NR 302 HEALTH ASSESSMENT EXAM 2 STUDY GUIDE
CHAPTER 11 Nutritional Assessment
Undernutrition: less than body requirements
Overnutrition: more than body requirements
Nutritional needs vary through the lifespan
Subjective Nutritional Data
24-hour diet recall- What have you eaten in the last 24 hours? What is your normal diet like?
Troubles swallowing? Nausea, vomiting, intolerances, allergies?
Metabolic Syndrome/Insulin-Resistance Syndrome: disorder in which there’s a complex set of
symptoms that relate together; Obesity, Heart Disease, Hypertension, Gout, Polycystic
Ovaries, and Type 2 Diabetes.
Criteria: If someone has 3+, they’re at risk for Coronary Heart Disease/Diabetes
Abnormal Levels=
Abdominal Obesity: Men >40” Women >35”
Fasting glucose >100 Triglycerides >150
HDL: <40 for Men, <50 for Women Blood Pressure >130/>85
Abnormal findings caused by nutritional deficiencies
Spongy gums= lack of Vitamin C
Rickets (bone softening)= Lack of Vitamin D
Glossitis (magenta tongue)= lack of Riboflavin
Cheilosis (lip inflammation) & Stomatitis (cracked lip corners)= lack of Riboflavin
Pitting edema= lack of Protein
Abnormal Findings
Obesity
Marasmus- protein/calorie malnutrition, cachexia appearance.
Kwashiorkor- low Albumin, fluid shifts into abdominal cavity.
Objective Data
-Anthropometric Measures (Quantitative Data):
Weight
Height & Weight/BMI: x 702 Normal 18.5-24.9
Height 2
Waist-to-hip ratio
Nutritional Assessment Form: ≤ 1.0 = good/normal for Men
≤ 0.8 = good/normal for Women
-Lab Studies
Anemia Assessment: by low Hemoglobin & Hematocrit Men 13.5-17.5 / Women 12-15.5
Cholesterol: Normal= <200 mg/dl
≥200 mg/dl = Cardiovascular disease High= over/undernutrition
, ≥160 mg/dl = Malnutrition Low= malnutrition
Serum Albumin: Normal= 3.5-5 g/L
Low levels= indicate depleted protein & malnutrition
Severe malnutrition= <2.1 g/L
Nursing Diagnosis
Deficient Nutrition Knowledge
Self-care feeding deficit
Risk for constipation
Impaired swallowing
Imbalanced nutrition: more> or less< than body requirements
Chapter 12 Skin, Hair, and Nails
Subjective Data
Changes in pigmentation or moles Bruising Diaphoresis (dryness)
Pruritis (itchy skin) Rashes/lesions Medications
Alopecia/hair loss Self-care behaviors Enviro/Occupational hazards
Relevant Health History: Previous diseases, allergies.
Objective Data
Color/tone & pigmentation: pallor (pale), erythema (red), cyanosis (blue), jaundice (yellow)
Moisture Vascularity & bruising Temperature Cleanliness/odor
Skin Lesion Assessment
Primary Skin lesions: wheal, vesicle
Secondary: crust, fissure
Vascular: petechiae
Assess all skin lesions for: Color, Elevation (ie. Flat, raised, pedunculated), Configuration &
Pattern (grouped, confluent), Location & Distribution, Exudate.
Hair
Vullus hair (thin, barely noticeable) & terminal hair (thick, long, dark)
Color, cleanliness Texure & Distribution Lesions
Nails
Hygiene, color, ridges
Capillary refill < 3 seconds is normal
Shape & Contour-clubbing
Melanoma Assessment ABCDE
Asymmetry- not regularly round/oval, both halves of lesion don’t look the same
Border irregularity- notching, scalloping, ragged edges, poorly defined margins
Color variation-areas of brown, tan, black, blue, red, white, or combo
Diameter greater than 6mm- ex. The size of a pencil eraser, although can be diagnosed smaller
Elevation or Evolution
Note: new pigment lesions, bleeding moles, “ugly duckling” sign (suspicious lesion)
Lifespan Considerations for Hair, Skin & Nails
CHAPTER 11 Nutritional Assessment
Undernutrition: less than body requirements
Overnutrition: more than body requirements
Nutritional needs vary through the lifespan
Subjective Nutritional Data
24-hour diet recall- What have you eaten in the last 24 hours? What is your normal diet like?
