Pattern 2 - Nutrition/Metabolic

PATTERN 2: NUTRITIONAL-METABOLIC

Required Readings:	Nutritional assessment - Jarvis - Chapter 7; Weber - pages 15-17 and Chapter 18
	Skin, hair, nails - Weber - Chapter 5; Jarvis - Chapt. 10
	Oral Cavity, throat - Weber-Chapter 6 & 7; Jarvis - Chapt. 11 & 14
	Abdomen - Weber - Chapter 14; Jarvis, Chapt. 19

Required Assignments:	Complete workbook - pp. 51-60, 73-84, 87-96, 199-128, 117-188


Required Videotapes:	Skin, hair, nails - Mosby's video series
	Mouth & throat - Bates Tape I
	Abdomen - Springhouse #503

Recommended Videotape:	Bates Tape VII

Exam 1: Will cover material related to Patterns 2 &3: Skin, hair, nails, oral cavity, throat and abdomen

Objectives:

Identify questions to ask related to the Nutrition-Metabolic pattern.

Describe physical examination skills used in assessing Nutritional-Metabolic status.

Demonstrate assessment techniques used in assessing Nutritional-Metabolic status.

Identify variations from normal.

Document findings on an assessment tool as appropriate.

Examination Skills:

General Inspection
Anthropometric Assessment
Exam of Skin, Hair, and Nails
Exam of Oral Cavity
Exam of Lymphs of Head & Neck
Exam of Thyroid Gland
Exam of Abdomen

NUTRITIONAL METABOLIC PATTERN

I. ASSESSMENT FOCUSES ON:

Amount of food and fluids consumed in relation to metabolic needs And degree to which the body demonstrates that the ingested Nutrients are adequately used.
General Appearance – cues associated with alterations in nutrition
Food and fluid pattern
Metabolic status
Diet adequacy r/t nutrient balance and metabolic needs
Cultural, psychological and sociological factors
Physiological alterations associated with nutritional processes
Physical indicators of malnutrition

ASSESSMENT OF THE SKIN, HAIR, AND NAILS

General approach
Equipment
Exposure and lighting
Thoroughness
Comparisons

SKIN ASSESSMENT

Color
1. Descriptive terms:
  - brown
  - tan
  - bronze
  - bluish
  - cyanotic - blue
  - reddish - blue
  - pale
  - yellow
  - red - erythema
  - red - injected
  - red - flush
  - red - rugor
  - pink
  - white
2. Areas to assess:
  - skin
  - conjunctiva
  - sclera
  - nail beds
  - soles and palms
3. Pallor
  - causes
  - appearance in light and dark skinned individuals
4. Cyanosis
  1. central
  2. peripheral
  3. variations in light and dark skinned individuals
5. Jaundice
  1. causes
  2. variations in light and dark skinned individuals
  3. increased carotene
6. Erythema
  1. causes
  2. variations in light and dark skinned individuals
II Moisture
1. Descriptive terminology:
  - wet
  - dry
  - moist
  - perspiration
  - clammy
  - diaphoretic
  - oily
  - greasy
  - scaly
  - waxy
2. Assessment of moisture
3. Variations from normal
Temperature
1. Descriptive terminology:
  - warm
  - cold
  - cool
  - fever
  - hot
2. Assessment technique

Texture & Thickness

Descriptive terminology:

smooth	callused
coarse	thin
rough	thick
cracked (excoriated)	tissue paper
wrinkled	parchment thin
velvety	corrugated
leathery	pebbly
indurated	scarred
soft	striae
resilient

Variations related to:
- age
- environmental factors
- gender
- health status:
- perthyroidism
- pothyroidism

Turgor & Mobility
1. Descriptive terminology
  
  loose dehydrated
  
  wrinkled turgor
  
  callused firm
  
  edematous
2. Assessment of turgor
3. Assessment and grading of edema
Hygiene

Lesions

Distribution
Configuration
1. grouped
2. linear
3. annular
4. arciform
5. scattered
C. Type
1. primary
2. secondary
3. vascular

Common lesions:

cyst	scar
macule	lichenification
patch	crust
papule	excoriation
plaque	fissure
nodule	ulcer
tumor	petechiae
wheal	ecchymoses
vesicle	purpura
bulla	spider angioma
pustule	capillary hemangioma

