Nurs 123 Clinical Skills

Question 1

The Initial Assessment

Answer 1

The moment you first meet you patient you notice these things:

1. Appearance – what are they doing, behavior, posture/positioning, level of consciousness, ability to interact.
2. Work of Breathing – listen for obvious sounds of abnormal breathing (those heard without a stethoscope) and look at their body position.
3. Circulation (color) – skin color, obvious bleeding.
   This is your first impression of the patient. If you have found major abnormalities in any of these areas (ie. Unresponsive, not breathing, cyanotic/grey), obtain help and initiate life-saving measures. Do NOT proceed with further assessment.

Question 2

The Primary Survey: A-B-C-D-E-F

Answer 2

The ABCDE approach begins your hands-on patient assessment. Originally designed for emergency and critical care settings, this is now widely utilized in routine nursing practice in any setting. Do NOT proceed to the next part of the assessment if there are life-threatening concerns. This is where we also take a full set of vital signs, which is “F” (HR, RR, BP, O2 Sat, Temp, Pain).

• A systematic & Structured Approach
• Useful in standard practice and emergency/critical care practice
  setting
• Respond to life-threatening findings in each component before moving onto the next

Question 3

Focused Physical Examination: Head-To-Toe

Answer 3

Based on health Priorities of your patient:
- Include one or more body systems
- Thorough review of systems
- Subjective & Objective data are collected using any or all
assessment techniques necessary.

Question 4

Why do a Focused physical Examination

Answer 4

is performed after both the initial assessment and primary survey reveal the patient is stable enough for you to proceed with a thorough review of the body system(s) that are most related to the reason for the individual’s appointment or admission. A complete head-to-toe is often required once per shift on most inpatients, followed by ongoing assessment of any focused area of concern when there are abnormal findings.
We will methodically learn:
1.Subjective data (history and interview questions) pertaining to each system
2.Objective data that must be obtained for each system
3.Methods of collecting data (inspection, palpation, auscultation, percussion)
4.Health promotion issues relevant to each body system

Question 5

Progression of a nursing assessment

Answer 5

Initial Assessment, primary survey, Focused Physical examination

Question 6

Initial assessment

Answer 6

• Appearance
• Work of Breathing
• Circulation (color)

Question 7

Primary Survey

Answer 7

• A-B-C-D-E-F
• Vital Signs
• Safety Check

Question 8

Focused physical Examination

Answer 8

• Body Systems
• Subjective & Objective Data

Question 9

A: Airway

Answer 9

Is the airway open/patent? Assess:
- Listen for air movement (ie. talking, snoring, gasping).
- Feel for air movement at the nose and mouth.
- Look at position of head and trachea

Question 10

Warning signs of an airway problem

Answer 10

• Unable to speak
• Gasping for air
• Abnormal noises – gurgling, snoring, gasping, wheezing, stridor
• Coughing, choking
• Labored or absent breathing

Question 11

The airway includes

Answer 11

nose, mouth, pharynx, larynx, trachea, bronchi, and bronchioles.

Question 12

IF no signs of air movement

Answer 12

assisted ventilation is required. This is the number one priority, as without an open airway, one may not survive.
If your patient is talking, they have an open airway. If your patient’s head is positioned in a way that is limiting air supply or mouth and nose is covered, repositioning is the first thing to try to correct the problem.
You will see this “Emergency Call Bell” icon throughout this course as we learn about assessment findings that require immediate nursing intervention. This means, stop and address the problem right away! This may include calling for help/activating the emergency response system, or reporting the findings to your immediate supervisor or experienced health care team member. We will learn about nursing interventions that are within your scope as a student nurse to respond in emergency situations.

Question 13

Airway Interventions

Answer 13

• Reposition – head tilt/chin lift or jaw thrust
• Suction – secretions, emesis
• Airway – adjunct, endotracheal intubation

Question 14

Other airway interventions

Answer 14

Nurses can perform nasal or oropharyngeal suctioning as a foundational skill. A yankuaer suction device can remove fluid, emesis, thick respiratory secretions from the mouth. This is different than tracheal suctioning which is deeper in the airway (advanced nursing competency).

