there is a decrease in nutritional requirements due to loss of lean body mass, the most metabolically active tissues and an increase in fat mass
cultural awareness in nutrition restrictions
buddhism- no meat
catholicism- ash wednesday, good friday and other holy days have restrictions
hinduism-beef pork and some forms of fowl, alcohol, garlic and onions by some, red colored foods (tomatoes, etc)by some
islam-all pork and pork products, meat not slaughtered according to ritual, alcoholic beverages and products (vanilla extract),coffee and tea, food and beferages before sunset during Ramadan
mormon-alcoholic beverages, caffeinated beverages, medicines containing caffeine or stimulants or alcohol
othodox judaism-all pork/pork products, meat not slaughtered according to ritual, all shellfish, dairy products and meat at same meal, leavened bread and cake during passover, food and beverages on yom kippur
seventh day adventist- all pork/pork products, shellfish, meat/dairy products/eggs by some, alcoholic beverages, coffee and tea, highly seasoned foods
purpose of nutritional assessment
1- identify individuals who are amalnourisehed or are at risk of developing malnutrition
2- provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition
3- establish baseline data for evaluating the efficacy of nutritional care
may be completed in any setting, based on easily obtained data
weight, weight history, conditions associated with increased nutritional risk, diet information and routine laboratory data
3 meals a day are not sufficient intake so snacks are good way to achieve enough intake
infants and children nutrition
children 2 and under should NOT drink skim or low fat milk because calories and fatty acids are needed for proper growth and development of the central nervous system
comprehensive nutritional assessment
dietary history and clinical information, physical examination for clinical signs, anthropometric measures and laboratory tests.
24 hour recall
easiest and most popular method for obtaining infomation about dietary intake
errors may occur when pt or family does not remember intake, they alter truth, snacks and gravies may not be recorded, intake may be different than usual intake
multiparous woman with pregnancies occurring less than one year apart has an increased risk of depleted nutritional reserves
recommended weight gain of 25-30 lbs for normal weight; 28-35 for underweight and 15-25 for overweight
<18.5 = underweight
18.5-24.9 = normal weight
25-29.9 = overweight
30-39.9 = obesity
40+ = severe obesity
>35 in women and >40 in men = increase risk of cardiovascular and metabolic diseases
estimate of body fat stores or the extent of obesity or undernutrition
biceps, subcapsular, suprailiac skinfolds can be used but triceps skinfold (TSF) is most common
values 10% above or below = under or overnutrition respectively
Midupper arm circumference (MAC)
estimates skeletal muscle mass and fat stores
midarm muscle area (MAMA)
good indicator of lean body mass and skeletal protein reserves
measures bone density
measures body composition
measuring frame size
elbow breadth = skeletal breadth and is most accurate method to measure to determine frame size
used to determin iron deficiency anemia
increased hemoglobin levels= polycethemia vera or dehydration
decreased hemoglobin levels= anemia, recent hemorrhage, hemodilution by fluid retention
measure of cell vloume, also indicator of iron status
low value=low hemoglobin formation
measured to evaluate fat metabolism and assess risk of heart disease
used to screen for hyperlipidemia and to determine risk of heart disease
these are age related
total lymphocyte count (TLC)
most common used test of immune function
important indicator of visceral protein status
to verify immunity to antigens
test is positive if response is 5mm or greater-commonly candida, tetanus, diptheria,strep,tuberculin,proteus,trichophyton
positive= malnutition, hepatic falure, infection and immunosuppressive drugs
measurement of visceral protein status
normal serum albumin in children older than 6 months and adults ranges from 3.5-5.5g/dl
low levels= protein/calorie deficiency, dehydration, decreased liver function
<2.8g/dl = severe depletion
consider persons history if this number is off because it can easily be altered
Clubbing of nails occurs with congenital chronic cyanotic heart disease
and with emphysema and chronic bronchitis, and is greater than 180 degrees.
happens with fever, local inflammation, emotional reactions
yellowing of the skin due to increased serum bilirubin from liver inflammation or hemolytic disease such as after severe burns or some infections
jaundice in the sclera of the eye
basal cell carcinoma
usually stars as a skin colored papule, with translucent top and overlyig telangiectasia. then develops rounded pearly borders with central red ulcer. looks like large open pore with central yellowing, most common form of skin cancer, slow but inexorable growth
squamous cell carcinoma
Squamous Cell Carcinoma is erythematous scaly patch with sharp margins, 1cm or more.
