NRSE 260 EXAM 3 LATEST
What is the risk assessment based on...?
Genetics
Sex
Physiologic factors
Environmental factors
Lifestyle- risk behaviors
Age
When you find risks, then promote health assessments. Like healthy diet,
manage diabeties, exersise, safe sex, immunization
What are the three levels of prevention?
1. Primary- addresses needs to healthy clients to promote health and
prevent disease with specific protections
ex. immunization, nutrition, fitness
2. Secondary- focuses on identifying illness, providing treatment, and
conducting activities that help prevent a worsening health status
ex. TB screening, early detection and promotion of diabetes, exercise
program for older adults
3. Tertiary—aims to prevent the long-term consequences of chronic
illness or disability and to support optimal functioning
ex. prevent pressure ulcers, promote independent after injury,
rehabilitation
Specific health promotion interventions that can be applied to a
variety of clients.
END OF
PAGE
1
, NRSE 260 EXAM 3 LATEST
Examine risk factors—refer clients to educational/community/support
resources. Help them realize benefits and overcome barriers. Advocate
for changes in the community!
Use behavior-change strategies-Identify client readiness to receive and
apply health info. Identify acceptable interventions, help motivate
change by setting up realistic timelines (SMART goals), reinforce steps
toward change, positive reinforcement!! Model healthy behaviors!
Promote healthy lifestyle behaviors—use stress management strategies,
get adequate sleep/rest, eat nutritious diet, maintain healthy weight,
avoid saturated fats, participate in regular exercise, wear protective
clothing/sunscreen while outside, wear safety gear (bike helmets,
knee/elbow pads), avoid tobacco products, alcohol, recreational drugs,
practice safe sex, seek medical care when necessary, get routine
screenings, perform recommended self-exams (breast, testicular)
What factors affect nutrition?
1. Religious and/or Cultural Practices
Limit "approved" foods, guide preparation, require fasting
2. Financial Concerns
Can prevent purchasing nutrient-dense foods
3. Negative Experiences
Previous illnesses related to food or unfamiliarity
4. Environmental Factors
Sedentary lifestyles, work/school schedules, and limited access to
healthy foods
5. Disease/Illness
END OF
PAGE
2
, NRSE 260 EXAM 3 LATEST
Can affect the ability to prepare, swallow, and absorb nutrients
6. Medications
May alter taste and appetite and interfere with nutrient absorption
What are the nutritional developmental considerations regarding
aging adults?
1. ↓ Metabolic Rate --> Less caloric intake needed
2. Increased risk for dehydration --> ↓ Thirst Mechanism & Fear of
Incontinence
3. Diminished hearing/vision and limited mobility --> Food prep
becomes difficult
4. ↓ Calcium Absorption --> ↑ dietary intake of Ca
5. ↓ Gastrointestinal Functioning --> ↑ fiber
Body Mass Index (BMI) Range
- BMI less than 18.5 - underweight
- BMI of 18.5 to 24.9 - normal (or healthy)
- BMI of 25 to 29.9 - overweight
- BMI of 30 or greater - obese.
- BMI does not always account for clients who are lean, such as athletes,
and may overestimate their BMI because muscle weighs more than fat.
Signs that indicate a person is not getting proper nutrition.
- Flaccid muscles
- Changes in mental status
- Loss of appetite with or without nausea and vomiting
- Change in bowel patterns, such as diarrhea or constipation
- The hair and nails may become dry and brittle
END OF
PAGE
3
, NRSE 260 EXAM 3 LATEST
- Gums may become inflamed and bleed
- Dentition may be decaying or missing, with foul breath
- If weight loss is profound and there has been a loss of subcutaneous
tissue, prominent protrusions may be evident in bony areas
- Weakness and fatigue may be present
When should monitoring intake & output occur?
Should be recorded for all clients, while those who have nutritional
deficiencies and fluid & electrolyte imbalances are often placed on
STRICT I&O.
Intake documentation
Intake - Includes oral fluids, foods that liquifies at room temperature
(Jell-O, ice cream, popsicles), IVFs, IV medications, enteral feedings
and catheter/tube irrigants.
Dietary intake is labeled in ounces (oz) but documented in milliliters
(mL)
1oz = 30mL
Output documentation
- Includes urine, blood, emesis, diarrhea, and drainage from tubes and
wounds.
- Weighing Clients - Is one of the most effective methods for monitoring
a client's fluid status.
- Weigh the patient around the same time each morning, after the client
voids.
- Encouraged the client to wear similar clothing each day.
- If using a bed scale, ensure same amounts of linen are on the bed each
END OF
PAGE
4
What is the risk assessment based on...?