Always ensure the bedside suction equipment is functioning and you have an appropriate suction device ready when performing your bedside safety checks.

An airway adjunct may be inserted by a nurse or respiratory therapist to keep the tongue out of the way and enable a clear path to deliver assisted ventilations. Only patients who are unconscious/unresponsive will tolerate an airway adjunct.

A bag-valve mask is used in more hospital settings to deliver assisted ventilations in an emergency situation.

Do NOT perform mouth-to-mouth in a healthcare setting. It is not advised for any first responder to perform mouth-to-mouth unless you know the victim and assume the risks of transmittable disease.

Advanced airway interventions include endotracheal intubation (performed by a physician or respiratory therapist), continuous positive airway pressure (CPAP), or cricothyrotomy (a needle puncture or surgical opening through the skin to the trachea).

Question 15

B: Breathing

Answer 15

Is the patient having any difficulty breathing? Assess:
Respiratory rate and effort
Depth and symmetry of chest rise
Breath sounds (auscultation)
Oxygen saturation

Question 16

Warning signs of breathing problem:

Answer 16

Labored breathing – use of accessory muscles (neck, shoulders), abdominal breathing, nasal flaring, tracheal tug, retractions
Unequal or shallow chest rise
Fast (>20) or slow (<12) RR or apnea
Abnormal breath sounds – crackles, wheezes
Oxygen saturation less than 96% on room air

Question 17

More about breathing

Answer 17

Breathing is the process by which air moves in and out of the lungs. It should be effortless with equal chest rise. You may place your hands on the chest to determine depth and symmetry of chest rise. Ideally, count the respiratory rate (RR) for one minute. If time does not allow, then 15 seconds and times by 4. Apnea is classified as no breathing for 20 seconds or more.
Auscultation of the lungs should reveal clear breath sounds and air entry audible to the upper, mid, and lower lungs. We will practice this thoroughly in the respiratory focused assessment. Abnormal lung sounds include crackles and wheezes.
Oxygen saturation should be equal to or greater than 96% on room air. Individuals with chronic respiratory disease (ie. COPD) may have an oxygen saturation between 88 – 92%, but it should not be assumed normal until you know their medical history.

Question 18

Breathing Interventions

Answer 18

Elevate head of bed or position of comfort
Apply oxygen – nasal prongs, face mask
Assist ventilation – bag-valve mask

Question 19

More breathing Interventions

Answer 19

Head of bed elevated to 45 or 90 degrees assists with lung expansion. The patient may only tolerate their own position of comfort (ie. Leaning over a bedside table, side lying), and this is usually best for them when in respiratory distress.
Oxygen can be delivered by a variety of methods: nasal prongs, face mask, non-rebreather. You will learn more about the specific oxygen delivery methods in second year, but for now, a simple face mask is the quickest way to deliver oxygen.
Applying oxygen is a foundational nursing competency. Start with a simple face mask at 6 – 10 L in an emergency situation.
A bag-valve mask is used in more hospital settings to deliver assisted ventilations in an emergency situation. Do NOT perform mouth-to-mouth in a healthcare setting. It is not advised for any first responder to perform mouth-to-mouth unless you know the victim and assume the risks of transmittable disease.

Question 20

C: Circulation

Answer 20

How is the patient’s circulation or perfusion status? Assess:
Heart rate and rhythm
Quality of pulses
Skin color, temperature, capillary refill
Blood pressure
Signs of bleeding
Intravenous access
Urine output

Question 21

Warning signs of Circulation problems

Answer 21

HR <50 or >90
Absent or poor quality pulses
Skin pale, cyanotic, grey
Cap refill >3 sec
BP less than 90 systolic
Hemmorhage
Urine output <0.5 ml/kg/hr

Question 22

More about Circulation

Answer 22

Check pulses (various sites to choose from – carotid or radial most common) or auscultate the apex to determine heart rate. Note whether the heart rhythm is regular or irregular.

Quality of pulses is a reflection of how well-perfused an individual is. Weak, thready pulses indicate poor perfusion.

