Exam 1 Flashcards
What is undernutrition? Overnutrition?
-20% above or below the optimal nutritional level
What is morbid obesity?
- 100% above the optimal body weight
- criteria for bariatric surgery
What is another name for overnutrition?
-obesity
What is overnutrition considered?
-malnutrition
What is Marasmus?
- wasting syndrome
- inadequate intake of protein and calories
What are examples of Marasmus?
- starvation
- anorexia
- bowel obstruction
- cancer cachexia
What are the keys of Marasmus?
- loss of subcutaneous fat
- effects on every organ system
- no edema
- decrease of anthropometric measures and weight
What is Kwashiorkor?
-eating enough calories but not enough protein
What are the keys of Kwashiorkor?
- edema
- appear in normal range of anthropometric measurements
- may even appear on the overweight side
What is Marasmus-Kwashiorkor mix?
-prolonged inadequate intake of calories and protein
What are the keys of Marasmus-Kwashiorkor mix?
- muscle wasting
- visceral muscle and fat loss
- immune incompetence
- high morbidity and mortality rate
When is Marasmus-Kwashiorkor seen?
- severe burn patients
- extensive surgery patients
- prolonged starvation patients
What are the ways of Nutrition Screening?
- 24-hour diet recall
- food frequency questionnaire
- food diaries- recorded every calorie for 2-3 weeks
- direct observation
Who is the Food Guide Pyramid not applied to?
-sick people
What are some examples of subjective data in a health history?
- eating patterns
- usual weight
- change in appetite
- recent trauma
- chronic illness
- vomiting, nausea, diarrhea
- allergies
- medications or supplements
- self-care behaviors
- alcohol or drug use
- exercise patterns
- family history
What are some examples of objective data in a health history?
- anthropometric measures: height, weight (ideal, current)
- skin fold thickness (3x and take the average)
- MAC (mid-upper arm circumference): muscle mass to fat storage
Why is a 2-1 waist to hip ratio dangerous?
-it can lead to diabetes, cardiac death, and other obesity-related diseases
What are some of the Laboratory Studies?
- hemoglobin
- hematocrit
- iron deficiency
What do you use in an inspection? Keys?
- all of your senses
- unhurried
- good lighting
- from head to toe
What are the different inspection techniques?
- palpation
- percussion
- auscultation
When is palpation used?
-to examine parts of the body under the skin
How deep is light palpation and when is it used?
- up to 1cm deep
- superficial rash
- visible lump
- pulse
How deep is deep palpation and when is it used?
- 2-4 cm; deeper if patient has more subcutaneous adipose tissue
- organs, distension, abdominal tenderness
When is palpation with the back of the hand used?
-when feeling for temperature
When is palpation with the sides of the hands used?
-when feeling for vibration
When is percussion used?
-when listening to the vibration of the stationary hand after the striking hand has hit it
What are the different sounds of percussion notes?
- resonant
- hyperresonant
- tympany
- dull
- flat
What does resonant sound like and when is it normal?
- clear, hollow, low pitched
- adult lung tissue
What does hyperreasonant sound like and when is it normal?
- louder, hollow, low pitched
- child lung tissue (excess of air)
What does tympany sound like and when is it normal?
- loud, high pitched, drumlike
- abdomen
- hollow organs
What does flat sound like and when is it normal?
- soft, high pitched
- muscle, bone, tumor
What does dull sound like and when is it normal?
- muffled, thud
- dense organs like the liver and spleen
What is auscultation?
-using a stethoscope to examine a patient
What sound does the diaphragm listen for and what does it listen to?
- high pitch sounds
- breathing
- bowel
- normal heart sounds
What sound does the bell listen for and what does it listen to?
- low pitch sounds
- extra heart sounds
What should not happen when listening with a stethoscope?
- no rubbing
- no clothes in the way
- no shivering
What are some behaviors that can be changes because of mental status?
CLMOAMATTP
- consciousness
- language
- mood
- orientation
- attention
- memory
- abstract reasoning
- thought process
- thought content
- perception
When do you need to perform a full mental status examination?
- behavioral change
- brain lesions
- aphasia
- symptoms of psychiatric mental illness
What objective data does a nurse record when examining for mental health status?
- posture
- body movements
- dress
- grooming and hygiene
- level of consciousness
- facial expression
- speech
- mood and affect
What are the levels of consciousness?
