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Nutrition Care Process: ADIM

Soap Notes. Nutrition Care Process: ADIM. S: Subjective (what patient tells you) O: Objective (measured/factual) A: Assessment PES Statement: P: diagnostic label; alteration in client’s nutritional status E: etiology; factors that contribute to the cause or existence of a problem

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Nutrition Care Process: ADIM

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  1. Soap Notes Nutrition Care Process: ADIM S: Subjective (what patient tells you) O: Objective (measured/factual) A: Assessment PES Statement: P: diagnostic label; alteration in client’s nutritional status E: etiology; factors that contribute to the cause or existence of a problem S: signs and symptoms; defining characteristics obtained from sub. and obj. data “The problem (p) is related to the etiology (e) as evidenced by the signs and symptoms (s). P: Plan Dx: plan for additional diagnosis or assessment Rx: plan for treatment PtEd: plan for patient education Assess: nutritional health status Diagnosis: interpret data to determine Implement: develop a plan of action Evaluate: monitor the effectiveness of the plan

  2. % IBWDegree of Undernutrition 80-90% mildly depleted 70-80% moderately depleted <70% severely depleted %UBWDegree of Undernutrition 85-95% mildly depleted 75-85% moderately depleted <75% severely depleted Amputations Hand - .3% of total body weight Forearm and hand – 2.6% Entire arm – 6.2% Foot – 1.7% Below knee – 7.0% Above knee – 11.0% Entire leg – 18.6% Anthroprometrics: Frame Size (r) = height (cm) wrist circumference (cm) R = males 38-43, females 35-41 Ideal Body Weight: Males: 106 # for first 5’ and 6# for each additional inch Females: 100 # for first 5’ and 5# for each additional inch Body Mass Index: weight (kg) / height (meters)2 Below 18.5 = underweight 18.5-24.9 = normal 25-29.9 = overweight (grade 1 obesity) Above 30 = obese (grade 2) 40 or above = morbidly obese (grade 3) %IBW = actual weight x 100 IBW %UBW = actual body weight x 100 UBW

  3. Hematocrit (Hct) % volume of whole blood occupied by RBCs Males: 40-54 ml/dL Females: 37-47 ml/dL Decreased: low iron Increased: dehydration Mean Corpuscular Volume (MCV) Size of RBC = Hct x 10 # of RBC (millions/mm³) Low: Fe or Cu deficiency High: folacin or B12 deficiency Mean Corpuscular Hemaglobin(MCH) Hemoglobin content per cell. Normal 27-31 MCH = Hgb (g/dL) x 10 # of RBC (millions/mm³) Low: Fe deficient; High: folacin or B12 def. Serum Albumin Normal: 3.5-5.0 g/dL <3 g/dL – possible edema <2.5 g/dL – extreme med. & nutritional risk Pre-Albumin Normal: 19-43 mg/dL Interpretation of Unintentional Weight Loss Time Frame Significant Severe 1 week 1-2% UBW >2% UBW 1 month 5% UBW >5% UBW 3 months 7.5% UBW >7.5% UBW 6 months 10% UBW >10% UBW Waist-Hip Ratio and Waist Circumference >1 in men or >.8 in women is android obesity Predictive of obesity: waist circumference Men >40 in, women >35 in (risk for Type II DM) Midarm Muscle Circumference MAMC = MAC (cm) – (.314 x TSF (mm)) Arm Muscle Area MAC x (3.54 x TSF) 2 (4) (3.54) Hemoglobin Males: 14-18 g/dL Females: 12-16 g/dL Deficiency: iron defic. anemia

  4. Transferrin • Normal: 215-380 mg/dL • Increased: Fe def.; Decreased: excess Fe • Total Lymphocyte Count • Normal > 2700 • TLC = Total WBC x % lymphocytes • 100 • Nitrogen Balance • Protein (gm) - (UUN (gm) + 4) • 6.25 • Basal Energy Expenditure (BEE) • Harris Benedict • Females: 655 + 9.6 Wt + 1.8 Ht (cm) – 4.7 A • Males: 66 + 13.7 Wt + 1.8 Ht (cm) – 6.8 A • TDE = BEE x AF x IF • Activity and Injury Factors • AF = Activity Factor • 1.1-1.2 Confined to Bed • 1.2-1.3 Ambulatory • 1.5-1.75 Normally Active Persons • 2.0 Extremely Active Persons • IF = Injury Factor • 1.0-1.3 Patients undergone minor surgery • 1.2-1.4 Patients with skeletal trauma • 1.44 Patients with elective surgery • 1.0-1.9 Patients with major sepsis • 1.88 Patients with trauma plus steroids • 2.1-2.5 Patients with severe burns • Weight Change • % WC = UBW – ABW • UBW • Time Sig. Wt. Loss Severe Wt. Loss • 1 wk. 1-2 % >2% • 1 mo. 5% >5% • 3 mo. 7.5% >7.5% • 6 mo. 10% >10% • Mifflin-St. Jeor • Female – 10W + 6.25H - 5 Age – 161 • Male – 10W + 6.25H – 5 Age + 5 • W = kg; H = cm • Adjusted Body Weight (Use w/BMI > 40) • ABW = [(actual wt. – IBW) x .25] + IBW

