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The third edition of Medical-Surgical Nursing Made Incredibly. Easy! is a must- have for students, working nurses, and nurses returning to practice. Medical- surgical nursing is a The typical med- surg patient is over age Medical-Surgical Nursing: Made Incredibly. Nursing StudentsNursing Tips Nursing NotesMedical Surgical NursingBest Nursing SchoolsMed Surg. Buy Medical-Surgical Nursing Made Incredibly Easy! (Incredibly MedSurg NCLEX® Essentials: Critical Information for Nursing Students NCLEX® Review.

Always palpate tender areas last. What makes it better or worse? Have you ever had heart surgery? You can do this Use reflection— repeating something the patient has just said—to obtain more-specific information. Patients faced with stressful situations may adopt defensive behaviors. Is his skin free from blemishes and rashes? Ask him to describe his current feelings in concrete terms and to suggest possible reasons for these feelings.

File Size: Click it to start your free download now. Download Link. Sunday, April 14, All Things Medicine. Share on Facebook. Foreword Chapter 1: Medical-Surgical Nursing Practice Chapter 2: The Nursing Process Chapter 3: Fluids and Electrolytes Chapter 4: Perioperative Care Chapter 5: Pain Management Chapter 6: Neurologic Disorders Chapter 7: Eye Disorders Chapter 8: Ear, Nose, and Throat Disorders Chapter 9: Cardiovascular Disorders Chapter Respiratory Disorders Chapter Gastrointestinal Disorders Chapter Endocrine Disorders Chapter Renal and Urologic Disorders Chapter Reproductive System Disorders Chapter Musculoskeletal Disorders Chapter Hematologic and Lymphatic Disorders Chapter Immunologic Disorders Chapter Do you wear a hearing aid?

Are you having pain, swelling, or discharge from your ears? If so, has this problem occurred before and how frequently? Nose knows Have you ever had nasal surgery?

Have you ever had sinusitis or nosebleeds?

If so, when did it happen and how was it treated? Do you have nasal problems that impair your ability to smell or that cause breathing difficulties, frequent sneezing, or discharge? Past the lips and over the gums Do you have mouth sores, a dry mouth, loss of taste, a toothache, or bleeding gums?

Do you wear dentures and, if so, do they fit properly? Do you have a sore throat, fever, or chills? How often do you get a sore throat, and have you seen a doctor for this? Do you have difficulty swallowing? If so, is the problem with solids or liquids? Is it a constant problem or does it accompany a sore throat or another problem? What, if anything, makes it go away? How long have you had this problem? Neck check Do you have swelling, soreness, lack of movement, stiffness, or pain in your neck?

If so, did something specific cause it to happen such as too much exercise? How long have you had this symptom? Does anything relieve it or make it worse? Your earrings? What about them? What makes it better or worse? How many pillows do you use at night?

Does breathing cause pain or wheezing? Do you have a cough? If so, do you cough up sputum? What color is it? How much sputum do you produce? Do you have night sweats? Have you ever been treated for pneumonia, asthma, emphysema, or frequent respiratory tract infections? If so, when and what was the treatment? Have you ever had a chest X-ray or tuberculin skin test? If so, when and what were the results?

Do you use oxygen?

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How much and how often? Have you ever had surgery for a lung problem? If so, what was the reason for the surgery? What type of surgery did you have and when? Do you ever use an inhaler? When and for what reason? Heart health hunt Do you have chest pain, palpitations, irregular heartbeat, fast or slow heartbeat, shortness of breath, or a persistent cough?

Does anything make it better or worse? Have you ever had an electrocardiogram? Do you have a pacemaker or an internal defibrillator? If so, when did you receive it and why? Have you ever had any other type of heart surgery?

What type of surgery was it? Do you have high blood pressure, peripheral vascular disease, swelling of the ankles and hands, varicose veins, cold extremities, or intermittent pain in your legs? How is it treated? Breast test Ask women these questions: Do you perform monthly breast selfexaminations? Have you noticed a lump, a change in breast or nipple contour, breast pain, or discharge from your nipples?

Have you ever had breast cancer? If yes, when and how was it treated? If not, has anyone else in your family had it? Have you ever had a mammogram? When and what were the results? Ask men these questions: Do you have pain in your breast tissue? Have you noticed lumps or a change in contour?

