Ha Midterm

NUTRITION ASSESSMENT AND CLASSIFICATION 3) Clinical assessment of altered nutritional
requirements and social or phychological issues that

Nutritional assessment – systematic process of
may preclude adequate intake
collecting and interpreting information
4) Measurement of dietary intake
 Anthropometric – measure the arm, chest
circumference, length, and weight. Food Frequency Questionnaire – examines how often
 Biochemical (laboratory) – refers to the food an individual eats certain foods and the size of portions.
the individual taking (macro mineral, vitamins
Food Group Questionnaire – to ask whether they ate or
etc.)
drank any of those foods previously.
 Clinical and Dietary data – determine people
who are sick, the health status of an individual. Bulimic (bulimia) – kain nang kain
- Get the history of a person, what did the
person eat
Optimal Nutritional Status – state of the body with

respect to each nutrient and overall body weight
condition.
Total calorie requirement: height = calorie
(5’2 = 105 kilos food – 1500 calories)
(5’4 = 120 kilos food)
BMI (Body Mass Index) – an indicator based on weight

on height ratio.
APVF – At water physiologic value of food
Calories will depend on the body activity:
Heavy work (laborer….)
Moderate (staff nurse, household)
Sedetary (if just eating)
Cheilosis – can be attributed with vitamin B

(inflammation of cracking on the corners of the mouth)
Nutritional Screening – to rapidly identify patients who

are at high nutritional risk.
ASSESSMENT APPROACH
- Simplest approach to assessment is serial

weight measurement.
A comprehensive nutritional assessment includes:
1) Anthropemetric measurement of body composition
2) Biochemical measurements of serum protein,

micronutrients, and metabolic parameters;
APGAR SCORING REFLEX SCORE
IRRITABILITY/RESPONSE
A- APPEARANCE (skin color) No reaction 0
Grimacing 1
- Evaluation of the baby’s skin color (blue/pink). Grimace, cough sneeze 2
P- PULSE (heart rate) MUSCLE TONE SCORE
- Measures if the baby’s heart rate is absent, Loose and fluffy 0
slow (<100 bpm), or fast (>100 bpm). Come tone 1
Active motion 2
G- GRIMACE (reflex irritability/response)
BREATHING ABILITY SCORE
- If the baby lacks a response to stimulation, Not breathing 0
responds with a grimace, or responds by crying Slow or irregular 1
and pulling away. Infant cries 2
A- ACTIVITY (muscle tone)
- If the baby is limp, has some flexion (joint Listed below are just a few of the complications that can
movement), or shows active motion. cause a baby to become oxygen-deprived, and may
manifest in low Apgar scores:
R- RESPIRATION (breathing ability)
 C-Section errors and delays
- If the baby is failing to breathe, has weak cry
and slow breathing, or if the baby is breathing  Fetal monitoring errors
well and crying normally.  Infections
When is APGAR testing done?  Maternal medical conditions
- 1 and 5 minutes after a baby is born.  Placental Abruption
- Repeated at 10, 15, 20 minutes if score is low
- Scoring is (0,1,2)  Preterm birth
What do Apgar scores mean?  Prolonged and arrested labor
- Apgar scores of 0-3 are critically low, especially  Umbilical cord problems
in term and late-preterm infants  Uterine hyperstimulation/tachysystole (this
- Apgar scores of 4-6 are below normal, and can be caused by the delivery
indicate that the baby likely requires medical drugs Pitocin and Cytotec)
intervention  Uterine rupture
- Apgar scores of 7+ are considered normal ANTHROPOMETRIC MEASUREMENTS
SKIN COLOR SCORE - Series of quantitative measurements of the
Pale Blue 0 muscle, bone, adipose tissue.
Body pink, extremities 1
- Core elements of anthropometry are height,
blue
weight, BMI, body circumferences (waist, hip,
Entire body pink 2
and limbs), and skinfold thickness.
HEART RATE SCORE Female Average new-born weight: 3.11 kg range of
No heart beat 0 (2.1kg to 4.2kg)
Hr <100 bpm 1
Hr > 100 2 Length: 48.49cm range of (45.1cm to 51.7am)
Head: 34.16cm range of (32.3cm to 36.4cm)