Genetics
Sex
Physiologic factors
Environmental factors
Lifestyle- risk behaviors
Age
When you find risks, then promote health assessments. Like healthy diet,
manage diabeties, exersise, safe sex, immunization
What are the three levels of prevention?
1. Primary- addresses needs to healthy clients to promote health and
prevent disease with specific protections
ex. immunization, nutrition, fitness
2. Secondary- focuses on identifying illness, providing treatment, and
conducting activities that help prevent a worsening health status
ex. TB screening, early detection and promotion of diabetes, exercise
program for older adults
3. Tertiary—aims to prevent the long-term consequences of chronic
illness or disability and to support optimal functioning
ex. prevent pressure ulcers, promote independent after injury,
rehabilitation
Specific health promotion interventions that can be applied to a
variety of clients.
END OF
PAGE
1
, NRSE 260 EXAM 3 LATEST
Examine risk factors—refer clients to educational/community/support
resources. Help them realize benefits and overcome barriers. Advocate
for changes in the community!
Use behavior-change strategies-Identify client readiness to receive and
apply health info. Identify acceptable interventions, help motivate
change by setting up realistic timelines (SMART goals), reinforce steps
toward change, positive reinforcement!! Model healthy behaviors!
Promote healthy lifestyle behaviors—use stress management strategies,
get adequate sleep/rest, eat nutritious diet, maintain healthy weight,
avoid saturated fats, participate in regular exercise, wear protective
clothing/sunscreen while outside, wear safety gear (bike helmets,
knee/elbow pads), avoid tobacco products, alcohol, recreational drugs,
practice safe sex, seek medical care when necessary, get routine
screenings, perform recommended self-exams (breast, testicular)
What factors affect nutrition?
1. Religious and/or Cultural Practices
Limit "approved" foods, guide preparation, require fasting
2. Financial Concerns
Can prevent purchasing nutrient-dense foods
3. Negative Experiences
Previous illnesses related to food or unfamiliarity
4. Environmental Factors
Sedentary lifestyles, work/school schedules, and limited access to
healthy foods
5. Disease/Illness
END OF
PAGE
2
, NRSE 260 EXAM 3 LATEST
Can affect the ability to prepare, swallow, and absorb nutrients
6. Medications
May alter taste and appetite and interfere with nutrient absorption
What are the nutritional developmental considerations regarding
aging adults?
1. ↓ Metabolic Rate --> Less caloric intake needed
2. Increased risk for dehydration --> ↓ Thirst Mechanism & Fear of
Incontinence
3. Diminished hearing/vision and limited mobility --> Food prep
becomes difficult
4. ↓ Calcium Absorption --> ↑ dietary intake of Ca
5. ↓ Gastrointestinal Functioning --> ↑ fiber
Body Mass Index (BMI) Range
- BMI less than 18.5 - underweight
- BMI of 18.5 to 24.9 - normal (or healthy)
- BMI of 25 to 29.9 - overweight
- BMI of 30 or greater - obese.
- BMI does not always account for clients who are lean, such as athletes,
and may overestimate their BMI because muscle weighs more than fat.
Signs that indicate a person is not getting proper nutrition.
- Flaccid muscles
- Changes in mental status
- Loss of appetite with or without nausea and vomiting
- Change in bowel patterns, such as diarrhea or constipation
- The hair and nails may become dry and brittle
END OF
PAGE
3
, NRSE 260 EXAM 3 LATEST
- Gums may become inflamed and bleed
- Dentition may be decaying or missing, with foul breath
- If weight loss is profound and there has been a loss of subcutaneous
tissue, prominent protrusions may be evident in bony areas
- Weakness and fatigue may be present
When should monitoring intake & output occur?
Should be recorded for all clients, while those who have nutritional
deficiencies and fluid & electrolyte imbalances are often placed on
STRICT I&O.
Intake documentation
Intake - Includes oral fluids, foods that liquifies at room temperature
(Jell-O, ice cream, popsicles), IVFs, IV medications, enteral feedings
and catheter/tube irrigants.
Dietary intake is labeled in ounces (oz) but documented in milliliters
(mL)
1oz = 30mL
Output documentation
- Includes urine, blood, emesis, diarrhea, and drainage from tubes and
wounds.
- Weighing Clients - Is one of the most effective methods for monitoring
a client's fluid status.
- Weigh the patient around the same time each morning, after the client
voids.
- Encouraged the client to wear similar clothing each day.
- If using a bed scale, ensure same amounts of linen are on the bed each
END OF
PAGE
4
