Assessment, Nutrition Flashcards
usually 1° F (0.5° C) higher than the normal oral temperature
Rectal temperature
about 1° F (0.5° C) lower than the normal oral temperature
tympanic and axillary temperature
oral temp contraindicated when:
wait 15-30mins after cold or hot drink
-nasal congestion
-nasal or oral surgery or had the jaws wired
-NGT
-unable to keep the mouth closed
-seizure prec
rectal temp contraindicated when:
place pt in Sim’s position
-cardiac pt
-rectal surgery
-diarrhea
-fecal impaction
-rectal bleeding or risk for bleeding
tympanic temp contraindicated when:
-inflammation auditory canal
-discharge from the ear
❌reading may be affected by an ear infection or excessive wax blocking the ear canal.
least accurate of all temp area
axillary temp
if pedal pulse is difficult to locate
use doppler utx stethoscope/
ultrasonic stethoscope
one-examiner technique in pulse deficit
Auscultate and count the apical pulse first and then immediately count the radial pulse
two-examiner technique in pulse deficit
One person counts the apical pulse and the other counts the radial pulse simultaneously.
pulse pressure
difference between the systolic and diastolic pressures
orthostatic v/s
check BP and pulse supine, sitting, and standing;
readings are obtained 1 to 3 minutes after changing of position.
arm BP cuff contraindicated when
wait for 30mins after smoke/exercise
-extremity w/ IV fluids
-AV shunt or fistula
-the side on which breast or axillary surgery has been performed, -extremity that has been traumatized or is diseased.
cutaneous stimulation for pain
hot, cold, pressure, vibration, therapeutic touch, massage
application of a battery-operated device that delivers a low electrical current to the skin and underlying tissues to block pain (some similar units can be purchased without a prescription)
TENS/PENS
(trans-/percutaneous electrical nerve stimulation)
blood samples will be inaccurate if:
-drawn blood from an extremity w/ IV
-prolonged use of torniquet (⬆️K)
aPTT is to _____, PT is to _____
heparin, warfarin
can increase absorption of Vit. K
green leafy vegetables
*shortens PT result
instrxn before
A. lipid panel
B. FBS
A.
-12-14 hrs fasting except water
-❌ alcohol 24hrs
-no eating high cholesterol the evening before
B.
-8-12 hrs fasting
WBC shift to the right
too many mature/old neutrophils
WBC shift to the left
too many immature neutrophils
dairy products and fruit juices w/ pulps
not clear liquids
hard candy, gelatin, ice pops, coffee&tea, lemonade, carbonated beverages,
clear liquid diet aside from water, bouillon, clear broth
plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, fruit juices, and strained vegetable juice
full liquid diet
part of a clear and full liquid diet, with the addition of all cream soups, ground or diced meats, flaked fish, cottage cheese, rice, potatoes, pancakes, light breads, cooked vegetables, canned or cooked fruits, bananas, peanut butter, and nonfried eggs
mechanical soft diet
foods to be avoided include nuts; dried fruits; raw fruits and vegetables; fried foods; tough, smoked, or salted meats; and foods with coarse textures
mechanical soft diet and soft diet
easily digestible foods such as pastas, casseroles, tender meats, canned fruit, cooked vegetables, cakes, and cookies without nuts or coconut
soft diet
All foods and seasonings are permitted; however, liquid, chopped, or pureed foods or regular foods with a soft consistency are tolerated best
soft diet
Drinking fluids through a straw may be easier than drinking from a cup or glass; a straw may not be allowed for clients with dysphagia
soft diet
white bread, refined cooked cereals, cooked potatoes without skins, white rice, and refined pasta
low fiber (low residue) diet
limit or avoid raw fruits (except bananas), vegetables, nuts and seeds, plant fiber, and whole grains
Dairy products should be limited to 2 servings a day
low fiber (low residue) diet
fruits, vegetables, whole grains, low-fat dairy foods, meat, fish, poultry, nuts, and beans; it is limited in sugar-sweetened foods and beverages, red meat, and added fats.