Skin should be pink/flesh colored, warm. Capillary refill time is the time is takes for blood to return to tissue blanched by pressure. It takes longer as perfusion decreases. Cap refill should be equal or less than 2 sec when pressed and then allowed to return to normal (check peripherally by holding the limb at the level of the heart, and then centrally by pressing on the forehead or sternum).
Blood pressure also indicates circulatory or perfusion status; low BP (less than 90 systolic) with symptoms of dizziness/fainting/lethargy can be signs of poor perfusion.

Any signs of bleeding must be investigated and controlled prior to moving on to any other assessment. This includes surgical drains and dressing sites.

Take note of whether or not the patient has an IV; check the site, patency, and fluids infusing.

Adequate circulation is also reflected by urine output as this indicates how well the kidneys are perfused. An indwelling catheter is often inserted in critically ill patients to accurately determine hourly outputs.

Question 23

Circulation Interventions

Answer 23

Chest compressions
Control of bleeding
IV access
Fluids, medications, blood transfusion

Question 24

More Circulation Interventions

Answer 24

Activate the emergency response system and start chest compressions when no pulses are felt after a 10 second check. It is withing your scope and an expectation for a student nurse to be competent in CPR. This is why you are required to update your Basic Life Support certification annually while in the nursing program (and as an RN). Remember, the appropriate response is to initiate CPR within 10 seconds of a pulse check and the person is unresponsive and not breathing (or gasping) and in the sequence C –A – B (compressions, airway, breathing).
Apply direct pressure on active hemorrhage sites (as possible - bleeding may also be internal).
IV access is required to give fluids, including blood products, and cardiac medications.

Question 25

D: Disability

Answer 25

What is your patient’s level of consciousness? Assess:
AVPU/GCS: Alert, verbal, Pain, unresponsive/ Glasgow coma Scale
Pupil response
Blood glucose/dextrose
Pain

Question 26

Warning signs of Disability Problem

Answer 26

Any decrease in level of consciousness
Change in pupil response – sluggish, non-reacting, unequal
Blood glucose < 4 mmol/L
Sudden or uncontrolled pain

Question 27

More about Disability

Answer 27

“D” is for Disability, and includes 3 elements: level of consciousness, pain, and blood sugar level (dextrose) .
AVPU – is the patient alert, or responds only to verbal stimulus, painful stimulus, or is unresponsive?
GCS – Glasgow Coma Scale is a more detailed assessment and scoring of how your patient responds in these three categories: eye opening, motor response, verbal response. Score out of 15. We will cover this in detail in the neurologic focused assessment.

It will be necessary to determine what your patient’s baseline level of consciousness is, especially if your patient is non-verbal or has a cognitive disorder.
Low blood glucose (dextrose) can also be a common cause of decreased level or consciousness or unresponsiveness. A blood glucose check with a glucometer is the fastest way to determine blood glucose level and can be performed by a nurse in an emergency situation without a physician’s order. Blood glucose less than 4 mmol/l is considered hypoglycemia and needs to be treated rapidly.
Decreased level of consciousness can also be caused by drugs, alcohol, and poisons. These need to be ruled out, usually by a toxicology test. Good to keep in mind, but outside of the scope of nursing (requires physician direction/order).
Pain can be assessed using a variety of tools. Pain is determined by what the patient says it is. In cases where the patient is non-verbal and unable to communicate pain, assessment scales that include physiologic measures are used. The pain assessment is often referred to as a “5th vital sign” and it is a nurses’ ethical responsibility to regularly assess and treat our patient’s pain. We will learn how to assess pain in a variety of different ways. Severe or uncontrolled pain is a medical emergency.

Question 28

Disability Interventions

Answer 28

Attempt to elicit a response – verbal, then painful stimulus
If unresponsive, obtain help and check breathing and pulses, repeat vital signs
Administer glucose
Treat pain

Question 29

More about Disability Interventions

Answer 29

Shake and shout (verbal). Elicit a painful stimulus - squeeze trapezius muscle, sternal rub.
Ensure patient still has a pulse and is breathing.
Glucose can be given by mouth if patient is responsive and can swallow (packs or glucose gel, juice, snack). Otherwise, will need IV access to administer glucose intravenously.
Know the analgesia that is available for you to administer to your patient and how is works (oral, subcutaneous, intramuscular, intravenous routes).