Troubles swallowing? Nausea, vomiting, intolerances, allergies?
Metabolic Syndrome/Insulin-Resistance Syndrome: disorder in which there’s a complex set of
symptoms that relate together; Obesity, Heart Disease, Hypertension, Gout, Polycystic
Ovaries, and Type 2 Diabetes.
Criteria: If someone has 3+, they’re at risk for Coronary Heart Disease/Diabetes
Abnormal Levels=
Abdominal Obesity: Men >40” Women >35”
Fasting glucose >100 Triglycerides >150
HDL: <40 for Men, <50 for Women Blood Pressure >130/>85
Abnormal findings caused by nutritional deficiencies
Spongy gums= lack of Vitamin C
Rickets (bone softening)= Lack of Vitamin D
Glossitis (magenta tongue)= lack of Riboflavin
Cheilosis (lip inflammation) & Stomatitis (cracked lip corners)= lack of Riboflavin
Pitting edema= lack of Protein
Abnormal Findings
Obesity
Marasmus- protein/calorie malnutrition, cachexia appearance.
Kwashiorkor- low Albumin, fluid shifts into abdominal cavity.
Objective Data
-Anthropometric Measures (Quantitative Data):
Weight
Height & Weight/BMI: x 702 Normal 18.5-24.9
Height 2
Waist-to-hip ratio
Nutritional Assessment Form: ≤ 1.0 = good/normal for Men
≤ 0.8 = good/normal for Women
-Lab Studies
Anemia Assessment: by low Hemoglobin & Hematocrit Men 13.5-17.5 / Women 12-15.5
Cholesterol: Normal= <200 mg/dl
≥200 mg/dl = Cardiovascular disease High= over/undernutrition
, ≥160 mg/dl = Malnutrition Low= malnutrition
Serum Albumin: Normal= 3.5-5 g/L
Low levels= indicate depleted protein & malnutrition
Severe malnutrition= <2.1 g/L
Nursing Diagnosis
Deficient Nutrition Knowledge
Self-care feeding deficit
Risk for constipation
Impaired swallowing
Imbalanced nutrition: more> or less< than body requirements
Chapter 12 Skin, Hair, and Nails
Subjective Data
Changes in pigmentation or moles Bruising Diaphoresis (dryness)
Pruritis (itchy skin) Rashes/lesions Medications
Alopecia/hair loss Self-care behaviors Enviro/Occupational hazards
Relevant Health History: Previous diseases, allergies.
Objective Data
Color/tone & pigmentation: pallor (pale), erythema (red), cyanosis (blue), jaundice (yellow)
Moisture Vascularity & bruising Temperature Cleanliness/odor
Skin Lesion Assessment
Primary Skin lesions: wheal, vesicle
Secondary: crust, fissure
Vascular: petechiae
Assess all skin lesions for: Color, Elevation (ie. Flat, raised, pedunculated), Configuration &
Pattern (grouped, confluent), Location & Distribution, Exudate.
Hair
Vullus hair (thin, barely noticeable) & terminal hair (thick, long, dark)
Color, cleanliness Texure & Distribution Lesions
Nails
Hygiene, color, ridges
Capillary refill < 3 seconds is normal
Shape & Contour-clubbing
Melanoma Assessment ABCDE
Asymmetry- not regularly round/oval, both halves of lesion don’t look the same
Border irregularity- notching, scalloping, ragged edges, poorly defined margins
Color variation-areas of brown, tan, black, blue, red, white, or combo
Diameter greater than 6mm- ex. The size of a pencil eraser, although can be diagnosed smaller
Elevation or Evolution
Note: new pigment lesions, bleeding moles, “ugly duckling” sign (suspicious lesion)
Lifespan Considerations for Hair, Skin & Nails
