2) Height And Weight Flashcards
Why are height and weight important measures?
- 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
Why monitor trends in height and weight?
- Changes can indicate health problems
- Downward trend in frail elderly signals reduced nutritional reserves
What should be assessed regarding weight changes?
- 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
What helps explain weight changes?
- Nursing history can identify possible causes
What is the purpose of BMI tables?
- 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
How is waist circumference used with BMI for adults?
- Measures health risk associated with obesity
- Measured midway between costal margin and iliac crest
- Taken at end of expiration, snug but not compressing tissue
Why is consistent weighing technique important?
- 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
What are advantages of electronic scales?
- Most reliable and commonly used
- Automatically calibrated each use
- Display weight digitally within seconds
How are weights obtained for non-ambulatory patients?
- Stretcher/chair scales with hydraulic lift measure weight
- Patient transferred onto scale, lifted above bed
- Weight shown on balance beam or digital display
What are proper techniques for weighing infants?
- 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
What should be assessed about weight changes?
- 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
For desired weight loss, what should be asked?
- Eating habits
- Diet plan followed
- Food preparation
- Calorie intake
- Appetite
- Exercise pattern
- Support group participation
- Weight goal
For undesired weight loss, what should be asked?
- Anorexia
- Vomiting
- Diarrhea
- Thirst
- Frequent urination
- Changes in lifestyle, activity, stress, alcohol intake
- Focuses on conditions causing weight loss like GI issues
What social/lifestyle factors should be assessed?
- More restaurant meals
- Rushing to eat meals
- Stress at work
- Skipping meals
- Lifestyle changes can contribute to weight changes
What medications should be assessed for weight changes?
- Chemotherapy, diuretics, insulin, fluoxetine, appetite suppressants, laxatives, oral hypoglycemics, herbal supplements (weight loss)
- Steroids, oral contraceptives, antidepressants, insulin (weight gain)
- Medication side effects
What eating disorder symptoms should be assessed?
- Preoccupation with weight/body shape
- Never feeling thin enough
- Unusually strict calorie intake
- Laxative abuse
- Induced vomiting
- Amenorrhea
- Excessive exercise
How do you measure the height of weight-bearing patients?
- 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
How do you measure the height of non-weight-bearing patients like infants?
- 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
What does the integumentary system consist of?
- Skin
- Hair
- Scalp
- Nails
Why is developing a routine approach to physical assessment important?
- Helps ensure completeness of the examination
What are two approaches to assessing the skin?
- Inspect all skin surfaces first
- Gradually inspect skin while examining other body systems
What skills should be used to assess the integument?
- Inspection
- Palpation
- Olfaction
What does skin assessment reveal?
- Changes in oxygenation
- Changes in circulation
- Changes in nutrition
- Local tissue damage
- Hydration status
Which patients are at high risk for skin lesions in hospitals?
- Older persons
- Debilitated patients
- Seriously ill young patients
- Neurologically impaired
- Chronically ill
- Orthopedic patients
What other factors increase skin lesion risk?
- Diminished mental status
- Poor tissue oxygenation
- Low cardiac output
- Inadequate nutrition
Why is routine skin assessment important?
- Identify primary/initial lesions early
- Prevent deterioration to secondary lesions
- Avoid extensive nursing care needs
What skin condition can lengthen hospital stays?
- Development of pressure injuries
- Unless prevented, discovered early, and treated properly
Why is thorough skin assessment crucial?
- Melanoma and cutaneous malignancies are common
- Allows patient education on self-examination
How can skin assessment findings guide nursing care?
- Reveal need for interventions
- Determine hygiene measures for skin integrity
- Identify need for nutrition/hydration therapy
What lighting is optimal for assessing most patients’ skin?
- Natural or halogen lighting
- Sunlight optimal for dark skin
Why is fluorescent lighting not recommended?
- Imparts bluish tone to dark skin
How does room temperature affect skin assessment?
- Warm room causes superficial vasodilation and increased redness
- Cool room causes cyanosis around lips and nails in sensitive patients
When should disposable gloves be used during palpation?
- If open, moist, or draining lesions are present
What does an initial overall visual sweep provide?
- Assessment of distribution and extent of lesions
- Evaluation of overall symmetry of skin color
Why will the patient need to assume multiple positions?
- To allow inspection of all skin surfaces
When should areas be palpated during the exam?
- If abnormalities are noticed during inspection
Where are skin odors usually apparent?
- In skin folds like axillae or under female breasts
What are the objectives for patient teaching on skin assessment?
- Patient will perform monthly self-skin examination
- Patient will identify skin cancer risk factors
- Patient will follow hygiene practices for skin integrity
What should patients be instructed on for self-skin examination?
- Conduct complete monthly exam of all skin surfaces
- Note moles, blemishes, birthmarks
- Cancerous melanomas start small, grow, change color, ulcerate, bleed
What skin changes should patients report to providers?
- Any change to a skin lesion
- Lesions that bleed or fail to heal
- Non-healing sores
- Especially important for older patients with delayed healing
What hygiene tips should be given for excessively dry skin?
- Avoid hot water, harsh soaps, drying agents like rubbing alcohol
- Use superfatted soaps like Dove
- Pat skin dry after bathing instead of rubbing
How can patients keep skin lubricated and supple?