Question 30

Glasglow Coma Scale

Answer 30

Responses: Eye-opening Response, Verbal Response, Motor Response

Eye-opening Score: 1-4 worst to best
Verbal Response Score: 1-5
Motor Response Score: 1 - 6

Minor Brain Injury = 13–15 points
Moderate Brain Injury = 9–12 points
Severe Brain Injury = 3–8 points

Question 31

E: Exposure

Answer 31

Have all body parts been examined? Assess:
Face and head
Torso (front and back)
Extremities
Skin
Temperature
Incontinence

Question 32

Warning Signs of Exposure problems:

Answer 32

Warning signs of an exposure problem:
Bleeding, burns, unusual markings
Petechiae, purpura
Temperature less than 36.1 or greater than 38.0 degrees

Question 33

More on Exposure

Answer 33

Exposure, or undressing/lifting off blankets to visualize the entire patient, is a component of the primary survey that must be done to ensure that nothing has been missed (ie. Bleeding, skin color change, injury, infection, incontinence). Nurses must ensure that dignity and privacy is maintained at all times (ask permission, explain why you need to do this, close curtains).
Temperature measurement. Goal is to maintain normothermia; use blankets or warmed fluids to heat, cool cloths or remove layers to cool.
Unusual markings may indicate trauma; need to investigate to determine if non-accidental/abuse.
Petechiae and purpura are non-blanchable red or purplish rashes that may signal internal bleeding or a bleeding disorder – we will learn more about this in the integumentary system assessment.

Question 34

Exposure Interventions

Answer 34

Control bleeding, investigate signs of abuse, maintain a normal temperature

Question 35

F: Full set of vital signs

Answer 35

Heart rate
Respiratory rate
Blood pressure
Temperature
Oxygen saturation

Question 36

Abnormal adult values that may be a warning sign or change in patient’s status

Answer 36

HR < 50 or >90
RR <8
BP systolic <90 or >180
Temp <36.0 or >38.0
O2 Sat <95%

Question 37

More on Full set of vital signs

Answer 37

Know the normal ranges of adult vital signs. Some tips:
HR – ideal to count for 60 seconds
RR – try to count while your patient is unaware you are doing so (ie. While your hand is on their radial pulse)
BP – an abnormal value must be repeated, especially from an automatic BP machine. Check: appropriate cuff size? patient talking or moving during the measurement?
Temperature – instruct patient to close mouth/lips around thermometer; if heavy breathing from nares, or recently drank hot or cold fluids, this may cause an inaccurate measurement
O2 Sat – best reading is on a warm extremity; the machine must show a consistent waveform/pleth and HR corresponds to actual pulse

Question 38

Pain

Answer 38

Pain is a highly complex and subjective process. Therefore, subjective data will be the most reliable indicator of a patient’s experience of pain as we conduct a comprehensive pain assessment. A beginning understanding of how pain is pathologically explained may help us to better appreciate our patient’s experience of pain and the importance of detailed assessments to inform treatment and intervention.
Pain may originate from the central nervous system (CNS), peripheral nervous system (PNS), or both.

Question 39

Four Phases of Nociception:

Answer 39

Transduction, Transmission, Perception, Modulation

Question 40

Transduction

Answer 40

a noxious stimuli is inflicted upon the individual

Question 41

Transmission

Answer 41

the impulse moves along the spinal cord to the brain, if not interrupted by the opioid receptors

Question 42

Perception

Answer 42

the noxious stimuli is interpreted as pain

Question 43

Modulation

Answer 43

the pain impulse may be slowed down by neurotransmitters that act like analgesia (ie. Serotonin, norepinephrine, endorphins, etc).

Question 44

Source of Pain

Answer 44

Nociceptive, Neuropathic

Question 45

Nocioceptive

Answer 45

Caused by tissue injury, often described as “aching” or “throbbing.”
Somatic
Visceral

Somatic = may be superficial (ie. Skin) or deep (ie. Muscles, tendons).

Visceral = internal organs (ie. Gallbladder, kidney, intestine, pancreas).

