《医学英语》五年制教学课件
医学英语五年制教学课件,医学英语,医学,英语,五年制,教学,课件
Assessment of Nutritional Status 吉林大学中日联谊医院风湿免疫科吉林大学中日联谊医院风湿免疫科马翠丽One must eat to live,and not live to eat.Jean Baptiste Moliere 1622-1673 Nutrition is one of the most important factors affecting an individuals health and disease because it affects almost every system.It has been shown that dietary habits contribute importantly to the pathogenesis of many of the major causes of death in the United States.词语辨析词语辨析affect vt.影响、(疾病)侵袭 n.感情、情感 blunted affect 情感迟钝 flat affect 情感淡漠effect vt.产生、招致、实现 n.结果、效应、作用、影响 be of no effect 无效;take effect 生效 side effect 副作用Two main nutritional problems in the United States:1.Obesity肥胖 Obesity is one of the most challenging nutritional problems.Obesity is a risk factor for many diseases,including hypertension,coronary artery disease,diabetes,osteoarthritis,cancers of the breast and endometrium,and hepato-biliary disease.2.Malnutrition营养不良 Malnutrition is a problem that targets a number of specific populations,including the elderly who live alone,chronically ill patients,adolescents who eat and diet erratically,and recently diagnosed patients with cancer,because chemotherapeutic and radiation therapeutic protocols may promote nutritional problems.相关词缀相关词缀mal-不良 malnourishment 营养不良 maldevelopment 发育不良dys-不良、困难、障碍 dysaudia 听力障碍;dysdipsia 饮水困难;dysfunction 功能不良a-不、无、缺 abacterial 无菌的相关词缀相关词缀hyper-过多、超过、过度、上、高、重 hyperabsorption 吸收过多 hyperglycemia 高血糖hypo-下、低、少、减退、迟、不足、次 hypoactivity 活动减退 hypolipemia 血脂过少 A patients ability to recover from an illness or from surgery frequently depends on his or her past and present nutritional status.Therefore,knowing what patients eat,the nutritional adequacy of their diets,and their clinical nutritional status is a necessary component of physical diagnosis.This chapter focuses on those aspects of the history and physical examination that constitute a nutritional assessment.At present,there is no standardized set of dietary history questions or method for assessing nutritional status.Rather,nutritional assessment requires the integration of information obtained from the medical history and physical examination.Throughout this chapter,nutritionally focused questions and examples of diet-related diseases are provided to assist in building history-taking and physical examination skills.Medical HistoryChief ComplaintHistory of Present IllnessBody Weight HistoryPast Medical HistoryPast Surgical HistoryMedicationsAllergies and IntolerancesSocial HistoryLifestyle HabitsDietary HistoryPhysical ActivityReview of SystemsChief Complaint The chief complaint is directly related to the patients nutrition,which may affect treatment and prognosis.The most common voice:“loss of appetite”,“weight loss”,“weakness”.Chief Complaint Changes in dietary intake and in weight are among the earliest signs of medical problems.These complains should prompt a detailed inquiry about diet and related symptoms in the history of present illness.History of Present Illness After asking the patient to describe the symptoms or medical problem that caused him or her to seek medical attention,begin to explore any diet-disease relationship that may exist.The following self-directed questions should guide your inquiry:History of Present IllnessDoes nutrition contribute to the cause,severity,or treatment of the illness?How has the illness affected the patients diet and nutritional status?Does the patient see a relationship between diet and disease?History of Present IllnessWas the patient ever advised to follow a special diet or use other nutritional therapy,such as defined formula supplements,tube feedings,or intravenous nutrition?What were the particular aspects of this therapy?What was the patients understanding of its potential efficacy?Body Weight History Body weight is a global indicator for overall health.Asking a patient whether he or she has experienced any weight loss is a good general indication of the severity or systemic nature of the presenting symptoms,whether they are acute or chronic.Body Weight History The underlying reasons for the weight change should be explored and the amount of weight loss clearly defined.Informative questions include the following:“Has your weight changed,either up or down,over the past several weeks or months?”If so,“In what way?”Body Weight History“How much weight did you lose or gain?”