2) Height And Weight Flashcards

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
What other factors increase skin lesion risk?
- Diminished mental status - Poor tissue oxygenation - Low cardiac output - Inadequate nutrition
26
Why is routine skin assessment important?
- Identify primary/initial lesions early - Prevent deterioration to secondary lesions - Avoid extensive nursing care needs
27
What skin condition can lengthen hospital stays?
- Development of pressure injuries - Unless prevented, discovered early, and treated properly
28
Why is thorough skin assessment crucial?
- Melanoma and cutaneous malignancies are common - Allows patient education on self-examination
29
How can skin assessment findings guide nursing care?
- Reveal need for interventions - Determine hygiene measures for skin integrity - Identify need for nutrition/hydration therapy
30
What lighting is optimal for assessing most patients' skin?
- Natural or halogen lighting - Sunlight optimal for dark skin
31
Why is fluorescent lighting not recommended?
- Imparts bluish tone to dark skin
32
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
33
When should disposable gloves be used during palpation?
- If open, moist, or draining lesions are present
34
What does an initial overall visual sweep provide?
- Assessment of distribution and extent of lesions - Evaluation of overall symmetry of skin color
35
Why will the patient need to assume multiple positions?
- To allow inspection of all skin surfaces
36
When should areas be palpated during the exam?
- If abnormalities are noticed during inspection
37
Where are skin odors usually apparent?
- In skin folds like axillae or under female breasts
38
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
39
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
40
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
41
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
42
How can patients keep skin lubricated and supple?
- Apply moisturizers like mineral oil regularly - Reduce itching and drying - Wear cotton clothing
43
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
44
How does skin color vary?
- Varies from body part to body part - Varies from person to person - Usually uniform over the body
45
What is the range of normal skin pigmentation in light skin?
- Ivory or light pink to ruddy pink
46
What is the range of normal skin pigmentation in dark skin?
- Light to deep brown or olive
47
How does skin pigmentation change in older persons?
- Pigmentation increases unevenly - Causes discolored skin
48
What can mask true skin color during inspection?
- Cosmetics - Tanning agents
49
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
50
What patient characteristics are risk factors for skin cancer?
- Fair, freckled, ruddy complexion - Light-colored hair or eyes - Tendency to burn easily
51
What questions determine skin cancer risk from sun exposure?
- If patient works or spends excessive time outside - If patient wears sunscreen or protective clothing
52
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
53
Why ask about bathing frequency and soap type?
- Excessive bathing and harsh soaps cause dry skin
54
Why ask about recent skin trauma?
- Some injuries cause bruising and texture changes
55
Why ask about allergies?
- Skin rashes commonly occur from allergies
56
Why ask about topical medications or home remedies?
- Incorrect use causes inflammation, irritation, compromised integrity
57
Why ask about tanning parlors, sun lamps, or tanning pills?
- Overexposure to these may cause skin cancer
58
Why ask about family history of skin disorders?
- May reveal information about patient's condition
59
Why ask about occupational exposures?
- Exposure to creosote, coal, tar, petroleum, arsenic, radium creates cancer risk
60
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)
61
What causes pallor (decreased color)?
- Reduced oxyhemoglobin from anemia - Reduced oxyhemoglobin visibility from decreased blood flow in shock - Assess face, conjunctivae, nail beds, palms
62
What condition causes patchy loss of skin pigmentation?
- Vitiligo - Congenital or autoimmune lack of pigment - Assess patchy areas on face, hands, arms
63
What indicates increased bilirubin deposit in tissues?
- Yellow-orange (jaundice) - Caused by liver disease, red blood cell destruction - Assess sclera, mucous membranes, skin
64
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
65
What causes tan-brown skin color?
- Increased melanin - From suntan or pregnancy - Areas exposed to sun: face, arms, areolae, nipples
66
Where should color assessment start?
- Areas not exposed to sun like palms of hands - Note if unusually pale or dark
67
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
68
Where are color hues best seen?
- Palms, soles, lips, tongue, nail beds - Areas of increased (hyperpigmentation) and decreased (hypopigmentation) color common
69
What should be noted about skin creases/folds in dark skin?
- Darker than rest of body
70
Where is pallor best identified?
- Face, buccal mucosa, conjunctivae, nail beds
71
Where should cyanosis be observed?
- Lips, nail beds, palpebral conjunctivae, palms
72
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
73
How is cyanosis assessed in dark skin?
- Observe areas with least pigmentation like conjunctivae, mucosa, tongue, nails, palms/soles - Verify findings with clinical manifestations
74
What is the best site to inspect for jaundice?
- Patient's sclera
75
Where is normal reactive hyperemia (redness) often seen?
- Areas exposed to pressure like sacrum, heels, trochanters
76
What do localized skin color changes indicate?
- Circulatory changes - Erythema from vasodilation like sunburn, inflammation, fever - Pallor from arterial occlusion or edema
77
How should erythema be assessed in dark skin?
- Difficult to observe visually - Palpate area for heat and warmth to note inflammation
78
What should you ask the patient?
- If they have noticed any skin color changes
79
What skin finding is associated with sedative hypnotics like alcohol?
- Diaphoresis (excessive sweating)
80
What skin findings are associated with alcohol and stimulant use?
- Spider angiomas (dilated blood vessels)
81
What skin finding is associated with alcohol use?
- Burns, especially on fingers
82
What skin finding is associated with opioid use?
- Needle marks
83
What skin findings are associated with alcohol and other sedative hypnotic use?
- Contusions, abrasions, cuts, scars
84
What skin finding may indicate cocaine or IV opioid use to prevent injection site detection?
- "Homemade" tattoos
85
What skin finding is associated with alcohol use?
- Increased vascularity (redness) of face
86
What skin finding is associated with phencyclidine (PCP) use?
- Red, dry skin
87