Question 46

Neuropathic

Answer 46

Often results from damage or disease of the somatosensory nervous system, may be described as “shooting” or “burning.”

Neuropathic = caused by damage or disease of the somatosensory nervous system (ie. Spinal cord injury, infectious or metabolic diseases, medication-induced).

Question 47

Referred Pain

Answer 47

Originates in one location but is experienced in another location.

Referred pain = same spinal nerve innervates both locations, so cannot assume the point of origin

For example, we will learn a technique to assess for kidney disease by eliciting back pain (costovertebral angle tenderness) as part of a genitourinary system exam.

Question 48

Type Of pain

Answer 48

Acute pain, Persistent (chronic) pain

Question 49

Acute pain

Answer 49

Short-term
Self-limiting
Follows a predictable trajectory
Dissipates after injury heals

Question 50

Persistent (Chronic) Pain

Answer 50

Continues for 6 months or longer
Malignant (cancer-related) or nonmalignant
Does not stop even after tissue has healed

Question 51

Developmental Considerations Infants and young children

Answer 51

Higher risk for undertreatment (because of belief that infants do not remember pain)
Words children may use to report pain
Fear of injections

Infants and children experience pain in the same way as adults but are not able to describe it in the same way.

Question 52

Developmental Considerations Older adults

Answer 52

Pain not a normal process of aging
Higher incidence related to chronic conditions

Older adults typically experience more varieties of pain, yet this is not a normal process of aging and must be treated accordingly (not assume they are just to live with it). They may be more hesitant to use medications to relieve pain due to long-held values and beliefs about addiction or the value of pain.

Question 53

Developmental Considerations Gender

Answer 53

Differences in prevalence rates of painful conditions
Genetic differences may account for differences in pain perception

Experience of painful conditions may be different between genders. Also, the expression of pain may differ, due to stereotypical gender roles.

Question 54

Pain Subjective data

Answer 54

Pain is whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968)

Question 55

Examples of questions to assess pain beliefs

Answer 55

Do you use traditional remedies?
How do others know you are in pain?
How do you usually describe your pain?
What does your pain mean to you?
How do family and friends help you?

An example of the negative impact of nurses not believing patient’s report of pain is stereotyping by health care providers of Indigenous/ First Nations youth.

Can result in HCP denial of analgesics and other interventions to this population, as they perceive they are not believed and stereotyped as substance users.

Question 56

Initial pain Assessment (OPQRSTUV)

Answer 56

• Onset: When did the pain start?
• Provocative or palliative: What makes your pain worse? Does anything make it better/relieved?
• Quality of pain: Words to describe pain?
• Region of body: Where? Does it radiate or move to other areas?
• Severity: How do you rate the pain on an intensity scale?
• Treatment and Timing of pain: What treatments have worked for you? Is it a constant, dull, or intermittent pain? Pain-free periods or changed over time?
• Understanding of pain: What do you believe is causing the pain? Goal for comfort?

-Values. Acceptable level of pain? Any other stressors or spiritual pain?

Question 57

Paint Assessment Tools

Answer 57

Adult Nonverbal pain scale – is an observational pain assessment tool. Used for non-verbal adults.

Brief Pain Inventory
Rates the pain within the
previous 24 hours
Graduated scale (0–10)

Question 58

Pain Rating Scales

Answer 58

Pain rating scales
Visual Analogue Scale or Numeric rating scale (0-10)
Descriptor Scale (no, mild, mod, severe)
Faces Pain Scale – Revised. Great for children!

Question 59

Pain Objective Data

Answer 59

“Pain is not discounted when there is no physical evidence of it.”

Use a pain assessment tool to help classify the type of pain the patient experiences: acute, persistent/chronic, or neuropathic.
Pain assessment tools help to translate the subjective data into an objective, measurable form.

Question 60

Non-Verbal/Behavioral Pain Assessment

Answer 60

Acute pain behaviors, Persistent (chronic) pain behaviors, The unconscious individual

Behavioral assessment tools help to determine the presence of pain, but not always the severity of it. Be aware of how pain may present in the non-verbal individual.