Malignant melanoma
1. Risk factors
2. Signs/symptoms
Staging of ulcers

Parasites
Dermatoglyphics

SKIN
DESCRIPTIVE TERMS:

COLOR	MOISTNESS	TEMPERATURE	TEXTURE
Brown	Wet	Warm	Coarse
Tan	Dry	Cold	Rough
Bronze	Moist	Fever	Cracked(excoriated)
Bluish	Perspiration	Hot	Wrinkled
Cyanotic (blue)	Clammy		Velvety
Reddish-blue	Diaphoretic		Flaky
Pale	Oily		Smooth
Yellow	Greasy		Leathery
Red-erythema	Scaly		Indurated
Red-injected	Waxy		Soft
Red-blushing			Resilient
Red-flush
Red-rugor
Pink
White

THICKNESS	MOBILITY
Calloused	Loose
Thin	Wrinkled
Thick	Calloused
Tissue paper	Edematous
Parchment thin	Dehydrated
Corrugated	Turgor
Pebbly	Firm
Scarred
Striae

NAILS

Shape and configuration

Nail base angle
Clubbing

Color
Capillary refill time
Lesions

Leukonychia
Splinter hemorrhages
Beau's lines

HAIR
Color and pigmentation
Quantity
Distribution

Alopecia

Texture
Hygiene
Infestations

N202 - Performance Evaluation Guide
PATTERN 2 - NUTRITION AND METABOLISM
Part A - Skin, Hair, Nails

Name: _____________________________

Date: _____________

Preparation for Exam	Comments
Prepares setting for exam. Uses professional interpersonal skills. Minimizes position changes (client's & own). Adapts exam to characteristics and needs of the client. Uses techniques to facilitate placing the client at ease. Provides for privacy and confidentiality. Sequences examination correctly. Uses universal precautions.
Observes shape of skull and size of head in proportion to body. Inspects scalp for color, lesions, & hygiene. Palpates scalp for symmetry, texture. Inspects hair for color, amount, distribution, texture, hygiene, and presence of parasites. Inspects and palpates the skin and hair of various body regions for color, temperature, moisture, vascular changes and lesions. Compares symmetrical parts. If a skin lesion is detected, inspects and palpates it for size, location, mobility and consistency and pattern. Assesses turgor - pinches up skin on sternum, under clavicle, or forearm and releases. Assess for edema - presses thumb over the tibia and medial malleolus for a count of five, releases. Inspects and palpates nails. inspects for color, shape, texture and lesions. palpates for capillary filling.

DOCUMENTATION OF SKIN, HAIR & NAILS
Skin

Color
Moisture
Temperature
Texture
Turgor
Lesions

Hygiene Hair

Color
Texture
Distribution
Hygiene

Nails

Shape
Color
Lesions
Capillary Refill

Resources/Examples
Weber p. 440-441
Jarvis p. 243, 885

ASSESSMENT OF THE JAW AND ORAL CAVITY

General Approach
Equipment
Exposure and Lighting
Inspect and Palpate the Outer Structures of the Oral Cavity
1. Malocclusion
2. Temporal Mandibular Joints
3. Lips
Examine the Lip and Buccal (Oral) Mucosa
Inspect the Teeth and Gingiva
Examine the Dorsal Surface of the Tongue
Examine the Lateral and Ventral Tongue Surfaces
Inspect the Hard and Soft Palates
Examine the Oropharynx, Posterior Tongue, And Uvula

Lymphatic System

Lymph nodes of the face and neck
1. Pre-auricular - in front of the ear
2. Post-auricular - Superficial to the mastoid process
3. Occipital - at the base of the skull posteriorly
4. Tonsillar - at the angle of the mandible
5. Submaxillary - halfway between the angel and the tip of the mandible
6. Submental - in the midline behind the tip of the mandible
7. Superficial cervical - superficial to the sternomastoid
8. Posterior cervical chain - along the anterior edge of the trapezius
9. Deep cervical chain - deep to the sternomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternomastoid muscle
10. Supraclavicular - deep in the angle formed by the clavicle and the sternomastoid