“What was your weight before the symptoms started?”“Over what period of time did you experience the weight loss or gain?”“How was your appetite over this time?”“Do you know what may have contributed to your change in weight?”Body Weight History Rapid weight gain is often an indicator of fluid retention and may be accompanied by edema or ascites.Common diseases associated with rapid weight gain include congestive heart failure,liver disease,and renal disease.Body Weight History Rapid weight loss usually signifies loss of body tissue,unless the patient has been undergoing therapeutic diuresis(increased urination)or is experiencing dehydration(decreased fluid ingestion,dry mouth,weakness,and dizziness).%weight change=(usual weight-current weight)/usual weight100相关词缀相关词缀in-内、在内、向、朝 innervation 神经支配de-脱、去、除、离、解除 deaminase 脱氨酶 decerebrate 去脑 degeneration 退变 denervation 去神经支配 Body Weight HistoryFour physiologic categories for weight loss:(1)decreased caloric intake,(2)malabsorption or maldigestion,(3)impaired metabolism or increased requirements,(4)increased losses or excretion.Past Medical History As patients list their past illness,ask the following questions:(1)How was the illness diagnosed and what treatment was rendered?(2)Whether did he or she receive dietary counseling or alter his or her diet in response to the diagnosis?Past Surgical History In this section,should record:(1)all surgical procedures,(2)serious surgical complications.These complications(such as draining fistulas,abscesses,open wounds,and chronic blood loss)often lead to malnutrition and the need for specialized nutritional support,including enteral and parenteral feedings.相关词缀相关词缀par-类、副、拟、旁、周、错乱、异常 parenteral 肠胃外的、非肠道的 parepigastric 上腹旁的post-在后、后 postdigestive 消化后的 postrenal 肾后的Medications The medication history should include both prescription and over-the-counter medications.Suggested questions are:“Are you taking any vitamins,minerals,herbs,or other dietary supplements,either prescription or over-the-counter?”If so,“What is the dosage?”Medications “What is the reason you are taking the supplement?”“Have you experienced any side effects or benefits from the supplements?”“Is anybody monitoring you,such as your doctor,nutritionist,or herbalist?”“What is your consumption of grapefruit and grapefruit juice?”Medications Drugs and nutrients interact in many ways to affect both nutritional status and the effectiveness of drug therapy.Drugs may influence nutritional status by several physiologic mechanisms:altering food intakeproducing malabsorptionmodifying excretionAllergies and Intolerances In addition to asking about allergies to medications and environmental allergens,inquire about allergies and intolerances to food.The most common allergenic foods among adults are peanuts,tree nuts,shellfish,fish,eggs,soy,wheat,and milk.Allergies and Intolerances Allergic symptoms may affect the respiratory tract,skin,or GI tract.A food allergy needs to be differentiated from food intolerance.Symptoms of food intolerance are usually confined to the GI tract and may be acute or chronic.Social History Multiple social factors affect the dietary and nutritional status of patients.For example,low socioeconomic status,low fixed income,homelessness,or lack of access to a variety of food choices may contribute to nutritional deficiencies.Religious observances,also determine eating patterns and the selection or avoidance of specific foods.Lifestyle Habits The lifestyle habits section of the medical history includes the dietary history,physical activity history,alcohol use,and smoking history.Dietary History The dietary history provides information about the patients food habits,diet,and any counseling he or she may have received.There are three methods commonly used:a 24-hour intake recall,a typical day,and food frequency.Dietary History A 24-hour intake recall,questions:I would like to know what you had to eat and drink for the entire day yesterday.Could you start with the first item you had to eat or drink and bring me through the entire day?I would also like to know the times you ate and the amounts.Dietary History A typical day,questions:I would like to know about your usual or typical diet.Can you bring me through a typical day,starting with the first item you eat or drink?I would also like to know the times you eat and the amounts.Dietary History Food frequency,questions:How often do you eat fruits and vegetables-daily,every few days,weekly,or rarely?When you eat them,how many servings do you choose?Dietary History Other informative questions:“What are your favorite foods and snacks?”