Stomach symptom search Do you have nausea, vomiting, loss of appetite, heartburn, abdominal pain, frequent belching, or passing of gas? If yes, how often and when does it occur and what makes it better or worse? Have you lost or gained weight recently?

How much and over what period of time? Have you noticed a change in your regular elimination pattern? Do you use laxatives frequently? Have you had hemorrhoids, rectal bleeding, hernias, gallbladder disease, or liver disease? Have you ever had surgery on your stomach? If yes, when, for what reason, and what type of surgery? Renal rundown Do you have urinary problems, such as burning during urination, incontinence, urgency, retention, reduced urinary flow, and dribbling?

If yes, when did it start? Do you get up during the night to urinate? If so, how many times? What color is your urine? Have you ever noticed blood in it? Have you ever been treated for kidney stones?

If yes, when and how were you treated? Reproduction review Ask women these questions: How old were you when you started menstruating? How often do you get your period, and how long does it usually last? Do you have pain or pass clots? Have you ever been pregnant? What was the method of delivery? How many pregnancies resulted in live births? How many resulted in miscarriages? Have you had an abortion?

Do you have multiple sex partners? Do you have anal sex? Have you ever had a vaginal infection or a sexually transmitted disease STD? When was your last gynecologic examination and Papanicolaou test?

What were the results? Have you ever had surgery for a gynecologic problem? If so, when and for what reason? Do you perform monthly testicular self-examinations?

Have you ever had a prostate examination and, if so, when? Have you noticed penile pain, discharge, or lesions or testicular lumps? Which form of birth control do you use? Have you had a vasectomy? Have you ever had an STD? Monitoring muscle Do you have difficulty walking, sitting, or standing?

Are you steady on your feet, or do you lose your balance easily? Do you have arthritis, gout, a back injury, muscle weakness, or paralysis? Keep in mind that stress levels and emotional well-being can affect every body system. When and how was it treated? Do you have joint pain? If yes, which joints? When did it start? Have you ever had a seizure? If yes, when? Do you know what type of seizure you had? Did anything in particular trigger it?

Do you ever experience tremors, twitching, numbness, tingling, or loss of sensation in a part of your body? Have you noticed any problem with your memory? See Tips for assessing a severely ill patient. Endocrine inquiry Have you been unusually tired lately? Do you feel hungry or thirsty more often than usual? Have you lost weight for unexplained reasons? How well can you tolerate heat or cold? Have you noticed changes in your hair texture or color? Have you been losing hair?

Circulatory study Have you ever been diagnosed with anemia or blood abnormalities? If yes, when and what was the diagnosis? How was it treated?

Do you bruise or bleed easily or become fatigued quickly? Have you ever had a blood transfusion? If so, what was the reason, and did you have any type of adverse reaction? Psychological survey Do you ever experience mood swings? Do you ever feel anxious, depressed, or unable to concentrate? How often does this happen? Are you feeling unusually stressed? Do you ever feel unable to cope?

What makes these feelings better or worse? With a severely ill patient, keep these key points in mind: Use a systematic approach and collect the appropriate information; then draw conclusions. Leading questions may initiate untrue or inaccurate responses because such questions: When obtaining a health history from a patient, ask first about: Take care of the biographic data first; otherwise, you might get involved in the patient history and forget to ask basic questions.

Silence is a communication technique used during an interview to: Silence allows the patient to collect his thoughts and continue to answer your questions. Data are considered subjective if you obtain them from: X-ray reports. The phrase is an example of confirmation, a technique that can help confirm information the patient has provided. Which of the following questions is considered open-ended?

Does your pain last through the night? Have you ever had heart surgery? Do you frequently get headaches? How would you describe your pain? Open-ended questions require the patient to express feelings, opinions, or ideas. They elicit more than just a simple yes-or-no response. This is only the first chapter. As you proceed through the physical examination, you can also teach your patient about his body. For instance, you can explain how to perform a testicular self-examination or why the patient should monitor the appearance of a mole.

More than anything else, successful assessment requires critical thinking. How does one finding fit in the big picture? An initial assessment guides your whole care plan, allowing you to give your patient the individualized care he deserves. Collecting the tools Before starting a physical assessment, assemble the necessary tools, which may include cotton balls, gloves, an ophthalmoscope, an otoscope, a penlight, a percussion hammer, safety pins, and a stethoscope.

For a more complete list, see Assessment tools, page Performing a physical assessment calls for the use of critical thinking. What clues do your findings give you about the larger picture? Two heads are better than one Use a stethoscope with a diaphragm and a bell.