  5. HDL Cholesterol – Desirable > 40 mg/dl LDL Cholesterol – Desirable < 130 mg/dl Borderline 130-159 mg/dl High risk > 160 mg/dl Triglycerides Desirable < 150 mg/dl Borderline high 150-199 High 200-499 Very High > 500 Fecal Fat – inspection of fat-stained specimens for lipid – indicate fat malabsorption. Normal 5 g/24 hours Blood Glucose Normal 70-110 mg/dl > 126 possible diabetes <110 – impaired glucose tolerance HBA1c – Hgb for 2-3 mo. Normal 5-7.5% Creatinine Height Index Indicates total muscle mass CHR = 24 hrs. measured urinary creatinine (mg) Height (cm) CHI = CHR% Deficit ideal CHR 5-15% = mild 6-30% = moderate >30% = severe Hydration Status (2 x Na + K) + BUN + Blood Glucose 2.8 18 Normal – 280-295 mOsm/kg Acceptable – 280-300 mOsm/kg 1 Osmol = 1 mol solute per 1 kg serum (~1 liter) Cholesterol Total Chol. < 150 = malnutrition Total serum/plasma chol Desirable < 200 mg/dl Borderline 200-239 mg/dl High Risk > 240 mg/dl

  6. Protein Requirements Adults .8 g/kg IBW 1.0 – 1/5 g/kg IBW with stress/trauma/disease 1.0 g/100-150 nonprotien kCal for illness 1.0 g/200 nonprotein kCal for healthy adults Type 1 Diabetes Nutrient Requirements Protein 10-20% kCal Sat. Fat < 10%; Polyunsaturated fat < 10% Dietary chol. <300 mg Sucrose < 10% kCal CHO at least 130 g/day Sodium < 3 g/day Limit alcohol Recommendation for Glycemic Control A1C < 7 % A1C for pregnant women < 6% Preprandial glucose 90-130 mg/dL Peak Postprandial glucose (1-2 hr) <180 mg/dL Liver Function Tests ALT and AST Alkaline Phosphatase (ALP) Bilirubin GGT

  7. Hepatomegaly – enlarged liver Hyperbilirubinemia – high bilirubin in blood Hyperinsulinemia – excrete excess insulin Hyperbilirubinemia – high bilirubin in blood Idiopathic – unknown cause Ileus – disruption of normal GI propulsion Ischemia – insufficient blood supply to an organ Kwashiorkor – moderate kCal deficit, severe protein deficit Laparotomy – incision into abdominal cavity Marasmus – severe protein and kCal deficit Oliguric – less than 500 ml urine/day Polycythemia – excess of RBCs Polydipsia – increased thirst Polyphagia – increased hunger Polyuria – frequent urination Postprandial – after eating Proteinuria – protein in urine Prothrombin time (PT) – time it takes for blood to clot Statin – drug used to lower blood cholesterol Tachycardia – abnormal heart rate Thrombophlebitis – inflammation of a vein Vagotomy – removal/severing of vagus nerve Varices – vericose vein in esophagus or stomach Venography – x-ray of veins Xerostomia – dry mouth/no saliva production TERMS ACE inhibitor – anti-hypertensive drug to lower BP Anergy – unresponsive T and B cells (no antibodies) Angina – chest pain caused by oxygen deficit to the heart unstable – occurs at rest stable – occurs w/physical exertion Anorexia – no appetite Ascites – fluid in abdominal cavity Atherosclerosis – thickening of blood vessel walls Azotemia – accumulation of N waste products in blood Cachexia – loss of lean muscle/waisting Cirrhosis – damage/death of liver tissue Colonoscopy – endoscopic inspection of large colon Colostomy – surgery to connect colon to anterior ab. Wall Colectom – surgical resection of part of colon (excision) Cyanotic – purple/blue discoloring of skin Decubiti – bed sores Diaphoretic – sweat droplets on skin Dislipidemia – abnormal blood lipids/lipoproteins in blood Diverticula – abnormal pounces in lining of colon Diverticulitis – inflammation of diverticula Diverticulosis – presence of abnormal pouches lining colon Dysgeusia – impaired taste Dyspnea – shortness of breath Edentulous – without teeth Encephalopathy – degeneration of brain function (secondary to disorder, organ failure, inflam., infection) Fistula – channel or tract to surface of skin Gastroparesis – no/delayed gastric emptying Gastro Vasculitis – inflammation of gastric blood vessels

