Exam 2 Flashcards
Family violence
controlling, corrosive behaviors seen to the intentional acts of violence inflicted in those familial or intimate relationships
factors affecting violence
Culture race Ethnicity Economy addiction vicious cycle- do not know any other way of life
Different types of family violence
Intimate partners- Physical, sexual, or psychological harm by a current or former partner or spouse. Increasing among men leaving with men (do not feel comfortable looking for help,70%)
Child abuse: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation.
Elder mistreatment- includes elderly people who live in facilities and home
Types of abuse
- Physical abuse- pushing, shoving, slapping, choking
- Physiological- insult blaming the victim
- Children or pets- to manipulate the victim
- Economic- preventing the victim from getting a job or controlling the financial aspect of the relationship
- Sexual- forcing the victim to perform sexual acts
Abuse assessment general survey
-observe how the patient appears
-Eye contact
-Mental status
-Evalutate vital signs
-Inspect skin (head and kneck)
-Several bruising injuries, healing in different stages
-Afraid to show you certain things
-Pain in abdomen, nausea, vomiting
-Burns, cigarette burns
Lacerations, cuts, bites
-If abuser in the room, they may have different behavior
-Describes self as accident prone
-Low self-esteem
-Anxiety, depression
-Substance abuse
-If partner wants to answer for client
-Does partner refuse interpreter
-Inspecting the eyes
-Inspect ears
-Inspect abdomen
-Check genitalia and rectal area
-Muscoskeletal system- do they have fractures?
assess neurological system
-Assess safety of returning home
-Ask if they feel safe returning home
-Ask when they are alone
-Abuser is staying there with the victim
-Assess and explain injuries
-Assess recent
-Look for discrepancies (in what client and partner says)
-Document all this
culture
totality of socially transmitted behavioral patterns beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population of people to guide their worldview and decision making
factors affecting approach to providers
- Ethnicity- how close are they to the primary culture
- Generational status- older family members may make the decisions for the younger client, or client looking for assistance from the elderly
- Education- can they read and understand English, need a translator (not a family member, have same gender translating)
- Religion- includes religious rule that can influence who or when someone can assess the patient, or if someone is in the room with them
- Previous health care experiences- had a bad experience with their provider, make it so that they can trust you
- Occupation and income level- they worry about how to pay for the health care, be very sick but if they cannot afford it then they will stay at home most times
- Communication needs/preferences- cultures have different ways of communicating, some soft spoken, some wont make eye contact, some very loud (accept different ways)
modifications to be considered for a culturally competent interview
- Communication- adapt to them
- Time- give them time
- Space- adapt to spacing
- Eye contact and face positioning- Eye contact can sometimes be rude to some cultures, do not force
- Body language and hand gestures- making a lot of gestures, adapt to patients
- Silence- can be very rude in some cultures, or very comfortable with it
- Touch- be yourself but let them do what is correct, ok to hug in some cultures, others it is very inappropriate
stereotyping
All members of a particular culture expecting group members to hold the same beliefs and behave in the same way.
Ethnocentrism
Perception that one’s worldview is the only acceptable truth and that one’s beliefs, values, and sanctioned behaviors are superior to all others
factors that affect disease and health state
-Biomedical variations- what is at the root of the disease
-Nutrition/dietary habits- are they eating enough, are they eating meat, do practices require nutrition intake
-Family roles and organization, patterns- some cultures the adult will eat first and more, or what is the better food
-Workforce issues- are they using protection at work, type of work safe
-High-risk behaviors- are they protecting themselves if they are riding motorcycle, sexually
-Pregnancy and childbirth practices- some believe pregnant women cannot eat something
-Death rituals
Religious and spiritual beliefs and practices
-Health care practices
-Health care practitioners
-Environment
Risk Factors for Nutrition Disorder and Disease
- Lower socioeconomic status (SES)
- Lifestyle
- Poor choices
- Makes nutritious food unaffordable
- Some people work too much, consume fast food, vending machines
- Dieting constantly, not taking what body needs
- Chronic Diseases- crohns disease, sclerosis, cancer (body does not absorb nutrition)
- Dental or other factors- may have loose teeth or will be unable to chew food (a lot do not have their dentures, lacking protein)
- depressed people have a lack of appetite
- Medication side effects make you lose taste sensation
- Limited access- an elderly person may not have access to food, or not enough, don’t have means or transportation
- eating disorders
- demented (forget to eat)
- Alzheimer’s (forget movement of eating)
- client just refuses to eat
- illness or trauma (extensive burns)
- obesity
Structure and Function of Skin
- Largest organ of the body
- Physical barrier: Protects underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration.