“Are you following any special diet?”If so,“What does this diet entail?”“How often are meals home cooked?Who prepares the meals?”Dietary History Other informative questions:“What sort of fats or oils do you use in cooking?”“How often do you eat out or order food in?”“How is food usually prepared?”Dietary History The Institute of Medicine recommends that the following guidelines be used for achieving a healthful diet:Carbohydrates:45%to 65%of caloriesFat:20%to 35%(10%saturated fat)Protein:10%to 35%of caloriesSodium:1.5 g(3.8 g of salt)each dayCholesterol:less than 300 mg each dayPhysical Activity Both nutrition and regular physical activity play an important role in the overall health of the individual.It is recommended that all adults have at least 30 minutes of physical activity daily.Physical ActivitySome helpful questions:“What is the most physically active thing you do in the course of the day?”“How do you spend your working day and leisure time?”“What types of physical activity do you enjoy?How often do you do them?”“Do you exercise regularly?”If so,“What exercises do you do regularly?How often?”Physical Activity“What gets in the way of you consistently doing physical activity?”“How many hours of TV do you watch every day?”“How many hours are you at a computer or desk every day?”“Do you belong to(and attend)a health club or exercise classes?”Review of Systems The review of systems section is a reexamination of the patients history by organ system.This section should include a general statement about the patients body weight history and appetite if not included in the history of present illness or past medical history.Physical ExaminationVital Signsheart ratepulseblood pressuretemperatureheightweightVital SignsHeight and weight provide significant information about the patients overall health status and are frequently used for medication dosing.Vital SignsThe nutritional status of the patient based on height and weight is interpreted by the body mass index(BMI).BMI is an international designation of relative weight for stature and is a more reliable index of obesity than are the older height-weight tables.BMI=weight(kg)/height(meters)2,or BMI=weight(pounds)/height(inches)2703Vital SignsBMIunderweight:less than 18.5 kg/m2healthy weight:between 18.5 and 25.0overweight:between 25.1 and 29.9obese:30 and aboveAppearanceA description of the patients general appearance is always found at the beginning of the physical examination report.For example,“On examination,Ms.B.is a well-developed,thin,white female.”AppearanceOther nutritionally descriptive terms are:Emaciated 瘦弱Cachectic 恶病质Malnourished 营养不良Thin/slim 苗条Underweight 低体重Normal weight 正常体重Fit 适合Overweight 超重Obese 肥胖Edematous 水肿性AppearanceNutrition-oriented aspects of the physical examination focus on the shin,eyes,mouth,skeletal muscle,and fat stores.Special PopulationsObese patientsMalnourished patientsElderly patientsObese PatientsWhen calorie intake continuously exceeds requirements,obesity results.Less than 1%of all cases of obesity are related to neuroendocrine causes,and these conditions rarely cause massive obesity.Obesity-Focused HistoryAn obesity-focused history should include a chronologic history of the patients weight,identifying age at onset,description of weight gain,and inciting events.The following questions should be considered part of an obesity-focused history:“When did you first consider yourself overweight or have a weight problem?”Obesity-Focused History“Do you remember what you weighed when you were in high school?College?Your 20s,30s,etc.?”“What was your lowest weight as an adult?”“What was your highest weight as an adult?”“Were there any particular life events that caused you to gain weight,such as pregnancy,stopping smoking,changing jobs,getting a divorce,etc.?”