DASH diet (Dietary Approaches to Stop Hypertension)
fruits and vegetables and whole-grain products
high fiber (high residue) diet
for malabsorption disorders, pancreatitis, gallbladder disease, and gastroesophageal reflux
Used to reduce symptoms of abdominal pain, steatorrhea, flatulence, and diarrhea associated with high intakes of dietary fat
fat restricted diet
for severe stress, burns, wound healing, cancer, human immunodeficiency virus, acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, respiratory failure, or any other type of debilitating disease
high calorie high protein diet
whole milk and milk products, peanut butter, nuts and seeds, beef, chicken, fish, pork, and eggs
high calorie high protein diet
snack between meals (milkshakes, instant breakfasts, nutri supplements)
high calorie high protein diet
for diabetes mellitus, hypoglycemia, hyperglycemia, and obesity
carbohydrate consistent diet
Exchange System for Meal Planning
carbohydrate consistent diet
for hypertension, heart failure, renal disease, cardiac disease, and liver disease
sodium restricted diet
4 g daily (no-added-salt diet),
2 to 3 g daily (moderate restriction)
1 g daily (strict restriction)
500 mg daily (severe restriction and seldom prescribed)
sodium restricted diet
for renal disease and end-stage liver disease
protein restricted diet
for celiac disease and gluten sensitivity
gluten free diet
for the client with acute kidney injury or chronic kidney disease and those requiring hemodialysis or peritoneal dialysis
renal diet
fluid restrictions on dialysis pt
hemodialysis pt have more fluid restrictions than peritoneal dialysis pt
applesauce, green beans, cabbage, lettuce, peppers, grapes, blueberries, cooked summer squash, cooked turnip greens, pineapple, and raspberries
low in potassium
Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Pork, beef, veal Potatoes Raisins Spinach Strawberries Tomatoes
high in potassium
for gout, kidney stones, and elevated uric acid
low purine diet
anchovies, herring, mackerel, sardines, scallops, organ meats, gravies, meat extracts, wild game, goose, and sweetbreads
foods high in purine
for clients with anemia
high iron diet
organ meats, meat, egg yolks, whole-wheat products, dark green leafy vegetables, dried fruit, and legumes
foods high in iron
aids in Iron absorption
Vitamin C
Lacto-vegetarian
-avoid fish, meat, poultry, eggs
- ➕milk, cheese, dairy products
Vegan
-no animal foods
-only foods with plant origin
-use of soy
Lacto-ovo-vegetarian
-same w/ lacto-vegetarian
BUT ✅ egg
(ovo=egg)
ovo-vegetarian
-only egg
-no dairy
water soluble vitamins
vit b and c
vit b complex
B1 thiamin
B2 riboflavin
B3 niacin
B6 pyridoxine
B9 folic acid
B12 cyanocobalamin
fat soluble vitamins
ADEK
percussion
resonance- healthy lung
hyperresonance-excessive air in lungs dullness- +lung densities, heart, liver, spleen
tympany- abdomen
flatness
dark skinned patient
cyanosis:
1. gray color lips & tongue
2. blue color nailbeds, palms & soles
3. conjunctiva for pallor
jaundice:
yellow color in oral mucuos membranes & sclera
bleeding:
swelled/darker area
& compare w/ unaffected side
inflammation:
warm, shiny, taut or pitting skin
& compare w/ unaffected side
crepitous/crepitation
crackling
abdominal assessment
auscultation first before palpation & percussion
romberg’s test
stand, hands to the side, close eyes,
pt should be able to balance
Stereognosis
Tests the client’s ability to recognize objects placed in his or her hand
Graphesthesia
Tests the client’s ability to identify a number traced on the client’s hand
positive Brudzinski’s sign
➕ meningeal irritation
passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column
positive Kernig’s sign
➕ meningeal irritation
knee and hip flexed
then knee extended
results to pain on the vertebral column
dix hallpike maneuver
check for nystagmus
sonorous wheeze
ronchi
pleural friction rub
pleurisy
leathery, scratchy sound
bronchophony
ninety nine
egophony
repeat eee-eee-eee sound
whispered pectoriloquy
whisper one, two, three
lordosis
swayback (curvature above buttocks)
kyphosis
hunchback (curvature thorax area)
scoliosis
lateral curvature
stridor
upper airway obstrxn
life threatening
wheeze
asthma
testicular self exam
after bath/shower (scrotum still warm, wet & soapy)
perform same day each month
cheyne stokes respiration
regular rate w/ apnea episodes
murmur
loud blow of swoosh
pericardial friction rub
leathery, scratchy sound
conductive hearing loss
physical obstrxn
sensorineural hearing loss
defective cochlea, cranial nerve 8 or brain
vit b12 source
nuts, dried beans, organ meats, citrus fruits, green leafy, yeasts