SKILLS NECESSARY DURING ANTENATAL CARE Triage categories in both systems:
 Leopold’s maneuver (determine fetal RED: Immediate evaluation by physician

orientation)
Orange: Emergent evaluation within 15 minutes
 Auscultation of fetal heart tones
Yellow: Potentially unstable, evaluation within 60 min
Leopold’s maneuver: 4 stages
Green: Non-urgent, re-evaluation every 180 min
First Maneuver - Fundal Grip (fundus)
Blue: Minor injuries or complaints, re-evaluation every
Second Maneuver - Umbillical Grip (identify fetal back)
240 min
Third Maneuver - Pawlik’s Grip (engaged or unengaged)
Step 1: Physiologic criteria
Head or Breech
Step 2: Anatomic Criteria
Fourth Maneuver - Pelvic Grip (flexion of fetal head or
determine attitude of habitus) Step 3: Mechanism of injury criteria
Abdominal examination during pregnancy: Step 4: Special Considerations
INSPECTION
- Scars Mnemonic “ABCDE”

- Shape and Size
 AIRWAY
PALPATION  BREATHING
 CIRCULATION
- Checking the fundic height
- Estimation of fetal weight  DISABILITY
- Leoppld’s maneuver  EXPOSURE
AUSCULTATION *Direct the walking wounded to casualty collection

points
- Fetal heart tones
- Normally 110-160 bph Level 1: Resuscitation
- If FHT cannot be heard after 6th month and no - Requires immediate lifesaving intervention
fetal movement – REFER
Level 2: Emergent
- Requires immediate nursing assessment and

4 BASIC TYPES OF ASSESSMENT: rapid treatment.
Initial Comprehensive Assessment – also known as
triage, helps to determine the nature.
CODE 55 – missing or abducted infant/pediatric patient.
Ongoing or Partial Assessment – once treatment has
been implemented. CODE H – help
Focused or Problem Oriented Assessment – is the stage RED – Immediate / notification service
in which the problem is exposed.
YELLOW – Delayed
TRIAGE GREEN – Walking wounded / utility failure

- Assessment
- Assess several signs at the same time PINK – Infant abduction, pediatric emergency and/or
obstetrical emergency
Purpose of triage is to save as many life as possible
BLUE – Critical and potentially fatal injuries/illness
GRAY – Aggressive person, requiring security personnel,

assault or violence
PURPLE – Bomb or substance threat
GOLD – Adult elopement (nagdulag)
SILVER - Shooter

Ha Midterm

Uploaded by

Copyright:

Available Formats

Ha Midterm

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ha Midterm

Uploaded by

Copyright:

Available Formats

NUTRITION ASSESSMENT AND CLASSIFICATION 3) Clinical assessment of altered nutritional

requirements and social or phychological issues that

Optimal Nutritional Status – state of the body with

Total calorie requirement: height = calorie

(5’2 = 105 kilos food – 1500 calories)

(5’4 = 120 kilos food)

BMI (Body Mass Index) – an indicator based on weight

APVF – At water physiologic value of food

Calories will depend on the body activity:

Heavy work (laborer….)

Moderate (staff nurse, household)

Sedetary (if just eating)

Cheilosis – can be attributed with vitamin B

Nutritional Screening – to rapidly identify patients who

- Simplest approach to assessment is serial

A comprehensive nutritional assessment includes:

1) Anthropemetric measurement of body composition

2) Biochemical measurements of serum protein,

What do Apgar scores mean?  Prolonged and arrested labor

Head: 34.16cm range of (32.3cm to 36.4cm)

 Leopold’s maneuver (determine fetal RED: Immediate evaluation by physician

Abdominal examination during pregnancy: Step 4: Special Considerations

- Scars Mnemonic “ABCDE”

AUSCULTATION *Direct the walking wounded to casualty collection

- Requires immediate nursing assessment and

TRIAGE GREEN – Walking wounded / utility failure

GRAY – Aggressive person, requiring security personnel,

PURPLE – Bomb or substance threat

GOLD – Adult elopement (nagdulag)

You might also like