyle factors should be assessed?

A
  • More restaurant meals
  • Rushing to eat meals
  • Stress at work
  • Skipping meals
  • Lifestyle changes can contribute to weight changes
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15
Q

What medications should be assessed for weight changes?

A
  • Chemotherapy, diuretics, insulin, fluoxetine, appetite suppressants, laxatives, oral hypoglycemics, herbal supplements (weight loss)
  • Steroids, oral contraceptives, antidepressants, insulin (weight gain)
  • Medication side effects
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16
Q

What eating disorder symptoms should be assessed?

A
  • Preoccupation with weight/body shape
  • Never feeling thin enough
  • Unusually strict calorie intake
  • Laxative abuse
  • Induced vomiting
  • Amenorrhea
  • Excessive exercise
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17
Q

How do you measure the height of weight-bearing patients?

A
  • Have patient remove shoes
  • Use a measuring stick/tape attached vertically to scale or wall
  • Have patient stand erect
  • Use metal rod on scale that swings over patient’s head
  • If no scale, place stick/book on head and measure at 90-degree angle
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18
Q

How do you measure the height of non-weight-bearing patients like infants?

A
  • Remove shoes and position patient supine on firm surface
  • Use portable device with headboard and footboard
  • Have parent hold infant’s head against headboard
  • Straighten infant’s legs and place footboard at feet
  • Record length to nearest 0.5 cm
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19
Q

What does the integumentary system consist of?

A
  • Skin
  • Hair
  • Scalp
  • Nails
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20
Q

Why is developing a routine approach to physical assessment important?

A
  • Helps ensure completeness of the examination
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21
Q

What are two approaches to assessing the skin?

A
  • Inspect all skin surfaces first
  • Gradually inspect skin while examining other body systems
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22
Q

What skills should be used to assess the integument?

A
  • Inspection
  • Palpation
  • Olfaction
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23
Q

What does skin assessment reveal?

A
  • Changes in oxygenation
  • Changes in circulation
  • Changes in nutrition
  • Local tissue damage
  • Hydration status
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24
Q

Which patients are at high risk for skin lesions in hospitals?

A
  • Older persons
  • Debilitated patients
  • Seriously ill young patients
  • Neurologically impaired
  • Chronically ill
  • Orthopedic patients
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25
Q

What other factors increase skin lesion risk?

A
  • Diminished mental status
  • Poor tissue oxygenation
  • Low cardiac output
  • Inadequate nutrition
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26
Q

Why is routine skin assessment important?

A
  • Identify primary/initial lesions early
  • Prevent deterioration to secondary lesions
  • Avoid extensive nursing care needs
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27
Q

What skin condition can lengthen hospital stays?

A
  • Development of pressure injuries
  • Unless prevented, discovered early, and treated properly
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28
Q

Why is thorough skin assessment crucial?

A
  • Melanoma and cutaneous malignancies are common
  • Allows patient education on self-examination
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29
Q

How can skin assessment findings guide nursing care?

A
  • Reveal need for interventions
  • Determine hygiene measures for skin integrity
  • Identify need for nutrition/hydration therapy
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30
Q

What lighting is optimal for assessing most patients’ skin?

A
  • Natural or halogen lighting
  • Sunlight optimal for dark skin
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31
Q

Why is fluorescent lighting not recommended?

A
  • Imparts bluish tone to dark skin
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32
Q

How does room temperature affect skin assessment?

A
  • Warm room causes superficial vasodilation and increased redness
  • Cool room causes cyanosis around lips and nails in sensitive patients
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33
Q

When should disposable gloves be used during palpation?

A
  • If open, moist, or draining lesions are present
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34
Q

What does an initial overall visual sweep provide?

A
  • Assessment of distribution and extent of lesions
  • Evaluation of overall symmetry of skin color
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35
Q

Why will the patient need to assume multiple positions?

A
  • To allow inspection of all skin surfaces
36
Q

When should areas be palpated during the exam?

A
  • If abnormalities are noticed during inspection
37
Q

Where are skin odors usually apparent?

A
  • In skin folds like axillae or under female breasts
38
Q

What are the objectives for patient teaching on skin assessment?

A
  • Patient will perform monthly self-skin examination
  • Patient will identify skin cancer risk factors
  • Patient will follow hygiene practices for skin integrity
39
Q

What should patients be instructed on for self-skin examination?

A
  • Conduct complete monthly exam of all skin surfaces
  • Note moles, blemishes, birthmarks
  • Cancerous melanomas start small, grow, change color, ulcerate, bleed
40
Q

What skin changes should patients report to providers?

A
  • Any change to a skin lesion
  • Lesions that bleed or fail to heal
  • Non-healing sores
  • Especially important for older patients with delayed healing
41
Q

What hygiene tips should be given for excessively dry skin?

A
  • Avoid hot water, harsh soaps, drying agents like rubbing alcohol
  • Use superfatted soaps like Dove
  • Pat skin dry after bathing instead of rubbing
42
Q

How can patients keep skin lubricated and supple?

A
  • Apply moisturizers like mineral oil regularly
  • Reduce itching and drying
  • Wear cotton clothing
43
Q

How should patient teaching be evaluated?

A
  • Observe patient performing skin self-exam
  • Have patient describe skin cancer signs and prevention
  • Ask patient to describe methods for skin lubrication
44
Q

How does skin color vary?

A
  • Varies from body part to body part
  • Varies from person to person
  • Usually uniform over the body
45
Q

What is the range of normal skin pigmentation in light skin?

A
  • Ivory or light pink to ruddy pink
46
Q

What is the range of normal skin pigmentation in dark skin?

A
  • Light to deep brown or olive
47
Q

How does skin pigmentation change in older persons?