  8. Risk Factors for Metabolic Syndrome • Abdominal obesity • Insulin Resistance • Dyslipidemia • Hypertension • Prothrombotic state • Diagnosis with 3 or more factors DASH (Dietary Approaches to Stop Hypertension) Grains: 7-8/day Vegetables: 4-5/day Fruits: 4-5/day Lowfat dairy: 2-3/day Meats/Poultry/Fish: < 2/day Fats: 2-3/day Sweets: 5/week 30 g fiber; 2400 mg sodium; Increase Ca, K and Mg TLC (Therapeutic Lifestyle Changes) Sat. fat < 7% kCal Cholesterol < 200 mg/day Soluble fiber 10-25 g/day Plant sterols/stanols 2 g/day Sodium < 2400 Breads > 6/day Vegetables 3-5/day Fruits 3-4/day Dairy 2-3/day Eggs < 2/week Meat/poultry/fish < 5 oz/day

  9. Insulin Types Blood Pressure Lipoprotein

  10. Hormonal Control of Energy Metabolism Lipoprotein Lab Values

  11. BS Bowel sounds, blood sugar, breath sounds BUN Blood urea nitrogen BUT Biopsy Urease test C centigrade CA Carcinoma CABG Coronary artery by-pass graft Cap Capsule CAPD Continuous ambulatory peritoneal dialysis CBC Complete blood count CC Chief Complaint CCU Coronary care unit CF Cystic fibrosis CHI Closed head injury CICU Coronary intensive care unit cl liqs Clear liquids C/O Complains of COPD – Chronic Obstructive Pulmonary Disease CPK Creatine phosphokinase CPK1-3Creatine phosphokinase isoenzymes Cr Creatinine CRP C-reactive protein CxR Chest X Ray CVR Cerebrovascular accident DBW Desirable body weight Abbreviations a.c. before meals ABG arterial blood gas ALP Alkaline phosphotase ALT (SGPT) Alanine Transferase AODM Adult onset diabetes mellitus ARC AIDS Related Complex ASA Acetylsalicylic acid (aspirin) AST (SGOT) Aspartate aminotransferase A-V Arteriovenous shunt or atrioventricular BCAA Branched chained AA BE Barium enema, below the elbow BEE Basal energy expenditure BIA Bioelectrical impedance b.i.d. Twice a day bili Bilirubin BMR Basal metabolic rate BPD Broncopulmonary displesia BR Bed rest BRB Bright red blood

  12. Hct Hematocrit HD Hemodialysis HDL High density lipoprotein Hgb Hemoglobin h.s. Hours of sleep or evening HTN Hypertension Hx History IBD Inflammatory Bowel Disease IBW Ideal Body Weight ICP Intracranial pressure IDDM Insulin dependent diabetes mellitus IM Intramuscular JODM Juvenile onset diabetes mellitus KUB Kidney, ureter, and bladder (x-ray) LAP Laparotomy LBM Lean body mass LDH Lactic dehydrogenase LDL Low density lipoprotein LES Lower esophageal sphincter LLQ Left lower quadrant LUQ Left upper quadrant lymph Lymphocytes lytes Electrolytes Abbreviations D/C Discontinue DKA Diabetic ketoacidosis D5NS Dextrose, 5% in normal saline DT Delirium tremens D5W Dextrose 5% in water DVT Deep vein thrombus Dx Diagnosis EGD Esophogastroduodenoscopy EKG Electrocardiogram ESRD End stage renal disease ETOH Ethanol or Alcohol f femto (10-15) FBS Fasting Blood Sugar FF Force Fluids FH Family History Fx Fracture GDM Gestational diabetes mellitus GERD Gastroesophageal reflux disease GTT Glucose tolerance test

