Week 6: nutrition, skin, assessment

nutritional status

reflects the balance between nutrient intake and metabolic requirements

• optimal nutritional status

• undernutrition

• overnutrition

optimal nutritional status

Achieved when sufficient nutrients are consumed to support daily body needs and increased metabolic demands

undernutrition

Occurs when nutritional reserves are depleted or nutrient intake is inadequate

• Vulnerable Populations: Infants, children, pregnant women, recent immigrants, low-income individuals, hospitalized patients, and older adults.

• Clinical Risks: Impaired growth/development, lowered infection resistance, delayed wound healing, longer hospital stays, and higher health care costs.

overnutrition

Caused by the consumption of nutrients (especially calories, sodium, and fat) in excess of body needs

• Clinical Risks: Increases risk for obesity, type 2 diabetes, cardiovascular disease, osteoarthritis, sleep apnea, chronic kidney disease, gallstones, and acid reflux

• obesity is multifactorial

culture and nutrition

• Occupation, socioeconomic status, gender, religion, health awareness all impact eating customs

• Religions use food as symbols in celebrations & rituals and also have restrictions:

  • Hinduism: lacto-vegetariansim favored

  • Islam & Orthodox Judaism: no pork or pork products, meat not slaughtered according to ritual

types of nutritional assessment

helps nurses determine whether a patient is getting enough nutrients, such as protein, vitamins, minerals, and calories, to stay healthy

1. malnutrition universal screening tool (MUST)

2. Mini nutritional assessment (MNA)

3. comprehensive nutritional assessment

4. 24 hour diet recall

5. food frequency questionnaire

6. food diaries

7. mobile apps

malnutrition universal screening tool

Identifies patients who are at risk for malnutrition.

MUST evaluates three main factors:

1. Body Mass Index (BMI): Is the patient underweight?

2. Unintentional weight loss: Has the patient lost weight without trying during the past 3–6 months?

3. Acute illness: Is the patient seriously ill and likely to have no nutritional intake for more than 5 days?

malnutrition

occurs when the body does not receive the right amount or balance of nutrients. This can include undernutrition or overnutrition.

score for MUST test

0	Low risk
1	Medium risk
2 or more	High risk

mini nutritional assessment (MNA)

Evaluates nutritional status and malnutrition risk, especially in older adults (65 years and older).

The MNA looks at factors such as:

• Recent weight loss

• Appetite and food intake

• Mobility (ability to move around)

• Recent illness or psychological stress

• Cognitive problems, such as dementia

• BMI or calf circumference

comprehensive nutritional assessment

Provides a detailed evaluation of a patient's overall nutritional health ( a complete picture of nutritional health)

This assessment is more thorough than MUST or the MNA.

It includes:

• Medical history: Does the patient have conditions affecting nutrition?

• Dietary history: What does the patient normally eat?

• Physical examination: Are there signs of muscle loss, fat loss, or nutrient deficiencies?

• Body measurements: Weight, height, BMI, and weight changes

• Laboratory tests: Blood tests that may help identify nutritional problems when interpreted with other findings

24 hour diet recall

Determines what a patient ate and drank during the previous 24 hours.

The nurse asks the patient to remember everything they consumed yesterday.

• This helps the nurse evaluate the patient's recent calorie and nutrient intake.

food frequency questionnaire

Determines how often a patient eats certain foods over a longer period, such as the past month or year.

The nurse might ask:

• How often do you eat vegetables?

• How many times per week do you eat fast food?

• How often do you drink soda?

• How frequently do you eat fruits?

This helps the nurse identify long-term dietary patterns.

food diaries

Tracks everything a patient eats and drinks over several days.

Unlike a 24-hour recall, the patient records their food intake as they eat throughout the day.