Usually on hands or head, areas exposed to solar radiation. Less common than
basil cell carcinoma but grows rapidly.
forms from preexisting nevi; usually brown but can be any color, even mixed
pigmentation; maybe scaling, flaking, oozing
inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord, usually due to the spread of an infection. The swelling associated with meningitis often triggers the "hallmark" symptoms of this condition, including headache, fever and a stiff neck. Most cases of meningitis are caused by a viral infection, but
bacterial and fungal infections also can lead to meningitis. Depending on the cause of the infection, meningitis can resolve on its own in a couple of weeks— or it can be life-threatening
The largest of the three pairs of salivary glands. It lies within the cheeks in the front of the ear extending from zygomatic arch down to the angle of the jaw. It secretes saliva from its duct, Stensen’s duct, which runs forward to open on the buccal mucosa opposite the second molar.
IS KNOWN TO BE FOUND IN AIDS PTS
Occurs with accelerated or turbulent blood flow. In the thyroid gland, indicates hyperplasia of the thyroid (e.g.hyperthyroidism). In the vascular system p.540: a bruit occurs with partial occlusion. In the Carotid artery p. 498: bruit identified as swishing blowing sound and indicates turbulence due to a local vascular cause such as atherosclerotic narrowing. In the abdomen, p. 571, the presence of any vascular sounds must be checked, especially in people with hypertension.
how do you manage an enlarged thyroid?
Auscultate for a presence of a bruit
Usually not palpable; if they are enlarged usually palpable before swallowing, or too tender to palpate
Q: A pt noticed a lump above her adams apple that seems to be getting bigger during
the assessment the findings reassures the nurse that it may not be a cancerous
thyroid nodule is that the lump is
A: Mobile and not hard
what does lymphadenopathy feel like?
Lymphadenopathy is an enlargement of the lymph nodes (greater than 1 cm) from infection, allergy, or neoplasm. Feels enlarged and tender.
Check the area for the source of the problem. For example, those in the upper cervical or submandibular area often relate to inflammation or neoplasm in the head and neck. Follow up on or refer your findings. Enlarged lymph node,
particularly when you cannot find the source of the problem, deserves attention.
Q: an Enlargement of the lymph nodes greater then 1cm from an infection, allergy, or
what is temporal arteritis?
Temporal artery is on bone between eye and top of ear, but it feels hardened, tortuous, and tender
on old olympus tiny tops a finn and german viewed some hops
some say marry money but my brother says boobs matter more
XI:spinal accessory- shrug shoulders, face against hand
XII:hypoglossal- stick tongue out and move side to side
what is normal intraocular pressure?
Glaucoma is increased intraocular pressure, which is abnormal
Determined by a balance between the amount of aqueous produced and
resistance to its outflow at the angle of the anterior chamber
how do you test visual accomodation?
Corneal light reflex: Shining a penlight towards eyes in the same place to the other eye; have patient stare straight ahead; See bright white dots
Confrontation test: Measures peripheral vision
6 Cardinal signs
what is presbyopia?
Glass-like quality decreases lens’ ability to change shape to accommodate for near vision” with aging
When patient needs to move card (or whatever is needing to be read), farther away
what are floaters?
Common with myopia or after middle age as a result of condensed vitreous fibers
Usually not significant but acute onset may occur with retinal detachment
what is the eustachian tube and its function?
An opening in the ear that connects the middle ear with the nasopharynx and allows the passage of air
Tube is normally closed but it opens with swallowing or yawning
what does the middle ear do?