“Did you experience weight gain after taking any medication?”If so,“Which medication,and how much weight did you gain?”Obesity-Focused HistoryIt is important to appreciate what impact the obesity has had on the patient.This information can be obtained with the following questions:“How does your body weight affect you?”“Is there anything that you cannot do because of your weight?”“Does your weight affect your own sense of self-worth?”“Have you participated in any weight management programs in the past?”If so,“What were they,and how did you respond?”Obesity-Focused Physical ExaminationAssessment of risk status due to overweight and obesity is based on the patients BMI,waist circumference,and existence of comorbid conditions.Obesity-Focused Physical ExaminationThe measurement of waist circumference:A horizontal mark is drawn just above the uppermost lateral border of the iliac crest.A cloth or metal tape is then placed in a horizontal plane around the abdomen at the level of the mark.The measurement is made at a normal minimal respiration.Malnourished PatientsMalnutrition is associated with slower wound healing,increased complications,longer length of hospital stay,higher health-care costs,and increased mortality.The Subjective Global Assessment(SGA)provides an integration of historical and physical examination data to arrive at an evaluation of the patients nutritional status.Malnourished PatientsFive features of the history and eight features of the physical examination are combined to assess risk.The historical features are weight loss,changes in dietary intake,significant GI symptoms,functional status or energy level,and metabolic demand of the patients underlying disease state.Malnourished PatientsPhysical findings are scored as normal(0),mild(1+),moderate(2+),or severe(3+),and include depletion of subcutaneous fat in the chest and triceps,muscle wasting in the quadriceps and deltoid muscles,and the presence of edema or ascites.Malnourished PatientsBased on the history and physical examination findings,patients are ranked according to the following three categories:A,good nutrition;B,moderate or suspected malnutrition;C,severe malnutrition.Elderly PatientsThe following risk factors associated with poor nutritional status in older Americans:inappropriate food intake,poverty,social isolation,dependency,or disability,acute or chronic diseases or conditions,and chronic medication use.Elderly PatientsThese factors have been incorporated into a risk factor checklist using the acronym DETERMINE,which identifies several warning signs for individuals at risk for poor nutritional status.Disease,Eating poorly,Tooth loss or mouth pain,Economic hardship,Reduced social contact,Multiple medications or drugs,Involuntary weight loss or gain,Need for assistance with self-care,Elderly years.Elderly PatientsThe National Institute on Aging suggests that the daily diet for the geriatric population include the following:Two servings of milk or dairy products low in lactoseTwo servings of high-protein foodsFour servings of fruit and vegetables,including a citrus fruit and a dark green leafy vegetableFour servings of bread or cereal productsConcluding ThoughtsAny good diet shouldInclude a wide variety of foods to ensure adequate amounts of all essential nutrientsEducate the person about proper nutritionBe based on sound biochemical factsHave no medical risks or metabolic side effectsBe economicalBe adaptable to a variety of lifestylesNutritional assessment does not stand alone as a separate process;it must be integrated into the entire history and physical examination.The depth of the assessment and the information recorded depend on the patients specific medical problems.相关词缀相关词缀合、同合、同co-用在元音或h前 coordination 协调、协作col-用在l前 collaborate 协作、合作 com-用在b,m,p前 commensurate 同量的、同大的、相当的cor-用在r前 correspond 符合、一致con-用在其他字母前 concurrent 同时发生的、并发的、共存的;confocal 同焦点的相关词缀相关词缀不、非、无不、非、无ir-在r前 irrational 非理性的、不合理的;irrealizable 不能实现的、不能达到的 il-在l前 illegal 非法的;illimitable 无限的、不可计量的im-在b,m,p前 imbalance 不平衡、失调;immaterial 非物质的、无形的、不重要的in-在其他字母前 inaction 无作用;incapable 无能力的、不能的致谢致谢值此论文完成之际,由衷感谢我的导师毕黎琦教授两年来在学习、生活中对我耐心的指导和无微不至的关怀。在恩师的精心指导和热情鼓励下,本课题才得以顺利完成。!衷心的感谢吉林大学中日联谊医院风湿免疫科刘波副教授对本论文课题设计、数据处理及论文撰写等过程的悉心指导和无私帮助!感谢风湿免疫科郭嘉隆、李萍副教授和全体老师以及与我朝夕相处的同学们在学习、生活、工作中给予我的关心和帮助!
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