A
  • Pigmentation increases unevenly
  • Causes discolored skin
48
Q

What can mask true skin color during inspection?

A
  • Cosmetics
  • Tanning agents
49
Q

What should you ask about the patient’s skin history?

A
  • Changes like dryness, itching, sores, rashes, lumps, color, texture, odor, non-healing lesions
  • Patient is best source to recognize changes
  • Skin cancer often first noticed as localized color change
50
Q

What patient characteristics are risk factors for skin cancer?

A
  • Fair, freckled, ruddy complexion
  • Light-colored hair or eyes
  • Tendency to burn easily
51
Q

What questions determine skin cancer risk from sun exposure?

A
  • If patient works or spends excessive time outside
  • If patient wears sunscreen or protective clothing
52
Q

Why ask about lesions, rashes, or bruises?

A
  • Most skin changes don’t develop suddenly
  • Change in lesion character may indicate cancer
  • Bruising indicates trauma or bleeding disorder
53
Q

Why ask about bathing frequency and soap type?

A
  • Excessive bathing and harsh soaps cause dry skin
54
Q

Why ask about recent skin trauma?

A
  • Some injuries cause bruising and texture changes
55
Q

Why ask about allergies?

A
  • Skin rashes commonly occur from allergies
56
Q

Why ask about topical medications or home remedies?

A
  • Incorrect use causes inflammation, irritation, compromised integrity
57
Q

Why ask about tanning parlors, sun lamps, or tanning pills?

A
  • Overexposure to these may cause skin cancer
58
Q

Why ask about family history of skin disorders?

A
  • May reveal information about patient’s condition
59
Q

Why ask about occupational exposures?

A
  • Exposure to creosote, coal, tar, petroleum, arsenic, radium creates cancer risk
60
Q

What skin color indicates increased deoxygenated hemoglobin (hypoxia)?

A
  • Bluish (cyanosis)
  • Caused by heart/lung disease, cold environment
  • Assess nail beds, lips, mouth, skin (severe cases)
61
Q

What causes pallor (decreased color)?

A
  • Reduced oxyhemoglobin from anemia
  • Reduced oxyhemoglobin visibility from decreased blood flow in shock
  • Assess face, conjunctivae, nail beds, palms
62
Q

What condition causes patchy loss of skin pigmentation?

A
  • Vitiligo
  • Congenital or autoimmune lack of pigment
  • Assess patchy areas on face, hands, arms
63
Q

What indicates increased bilirubin deposit in tissues?

A
  • Yellow-orange (jaundice)
  • Caused by liver disease, red blood cell destruction
  • Assess sclera, mucous membranes, skin
64
Q

What causes red (erythema) skin color?

A
  • Increased oxyhemoglobin visibility from dilation/increased blood flow
  • Fever, trauma, blushing, alcohol intake
  • Assess face, trauma areas, sacrum, shoulders
65
Q

What causes tan-brown skin color?

A
  • Increased melanin
  • From suntan or pregnancy
  • Areas exposed to sun: face, arms, areolae, nipples
66
Q

Where should color assessment start?

A
  • Areas not exposed to sun like palms of hands
  • Note if unusually pale or dark
67
Q

What areas are more difficult for assessing pallor or cyanosis in dark skin?

A
  • Sun-exposed areas like face and arms will be darker
  • More difficult in patients with dark skin tones
68
Q

Where are color hues best seen?

A
  • Palms, soles, lips, tongue, nail beds
  • Areas of increased (hyperpigmentation) and decreased (hypopigmentation) color common
69
Q

What should be noted about skin creases/folds in dark skin?

A
  • Darker than rest of body
70
Q

Where is pallor best identified?

A
  • Face, buccal mucosa, conjunctivae, nail beds
71
Q

Where should cyanosis be observed?

A
  • Lips, nail beds, palpebral conjunctivae, palms
72
Q

How does pallor present in dark skin?

A
  • Normal brown appears yellow-brown
  • Normal black appears ashen grey
  • Assess lips, nails, mucous membranes for generalized pallor
73
Q

How is cyanosis assessed in dark skin?

A
  • Observe areas with least pigmentation like conjunctivae, mucosa, tongue, nails, palms/soles
  • Verify findings with clinical manifestations
74
Q

What is the best site to inspect for jaundice?

A
  • Patient’s sclera
75
Q

Where is normal reactive hyperemia (redness) often seen?

A
  • Areas exposed to pressure like sacrum, heels, trochanters
76
Q

What do localized skin color changes indicate?

A
  • Circulatory changes
  • Erythema from vasodilation like sunburn, inflammation, fever
  • Pallor from arterial occlusion or edema
77
Q

How should erythema be assessed in dark skin?

A
  • Difficult to observe visually
  • Palpate area for heat and warmth to note inflammation
78
Q

What should you ask the patient?

A
  • If they have noticed any skin color changes
79
Q

What skin finding is associated with sedative hypnotics like alcohol?

A
  • Diaphoresis (excessive sweating)
80
Q

What skin findings are associated with alcohol and stimulant use?

A
  • Spider angiomas (dilated blood vessels)
81
Q

What skin finding is associated with alcohol use?

A
  • Burns, especially on fingers
82
Q

What skin finding is associated with opioid use?

A
  • Needle marks
83
Q

What skin findings are associated with alcohol and other sedative hypnotic use?

A
  • Contusions, abrasions, cuts, scars
84
Q

What skin finding may indicate cocaine or IV opioid use to prevent injection site detection?

A
  • “Homemade” tattoos
85
Q

What skin finding is associated with alcohol use?

A
  • Increased vascularity (redness) of face
86
Q

What skin finding is associated with phencyclidine (PCP) use?

A
  • Red, dry skin
87
Q
A

Nursing 20G - Health Assessment And Physical Examination (2 decks)

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