- Vital role in temperature maintenance
- Fluid and electrolyte balance, absorption, excretion
- Sensation
- Vitamin D synthesis
Skin
- Epidermis: Outer layer of skin
- Dermis: Inner layer of skin -Sebaceous glands:attached to hair follicles
- Sweat glands: eccrine and apocrine glands
- Subcutaneous layers: a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.
Hair
- Vellus: Peach fuzz, short, pale, fine, and present over the body.
- Terminal: Particularly scalp and eyebrows, is longer, generally darker, and coarser than vellus.
Nails
Nail body: Extends over the entire nail bed and has a pink tinge
Lunula: Crescent-shaped area located at the base of the nail.
Religion
Rituals, practices, and experiences involving a search for the sacred- find out and assess if religious practices are safe for them, support it, invite and encourage family in to pray, give them privacy and time
- Shared within a group
- Some faiths, this idea of religion encompasses the concept of spirituality and is a natural outflow of that idea
- Others may view spirituality as a separate concept, possibly disconnected from any religious institution
- never impose own beliefs on patient
Spiritual Assessment
-Explore the client’s religious and spiritual background
-Observe nonverbal and verbal communication patterns in the presence of others
-Focus questions:
Daily spiritual experiences
Religious Beliefs
- Be aware of own beliefs so you can understand other peoples
Factors involved in nutrition
- Healthy diet should consist of 45% to 65% carbohydrates with 75% of those carbohydrates being complex (grains, starchy vegetables)
- Certain diseases, disorders, or lifestyle behaviors can place clients at risk for undernutrition or malnutrition and can exacerbate or facilitate disease processes (alcohol, eating disorders, drugs)
- malnutrition- lack of nutritional needs
- Increased caloric consumption- especially of food high in fat and sugar, with decreased energy expenditure has led to near-epidemic obesity.
Risk Factors for Nutrition Disorder and Disease
- Lower socioeconomic status (SES)
- Lifestyle
- Poor choices
- Makes nutritious food unaffordable
- Some people work too much, consume fast food, vending machines
- Dieting constantly, not taking what body needs
- Chronic Diseases- crohns disease, sclerosis, cancer (body does not absorb nutrition)
- Dental or other factors- may have loose teeth or will be unable to chew food (a lot do not have their dentures, lacking protein)
- depressed people have a lack of appetite
- Medication side effects make you lose taste sensation
- Limited access- an elderly person may not have access to food, or not enough, don’t have means or transportation
- eating disorders
- demented (forget to eat)
- Alzheimer’s (forget movement of eating)
- client just refuses to eat
Skin Cancer
-Most common of cancers
Melanoma
-Basal Cell Carcinoma
-Squamous cell carcinoma
Risk Factors of skin cancer
- Sun exposure
- non-solar sources of ultraviolet radiation
- medical therapies
- family history and genetic susceptibly
- moles
- pigmentation irregularities
- fair skin that burns and freckles easily; light hair
- age
- actinic keratosis
- male gender
- Chemical exposure
- Human papillomavirus
- Xeroderma pigmentosum
- Long-term skin inflammation or injury
- Alcohol intake; smoking
- Inadequate niacin in diet
- Bowen disease (scaly or thickened patch) (SCC)
- Depressed immune system
Risk Reduction in Skin Cancer
- Reduce skin exposure.
- Use sunscreen.
- Wear long-sleeve shirts and wide-brimmed hats.
- Avoid sunburns.
- Wear sunglasses that wrap around.
- Education
- Have annual skin cancer screenings.
ABCDE mnemonic to assess skin lesions
Asymmetry Border Color Diameter Evolution
Cultural Variations of skin cancer
- Asians are less susceptible to skin cancer
- African Americans, Asians, and Hispanics are susceptible to melanoma
- Asian Americans and African Americans tend to present with more advanced disease at diagnosis
Nursing History of skin, hair, and nails assessment
- Personal health history
- Family history
- Lifestyle and health practices
- Exposure to sun or chemicals
- Daily care of skin, hair, and nails
- Usual diet and exercise patterns
Methicillin-Resistant Staphylococcus aureus (MRSA): community-acquired
Assess for community-acquired MRSA risk factors:
- Participating in contact sports
- Sharing personal items such as towels or razors
- Suppression of immune system function (e.g., HIV, cancer, or chemotherapy)
- Residing in unsanitary or crowded living conditions (e.g., dormitories or military barracks)
- Working in the health care industry
- Receiving antibiotics within the past 3 to 6 months
- Young or advanced age
- Men having sex with men
- Hemodialysis
Measures to Reduce Risk Factors for MRSA
- Keep wounds covered.