Question 61

Acute Pain behavior

Answer 61

At high risk of undertreatment if unable to report pain
If nonverbal but cognitively intact, intensity may be indicated by numerical rating scale, written description, or pointing to location

Question 62

Persistent (chronic) pain behaviours

Answer 62

Adapt over time
May give little indication of pain
Higher risk for under-detection
Ask patient how he or she behaves when in pain

Question 63

The unconscious individual

Answer 63

Grimacing, wincing, moaning, rigidity, arching, restlessness, shaking, pushing to indicate pain
Critical-Care Pain Observation Tool

Question 64

A sudden change or increase in pain may signal an underlying pathological process and must be investigated.

Answer 64

Critical findings in your pain assessment (ie. Sudden change or increase in pain) must be reported/investigated.
Example: Sickle cell crisis - vaso-occlusive disorder signaled by severe pain. Tissue injury may occur if not rapidly treated.

Question 65

Which type of pain would cholecystitis (gallbladder disease) cause?

Somatic
Visceral
Cutaneous
Persistent

Answer 65

Correct answer: 2
Visceral pain originates from the larger interior organs (e.g., kidney, intestine, gallbladder, and pancreas). Somatic, or cutaneous, pain is derived from the skin surface and subcutaneous tissues; persistent pain is either cancer related or associated with musculoskeletal conditions

Question 66

Which anticipated persistent pain finding should guide a nurse’s care planning?
Patients with persistent pain have trouble sleeping.
Patients with persistent pain show elevated blood pressure.
Patients with persistent pain need less medication.
Patients with persistent pain may show few or no outward signs of pain.

Answer 66

Correct answer: 4
Patients with persistent pain may show few or no outward signs of pain.

Question 67

A crying patient says, “Please, get me something to relieve this pain.” What should the nurse do next?

Verify that the patient has an order for pain medication and administer the order, as directed.

Assess the level of pain and ask the patient what usually works for his or her pain; administer pain medication as needed, and then reassess pain level.

Assess the level of pain, give medication according to the pain level, and then reassess the pain.

Reposition the patient and then reassess the pain after intervention.

Answer 67

1. The correct answer is 2. Pain management should be collaborative and ongoing, and this response includes the patient as part of the decision-making process.

Answers 1, 3, and 4 are incorrect because these answers do not include the patient as part of the decision-making process about managing his or her pain. The correct answer is 2. Patients have the right to be free of pain, and a level of 3/10 indicates that the patient is still in pain.

Question 68

What are the functions of the skin?

Answer 68

Protection – waterproof, resilient; protection from physical, chemical, thermal, light wave injury.
Prevention of penetration – a barrier that keeps out micro-organisms, prevents loss of water and electrolytes.
Perception – sensory end organs for touch, pain, temperature, and pressure all reside in the skin.
Temperature regulation – sweat glands and subcutaneous insulation for heat dissipation and storage.
Identification – unique facial characteristics, hair, skin color, fingerprints.
Communication – face and body posture signal emotional states (ie. Blushing).
Wound repair – allows for cell replacement.
Absorption and excretion – some excretion of metabolic wastes (ie. Minerals, sugars, amino acids, cholesterol, uric acid, urea).
Production of vitamin D – UV light converts cholesterol into vitamin D on the surface of the skin.

Question 69

What are the 3 main layers of the skin

Answer 69

• Epidermis – the outer, thin but tough layer. Cells are constantly shedding (desquamation) and are fully replaced every 4 weeks. Think about how this relates to wound assessment and healing
• Dermis – the inner, supportive layer; mostly consists of connective tissue (collagen); gives skin its stretch. Nerves, sensory receptors, blood vessels, and lymphatic vessels are contained in the dermis.
• Subcutaneous later – beneath the dermis, is adipose tissue (fat cells); provides insulation/thermoregulation and cushioning/protection.

Question 70

Subjective Data: Health History

Answer 70

Previous history of skin disease (allergies, hives, psoriasis, or eczema)
Pruritus
Excessive dryness or moisture
Change in pigmentation
Change in mole (size or colour)
Rash or lesion
Excessive bruising
Medications
Hair loss
Change in nails
Environmental or occupational hazards
Self-care behaviours

Question 71

How are older adults at risk for alterations in the integumentary system?