A food diary may include:

• Type of food eaten

• Amount consumed

• Time of eating

• Beverages consumed

• Snacks

mobile apps

Uses technology to help patients track their nutritional intake (digital food diary)

Patients may use apps to monitor:

• Calories consumed

• Protein, carbohydrate, and fat intake

• Water consumption

• Meals and snacks

• Dietary patterns

The nurse can review this information to help identify nutritional concerns.

subjective assessment

• Eating patterns

• Usual weight

• Changes in appetite, taste, smell, chewing, swallowing

• Nausea, vomiting, diarrhea, constipation

• Food allergies or intolerances

• Medications and/or nutritional supplements

• Patient centered care

  • Meal preparation

  • Transportation/access to grocery store, income for food

  • Environment during mealtimes

nutrition for infants

• Breastfed or bottle fed

• Timing and method of weaning

• Introducing solid foods

nutrition for children

• Special likes or dislikes

• How much do they eat

• teaching about aspiration

general appearance

The nurse looks at the patient's overall physical appearance to identify signs of poor nutrition

• inspecting for signs of cachexia

• looking at anthropometric measures

cachexia

is a condition characterized by severe loss of muscle mass, often accompanied by loss of body fat and weight. (disease related muscle loss)

It is commonly associated with serious chronic illnesses, such as cancer, heart failure, or COPD.

signs of cachexia

• Extremely thin appearance

• Prominent bones (ribs, collarbones, shoulders)

• Significant muscle wasting

• Loss of body fat

• Weakness and reduced strength

anthropometric measures

are measurements of the human body used to evaluate nutritional status and health risks

• weight

• BMI

• waist circumference

weight

The nurse measures the patient's body weight and monitors changes over time.

Why is this important?

• Unintentional weight loss may indicate malnutrition or illness.

• Excessive weight gain may indicate increased body fat or fluid retention.

• Sudden weight changes may indicate fluid imbalance.

body mass index (BMI)

is a measurement that compares a person's weight to their height, is only a screening tool. It does not directly measure body fat or determine nutritional health by itself

Below 18.5 - Underweight

18.5–24.9 - Healthy weight

25.0–29.9 - Overweight

30.0 or higher - Obesity

below 18.5

underweight BMI

18.5 - 24.9

healthy weight BMI

25.0 - 29.9

overweight BMI

30.0 or higher

obesity

waist circumference

Waist circumference measures the distance around a patient's abdomen.

Why is this important?

Excess fat around the abdomen is associated with an increased risk of:

• Heart disease

• Type 2 diabetes

• High blood pressure

• Metabolic syndrome

Larger waist circumference = Greater risk of certain metabolic and cardiovascular diseases

women

waist circumference = 35 inches

• anything above this level is increased risk

men

waist circumference = 40 inches

• anything above this level is increased risk

objective nutritional assessment

1. Look at the patient's general appearance for signs of muscle or fat loss.

2. Measure the patient's weight and calculate BMI.

3. Measure waist circumference when appropriate to evaluate abdominal fat-related health risks.

clinical signs of malnutrition

• Skin: dry, flaking, scaling, petechiae or bruising,

• Hair: dull, dry, or sparse

• Eyes: plaques, dryness, pale or red conjunctivae

• Lips: cheilosis, angular stomatitis

• Tongue: glossitis, pale

• Gums: bleeding

• Nails, brittle, ridged, splinter hemorrhages

• Musculoskeletal: pain in legs, osteomalacia,

• rickets, joint pain

• Neurological: hyporeflexia, disorientation or irritability

skin

dry, flaking, scaling, petechiae or bruising

hair

dull, dry, or sparse

Eyes

plaques, dryness, pale or red conjunctivae

Lips

cheilosis: Red, swollen cracks or sores at the corners of the mouth

angular stomatitis: Red, smooth, beefy-appearing tongue (often due to vitamin B complex deficiency

vitamin b complex deficiency

can cause red, smooth, beefy appearing tongue (angular stomatitis)

vitamin C deficiency

can cause bleeding gums

gums

bleeding

Nails

brittle, ridged, splinter hemorrhages

Musculoskeletal

pain in legs, joint pain

osteomalacia (soft bones)

rickets (bowing of leg bones in children due to vitamin D / calcium deficiency)

vitamin D / calcium deficiency

can cause rickets - bowing of leg bones in children

neurological

hyporeflexia - exaggerated or overactive reflexes

disorientation or irritability

melanin and skin tone

• Melanin protects skin from UV rays

• Incidence of skin cancer differs with skin tone

• Differences in hair with ancestral descent

skin subjective assessment

• History of skin diseases

• Changes in pigmentation

• Change in mole

• Excessive dryness or moisture: seborrhea, xerosis

• Pruritis

• Excessive bruising

• Rash or lesions

• Medications

• Hair loss: alopecia, hirsutism

• Changes in nails

• Environmental or occupational hazards

skin objective assessment

nurses observe the patient's normal skin pigmentation and look for unusual color changes

1. general pigmentation

2. vitiligo

3. pallor, cyanosis, erythema

4. jaundice

5. note any tattoos - Nurses should inspect tattooed areas for irritation, infection, or other abnormalities, documenting tattoos can help establish a baseline of the patient's skin appearance.

general pigmentation

pigmentation refers to the natural color of a person's skin.

