Nutrition,feeding,and vital signs

• Anthropometry
• Biochemical test
• Dietary history
• Health history
• Clinical signs

Measurement system of the body size and make up

• Test for plasma protein measurement
• Nitrogen balance
• Hgb levels
• Electrolyte levels

• Eating habits
• Preferences
• Allergies

• Clt illness
• Activity level to determine energy requirements
• Health status
• Age
• Cultural background
• Socioconomic status
• Food preferences
• Alcohol use
• Herbal or other medications
• Nutrition knowledge

• Key to nursing assessment.
• Dry skin/edema
• Obesity/anorexia
• Fatigued
• Irritability
• Inattention
• Weak
• Inability to walk

• Nutritional assessment tool to measure weight, corrected for height
•    BMI = Client's Weight (kg)                                                                                                     Client's height (meters)²

• Caloric theory approach
• Glycemic index approach

• Calories measure the amount of energy that is released as food is broken down(metabolized)
•  Basal Metabolic rate (BMR) - energy requirement of a person at rest
• Emergency Balance
• - Maintaining the same weight =calorie used
• -Gain weight = calories in > calories used
• -Lose weight = calories in< calories used

• Measures how quickly blood glucose level rise after eating a carbohydrate
• Hyperglycemia - rapid increase of glucose in the blood

Eat only foods originating from plant source

In addition to plant source foods, will also eat dairy products and eggs.

In addition to Vegan, Lacto-ovo, it includes fish.

• Clear juices - apple juice, cranberry
• Clear broth
• Jello
• Pop
• Tea
• Popsicles

• Liquids of foods that turn to liquid at bosy temperature.
• Ex. Clear liquid plus
• -Milk
• -Cream
• -Yogurt
• -Pudding
• -Custard
• -Ice cream
• -Pureed vegetables
• -smooth peanut butter
• -Refined cereal

• Foods that are soft, wasy to chew and digest
• Ex. - Full liquid plus
• -soft cooked vegies
• -Stew
• -Ground beef
• - Fish
• -Spagetti
• -Caned fruit
• -Banana

• Determine the clients Health status
• Create a baseline reference
• Monitor a condition
• Identify issues
• Evaluate the effectiveness of an intervention

• On admission
• According to institutional policy/as ordered by physicians
• Before and after:
• -Surgical procedures
• - invasive diagnostic procedures
• - meds that affects VS
• -interventions that might affect VS(ex. blood transfusion)
• Any change in client condition - Ex. dizziness, or feeling funny

• Temperature of deep tissues and organ
• Ex. rectum, tympanic membrane, tempral artery, esophagus, pulmonary artery and uninary bladder.

• Fluctuates depending on blood flow to skin and heat lost to the external environment
• Ex. skin, mouth, axillae

• The balance between heat lost and heat produced by the body
• Anterior Hypothalamus controls - heat loss mechanism.
• Posterior Hypothalamus controls - heat production

• Cellular metabolism - heat is a by-product of chemical reactions in all body cells
• .Heat Porduce suring:
• - Rest (BMR)
• -Voluntary movement
• -Involuntary movement
• -Non-shevering thermogenesis(infant 0-2wk)
• Physical activity increase metabolic rate
• If metabolic rate increase, then heat is produce.

Heat produced by the body at absolute rest

Muscle activity during exercise increase BMR significantly and produce heat 50 times normal.

• SHIVERING
• Can produce 4-5 times heat production than normal, and therefore deplete a very fragile client's energy reserves

Infant less than 2 wks unable to shiver. Rely on vasoconstriction through an increase in norepinephrine

• Body skin exposure to:
• -Radiation
• -Conduction
• -Convection
• -Evaporation

• When body feels warm and want to release heat.
• Dilates blood vessels and closer to the skin surface.

• When body feels cold and want to keep warn temperature in the body
• Contrict blood vessels and away tot he skin surface

• An alterration in the hypothalamus "set point" for normal. The point is set above normal
• 3 phase of fever:
• -Phase1 - the chill phase
• -Phase2 - fever phase
• -Phase3 - Resolution phase

Pyrogen triggers the immune system to cause a rise in the body temp

Chill phase resolve as body reaches the new set point, and client feels warm and dry.

• As pyrogens are removes or destroyed, the hypothalamus set point drops to normal, initiating heat lost "Fever breaks"
• Ex. sweeting

• Hyperthermia
• Heat exhaustion
• Heat stroke
• Hypothermia
• Frosbite

Elevated(high) body temperature r/t body inable to promote heat lost or reduce heat production.

Profuse diaphoresis leads to loss of water and electrolytes

Prolonged exposure to sun or high temperature overwhelm body's heat/loss mechanisms. heat depresses hypothalamus function

• Environmental condition overwhelm body mechanisms - core tem, drops below normal
• Ex. falling to ice

• Exposure of body to subnormal temp(low temp).
• Ice crystals formation inside cell can result in permament circulatory and tissue damage
• Common areas: ear lobes, fingers, nose and toes.

• Oral
• Axillary
• Tympanic membrane
• Rectal

• Most accessible
• Comfortable
• Reflects rapic changein core temp.
• Disadvantage:
• -Inaccurate if not held in the mouth correctly
• -Not use after oral surgery
• -Not to be used for infants, small children, confused clt, comatose clt.
• -Reading affected by hot/cold food and drink

• Safet and non-invasive
• Can be used with new borns and uncooperative clt
• Disadvantages:
• - Usually 0.5 below oral
• -Must expose torso to obtain reading
• -During rapid temperature changes, axial slower to refect core changes.
• -Not recomended to detect fever in infant and young children

• Argued to be more reliable if oral not able to be obtained
• Usually 0.5^oC above oral
• Disadvantages:
• -Not to be used with diarrhea, rectal surgery, rectal disorder, or bleeding disorfer
• -Special positioning required
• -Risk of exposure to body fluids

• Normal adult rage = 60-100 beats/min.
• Higher = tachycardia
• Lower = bradycardia

• Small bolus of blood flow that can be felt
• Its a measurement of the rate that blood is being pumped through the body

Volume of blood pumped out by the heart during 1 minute

• Temporal
• Coratid
• Apital
• Brachial
• Radial
• Ulnar
• femoral
• Popliteal
• Posterior tibial
• Dorsalis pendis
• 

• 1 Repiratory CYCLE = 1 inspiration + 1 expiration
• Normal adult rate = 12-20 breaths per min.
• Apnea - absence of breathing

• Inspiration
• Expiration

• Contration of diaphram, lung area enlargement, vacuum suck air into the lung
• Active process

• Diaphram relaxes, elastic ling tissue return to original shape, air moves out
• Passive process

• Ease/Effort - normally effortless
• Dyspnea - difficult breathing
• Orthopnea - need to sit up to breath

• Breath Sounds - normally quite
• Wheezes
• Crackles
• Rub
• Cough

LED probe that detects the amount of oxygen bound to the hemoglobin and calculates the pulse saturation (SpO₂)

• The force exerted on the walls of an artery by the pulsing blood under pressure from the heart
• Normal adult range = 120/80
• Systolic = <140
• Diastolic = <90
• Hypertensive = systolic >140/diastolic >90
• Hypotensive = systolic <90

the resistance to blood flow is determined bu the tone of the muscle layer in the blood vessels and the blood vessel diameter

Thinkness of blood affects the ease with which blood flows through small vessels

Arteries are normally elastic and easily distensible (stretch)