Nursing Fundamentals - Health and Physical Assessment Part 2
Look for bluish or grayish discoloration in areas with less pigmentation—especially the lips, tongue, conjunctiva, mucous membranes, nailbeds, palms, and soles—which are more reliable indicators than the skin tone itself.
How is cyanosis assessed in a dark-skinned client?
Look for a bluish color by checking lips, tongue, nail beds, palm soles, and conjunctiva.
Key Terms
How is cyanosis assessed in a dark-skinned client?
Look for a bluish color by checking lips, tongue, nail beds, palm soles, and conjunctiva.
Define: erythema
Redness of the skin.
It indicates injury, inflammation or infection.
Define: pallor
Skin that is lighter than what the client is normally.
It can indicate decreased blood flow.
Define: jaundice
Yellowing of the skin, mucous membranes, and whites of the eyes.
It indicates liver failure.
Define: ecchymosis
Bruising of the skin.
What questions are asked for a nursing pain assessment?
Location: where is the pain?
Severity: how bad is it? Use appropriate pain scale.
Character: what does it feel like?
Onset: when ...
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| Term | Definition |
|---|---|
How is cyanosis assessed in a dark-skinned client? | Look for a bluish color by checking lips, tongue, nail beds, palm soles, and conjunctiva. |
Define: erythema | Redness of the skin. It indicates injury, inflammation or infection. |
Define: pallor | Skin that is lighter than what the client is normally. It can indicate decreased blood flow. |
Define: jaundice | Yellowing of the skin, mucous membranes, and whites of the eyes. It indicates liver failure. |
Define: ecchymosis | Bruising of the skin. |
What questions are asked for a nursing pain assessment? | Location: where is the pain? Severity: how bad is it? Use appropriate pain scale. Character: what does it feel like? Onset: when did it begin? Associated factors: are there other symptoms that occur with it? Pattern: what makes it better? what makes it worse? What pain meds do you take? Do you use alternative therapies to manage pain? |
What pain scale is used for alert and oriented adults? | 0 - 10 pain scale 0 is no pain; 10 is the worst pain. |
What two pain scales can be used for non-verbal adults or young children <10 years old? | FLACC pain scale & Wong-Baker faces pain scale: Face Legs Activity Cry Consolability |
What are some signs/symptoms of pain in an unconscious or non-verbal client? | ↑ heart rate ↑ respirations shallow respirations facial grimacing gasping stooped moaning rubbing a body part guarding crying |
Define: acute pain | Has a short duration and identifiable cause such as a surgery. Vital signs are typically increased with acute pain. |
Define: chronic pain | Has a long duration such as cancer, fibromyalgia, and back pain. Vital signs are typically normal with chronic pain. |
What are basic documentation guidelines for nursing? | use black ink date/time/name on each entry document right after activity be factual use quotes for subjective data document refusals of treatments and calls to HCP |
How should an error be documented in a client's medical chart? | Draw one line through the error, initial, and date. |
What is unacceptable for nursing documentation? | do NOT document for others do NOT leave blank spaces on forms do NOT use unacceptable abbreviations |
What are modifiable risk factors? | Things the client can change such as diet or exercise. |
What are non-modifiable risk factors? | Things the client can't change, such as family history/genetics, age, and sex. |
What are the 3 levels of disease prevention? | Primary Secondary Tertiary |
What are some examples of primary disease prevention? | teaching about a healthy lifestyle (diet and exercise) teeth brushing car seats and seat belts vaccinations sunscreen not smoking preventing falls limiting/eliminating alcohol wearing masks in public |
What are some examples of secondary disease prevention? | preventing cancer with mammograms, colonoscopy, pap smear stopping smoking safer sex practices |
What are some examples of tertiary disease prevention? | support groups cardiac rehab skin care for diabetics |
What are some neuro changes in older adults? | confusion and lethargy with infections hard of hearing unable to see as well decreased sensitivity to pain and temperature taking longer to learn and remember |
What are some mental health issues older clients are more at risk for? | older white men that live alone are higher risk for suicide increased risk of being abused |
What are some immune changes that occur with older adults? | decreased healing time decreased immune system increased risk of cancer |
What are some renal changes with older adults? | decreased kidney function increased risk of incontinence |
What are some respiratory changes in older adults? | decreased lung function getting out of breath easier |
What are some skin changes in older adults? | dry skin wrinkles skin tears spider angioma varicose veins bruising (ecchymosis) |
What are some musculoskeletal changes in older adults? | osteoporosis decreased muscle mass increased risk of falls |
What are some gastrointestinal changes in older adults? | nutritional changes loss of teeth decreased liver function |