Methods of Nutritional Assessment
- 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
- Clt illness
- Activity level to determine energy requirements
- Health status
- Cultural background
- Socioconomic status
- Food preferences
- Alcohol use
- Herbal or other medications
- Nutrition knowledge
- Key to nursing assessment.
- Dry skin/edema
- Inability to walk
Body Mass Index (BMI)
- Nutritional assessment tool to measure weight, corrected for height
- BMI = Client's Weight (kg) Client's height (meters)2
Maintaining a Healthy Weight
- Caloric theory approach
- Glycemic index approach
Caloric Theory 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
Glycemic Index Approach
- Measures how quickly blood glucose level rise after eating a carbohydrate
- Hyperglycemia - rapid increase of glucose in the blood
Vegeterian Diet Vegan
Eat only foods originating from plant source
Vegeterian Diet Lacto-ovo-vegetarian
In addition to plant source foods, will also eat dairy products and eggs.
Vwgeterian Diet Pesco Vegeterian
In addition to Vegan, Lacto-ovo, it includes fish.
Clear Fluid/Transparent Fluids
- Clear juices - apple juice, cranberry
- Clear broth
- Liquids of foods that turn to liquid at bosy temperature.
- Ex. Clear liquid plus
- -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
- -Ground beef
- - Fish
- -Caned fruit
Vital signs are Measured to
- Determine the clients Health status
- Create a baseline reference
- Monitor a condition
- Identify issues
- Evaluate the effectiveness of an intervention
When should we take Vitals?
- 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
Core body temperature
- Temperature of deep tissues and organ
- Ex. rectum, tympanic membrane, tempral artery, esophagus, pulmonary artery and uninary bladder.
Surface temperature of skin
- 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
What is the main source of heat production in the body?
- 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.
Source of heat production: Basal Metabolic Rate (BMR)
Heat produced by the body at absolute rest
Source of heat production: Voluntary movement
Muscle activity during exercise increase BMR significantly and produce heat 50 times normal.
Source of heat production: Involuntary Movement
- Can produce 4-5 times heat production than normal, and therefore deplete a very fragile client's energy reserves
Source of heat production: Non-shivering thermogenesis
Infant less than 2 wks unable to shiver. Rely on vasoconstriction through an increase in norepinephrine
Body loss heat when?
- Body skin exposure to:
- 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
Alteration in temperature: Fever/pyrexia
- 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
Fever Phase 1 - The chill phase
Pyrogen triggers the immune system to cause a rise in the body temp
Fever Phase 2 - Fever phase
Chill phase resolve as body reaches the new set point, and client feels warm and dry.
Fever Phase 3 - Resolution
- As pyrogens are removes or destroyed, the hypothalamus set point drops to normal, initiating heat lost "Fever breaks"
- Ex. sweeting
Other alteration in Temperature:
- Heat exhaustion
- Heat stroke
Other alteration in temperature: Hyperthermia
Elevated(high) body temperature r/t body inable to promote heat lost or reduce heat production.
Other alteration in temperature:Heat exhaustion
Profuse diaphoresis leads to loss of water and electrolytes
Other alteration in temperature: Heat stroke
Prolonged exposure to sun or high temperature overwhelm body's heat/loss mechanisms. heat depresses hypothalamus function
Other alteration in temperature: Hypothermia
- Environmental condition overwhelm body mechanisms - core tem, drops below normal
- Ex. falling to ice
Other alteration in temperature:Frosbites
- 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.
- Tympanic membrane
Measuring temp. at Oral
- Most accessible
- Reflects rapic changein core temp.
- -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
Measuring temp. at Axillary
- Safet and non-invasive
- Can be used with new borns and uncooperative clt
- - 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
Measuring temp. at Rectal
- Argued to be more reliable if oral not able to be obtained
- Usually 0.5oC above oral
- -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
What is pulse?
- 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
Where we take pulses?
- Posterior tibial
- Dorsalis pendis
- 1 Repiratory CYCLE = 1 inspiration + 1 expiration
- Normal adult rate = 12-20 breaths per min.Apnea - absence of breathing
Two Mechanical process of ventilation
- 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
Assessment of Respirations
- Ease/Effort - normally effortless
- Dyspnea - difficult breathing
- Orthopnea - need to sit up to breath
- Breath Sounds - normally quite
Pulse oximetre (SpO2)
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
Physiology of blood pressure: Peripheral Vascular Resistance
the resistance to blood flow is determined bu the tone of the muscle layer in the blood vessels and the blood vessel diameter
Physiology of blood pressure:Blood Voscosity ( thickness)
Thinkness of blood affects the ease with which blood flows through small vessels
Physiology of blood pressure: Arterial Elasticity
Arteries are normally elastic and easily distensible (stretch)