The diaphragm has a flat, thin, plastic surface that picks up high-pitched sounds such as breath sounds. The bell has a smaller, open end that picks up low-pitched sounds, such as third and fourth heart sounds. An ophthalmoscope enables you to examine the internal structures of the eye; an otoscope, the external auditory canal and tympanic membrane.

Other tools include cotton balls and safety pins to test sensation and pain differentiation, a percussion hammer to evaluate deep tendon reflexes, and gloves to protect the patient and you. Performing a general survey After assembling the necessary tools, move on to the first part of the physical assessment: This information will direct the rest of your assessment. Memory jogger Remembering that the bell of a stethoscope is used to hear lowpitched sounds and the diaphragm is used to hear highpitched sounds is easy: Bell and low both contain the letter l.

Symmetry—Are his face and body symmetrical? Trunk—Is he lean, stocky, obese, or barrel-chested? Old—Does he look his age? Mental acuity—Is he alert, confused, agitated, or inattentive? Extremities—Are his fingers clubbed? Does he have joint abnormalities or edema? Expression—Does he appear ill, in pain, or anxious? Appearance—Is he clean and appropriately dressed? Movement—Are his posture, gait, and coordination normal? Speech—Is his speech relaxed, clear, strong, understandable, and appropriate?

Does it sound stressed? Carefully observe him for unusual behavior or signs of stress or illness. Meeting you under lessthreatening circumstances might decrease his anxiety when you perform the assessment. See Tips for assessment success. As you perform the assessment, explain each step in detail. Put your patient at ease but know where to draw the line. Maintain professionalism during the examination. Humor can help Peak technique Tips for assessment success Before starting the physical assessment, follow these guidelines: Get it down on paper Document your findings up to this point in a concise paragraph.

Include only essential information that communicates your overall impression of the patient. For example, if your patient has a lesion, simply note it now. The first time you assess a patient, record his baseline vital signs and statistics. A series of readings usually provides more valuable information than a single set. See Tips for interpreting vital signs.

Height and weight Height and weight are important parameters for evaluating nutritional status, calculating medication dosages, and assessing fluid loss or gain. See Measuring height and weight. Keep this information handy so you can refer to it quickly, if needed. Note that these measurements differ for pediatric patients. See Obtaining pediatric measurements, page For example, a rapid, thready pulse along with low blood pressure may signal shock.

For example, temperature decreases with age, and respiratory rate may increase with age or with an underlying disease. Individuality Also remember that an abnormal value for one patient may be a normal value for another. Each patient has his own baseline values, which is what makes recording vital signs during the initial assessment so important. Then use these techniques to measure his height and weight. Balancing the scale Slide both weight bars on the scale to zero.

The balancing arrow should stop in the center of the open box. If the scale has wheels, lock them before the patient gets on. Upper weight Balancing arrow Lower weight Measuring height Ask the patient to step on the scale and turn his back to it.

Move the height bar over his head and lift the horizontal arm. Then lower the bar until the horizontal arm touches the top of his head. Now read the height measurement from the height bar.

For example, if you think the patient weighs lb Slide the upper weight across until the arrow on the right stops in the middle of the open box. If the arrow hits the bottom, slide the weight to a lower number. If the arrow hits the top, slide the weight to a higher number.

For example, if the lower weight is on lb 68 kg and the upper weight is on 12 lb 5. Normal body temperature ranges from A fever is an elevation in oral body temperature over Horizontal arm Height bar When measured in this fashion, height is commonly referred to as length. Because infants tend to flex and curl, here are three steps to make measuring length easy and accurate: Hold his knees together with your other hand, gently pressing them down toward the table until fully extended.

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Measure the length. Infant scales may be digital or use a balancing arrow. To prevent injury, never turn away from a child on a scale or leave him unattended.

You can usually use an adult scale to weigh children older than age 2 or 3. This measurement reflects the growth of the cranium and its contents. From F to C and back again To convert a Celsius measurement to a Fahrenheit measurement, multiply the Celsius temperature by 1. To convert Fahrenheit to Celsius, subtract 32 from the Fahrenheit temperature and divide by 1. See How temperature readings compare.

The radial pulse is commonly the most accessible. However, in cardiovascular emergencies, you should palpate for the femoral or carotid pulses. See Pinpointing pulse sites. Feeling the beat To palpate for a pulse, use the pads of your index and middle fingers.