Skin color is mainly determined by melanin, a pigment produced by cells in the skin.

During an assessment, the nurse looks for:

• Changes in the patient's normal skin color

• Unusually pale, blue, red, or yellow areas

• Uneven pigmentation

• Areas where skin color has been lost

vitiligo

is a condition in which the skin loses its natural pigment, causing lighter or white patches.

This happens because melanocytes (cells that produce melanin) are destroyed, usually through an autoimmune process.

• White or lighter patches on the skin

• Irregularly shaped areas of pigment loss

• Can occur anywhere on the body

pallor

pale skin

• It can occur when there is decreased blood flow to the skin or reduced hemoglobin.

cyanosis

occurs when the skin or mucous membranes develop a bluish or grayish appearance due to increased deoxygenated hemoglobin in the blood

erythema

means redness of the skin caused by increased blood flow near the skin's surface

Possible causes:

• Inflammation

• Infection

• Allergic reactions

• Sunburn

• Pressure-related skin injury

jaundice

yellowing of the skin, yellowing of the sclera occurs when too much bilirubin builds up in the blood

Bilirubin is a yellow substance produced when the body breaks down old red blood cells. The liver normally processes bilirubin so it can be eliminated.

objective assessment pt 2

• Moisture

• Texture

• Edema

• Mobility & turgor - skins elasticity, how quickly skin returns tot its normal position after being gently pinched and released

• lesions

• Vascularity & bruising

  • Petechiae

  • Ecchymosis/Contusion/Hematoma

  • Cherry (senile) angiomas

petechiae

are tiny, pinpoint red, purple, or brown spots caused by bleeding from small blood vessels under the skin.

• they do not blanch / turn pale when pressed

ecchymosis

A larger flat area of discoloration caused by bleeding under the skin

contusion

A bruise caused by an injury or trauma

hematoma

A localized collection of blood outside blood vessels, sometimes forming a swollen lump

cherry (senile) angiomas

are small, usually harmless red or purple growths formed by clusters of tiny blood vessels.

They become more common with age.

• Small, round spots

• Bright red to dark purple

• Usually smooth and slightly raised

• Common on the trunk, arms, and shoulders

lesions

any traumatic or pathologic changes in skin structure

can develop because of:

• Injury or trauma

• Infections

• Allergic reactions

• Skin diseases

• Inflammation

types: primary and secondary

primary lesions

Traumatic or pathological changes on previously healthy, intact skin, represent the initial skin change

Examples include:

• Macule: Flat spot with a different color, such as a freckle.

• Papule: Small, raised bump, such as a pimple.

• Vesicle: Small, fluid-filled blister.

• Pustule: Raised lesion containing pus.

secondary lesions

develop when a primary lesion changes over time, such as from scratching, infection, or healing, the original lesion has changed

Examples include:

• Crust: Dried blood or fluid on the skin (scab).

• Scale: Flaking skin.

• Ulcer: Open sore with loss of skin tissue.

• Scar: Tissue that forms after an injury heals.

• Excoriation: Scratch or abrasion caused by rubbing or scratching.

note for assessing lesions

• Color

• Elevation

• Pattern or shape

• Size

• Location & distribution

• Exudate (if any) - fluid or drainage coming from a lesion

lesion patterns

describes the shape or arrangement of skin lesions

1. annular

2. confluent

3. discrete

4. gyrate

5. grouped

6. linear

annular

ring shaped or circular

• Lesion forms a ring.

• The center may appear clearer than the edges.

• Example: Ringworm (tinea corporis

confluent

lesions merge together

• Several individual lesions join to form a larger area.

• The borders between lesions become less distinct.

• Example: Some widespread inflammatory or drug-related rashes.

discrete

separate, individual lesions

• Lesions are not connected.

• Each lesion has its own distinct borders.

• Example: Several separate insect bites.

grouped

Lesions clustered closely together

• Several small lesions appear in one area.

• They remain distinguishable rather than merging into one large lesion.

• Example: Herpes simplex blisters.

linear

Lesions arranged in a line

• Lesions follow a straight or nearly straight path.