  13. NPO Nothing by mouth NS Normal Saline NSICU Neurosurgical intensive care unit NST Nutritional Support Team NTG Nitroglycerin N/V Nausea and vomiting OGTT Oral glucose tolerance test OTC Over the counter Pa pressure PaCO2 Partial pressure of carbon dioxide PaO2Partial pressure of Oxygen PC Packed cells p.c. After meals PD Peritoneal dialysis pDEXA Peripheral duel energy x-ray absorptiometry PED Percutaneous endoscopic duodenoscopy PEG Percutaneous endoscopic gastrostomy PEJ Percutaneous endoscopic jejunumostomy Abbreviations MAC Midarm circumference MAMC Midarm muscle circumference mcg microgram MCH Mean corpuscular hemoglobin MCHC Mean corpuscular hemoglobin concentration MCT – medium chain trigyceride MCV Mean corpuscular volume MDI Multiple daily injections mech Mechanical mEq Milliequivalent MH Medical history MOM Milk of Magnesia mOsm Milliosmole MTE Mixture of trace elements MVA Motor vehicle accident MVI Multiple vitamin Infusion N/G Nasogastric NH Nutritional History NIDDM Noninsulin dependant diabetes mellitus

  14. SBR Strict bed rest SBS Short Bowel syndrome SC Subcutaneous Ser alb Serum albumin SG Specific Gravity SGOT Serum glutamic-oxaloacetic transaminase SGPT Serum glutamic-pyruvic transaminase SH Social history SOB Short of breath S/P Status post TBIL Total bilirubin TF Tube feeding TG Triglycerides t.i.d. Three times a day TLC Total lymphocyte count TP Total protein TPN Total parental nutrition trach Tracheostomy TSF Triceps skin fold TSH Thyroid-stimulating hormone U/L Units per Liter UTI Urinary tract infection UUN Urinary urea nitrogen Abbreviations PICU Pediatric intensive care unit p.o. By mouth Post-op Post-operative prn As needed PT Prothrombin time, physical therapy pt Patient ptEd Patient Education PUD Peptic ulcer disease PVC Premature ventricular contraction PVD Peripheral ventricular disease q AM Every morning qid Four times a day q4H Every 4 hours RLQ Right lower quadrant R/O Rule out RUQ Right upper quadrant Rx Prescription Sat Saturated SBO Small bowel obstruction

  15. Normal Lab Values

  16. Normal Lab Values

  17. kCal value of Alcohol .8 x proof x oz = kCal Conversions

  18. Nausea/Vomitting Implications - inadequate intake, dehydration, acid- base imbalance, food aversions NI – small, frequent meals w/low fat and odor; dry, starchy and/or salty foods; ginger ale, tea, dried ginger; clear liquids, gelatin, juice PUD Implications – wt. loss; nutrient imbalances NI – restrict foods known to increase acid secretion or direct irritation to gastric mucosa (coffee, black and red pepper, caffeine, alcohol); do not lie down after eating, avoid large meals Gastric Surgery Implications – decreased intake, maldigestion/malabsorption (vit. B12, Fe, Ca), dumping syndrome, possible lactose intolerance NI – high protein and fat, avoid simple sugars, watch lactose, liquids b/t meals, small/fequent meals, lie down after meals, increase fiber GI Disease - Upper GERD NI - no/low: peppermint, chocolate, fried/high fat foods, alcohol, coffee, pepper watch: cola, tea, milk/products, eggs GOAL – reduce gastric acidity, restrict foods that lower LES pressure, improve clearance of espohagus Lifestyle: no smoking, small meals, no lying down after meal, no tight clothing, head raised in bed, weight control Dysphagia 4 stages: 1. Oral preparatory 2. Oral 3. Pharyngeal 4. Esophageal NI – Diet 1: “Dysphagia Pureed” Diet 2: “Dysphagia Mechannically Altered” Diet 3: “Dysphagia Advanced” – no fresh F/V Achalasia – weak esophageal peristalsis, high LES pressure NI – avoid extreme temperature foods, spicy foods, eat small, frequent meals