Press the area over the artery until you feel pulsations. If the If the patient has an irregular heartbeat or if he has a pacemaker, be sure to count his pulse for a full minute. The chart below describes each method. Method Normal temperature Used with Oral Brachial pulse Carotid pulse rhythm is regular, count the beats for 30 seconds and then multiply by 2 to get the number of beats per minute.

If the rhythm is irregular or your patient has a pacemaker, count the beats for 1 minute. If you need to palpate the carotid arteries, avoid exerting a lot of pressure, which can stimulate the vagus nerve and cause reflex bradycardia. Also, never palpate both carotid pulses at the same time. Off beat When you note an irregular pulse: You should feel the pulse every time you hear a heartbeat. Measuring the pulse deficit allows you to evaluate indirectly the ability of each cardiac contraction to eject sufficient blood into the peripheral circulation.

Radial pulse Pedal pulse Femoral pulse Popliteal Posterior pulse tibial pulse To do this, use a numerical scale or descriptive term to rate or characterize the strength. Numerical scales differ slightly among facilities but the following scale is commonly used: Respirations As you count respirations, be aware of the depth and rhythm of each breath. To determine the respiratory rate, count the number of respirations for 60 seconds.

To avoid this, take his respirations while you take his pulse. Is his breathing shallow, moderate, or deep? Observe the rhythm and symmetry of his chest wall as it expands during inspiration and relaxes during expiration. Be aware that skeletal deformity, fractured ribs, and collapsed lung tissue can cause unequal chest expansion.

Accessory to the act…of breathing Use of accessory muscles can enhance lung expansion when oxygenation drops. Patients with chronic obstructive pulmonary disease COPD or respiratory distress may use neck muscles, including the sternocleidomastoid muscles, and abdominal muscles for breathing. Patient position during normal breathing may also suggest problems such as COPD. Normal respirations are quiet and easy, so note any abnormal sounds, such as crackles, wheezing, or stridor.

Blood pressure Blood pressure measurements are helpful in evaluating cardiac output, fluid and circulatory status, and arterial resistance.

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Blood pressure measurements consist of systolic and diastolic readings. The systolic reading reflects the maximum pressure exerted on the arterial wall at the peak of left ventricular contraction. Normal systolic pressure ranges from to mm Hg. The systolic reading is the maximum pressure exerted on the arterial wall at the peak of left ventricular contraction.

This reading is generally more significant than the systolic reading because it evaluates arterial pressure when the heart is at rest. Normal diastolic pressure ranges from 60 to 79 mm Hg.

See Blood pressure variations. Unpronounceable and indispensable The sphygmomanometer, a device used to measure blood pressure, consists of an inflatable cuff, a pressure manometer, and a bulb with a valve. To record a blood pressure, the cuff is centered over an artery, inflated, and deflated. See Using a sphygmomanometer. As the cuff deflates, listen with a stethoscope for Korotkoff sounds, which indicate the systolic and diastolic pressures.

Blood pressure can be measured from most extremity pulse points. The brachial artery is used for most patients because of its accessibility. See Tips for hearing Korotkoff sounds, page Using the bell helps you better hear Korotkoff sounds, which indicate pulse. The start of the pulse sound indicates the systolic pressure.

The last Korotkoff sound you hear is the diastolic pressure. For example, black women tend to have higher systolic blood pressures than white women, regardless of age. Furthermore, after age 45, the average blood pressure of black women is almost 16 mm Hg higher than that of white women in the same agegroup.

With this in mind, carefully monitor the blood pressures of your black female patients, being alert for signs of hypertension.

Early detection and treatment— combined with lifestyle changes—can help prevent such complications as stroke and kidney disease. Here are two techniques. Have the patient raise his arm Palpate the brachial pulse and mark its location with a pen to avoid losing the pulse spot. Apply the cuff and have the patient raise his arm above his head.

Have him lower his arm until the cuff reaches heart level, deflate the cuff, and take a reading. Have him rapidly open and close his hand approximately 10 times; then deflate the cuff and take the reading. Performing a physical assessment During the physical assessment, use drapes so only the area being examined is exposed.

Develop a pattern for your assessments, starting with the same body system and proceeding in the same sequence. Organize your steps to minimize the number of times the patient needs to change position. Use these techniques in sequence except when you perform an abdominal assessment.

