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Nursing Fundamentals - Health and Physical Assessment Part 2

Nursing28 CardsCreated 3 months ago

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.

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Key Terms

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 ...

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TermDefinition

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