- Apply moisturizers like mineral oil regularly
- Reduce itching and drying
- Wear cotton clothing
How should patient teaching be evaluated?
- Observe patient performing skin self-exam
- Have patient describe skin cancer signs and prevention
- Ask patient to describe methods for skin lubrication
How does skin color vary?
- Varies from body part to body part
- Varies from person to person
- Usually uniform over the body
What is the range of normal skin pigmentation in light skin?
- Ivory or light pink to ruddy pink
What is the range of normal skin pigmentation in dark skin?
- Light to deep brown or olive
How does skin pigmentation change in older persons?
- Pigmentation increases unevenly
- Causes discolored skin
What can mask true skin color during inspection?
- Cosmetics
- Tanning agents
What should you ask about the patient’s skin history?
- 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
What patient characteristics are risk factors for skin cancer?
- Fair, freckled, ruddy complexion
- Light-colored hair or eyes
- Tendency to burn easily
What questions determine skin cancer risk from sun exposure?
- If patient works or spends excessive time outside
- If patient wears sunscreen or protective clothing
Why ask about lesions, rashes, or bruises?
- Most skin changes don’t develop suddenly
- Change in lesion character may indicate cancer
- Bruising indicates trauma or bleeding disorder
Why ask about bathing frequency and soap type?
- Excessive bathing and harsh soaps cause dry skin
Why ask about recent skin trauma?
- Some injuries cause bruising and texture changes
Why ask about allergies?
- Skin rashes commonly occur from allergies
Why ask about topical medications or home remedies?
- Incorrect use causes inflammation, irritation, compromised integrity
Why ask about tanning parlors, sun lamps, or tanning pills?
- Overexposure to these may cause skin cancer
Why ask about family history of skin disorders?
- May reveal information about patient’s condition
Why ask about occupational exposures?
- Exposure to creosote, coal, tar, petroleum, arsenic, radium creates cancer risk
What skin color indicates increased deoxygenated hemoglobin (hypoxia)?
- Bluish (cyanosis)
- Caused by heart/lung disease, cold environment
- Assess nail beds, lips, mouth, skin (severe cases)
What causes pallor (decreased color)?
- Reduced oxyhemoglobin from anemia
- Reduced oxyhemoglobin visibility from decreased blood flow in shock
- Assess face, conjunctivae, nail beds, palms
What condition causes patchy loss of skin pigmentation?
- Vitiligo
- Congenital or autoimmune lack of pigment
- Assess patchy areas on face, hands, arms
What indicates increased bilirubin deposit in tissues?
- Yellow-orange (jaundice)
- Caused by liver disease, red blood cell destruction
- Assess sclera, mucous membranes, skin
What causes red (erythema) skin color?
- Increased oxyhemoglobin visibility from dilation/increased blood flow
- Fever, trauma, blushing, alcohol intake
- Assess face, trauma areas, sacrum, shoulders
What causes tan-brown skin color?
- Increased melanin
- From suntan or pregnancy
- Areas exposed to sun: face, arms, areolae, nipples
Where should color assessment start?
- Areas not exposed to sun like palms of hands
- Note if unusually pale or dark
What areas are more difficult for assessing pallor or cyanosis in dark skin?
- Sun-exposed areas like face and arms will be darker
- More difficult in patients with dark skin tones
Where are color hues best seen?
- Palms, soles, lips, tongue, nail beds
- Areas of increased (hyperpigmentation) and decreased (hypopigmentation) color common
What should be noted about skin creases/folds in dark skin?
- Darker than rest of body
Where is pallor best identified?
- Face, buccal mucosa, conjunctivae, nail beds
Where should cyanosis be observed?
- Lips, nail beds, palpebral conjunctivae, palms
How does pallor present in dark skin?
- Normal brown appears yellow-brown
- Normal black appears ashen grey
- Assess lips, nails, mucous membranes for generalized pallor
How is cyanosis assessed in dark skin?
- Observe areas with least pigmentation like conjunctivae, mucosa, tongue, nails, palms/soles
- Verify findings with clinical manifestations
What is the best site to inspect for jaundice?
- Patient’s sclera
Where is normal reactive hyperemia (redness) often seen?
- Areas exposed to pressure like sacrum, heels, trochanters
What do localized skin color changes indicate?
- Circulatory changes
- Erythema from vasodilation like sunburn, inflammation, fever
- Pallor from arterial occlusion or edema
How should erythema be assessed in dark skin?
- Difficult to observe visually
- Palpate area for heat and warmth to note inflammation
What should you ask the patient?
- If they have noticed any skin color changes
What skin finding is associated with sedative hypnotics like alcohol?
- Diaphoresis (excessive sweating)
What skin findings are associated with alcohol and stimulant use?
- Spider angiomas (dilated blood vessels)
What skin finding is associated with alcohol use?
- Burns, especially on fingers
What skin finding is associated with opioid use?
- Needle marks
What skin findings are associated with alcohol and other sedative hypnotic use?
- Contusions, abrasions, cuts, scars
What skin finding may indicate cocaine or IV opioid use to prevent injection site detection?
- “Homemade” tattoos
What skin finding is associated with alcohol use?
- Increased vascularity (redness) of face
What skin finding is associated with phencyclidine (PCP) use?
- Red, dry skin