  19. Irritable Bowel Implications – underweight/malnutrition NI – decreased anxiety, normalize dietary patterns, adequate nutrition intake, sufficient fiber, reduce gas production, pre/probiotics; ID problem foods Inflammator Bowel (UC or Chrons) Implications – malnutrition NI – During: low-residue, lactose-free, small/frequent meals, multivitamin After: maximize energy & protein intake; normalize dietary pattern; increase antioxidants and omega-3 FAs; lower intake of high oxalate foods (cocoa, tea, wheat germ, strawberries, nuts, spinach, beets, baked beans, PB, high vit. C); pro/prebiotics. Diverticulitis Implications – infection increase nut. requirement NI – high fiber (30-35 g); avoid nuts, seeds, hulls Ileostomy/Colostomy Implications – malabsorption/malnutrition NI – decrease risk of obstruction; maintain fluid and electrolyte balance; reduce fecal output, minimize gas; eat slowly/thoroughly; vit. B12 GI Disease - Lower Diarrhea Implications – dehydration; electrolyte/acid-base imbalance; hyponatremia; hypokalemia; loss of bicarbonate ions; malnutrition/nutrient deficiencies; decreased appetite; decreased transit time NI – oral rehydration solutions; low-residue; foods with pro/prebiotics Constipation NI – 20-30 g fiber; adequate water intake, pro/prebiotics Malabsorption Fat: NI – restrict fat to 25-50 g/day; MCT CHO: NI – restrict milk/dairy products Celiac Implications – wt. loss; vitamin/mineral deficiencies; protein/energy malnutrition/malabsorption NI – initially: low-residue, low-fat, lactose & gluten free Lifelong: no wheat, rye, barley, or malt

  20. Osmolality: # of osmotic particles per kilogram of solvent (water) • Osmolarity: # of osmotic particles per liter of solution • Most commercial feedings: 300-500 mOsm/kg • Renal Solute Load • Normal concentration of urine = 1200-1400 mOsm/L • RSL = (g protein x 5.7) + mEq (Na + K + Cl) • Kidneys work best when urine output = • 1.5 – 2 ml x RSL • kCals for Formulas • Avail. 1-2 kCal/ml • Water– 1 ml/kCal or 30-35 ml/kg • 1 kCal/ml = 80% water • 2 kCal/ml = 65% water • kCal requirements • 30 kCal/kg normal wt • 25 kCal/kg overweight Enteral Nutrition • Protein • Soy or casien 10-25% kCal • Elemental or chemically defined • .8 g/kg for healthy • 1 g/kg for elderly • Max = 2.8 g/kg for burn victims • CHO • Lactose and sucrose free • 55% of kCal • Max is 4 mg/kg/min • Fat • Corn or soy oil • Long and medium chain TG • Omega 3 FAs • 30% of kCal • Min = 10% of kCal, Max= 1.2 g/kg/day • Tubes • Measured diameter in french units • 1F = .33 mm • Commonly 8F or 9.6F

  21. Parenteral Nutrition – TPN/PPN • Energy Needs • 25-30 kCal/kg body wt • 1.5 X BEE for most pt w/mild stress • Fluid • 30-35 ml fluid/kg body wt. Short-Term Access - subclavian, jugular, femoral veins Long-Term Access - tunneled catheters - implantable ports Solutions 2 in 1: dextrose and AAs, lipids separate 3 in 1: dextrose, AAs and lipids in one Protein • Individual AAs 3.5-20% • 3.5% = 35 g/L • 20% = 200 g/L .8 g pro/kg normal, max 1.8 g/kg • CHO • Dextrose monohydrate = 3.4 kCal/g • Min= 1 mg/kg/min • Max= 7 mg/kg/min • Fat • Min= 10% of kCal • 10-20% solutions • 10% = 1.1 kCal/ml • 20% - 2 kCal/ml Osmolarity of Solution – max= 900 mOsm Standards: 1 g AA/L = 10 mOsm 1 g dextrose/L = 5 mOsm 1 g lipid (20% sol.)/L = 1.3 mOsm 1 mEq Ca Gluconate/L 1.4 mOsm 1 mEq Mg Sulfate/L = 1.0 mOsm 1 mEq K & Na/L = 2 mOsm