- Do not share personal items.
- Avoid unsanitary or unsafe nail care practices.
- If treatment has been started, do not stop until recovery is complete.
- Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands.
- Clean sports equipment between uses to avoid spread of infection.
- Wash clothes, sheets, towels, razors, and other personal items before and after use.
- Clean hands often.
Assessment of skin, hair, and nails: Present Health Concerns
- Body odor problems
- Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)
- Changes in lesion appearance
- Feeling changes (pain, pressure, itch, tingling)
- Hair loss or changes
- Nail changes
Nursing History of skin, hair, and nails
- Personal health history
- Family history
- Lifestyle and health practices
- Exposure to sun or chemicals
- Daily care of skin, hair, and nails
- Usual diet and exercise patterns
Interview for nutritional and hydration history
-Nutritional screening tools
-Collection of subjective data: The nursing health history
History of present health concern
Personal health history
Family history
Lifestyle and health practices
Physical Assessment
- Overall appearance
- Body build
- Muscle mass
- Fat distribution
- Measure skin folds for fat distribution
- Measure waist
Client Preparation for skin, hair, and nails assessment
- Ask the client to remove all clothing and jewelry.
- Have the client sit comfortably.
- Ensure privacy.
- Maintain comfortable room temperature
Equipment for skin hair and nails assessment
- Gloves
- Examination light and penlight
- Mirror for client’s self-examination of skin
- Magnifying glass
- Centimeter ruler
- Wood light
- Examination gown or drape
- Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk
- Assessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing
Inspection for skin, hair, and nails assessment
- Inspect skin coloration
- Note any distinctive odor
- Generalized color variations
- Skin breakdown
- Primary, secondary, or vascular lesions
Palpation of skin, hair, and nails assessment
- Lesions
- Texture
- Temperature and moisture
- Thickness of skin
- Mobility and turgor
- Edema
Primary Skin Lesions
- Macule and patch: Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Examples include freckles, flat moles, petechiae, rubella, vitiligo, port wine stains, and ecchymosis.
- Papule and plaque: Elevated, palpable, solid mass. Examples of papules include elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis and actinic keratosis.
- Nodule and tumor: Elevated, solid, palpable mass that extends deeper into dermis than a papule. Examples of nodules include keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma. Examples of tumors include larger lipoma and carcinoma.
- Vesicle and bulla: Circumscribed elevated, palpable mass containing serous fluid. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn. Examples of bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
- Wheal: Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include urticaria (hives, pictured below) and insect bites.
- Pustule: Pus-filled vesicle or bulla. Examples include acne (pictured below), impetigo, furuncles, and carbuncles.
- Cyst: Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis. Examples include sebaceous cyst and epidermoid cyst (pictured below).
Secondary Skin Lesions
Erosion: Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area. Examples include rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, commonly called a canker sore, pictured below).
Ulcer: Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are possible. Examples include stasis ulcer of venous insufficiency (stasis dermatitis with venous stasis ulcer, pictured below) and pressure ulcer.
Scare: Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Young scars are red or purple, whereas mature scars (pictured below) are white or glistening. Examples include healed wound and healed surgical incision.
Fissure: Linear crack in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete’s foot. Interdigital tinea pedis with fissures and maceration is pictured below.
Vascular Skin Lesions
- Associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic disease.
- Petechia: Round red or purple macule.
- Ecchymosis: Round or irregular macular lesion that is larger than petechial lesion. The color varies and changes: black, yellow, and green hues.
- Hematoma: A localized collection of blood creating an elevated ecchymosis. It is associated with trauma.
- Cherry angioma: Papular and round, red or purple lesion found on the trunk or extremities. It may blanch with pressure. It is a normal age-related skin alteration and usually not clinically significant.
- Spider angioma: Red arteriole lesion with a central body with radiating branches. It is usually noted on the face, neck, arms, and trunk. It is rare below the waist. Compression of the center of the arteriole completely blanches the lesion. It is associated with liver disease, pregnancy, and vitamin B deficiency.
