Health Assess 15

Risk for Complications

Risk for Complications

Assessment of a patient's potential for adverse health outcomes related to spirituality.

Spirituality's Effect

Complications are primarily due to the effect of spirituality on stress.

Nirvana

A state of ultimate existence associated with Buddhism.

Spiritual Assessment Justification

"Spirituality actually has a significant effect on your overall health."

Patient's Treatment Acceptance

Follow up by prioritizing complementary interventions in the patient's care.

SPIRIT Acronym

The assessment should begin by identifying the patient's spiritual belief system.

Nursing Diagnosis Priority

Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination.

Midarm Muscle Circumference

Low percentile indicates potential malnutrition.

Body Mass Index Calculation

A patient weighing 175 pounds and 5 feet 6 inches tall has a BMI of 28.

Percentage of Ideal Body Weight

A patient weighing 106 pounds and 5 feet 5 inches tall is mildly malnourished.

Serum Albumin Level

A serum albumin of 2.6 g/dL indicates potential malnutrition.

Overhydration Assessment

Prioritize assessments for a patient experiencing early congestive heart failure.

Early Indicator of Malnutrition

Protein stores are lower than normal.

Intradermal Injection Reaction

No reaction may indicate immunosuppression resulting from undernourishment.

Nutritional Assessment Initiation

"Can you tell me what you've eaten in the last 24 hours?"

Skeletal Muscle Mass Measurement

Mid-arm circumference yields the most valid data.

Concerning Laboratory Value

Hemoglobin A1c of 9% indicates potential nutritional issues.

Fluid Gain Interpretation

A 2.2 lbs weight increase suggests a fluid gain of 1.0 liters.

Health Promotion Diagnosis

Health-seeking behaviors related to desire to alter food intake.

Objective Data in Nutrition

Tenting of patient's skin observed upon skin pinch.

Insensible Fluid Losses

Include 800 to 1000 mL in 24-hour fluid balance assessment.

Fluid Overload Assessment Finding

Distended neck veins with head elevated at 45 degrees.

Diet Improvement Suggestion

"The majority of your diet should consist of whole grains."

Nutritional Status Indicator

Brittle hair indicates inadequate nutritional status.

Health Status Knowledge Elicitation

"Can you tell me what you consider to be a healthy meal?"

Measuring Height of Non-Standing Patient

Extend a ruler from the forehead to the tip of the patient's toes.