• Example: Scratches or poison ivy contact dermatitis

gyrate

curved or winding lesions

primary skin lesions

1. macule / patch

2. papule

3. plaque

4. nodule

5. wheal / urticaria

6. vesicles / bulla

7. cyst

8. pustule

macule

flat, color changed spot eg. freckle (non palpable)

patch

flat macule larger than 1 cm (eg. vitiligo) (non palpable)

papule

solid, elevated lesion less than 1 cm (elevated mole, wart)

plaque

disk shaped, elevated lesion wider than 1 cm

nodule

solid, hard, or soft elevation extending deeper into the dermis, greater than 1 cm

tumor

Larger nodule, greater than 2-3 cm, firm or soft, deep into dermis.

wheal

Superficial, raised, transient, erythematous lesion with irregular borders caused by fluid in tissues (e.g., mosquito bite, allergic reaction)

urticaria (hives)

Confluent eruption of multiple wheals causing intense itching.

vesicles

Elevated cavity containing clear fluid, up to 1 cm (e.g., herpes zoster/shingles, varicella/chickenpox); fluid filled

bulla

Elevated fluid-filled cavity larger than 1 cm (e.g., friction blister, severe burn)

• bigger vesicle

pustule

Turbid, pus-filled cavity (e.g., acne, impetigo)

cyst

Encapsulated fluid-filled cavity in dermis or subcutaneous layer

secondary skin lesions

1. crust

2. scale

3. fissure

4. erosion

5. ulcer

6. excoriation

7. scar

8. atrophic scar

9. keloid

10. lichenification

crust

Thickened, dried-out exudate left when vesicles/pustules burst or dry up (e.g., impetigo)

scale

Compact, dried flakes of skin shedding excess dead keratin cells (e.g., psoriasis, eczema)

fissure

Linear crack with abrupt edges extending into the dermis (e.g., cheilosis, athlete's foot).

erosion

Scooped-out, shallow depression; superficial loss of epidermis (moist, no bleeding, heals without scar)

ulcer

Deeper depression extending into dermis, irregular shape, bleeds and leaves a scar (e.g., pressure injury, stasis ulcer)

excoriation

Self-inflicted superficial abrasion from intense scratching (e.g., insect bite scratches)

scar

A scar is a mark left on the skin after an injury or wound heals.

atrophic scar

is a scar that appears sunken or depressed below the surrounding skin.

keloid

is an overgrowth of scar tissue that extends beyond the boundaries of the original wound.

lichenification

Prolonged, intense scratching that thickens skin and produces tightly packed sets of papules (looks like surface of moss or lichen)

moles

Clump of melanocytes (nevus)

danger signs of moles

(ABCDEF) - looking at moles for potential malignant melanoma

• Asymmetry - The two halves of the mole do not match.

• Border irregularity - Notched, scalloped, ragged, or poorly defined edges.

• Color variation - non uniform color; areas of brown, black, tan, blue, red, or white

• Diameter - greater than 6 mm

• Elevation - Elevation above skin surface.

• Evolution - evolution/changes over time in size, shape, color, or symptoms (itching, bleeding)

• Funny looking - (Ugly Duckling Sign): A mole that looks noticeably different from all the other moles on the client's body

pressure injuries

(also called a bedsore or pressure ulcer)

occur over bony prominences due to localized pressure, friction, or shear forces

occurs when prolonged pressure, or pressure combined with shear, damages the skin and underlying tissues.

Pressure injuries commonly occur in patients who are bedridden, use wheelchairs, or cannot reposition themselves

(4 stages)

stage 1

non blanchable erythema

The skin is still intact (not broken), but there is persistent discoloration caused by pressure.

• Redness does not turn white when pressed (non-blanchable).

• May feel warmer, cooler, firmer, or softer than surrounding skin.

• In darker skin, discoloration may appear different from red.

stage 2

partial thickness skin loss

The epidermis and part of the dermis are damaged.

• Open, shallow wound with a pink or red, moist wound bed.

• May appear as an intact or ruptured serum-filled blister.

• Fat, muscle, and bone are not visible.

stage

full thickness skin loss

The injury extends through the epidermis and dermis into deeper tissue.

• Subcutaneous fat may be visible.

• Wound is deeper than Stage 2.

• Muscle, tendon, and bone are not exposed.