Conducts sound vibrations from outer ear to central hearing apparatus in the inner ear
Protects the inner ear by reducing the amplitude of loud sounds
Eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (Ex: during altitude changes in an airplane)
what is the importance of air conduction?
Air conduction is most efficient Pathway: Sounds waves produce vibrations on the tympanic membrane and are carried by the ossicles in the middle ear, it travels up the coils of the cochlea; On the way it vibrated the basilar membrane to signify frequency; The fibers on the basilar membrane (organ of Corti) are bent from vibrations and turns into electric impulses, sending signal to brain; the function of the cortex interprets the meaning of sound and begins appropriate response.
Vibrations transmitted directly to inner ear and cranial nerve VIII
what is sensory or neural hearing loss?
Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex
Simple increase in amplitude may not enable patient to understand words
May be caused by presbycusis, a gradual nerve degeneration that occurs with aging
what is the purpose of ciliated mucous membrane?
Nasal cavity lined with blanket of ciliated mucous membranes
Filters inhaled air by sweeping out dust and bacteria
Bronchi are lined with cilia which sweeps particles upwards where they can be swallowed or expelled
what holds the tongue in the mouth?
Frenulum is a midline fold of tissue that connects the connect to the floor of the mouth
where are the salivary glands located?
Parotid gland (the largest): lies within the cheeks in front of the ear extending from the zygomatic arch down to angle of jaw
Submandibular gland (size of walnut): lies beneath the mandible at the angle of the jaw
Sublingual (size of almond): under the tongue
what are deep crypts in tonsils?
Tonsil Crypts are small pockets that form on the outside of your tonsils.
Same color as surrounding mucous membranes, look more gradular
These pockets or tonsil crypts collect debris, ike the mucus from nasal drip as well as food particles
what is xerostomia?
Dry mouth”; side effect of many drugs like antidepressants, antihypertensive, bronchodilators
what part of breast is most important?
Tail of Spence = cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.
The upper outer quadrant is the site of most breast tumors
what are normal hormonal changes for women?
Adolescents- at puberty, estrogens stimulate the growth of cells in
the reproductive tract and the development of secondary sex characteristics
Aging female- Ovaries stop producing progesterone and estrogen.
During menopause bring dramatic physical changes. Uterus shrinks; vagina becomes shorter, narrower and less elastic.
Secretion of estrogen and progesterone decreases causing the breast glandular tissue atrophy
what is gynecomastia?
Non-inflammatory enlargement of breast tissue in male
Usually affect 1 breast and temporary at puberty
Occurs with use of anabolic steroids, some medications, and some disease states
Common in aging male due to hormonal changes, bilateral and may be tender
occurs with hormone stimulations, Cushing’s syndrome, cirrhosis of liver, leukemia occasionally, sometimes with medication
Person is sitting, leaning forward slightly. Person should breath through the mouth, a bit deeper than usual, but to stop if he/she begins to feel dizzy. Listen to one full respiration in each location.
Use flat diaphragm end piece of stethoscope and hold it firmly on person’s chest wall.
what is short popping sounds that stop after deep breathing and may occur right after waking up from sleep?
Atelectatic crackles – sound like fine crackles but do not last and are not pathogenic. Disappear after the first few breaths.
Only heard in periphery (axillae and bases), usually dependent portion of the lungs
direction of blood flow through the heart
Unoxygenated blood (systemic veins) → Superior Vena Cava/Inferior
Vena Cava R. atrium→ R. ventricle→ Tricuspid valve → Pulmonic valve → Lungs by
valve → L. ventricle → Aortic valve → Systemic circulation
valves of the heart
4 valve2 AV (atrioventricular) valves separate atria and ventricles: R =Tricuspid; L = Mitral
2 SL (semilunar) valves separate ventricles and arteries: R =
electrical sequence of heart
SA nodes (pacemaker) →AV node → Bundle of His →R&L bundle branches
Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and
needing to be upright to achieve comfort
Relates to cardiac problems
Q: A 65 yr old pt is awaken from sleep with SOB what would the nurse do?
