Nutritional Assessment
List risk factors for being undernourished.
Being 85 years of age or older, dental disease, poor appetite, taking more than 10 oral prescription medications daily
What is the best way to determine your clients dietary intake?
Ask them to perform a 24-hour dietary recall.
Describe the ABCDE rule
A - assymmetry
B - border
C- characteristics/color
D - diametr
E - elevation
How to assess for edema
Press in on the skin and normally it should rebound and not remain indented when pressure is released. Graded from 1+-4+ with 4+ being the most severe. 6mm or > is considered 3+ pitting edema.
List factors that influence someones nutritional status.
Socioeconomic status, lack of transportation, cultural/ethnic influences, lack of knowledge about good nutrition.
Symptoms of lactose intolerance
Gas, bloating, abdominal cramping, and heartburn
What are the steps for completing a skin assessment
1. Inspect the skin
2. Palpate the skin and check for edema and skin turgor
3. Inspect and palpate the hair
4. Inspect and palpate the nails and check for capillary refill
How to assess skin turgor
Gently pinch the skin on the clavicle or at the risk. The skin will normally rebound to its normal shape if tenting is noted it should be documented and could indicate dehydration.
Risk factors associated with individuals who are overly nourished or obese.
Cardiovascular disease, Type II diabetes, Hypertension, Cancer, Gallbladder Disease, & Sleep Apnea
A client presents with a low-grade fever and tachycardia and reports not eating or drinking x 24 hours. This client is likely experiencing?
Dehydration
Describe the inspection of the nails and what is normal vs abnormal.
Normally clean and manicured with pink tones and some ridging is normal. Pale or cyanotic nails may indicate hypoxia or anemia.
The normal nail is a 160 degree angle
Clubbing - when the nail bed exceeds 180 degree angle - seen with hypoxia
Which patient population is high-risk for pressure ulcers?
Elderly
Bedridden
Diabetics
What is the recommended daily water intake?
8-8oz glasses/day
List one characteristic related to the elderly population and nutrition.
Muscle tone and muscle mass decrease with aging so they have less subcutaneous fat.
How to check for capillary refill
Press the nail tip then release; normal when pink tone immediately returns and abnormal if it takes > 2 seconds to return.
What are symptoms associated with skin lesions that are concerning and need further evaluation?
Which patient population is at greatest risk for overhydration?
Patients with kidney, liver, and cardiac disease (CHF)
Inspecting the color of the skin. Normal vs Abnormal findings.
Skin should be evenly colored consistent with genetic background.
Pallor - loss of color
Cyanosis - blue-tinged skin and conjunctival sacs; dark skinned people may appear bluish gray.
Erythema - red
Jaundice - yellow
When a nurse identifies/notes a skin lesion what needs to be documented?
Color
Shape and configuration
Size
Location and distribution on body