ASSESSMENT OF THE THYROID GLAND

General Approach
Exposure and Lighting
Assessed For Enlargement, Tenderness, Nodules, Bruits
Structures: Thyroid Cartilage, Cricoid Cartilage, Isthmus Of The Thyroid, Right And Left Lateral Lobes
Inspect Anterior Neck
1. Normal Position
2. Slight Extension
3. Swallows
Palpate the Thyroid Using Anterior or Posterior Approach
1. Movements of the Gland While the Client Swallows
2. Adequate Exposure Of The Gland By Tilting The Head To One Side To Relax The Muscles
3. Manual Displacement of Surrounding Structures To Better Expose the Gland
4. Comparison of One Side of the Gland with the Other
Auscultate the Thyroid

NUR 202 - Performance Evaluation Guide PATTERN 2 - NUTRITION & METABOLISM PART B - ORAL CAVITY & NECK

Name: ______________________________

Date: ________

Preparation for Exam	Comments
Prepares setting for exam. Uses professional interpersonal skills. Minimizes position changes (client's & own). Adapts exam to characteristics and needs of the client. Uses techniques to facilitate placing the client at ease. Provides for privacy and confidentiality. Sequences examination correctly. Uses universal precautions.
Outer Structures of Oral Cavity Assesses for malocclusion. Palpates the temporal mandibular joint. Inspects and palpates the skin over the parotid glands. Inspects the lips.
Mouth Uses penlight or otoscope light and tongue blade, gauze and gloves as appropriate. Uses tongue blade to inspect all structures of mouth; lips, buccal mucosa, hard and soft palpates, teeth. Examines the dorsal, lateral and ventral tongue surfaces. Palpates suspicious areas for induration and tenderness.
Pharynx Asks person to extend the tongue and say "ah". Inspects all structures of pharynx: oropharynx, posterior tongue, uvula. Uses tongue blade if person has difficulty holding tongue flat.
Neck Palpates the lymph nodes of the head and neck. Asks person to flex neck slightly forward. Uses pads of index and middle fingers to move skin over underlying tissues in each area. Inspects the area of the anterior neck containing the thyroid gland. Note deviations and bulges in a relaxed position. Observes as person extends neck slightly and swallows. Palpates the thyroid (anterior approach). Stands facing the person. Asks patient to extend neck slightly and to swallow. Uses pads of fingers to feel below the cricoid cartilage for the thyroid isthmus. Asks the person to swallow and feels the isthmus rising upward under fingers. Asks person to flex neck slightly forward and to their right. Places right thumb on the lower portion of thyroid cartilage and displaces it to the person's right. Hooks the tips of the second and third fingers of the left hand behind the sternomastoid muscle and feels in front of muscle with left thumb. Palpates for lateral lobe as person swallows. Reverses the procedure for the left lobe. Auscultates each lobe for bruits if enlargement noted. OR Palpates the thyroid (posterior approach). Stands facing the person. Asks patient to extend neck slightly and to swallow. Uses pads of fingers to feel below the cricoid cartilage for the thyroid isthmus. Asks the person to swallow and feels the isthmus rising upward under fingers. Stands behind the person. Rests thumbs on back of person's neck. Uses index and middle fingers of both hands to feel for the thyroid isthmus and for anterior surfaces of lateral lobes. Asks person to flex neck slightly forward and to the right. Displaces the thyroid cartilage to the right with fingers of left hand. Palpates the right lobe using fingers of right hand while person swallows. Reverses the procedure for the other side. Auscultates each lobe for bruits if enlargement noted.

DOCUMENTATION OF ORAL CAVITY

Lips:	Color
	Moisture
	Surface
Mouth:	Mucosa Color
	Moisture
	Surface
Gums:	Color
	Surface
	Margin
Teeth:	General Condition
Tongue:	Symmetry
	Mobility
	Surface
Tonsils:	Presence/Absence
	Exudate
	Lesions
Uvula:	Position
	Movement
Posterior Pharynx:	Color
	Lesions

Resources/Examples:
Weber, p. 442
Jarvis p. 410, 886

DOCUMENTATION OF THE NECK AND THYROID

Symmetry
Trachea position
Thyroid:	size
	Consistency
	Surface
Lymph nodes:	palpable/non-palpable
if palpable - location
	Size
	Surface characteristics
	Consistency
	Mobility
	Tenderness
	Changes in overlying skin

Resources/Examples:
Weber, pgs. 441
Jarvis, pgs. 289, 886

loose	dehydrated
wrinkled	turgor
callused	firm
edematous