- alert
- lethargic
- obtunded
- stupor or semi-coma
- coma
- delirium or acute confusional state
What does someone who is alert look like?
- awakens easily
- aware of environment
- responds to stimulus
What does someone who is lethargic look like?
- drifts off to sleep when not stimulated
- responds slowly to name
What does someone who is obtunded look like?
- physical contact needed
- sleeps most of the time
- difficult to arouse
- remains sleepy
- speech can be mumbled
What does someone who is semi-coma look like?
-responds only to contact and appropriate response to pain only
What are some cognitive functions that a nurse might directly observe when evaluating a patients mental health status?
- orientation
- attention span
- recent memory
- remote memory
- new learning/ four unrelated word test
- judgment
What are some thought processes and perceptions that a nurse might directly observe when evaluating a patients mental health status?
- thought processes
- thought content
- thought perceptions
- screening for suicidal thoughts
What are the different lymph nodes of the head and neck?
- preauricular
- posterior auricular
- occipital
- submental
- submandibular
- jugulodigastric
- superficial cervical
- deep cervical
- posterior cervical
- supraclavicular
When are lymph nodes the most palpable?
-when they are enlarged
What does it mean most often when lymph nodes are soft and tender?
-infections
What does it mean most often when lymph nodes are hard and fixed?
-leaning towards cancer
What are some examples of subjective data when relating to the head and neck region?
- headache
- head injury
- dizziness
- neck pain, ROM limitation
- lumps or swelling
- history of head or neck surgery
What are some questions to ask relating to head or neck pain?
- when did it start
- how sudden
- how painful
- was there an injury
- what happened after that injury
Where are some places to inspect related to the head and neck area?
-insect and palpate the size and shape of the skull
-focus on temporal area
inspect the facial structures for abnormalities, lesions, and tics
-inspect and palpate the symmetry, ROM, lymph nodes, trachea, thyroid gland of the neck
What are some characteristics of a normal trachea? three m
- midline
- move up with swallowing
- mobile
What are some abnormal findings related to the head and neck region?
- parkinsons
- cushings syndrome
- hyperthyroidism
- hypothyroidism
- bells palsy
- cerebrovascular accident
- cachectic appearance
- scleroderma
What are the symptoms of cushings syndrome?
- moonlike appearance
- red cheeks
What are the symptoms of hyperthyroidism?
- goiter
- bulging eyes
- nervous
- fatigue
- weight loss
What are the symptoms of hypothyroidism?
- aka myxedema
- edema around the eyes
- dry skin
- course hair
What are the symptoms of cachectic appearance?
- dehydration
- skinny
- sunken eyes
What are the symptoms of scleroderma?
-hardened skin
What is the purpose of taking a health history?
- to collect, document, and analyze
- helps determine scope of practice
What are the expanding assessment factors?
- growth and development
- biophysical status
- emotional status
- cultural and religious background
- performance of ADLs
- patterns of coping
What are the four types of data to collect?
- complete health history
- problem-centered data base (only addressing the problem you come in for)
- follow up data base
- emergency data base (getting as much info as possible while addressing vitals and critical areas)
What are the two frequencies of assessments?
- annual checkups
- age-specific charts for periodic health examination (focuses on major risk factors specific for each age group)
What are four things to get in the health history?
- biographical data
- source of history
- reason for seeking care
- present health or history of present illness
What are the critical characteristics of a symptom?
PQRSTU
- provocative or palliative
- quality or quantity
- region or radiation
- severity scale
- timing
- understand patients perception
What are the different body areas to review?
- overall
- skin
- hair
- head
- eyes
- ears
- nose and sinuses
- mouth and throat
- neck
- breast axilla
What are the different body systems to review?
- cardiovascular
- peripheral vascular
- gastrointestinal
- urinary system
- genital system
- sexual health
- musculoskeletal
- neurologic
- hematologic
- endocrine
What are some factors of functional assessment?
SASNSIC
- self-esteem, self-concept
- activity, exercise
- sleep, rest
- nutrition, elimination
- spiritual resources
- interpersonal relationships, resources
- coping and stress management
What are the personal and social history factors of functional assessment?
- personal habits
- alcohol
- street drugs
- environment, hazards
- intimate partner violence
- occupational health
- perception of health
