NUTRITION TOOLS, STANDARDS, AND GUIDELINES NUTRIENT Flashcards
seeks to guarantee that all patients get prompt and uniform nurse evaluations
PHYSICAL ASSESSMENT
• Provide care for client that use individualize, holistic, effective and efficient.
PHYSICAL ASSESSMENT
- Initial assessment
- Problem-Focused
- Emergency
- Time-Lapsed
4 TYPES OF ASSESSMENT
age and developmental stage of the child.
PA considerations
Implement behaviors that show respect for child’ s age, gender, cultural values and personal preferences.
PA considerations
• Modify language and communicate style to be consistent with child’ s needs.
PA considerations
• Modify language and communicate style to be consistent with child’ s needs.
PA considerations
Gather as much information as possible by observation first
PA considerations
important to all levels of nursing practice.
PHYSICAL ASSESSMENT
an essential skill that falls within the scope of nursing practice. It can be helpful because it can help determine the status of your health.
PHYSICAL ASSESSMENT
help you have open communication with your doctor and give you an opportunity to share information about your symptoms and overall health.
PHYSICAL ASSESSMENT
help you assess which areas of your health need attention so they don ’t cause bigger issues later on.
PHYSICAL ASSESSMENT
• Blood Pressure
• Cholesterol
• Blood glucose level
• Body mass index
PHYSICAL ASSESSMENT example
- Inspection
- Palpation
- Percussion
- Percussion
4 TECHNIQUES USED IN PHYSICAL ASSESSMENT
It involves using vision to differentiate between normal and abnormal discoveries. Examining body parts for color, shape, symmetry, motion, and texture
Inspection
It involves the use of hands to touch body parts for data collection. It detects body temperature, moisture, turgor, texture, tenderness, thickness, and distention.
Palpation
It is the technique in which one or both hands are used to strike the body surface to produce a sound called percussion note. The character of the sound determines the location, size and density of underlying structure to verify abnormalities.
Percussion
It is a general term that refers to the process of listening to the sound within the body , usually using a stethoscope
Auscultation
SKIN
HAIR
NAILS
INTEGUMENTARY
client’ s skin is consistent in tone, free of blemishes, and feels pleasant. He has healthy skin turgor and a normal range for skin temperature.
SKIN
thick, silky hair that is uniformly spaced out and varying amounts of body hair. Additionally, no evidence of illness or infestation has been found.
HAIR
are light brown and have a convex curve in their shape. It is smooth and the epidermis is still present.
NAILS
revert to their normal color in less than 3 seconds when pushed between the fingers (Blanch Test).
NAILS
The customer has a rounded, symmetrical, normocephalic head.
HEAD
• When the skull is palpated, there are no nodules, masses, or depressions.
HEAD
uniformly smooth, without any nodules or lumps, and with consistent consistency.
FACE
Make sure there is good communication between management and staff
VISION AND THE EYES
hair is spread equally
equivalent amount of movement
Eyebrows:
even distribution and a modest outward curl.
Eyelashes
no discharges, no discoloration, and closed symmetrically with 15-20 unconscious blinks a minute.
Eyelids
translucent and had few visible capillaries.
Bulbar conjunctiva
white
sclera
pink, lustrous, and smooth.
palpebral conjunctiva
neither torn or edematous.
lacrimal gland
PERRLA
pupils
round and flat.
iris
moved parallel to one another and in synchrony when the extraocular muscle was tested.
eyes
symmetrical
Color same as facial skin
aligned with the outer canthus of the eye
Movable, firm and not tender
Pinna recoils after it is folded
Auricles
Distal third contains hair follicles and glands
Pearly gray color, semitransparent
External Ear Canal and Tympanic Membrane
Normal voice tones audible
Able to repeat the phrases correctly in both ears
Gross Acuity Test
heard in both ears or is localized at the center of the head (Weber negative)
Weber’s test
o Air-conducted hearing is greater than bone-conducted hearing (positive Rinne)
• Rinne test
• Symmetric and straight
• No discharge or flaring
• Uniform color
• Not tender; no lesions
• Air moves freely as the client breathes through the nares
• Mucosa pink
• Clear watery discharge
• Nasal septum intact and in midline
Nose
Not Tender
Facial Sinuses
• Symmetrical anterior thorax
• no thorax deformities, masses, or swelling
• Loud, high-pitched bronchial breath sounds over the trachea.
• Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung fields
Thorax and Lungs
• Dome-shaped abdomen
• Soft to palpation
• There are no visible lesions or scars
• The aorta is midline without bruit or visible pulsation.
Abdomen
length and size are symmetrical
without swelling or erythema.
atraumatic in appearance without tenderness or deformity.
Full range of motion is noted to all joints.
Muscle strength is 5/5 bilaterally.
EXTREMITIES
equipment used to measure various bodily components such as muscle, bones, and adipose tissue or body fat.
ANTHROPOMETRIC MEASUREMENTS TOOL
Tool comprised of rods that can be configured for many body measurements.
may reference a small or large bone
Anthropometer
a tool to measure the lengths of the human body.
Anthropometer
a sliding caliper usually between 140-200mm used to measure width of small bones, such as wrist, knee, elbow, ankle.
Small Bone Anthropometer
measures knee height and other bone lengths, such as forearm
Segmometer
used to locate the midpoint of upper arm for body test measurement
Segmometer
usually has a 3m range and is the size of a standard handheld tape measure for easy transport.
Segmometer
a sliding caliper usually with a range of 600mm used to measure large bones, such as shoulder width and chest depth. Chest depth can also be measured by a breadth caliper.
Large Bone Anthropometer
measures the anterior-posterior chest depth, shoulder, and pelvis, usually has a range of 50cm / 20 inch.
Breadth Caliper
measures the height of bedridden patients, elderly persons, and persons in wheelchairs, by means of measuring the height of the leg
Knee Height Caliper
usually rigid metal and about 80cm long (just under 2.5 ft). It may sometimes be referred to as a rigid segmometer.
Knee Height Caliper
a collection of calipers and measurement instruments for complete anthropometric evaluation
Anthropometry Kit
usually includes a small bone and large bone anthropometer, a stadiometer, anthropometric tape measure, segmometer, and transport case. a complete kit usually includes a skinfold caliper as well
Anthropometry Kit
measure wrist, ankle, waist. Also for locating midpoint of upper arm for body fat testing.
Anthropometric Tape Measure
Has a thin (6mm wide), flat, flexible steel blade with blank space before the zero (6-8cm), and uses the metric system, about 2 meters in length.
Anthropometric Tape Measure
To measure wrist, ankle, waist. Also, for locating midpoint of upper arm for body fat testing.
Anthropometric Tape Measure
• Body fat caliper with jaws that measure the thickness of skinfolds, usually with a range of 60- 100mm.
Skinfold Caliper
• Measure skinfold thickness at multiple sites on the body in order to calculate body fat percentage
Skinfold Caliper
Height Meter a straight vertical meter usually 200- 300cm in length.
Stadiometer
Used to measure height of a person standing up
Stadiometer
includes a variety of healthy foods
healthy eating
the distance from the bottom of the feet to the top of the head in a human body, standing erect.
Height/stature
a measurement of mass
Weight
a measure that relates body weight to height
BODY MASS INDEX (BMI)
A Belgian mathematician who created the formula for BMI
Lambert Adolphe Jacques Quetelet
ho renamed the formula to BMI
Ancel Benjamin Keys
calculated by dividing a person’s height in meters squared by their weight in kilograms.
BMI
for muscle builders, long distance athletes, pregnant women, the elderly or young children.
BMI is not used
BMI is interpreted by using standard weight status categories that are the same for all ages and for both men and women
for adults 20 years and older
Below 18.5
Underweight
18.5 – 24.9
Normal
25.0 – 29.9
Overweight
30.0 and Above
Obese
BMI classifications do not depend on age or sex.
For adults
BMI is interpreted relative to a child’s age and sex, because the amount of body fat changes with age and varies by sex.
For children and adolescents between 2 and 20 years old
Less than 5th percentile
Underweight
5th percentile to less than 85th percentile
Healthy weight
85th percentile to less than 95th percentile
Overweight
Equal to or greater than the 95th percentile
Obese