A: A test for PND or Paroxysmal nocturnal dyspnea
Q: A 45 yr old man is going for a routine physical during the history the pt states he is having difficult breathing, sleeps fine, and then wakes up and cant catch his breath. The nurses best response would be
A: Do you have any history of problems with your heart
risk factors for heart disease?
Sedentary lifestyle (physical inactivity)
High blood pressure
High cholesterol levels
Oral contraceptives and postmenopausal hormones
Blacks → White→ Mexican-American
Q: During a cardiac assessment on an adult pt in the hospital for chest pains the nurse finds the following jugular veins 4 cm above the sternal angle when elevated at 45 degrees, Bp of 98/60, HR 130, angle edema, difficult breathing when suspine, and a S3
A: Heart failure
difference between S3 and S4
(pg. 518) – ventricular filling sound.
Occurs early diastole during rapid filling phase
Heard best at apex or lower left sternal border; the split S2 at base (heard right after S2)
Dull, soft sound, low pitched (lower than S2)
May be physiologic (normal) = in children and young adults
May be pathologic (abnormal) = in adults usually, S3 gallop, increase compliance of ventricles, (heartfailure), L/R ventricle, L-sided S3 at apex in left lateral position, R-sided S3 at LL sternal border and louder with inspiration
(pg. 519) – ventricular filling sound. Occurs when atria contract late in
Heard immediately before S1
Very soft, very low pitched
Heard best at apex, left lateral position
Physiologic = adults >40/50 years old with no evidence of cardiovascular
Pathologic = atrial gallop or S4 gallop, decreased compliance of ventricle & systolic overload (after load), outflow obstruction of ventricles (aortic stenosis), systemic HTN – L-sided
R-sided S4 = less common, heard at LL sternal border and may increase with inspiration, occurs with pulmonary stenosis or pulmonary HTN
Know all about apical pulse, assessing the carotids for bruits
PMI (pg. 501)– pulsation created as the left ventricle rotates against the chest wall during systole
Location: 4th or 5th intercostals or medial to midclavicular line
Size: 1 cm x 2 cm normally
“exhale and hold”
Short gentle tap, occupies only 1st ½ of systole
Not palpable in half of adults especially those who are obese or with thick chest walls
TEST QUESTION: Can be seen in vestibular exam- Urethral meatus and vaginal orifice.
Internal: vagina, (9cm), rugae, cervix (covered in smooth, pink,stratified squamous epithelium), os (covered with columnar epithelium),squamocolumnar junction, anterior/posterior fornix, retouterine pouch (cul-de-sac of Douglas), uterus, fallopian tubes, ovaries
Excessive fat in the stool as in malabsorption of fat
exected symptoms with menopause:
Cessation of the menses, around age 45-51.
Female hormones decrease rapidly
Preceding 1-2 yrs of decline in ovarian function (irregular menses become father apart and lighter flow)
Ovaries stop producing progesterone and estrogen (causing dramatic physical changes)
Uterus shrinks due to ↓myometrium
Ovaries atrophy to 1-2cm and not palpable
Ovulation may still occur
Sacral ligament relax and musculature weakens, uterus droops (may protrude prolapsed into vagina)
Cervix shrinks and paler with thick, glistening epithelium
Vagina shorter, narrower, and less elastic
Without sexual activity, vagina atrophies half its former length and width
Vaginal epithelium atrophies, becomes thinner, drier, and itchy
Risk for bleeding and vaginitis (dry irritations and pain with sex– dyspareunia)
pH more alkaline
Mons pubis smaller
labia and clitoris ↓ in size
pubic hair thin and sparse
Orgasms shorter, resolution more rapid, vaginal secretions andlubrication reduced
What is blood flow disturbance and how do u assess it?
Q: A 30 yr old women with a history of MVP states she is very tired the nurse palpates a thrill and lift at the 5th intercostals space and midclavicular line and in the same area the nurse hears a blowing, swishing sound at S1. These findings are most consistent with