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Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. Inspection Inspect the patient using vision, smell, and hearing to observe normal conditions and deviations. Performed correctly, inspection can reveal more than other techniques. Inspection begins when you first meet the patient and continues throughout the health history and physical examination. As you assess each body system, observe for color, size, location, movement, texture, symmetry, odors, and sounds.

Inspection Palpation Percussion Auscultation. To do this, you need short fingernails and warm hands. Always palpate tender areas last. See Types of palpation. Check out these features As you palpate each body system, evaluate the following features: Peak technique Types of palpation The two types of palpation, light and deep, provide different types of assessment information.

Light palpation Perform light palpation to feel for surface abnormalities. Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Deep palpation Deep palpation is used to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility. If necessary, use one hand on top of the other to exert firmer pressure. The technique helps you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.

See Types of percussion. Peak technique Types of percussion You can perform percussion using the direct or indirect method. Direct percussion Direct percussion reveals tenderness. Using one or two fingers, tap directly on the body part. Ask the patient to tell you which areas are painful and watch his face for signs of discomfort. Indirect percussion Indirect percussion elicits sounds that give clues to the makeup of the underlying tissue.

Press the distal part of the middle finger of your nondominant hand firmly on the body part. Keep the rest of your hand off the body surface. Flex the wrist of your dominant hand. Listen to the sounds produced. Percussion requires a skilled touch and a trained ear.

Each sound is related to the structure underneath. This chart offers a quick guide to percussion sounds and their sources. Organs and tissues, depending on their density, produce sounds of varying loudness, pitch, and duration.

For instance, air-filled cavities such as the lungs produce markedly different sounds than the liver and other dense tissues. See Sounds and their sources. As you percuss, move gradually from areas of resonance to those of dullness and then compare sounds. Also, compare sounds on one side of the body with those on the other side. Auscultation Auscultation, usually the last step, involves listening for various breath, heart, and bowel sounds with a stethoscope.

As you identify different sounds while assessing a body system, make sure you note the intensity and location of each sound. To prevent the spread of infection among patients, clean the heads and end pieces of the stethoscope with alcohol or a disinfectant before each use.

See Using a stethoscope, page First, your stethoscope should have these features: Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds. You can minimize this problem by lightly wetting the hair before auscultating. A few more tips Also keep these points in mind: Next, precisely record all information you obtained using the four physical assessment techniques.

See Documenting your findings. Just as you should follow an organized sequence in your examination, you should also follow an organized pattern for recording The illustration below is an example of part of an initial assessment form similar to one you might use. Is alert and well-groomed. Communicates well. Makes eye contact and expresses appropriate concern throughout exam. Smith, RN your findings. Document all information about one body system, for example, before proceeding to another.

Locate landmarks Use anatomic landmarks in your descriptions so other people caring for the patient can compare their findings with yours.

Start with the same body system; proceed in the same sequence. However, when examining the abdomen, use inspection, auscultation, percussion, and palpation in that order.

Observe their loudness, pitch, and duration. Record your findings by body system to organize the information. The first technique in your physical assessment sequence is: The assessment of each body system begins with inspection. When palpating the abdomen, begin by palpating: Light palpation is always done first to detect surface characteristics. Because the friction caused by chest hair can mimic abnormal breath sounds, wet the hair slightly to prevent friction.

The pulse deficit measures the difference between the: The pulse deficit is the difference between the apical and radial pulse rates. It provides an indirect evaluation of the ability of each heart contraction to eject enough blood into the peripheral circulation. During percussion you hear a flat sound.

The most likely source of this sound is: Flatness is most commonly heard over dense tissue, such as muscle and bone. If you answered four questions correctly, terrific! In our assessment, you have unfulfilled potential. See Parts of a nutritional assessment. Normal nutrition Nutrition refers to the sum of the processes by which a living organism ingests, digests, absorbs, transports, uses, and excretes nutrients. For nutrition to be adequate, a person must receive the proper nutrients, including proteins, fats, carbohydrates, water, vitamins, and minerals.

Also, his digestive system must function properly for his body to make use of nutrients. Parts of a nutritional assessment Remember the four parts of a nutritional assessment, shown here. The mechanical breakdown of food begins in the mouth with chewing and continues in the stomach and intestine as food is churned in the GI tract.

The chemical processes start with the salivary enzymes in the mouth and continue with acid and enzyme action throughout the rest of the GI tract. For example, glucose, a carbohydrate, is stored in the muscles and the liver.