  22. Pulmonary Disease Important Nutrients Vit. C – collage formation Vit. A – mucus production Protein – antibody production Zinc – immunity Vit. B6 – protein and antibody production Mg - relaxation Clinical Symptoms • Early satiety, anorexia, wt. loss, cough, dyspnea during eating COPD – presence of chronic brochitis or emphysema leading to airway obstruction Nutrition Implications: Malnutrition due to increase energy expenditure and decreased energy intake NI: may need Na and fluid restriction • Energy requirements 125-150%>BEE • Sufficient protein – maintain lung/muscle strength, immune function • Balanced ratio of CHO:Pro:Fat • Supplement antioxidants • Monitor Ca and Vit. D • Manage Weight • 1L Oxygen = 4 kCal burnt • Respiratory Quotient = CO2/O2 • CHO = 1 • Protein = .9 • Fat = .7 • Never want more than 1 • Triglyceride synthesis from CHO higher • Energy Requirements • CHO = 40-55% or 2-4 g/kg, max= 5g/kg/min • Pro= 15-20% or 1.2-1.7 g/kg (1.2 standard) • Fat= 30-45% • Calcium = 1200 – 1500 mg • Vit. D = 400 IU

  23. Liver Disease

  24. Jaundice – yellow tint to body tissues and skin • Biliruin > 2.4 – 3 mg/dl • Lab tests for liver disease: plasma bilirubin, urine bilirubin, ALT, AST, alkaline phosphatase, total protein w/albumin & globulin, prothrombin time (longer) • Hepatitis – widespread inflammation of liver • NI: increased kCal, Pro, Vitamins/Minerals, no alcohol, small feedings • 30-35 kCal/kg • 3000 kCal • 1-1.2 g pro/kg • 30-40% kCal from fat • 50-55% CHO • Supplement Vit. K • *For every degree F increase beyond 98.6, kCal need increases 7% • Nutrition Care for Liver Disease • 30-35 kCal/kg or 1.2-1.5 x BEE/day • Fat 24-40% of kCal • Protein 1 g/kg (dry weight) • Vitamin and mineral supplements • Fluid restriction • Low sodium (2 g or 500 mg) Liver Disease • Alcoholic Liver Disease • 3 stages: • Hepatic steatosis (fatty liver) • Alcoholic hepatitis • Chirrhosis • Fatty Liver • Hepatomegaly • Dark urine • Elevated AST and ALT • Lipid >5% liver weight

  25. Chronic Renal Failure • Stages of Management: • Conservative management with diet and drug • Dialysis • Kidney transplant • Renal Replacement Therapy • Serum creatinine 6 mg/dl for non-diabetics • Serum creatinine <15 ml/min for diabetics • Hemodialysis: manmade membrane - 3 days/wk for 4 hrs • Peritoneal dialysis: lining of pt’s peritoneal wall is selective membrane • GFR = ave. of Creatinine Clearance and Urea Clearance Kidney Disease Glomerular Filtration Rate (GFR) Normal: 80-120 ml/min Mildly impaired: 56-100 ml/min Moderately impaired: 25-55 ml/min Severely impaired: <25 ml/min Nephrotic Syndrome: deficiency of pro. In blood and its excretion in urine due to impaired glomerular function Nutrition Requirements Energy: 35 kCal/kg/day Protein: .8-1.0 g/kg/day (do not overload) Fat: <30% of total kCal; 10% PUFA; 12 g/day fish oil for IgA nephropathy Cholesterol: <200 mg/day Sodium/Fluids: <2000mg/day, fluids not restricted Vitmains/Minerals: Zinc and iron if deficient; Ca and Vit. D if deficient Chronic Renal Failure • Sodium retention, edema, hypertension • Metabolic acidosis • Hyperkalemia • Microcytic anemia and iron deficiency • Renal osteodystrophy

  26. Physical Signs Skin • Normal is smooth, slightly moist, good turgor • Abnormal is dry, oily, broken out in rash, scaly, rough, bruised Cardiovascular System • Normal heart rate and blood pressure within normal ranges, regular heart rhythm • Abnormal could be a rapid heart rate, elevated blood pressure, irregular heart rhythm Validity • Normal is vigorous, energetic, sleeping well • Abnormal is lacking energy, tired, apathetic, sleeping poorly Neurologic System • Normal reflexes, alert, good attention span, emotionally stable • Abnormal reflexes are decreased, irritable, inattentive, confused, emotionally labile Gastrointestinal System • Normal includes a good appetite, elimination regular and normal • Abnormal includes anorexia, indigestion, diarrhea, constipation Hair • Normal is shiny, neither dry or oily • Abnormal is oily, dry, dull, patchy in growth. Easily pluckable could be a protein or zinc deficiency or both. Horizontal patches or fed ould indicate protein/calorie deficiency. Muscles • Normal are firm and well-developed • Abnormal are poor in tone, soft, underdeveloped Tongue • Normal is pink and moist • Abnormal is reddened in patches, swollen Mucous Membranes • Normal is reddish pink and moist

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