- Telangiectasis: Bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. It does not blanch when pressure is applied.
Nail Risk Reduction
- Wear leather shoes except for sports.
- Avoid wearing closed shoes all the time.
- Wear socks that wick away moisture.
- Avoid going barefoot in damp public areas.
- Avoid too much perspiration or water (wear gloves for hands).
- Avoid trauma to nails.
- Avoid unsanitary or unsafe nail care practices.
- If treatment is started, do not stop until recovery is complete.
Pressure Ulcer Risk Reduction
- Inspect the skin at least daily
- Use risk assessment tool (such as Braden Scale or PUSH tool)
- Document.
- Keep patient dry/clean
- Limit friction
- For dry skin: use moisturizers; avoid low humidity and cold air.
- Avoid vigorous massage.
- Use careful positioning, turning, and transferring techniques
- Refer nutritional supplementation needs to primary care provider or dietitian
- Refer incontinence condition to primary care provider.
- Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.
Inspection and Palpation of the scalp and hair
Inspection and palpation
- General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
- Amount and distribution of scalp, body, axillae, and pubic hair
Nail Assessment
Nails
- Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails
- Palpation: Assess texture and consistency, capillary refill
Common Nail Disorders
- Longitudinal ridging: Parallel ridges running lengthwise. May be seen in the elderly and some young people with no known etiology.
- Half-and-half nails: Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease.
- Pitting: Seen with psoriasis.
- Koilonychia: Spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease.
- Yellow nail syndrome: Yellow nails grow slow and are curved. May be seen in AIDS and respiratory syndromes.
- Paronychia: Local infection
Nails Disorders Risk Factors
- Nails in moist environment
- Nail injury, trauma, or irritation
- Repeated irritation (especially water, detergents)
- Immune system disorders
- Skin conditions such as psoriasis or lichen
- Some trades or professions
- Contagion from one digit to another or one person to another
- Possibly family predisposition
Nail Risk Reduction
- Wear leather shoes except for sports.
- Avoid wearing closed shoes all the time.
- Wear socks that wick away moisture.
- Avoid going barefoot in damp public areas.
- Avoid too much perspiration or water (wear gloves for hands).
- Avoid trauma to nails.
- Avoid unsanitary or unsafe nail care practices.
- If treatment is started, do not stop until recovery is complete.
Physical assessment equipment: Nutrition
- Balance beam scale with height attachment
- Metric measuring tape
- Marking pencil
- Skin calipers
Anthropometrics Measurements
- Height and weight
- Body mass index (BMI) Estimate total body fat
- Waist circumference Determine extent of abdominal visceral fat in relation to body fat
- Mid-arm circumference Assess skeletal muscle mass
- Triceps skin-fold thickness Evaluate subcutaneous fat stores
- Mid-arm muscle circumference Evaluate muscle reserve
BMI
weight in kilograms/height in meters squared
height and weight with aging
elderly- starts at 50 years
Vertebral disks become thinner
Spine is bending
Body weight decreases, lose muscles
Hydration Assessment
- Weight- assess hydration by weight
- Intake and output- monitor everything they eat, drink, and pee (measured on chart), medications
- Skin turgor- skin will tent if dehydrated
- Pitting edema- skin will be indented
- Skin for moisture- dry, cracking
- Venous filling- dangle feet or arms and see how long it take to feel the veins
- Neck veins in supine position with head elevated 45 degrees- if fluid overload will see jugular vein distended
- Tongue furrows- can see hydration, cracks, sticky saliva
- Eyeball palpation
- Eye position
- Lung sounds- dehydrated, rubbing sound. Over hydrated, crackles and gargles
- Blood pressure- dehydrated, low BP. Fluid overload, BP high
factors affecting hydration
- High temperatures
- Lack of fluid intake (water)
- Excess intake of alcohol
- Diuretics
- Illnesses
- Impaired thirst mechanisms
- High fevers
over hydration signs and symptoms
- Weight gains of 6 to 10 lb in a week
- Pitting edema
- Visible neck veins
- Cracking lung sounds
- Elevated pulse rate and blood pressure
dehydration signs and symptoms
- Weight losses of 6 to 10 lb in 1 week
- Tenting
- Filling or emptying of venous filling more than 6 to 10 seconds
- Flat veins in supine client
- Tongue is dry
- Sunken eyes
- Blood pressure decreased with elevated pulse rate
- Radial pulse rate +1 and thready
- pulse weak and fine