It can be converted quickly when the body needs energy fast. If glucose is unavailable, the body breaks down stored fat, a source of energy during periods of starvation.

See Anabolism and catabolism. Anabolism and catabolism Anabolism is a building up process that occurs when simple substances such as nutrients are converted into more complex compounds to be used for tissue growth, maintenance, and repair. Protein power The body needs protein to ensure normal growth and function and to maintain body tissues. Protein is stored in muscle, bone, blood, skin, cartilage, and lymph.

Because the body typically preserves protein to maintain body functions, protein is used as a source of energy only when the supply of carbohydrates and fat is inadequate. Carbohydrates and fat are the primary sources of energy for the body. Vitamins, minerals, and water are also essential for normal functioning. To be transported throughout the body, they must combine with plasma proteins to form lipoproteins. Likewise, free fatty acids combine with albumin, whereas cholesterol, triglycerides, and phospholipids bind to globulin.

Obtaining a nutritional health history A patient may relate various nutrition-related complaints, such as weight gain or loss; changes in energy level, appetite, or taste; dysphagia; GI tract problems, such as nausea, vomiting, and diarrhea; or other body system changes, such as skin and nail abnormalities. Catabolism is a breaking down process that occurs when complex substances are converted into simple compounds and stored or used for energy.

Also, ask about a family history of obesity, diabetes, metabolic disorders such as hypercholesterolemia, and stomach and GI disturbances. These problems have a tendency to occur in more than one family member. A day in the life Also, ask the patient to describe his typical day.

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This will give you important information about his routine activity level and eating habits. Ask him to recount what and how much he ate yesterday, how the food was cooked, and who cooked it. See Understanding differences in food intake.

Bridging the gap Understanding differences in food intake What your patient eats depends on various cultural and economic influences. Low socioeconomic status can lead to nutritional problems, especially for small children and pregnant women, who may give birth to infants with low birth weights or experience complications during labor.

For example, fish and rice are staple foods for many Asians. Whoever made this meal was quite the chef! Remember that nutritional problems may be associated with various disorders or factors. See Tips for detecting nutritional problems. Does he look rested? Is his posture good?

Is his speech clear? Are his height and weight proportional to his body build? Are his physical movements smooth with no apparent weaknesses? Is he free from skeletal deformities? Tips for detecting nutritional problems Nutritional problems may stem from physical conditions, drugs, diet, or lifestyle factors. Listed below are factors that might indicate your patient is particularly susceptible to nutritional problems.

Is his hair shiny and full? Is his skin free from blemishes and rashes? Is it warm and dry, with normal color for that particular patient? Is the turgor normal?

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Are his nails firm with pink beds? Is he wearing contacts or glasses? Are the mucous membranes in his nose moist and pink? Is his tongue pink with papillae present? Are his gums moist and pink? Is his mouth free from ulcers or lesions? Does his breath have an odor? Is his neck free from masses that would impede swallowing? Neurologic system Is the patient alert and responsive? Are his reflexes normal? Is his behavior appropriate? Are his heart rate and blood pressure normal for his age?

Are his extremities free from swelling? Are his peripheral pulses palpable? Is he breathing at a normal rate without effort? Is his chest expansion with breathing normal? GI system Does the patient have normal bowel sounds? Do you see any visible scars on his abdomen?

Is his abdomen free from abnormal masses on palpation? Does he flinch or grimace on palpation? Have you been brushing regularly? How much fluid does he drink each day? Does he urinate frequently? Does he get up during the night to urinate? Musculoskeletal system Does the patient have any evidence of muscle wasting?

Can he perform the full range of motion with his extremities? Does he have any difficulty walking? Do you note any obvious joint deformities? Anthropometric measurements The second part of the physical assessment is taking anthropometric measurements. These measurements can help identify nutritional problems, especially in patients who are seriously overweight or underweight.

Measuring height and weight If your patient can stand without assistance, weigh him using a calibrated balance beam scale, and measure his height using the height bar on the scale. See Overcoming problems in measuring height. See Height and weight table.

Weighty terms Here are some weight-related definitions: Overcoming problems in measuring height Is your patient confined to a wheelchair? Is he unable to stand straight because of scoliosis? Have the patient hold his arms straight out from the sides of his body.

