Chapter 3: Clinical Assessment Flashcards
the methodology used during the advanced stages of nutritional deficiency
should not be used as the only method of assessment
clinical assessment
should be used as adjunct to clinical assessment
biochemical or lab results
useful for identifying the severity of the problem and measuring progress toward long-range goals to eradicate nutrient deficiencies
clinical measurements
components of physical assessment (2)
medical history and physical examination
components of physical assessment
defined as changes, believed to be related to inadequate nutrition, can be seen or felt in superficial epithelial tissue, esp. the skin, eyes, hair, and buccal mucosa, or in organs near the surface of the body
physical examination
components of physical assessment
may reveal evidence of certain nutritional deficiencies which will not be detected by dietary or lab methods
physical examination
corroborated or validates the findings obtained by medical history
physical examination
components of physical assessment
obtained thru interview of patient or from records or both
includes a description of the patient and relevant environmental, social, and family factors
medical history
types of medical records
consists of patient identification data, admission notes, physician’s orders, lab reports, medication records, consent, consultations, operating room records, progress notes, flow sheets
source-oriented medical record (SOMR)
types of medical records
consists of a defined database, a complete problem, the initial care plan, progress notes, flow sheets, and discharge summary
problem-oriented medical record (POMR)
nasolabeal seborrhea deficiency (3)
prydoxine, riboflavin, niacin
cheilosis and angular stomatitis (5)
riboflavin, niacin, biotin, vitamin b6, iron
glossitis of the tongue (4)
riboflavin, niacin, folic acid, vitamin b12
who classification of physical signs most often associated with malnutrition
signs that are considered to be of value in nut assessment
often associated with nutritional deficiency status
signs of malnutrition may often be mixed and may be due to the deficiency of 2 or more micronutrients
group 1
who classification of physical signs most often associated with malnutrition
sings that need further investigation
may be related to malnutrition, perhaps of a chronic type, but are often found in populations of developing countries where other health and environmental problems (poverty and illiteracy), coexist
group 2
who classification of physical signs most often associated with malnutrition
signs that have no relation to malnutrition
may be similar to physical signs found in persons with malnutrition and must be carefully delineated from them
usually takes the particular expertise of a physician or other health worker expertly trained in nutritional diagnosis
group 3
are assessment of clinical vitamin a deficiency in individuals and populations (2)
xerophthalmia and night blindness
include growth retardation and decreased immune function in lowering effects of measles and diarrhea episodes
vitamin a deficiency - non-ocular signs
allow diagnosis on clinical grounds, esp. when the condition is moderately advanced
ocular signs
classification of xerophthalmia
is often the first evidence of vitamin a deficiency
the individual has a reduced ability to see in dim light
parents may notice that their young child is clumsy in the dark or fails to recognize people in a poorly lit room
night blindness (XN)
night blindness occurs because vitamin a deficiency reduced the _____ in the rods of the retina
rhodopsin
classification of xerophthalmia
dying if the conjunctiva
patches of xerosis give the appearance of sandbanks at receding tide
the conjunstiva loses its shiny lustre and often becomes thickened, wrinkled, and sometimes pigmented
conjunctival xerosis (X1A)
classification of xerophthalmia
sometimes accompanying the conjunctival xerosis
usually triangular-shaped, raised whitish plaques that occur in both eyes
bitot’s spots (X1B)
classification of xerophthalmia
when examined closely they look like a fine foam with many tiny bubbles
this foamy, sticky material can be wiped away
bitot’s spots (X1B)