The higher weights in each category apply to men, who typically have more muscle and bone than women do. Height measurements are for patients not wearing shoes; weight measurements are for patients not wearing clothes. BMI is a measure of body fat based on height and weight. See Interpreting BMI, page Anthropometric alternatives Other anthropometric measurements include midarm circumference, midarm muscle circumference, and skin-fold thickness. These measurements are used to evaluate muscle mass and subcutaneous fat, both of which relate to nutritional status.

See Taking anthropometric arm measurements, page Being significantly overweight or underweight can have serious health consequences. BMI can be used as a measure of obesity and protein-calorie malnutrition as well as an indicator of health risk.

All measures other than normal place the patient at a higher health risk, and nutritional needs should be assessed accordingly. Below are some common biochemical tests that may be performed as part of a nutritional assessment as well as possible outcomes and interpretations. Other tests, such as thyroid function tests and serum electrolyte and vitamin levels, may also be ordered.

All about albumin Serum albumin level is used to assess protein levels in the body. It also functions as a carrier protein for various substances important for nutritional health, such as iron. Keep in mind that albumin production requires functioning liver cells and an adequate supply of amino acids, which are the building blocks of proteins. Serum albumin level is decreased with serious protein deficiency and loss of blood protein resulting from burns, malnutrition, liver or renal disease, heart failure, major surgery, infections, or cancer.

Hemoglobin is the main component of red blood cells RBCs , which transport oxygen. Its formation requires an adequate supply of protein in the form of amino acids. A decreased hemoglobin level suggests iron deficiency anemia, protein deficiency, excessive blood loss, or overhydration.

An increased hemoglobin level suggests dehydration or polycythemia. Hemoglobin values let you know how well we red blood cells are doing at our job of carrying oxygen. Triceps skin-fold thickness 1. Place the calipers at the midpoint and squeeze for 3 seconds.

Record the measurement to the nearest millimeter. Take two more readings and use the average. Midarm circumference and midarm muscle circumference 1.

At the midpoint, measure the midarm circumference, as shown below. Record the measurement in centimeters. Calculate the midarm muscle circumference by multiplying the triceps skin-fold thickness—measured in millimeters—by 3. Subtract this number from the midarm circumference. Recording the measurements Record all three measurements as a percentage of the standard measurements see chart below , using this formula: This test helps diagnose anemia and dehydration.

Decreased values suggest iron deficiency anemia, excessive fluid intake, or excessive blood loss. Increased values suggest severe dehydration or polycythemia. Carry on with transferrin Transferrin is a carrier protein that transports iron. The molecule is synthesized mainly in the liver.

The level decreases along with protein levels and indicates depletion of protein stores. Decreased values may also indicate inadequate protein production resulting from liver damage, protein loss from renal disease, acute or chronic infection, or cancer. Elevated levels may indicate severe iron deficiency. Proteins contain nitrogen. When proteins are broken down into amino acids, nitrogen is excreted in the urine as urea. Nitrogen intake and excretion should be equal. Nitrogen balance is the difference between nitrogen intake determined by a calorie count done during the same time frame as the hour urine collection and excretion.

Results may vary in patients with such conditions as burns and infection. Trust in triglycerides Triglycerides are the main storage form of lipids. Measuring triglyceride levels can help identify hyperlipidemia early. Patients who consume large amounts of sugar, soda, and refined carbohydrates commonly have elevated triglyceride levels.

Decreased triglyceride levels commonly occur in those who are malnourished. Count the cholesterol A total cholesterol test measures circulating levels of free cholesterol and cholesterol esters. A diet high in saturated fats raises cholesterol levels by stimulating lipid absorption. Increased levels indicate an increased risk of coronary artery disease. Decreased levels are commonly associated with malnutrition.

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Patients who consume large amounts of sugar and soda commonly have elevated triglyceride levels. So, no matter how tasty the cake looks, stick to just one slice!

Remember that clinical signs of nutritional deficiencies appear late. Also, be aware that patients hospitalized for more than 2 weeks risk developing a nutritional disorder. See Nutritional assessment findings, page Excessive weight loss Patients with nutritional deficiencies usually experience weight loss. Weight loss may result from decreased food intake, decreased food absorption, increased metabolic requirements, or a combination of the three.

Other possible causes include endocrine, neoplastic, GI, and psychiatric disorders; chronic disease; infection; and neurologic lesions that cause paralysis and dysphagia. Excessive weight loss may also occur if the patient has a condition that prevents him from consuming a sufficient amount of food, such as painful oral lesions, ill-fitting dentures, or a loss of teeth.