Answer 71

• just as all organs, the skin is affected by the aging process.
• the epidermis thins and flattens = easier entry of microorganisms or chemicals into the skin (loss of protective barrier).
• the dermis experiences a loss of connective tissue (collagen) = risk of shearing and tearing.
• the subcutaneous layer decreases = less cushioning from physical injury
• decrease in amount of sweat and sebaceous glands = skin is dry, less thermoregulatory response.
• psychological impact of a loss of youthful appearance, linked to self-esteem (wrinkling skin, thinning and greying hair, dull skin tone and age spots). Compounded by culture, beliefs, media, social norms and roles.

Question 72

Objective Data: Physical Exam

Answer 72

Skin Colour
General pigmentation
Presence of freckles, moles, birthmarks
Widespread colour change
Pallor
Erythema
Cyanosis
Jaundice

Skin—Inspect and palpate
Texture
Thickness
Edema
Mobility and turgor
Vascularity or bruising
Temperature
Moisture

The skin holds information about the body’s circulation, nutritional status, and signs of systemic disease.
Skin assessment is integrated throughout a physical exam – not a separate step. Begins at first glance, general appearance. You will notice the majority of these points as you gather other assessment data (ie. touch during vital signs).
Know a person’s baseline skin color and note changes. Know the terms: pallor, erythema, cyanosis, jaundice. Helpful information on p.239-241 to detect color change in both light and dark skin.
Must separate skin folds during physical exam, as there is a greater risk of irritation and infection (moist, warm, dark).
Texture – smooth, firm, ridges, uneven.
Thickness – thin and shiny, or thick and callused.
Edema – extra fluid that accumulates in the intercellular spaces (abnormality). To check for edema, imprint your thumb firmly against the ankle, if it leaves a dent in the skin, “pitting” edema is present.
Mobility and Turgor – mobility is the skin’s ease of rising and turgor is its ability to return to place when released (reflects elasticity).
Vascularity – smooth, slightly raised bright red dots that commonly appear in adults older than 30 yrs, are not usually significant.
Temperature – note any differences between extremities and core temperature.
Moisture – risk for skin breakdown if moist areas.

Question 73

Objective Data: Physical Exam, continued

Answer 73

Hair – inspect and palpate
Colour
Texture
Distribution
Lesions

Nails – inspect and palpate
Shape and Contour
Consistency
Colour
Capillary Refill Time

Note irregularities with hair distribution, condition of scalp, presence of lesions.
Nails can be a source of information on self-care ability/habits, and certain diseases. For example, clubbing of nails occurs with heart disease and emphysema.
Capillary refill time – assess on hands and feet bilaterally. < 3 sec is normal, > 2 sec is delayed.

Question 74

Known the danger signs of Skin lesions (skin cancer)

Answer 74

Teach skin self-examination, using the ABCDE rule:
A: asymmetry
B: border irregularity
C: colour variation
D: diameter
E: elevation and enlargement
Health promotion opportunity – skin cancer continues to be the most common form of cancer diagnosed in Canda. Excessive exposure to UV rays can lead to skin cancer

Question 75

Stages of pressure Injury

Answer 75

If your patient is limited in movement, consider risk for pressure ulcers and be sure to assess high pressure areas: head, scapulae, ribs, elbows, coccyx, hips, ankles, heels.

Stage 1 – intact skin appears red, but unbroken. Localized erythema, blanchable (turns light with pressure, then back to skin color).

Stage 2 – partial thickness, loss of epidermis +/- dermis. Looks like an abrasion or open blister.

Stage 3 – full-thickness, extends into the subcutaneous tissue. Looks like a crater, may see subcutaneous tissue.

Stage 4 – full-thickness, involves all skin layers and extends into supporting tissue; muscle, tendon, bone may be exposed, black or brown necrotic tissue (eschar).

Consider how nurses’ assessments are critical in identifying pressure injury risk, prevention, and appropriate treatment.

Question 76

Stage 1

Answer 76

intact skin appears red, but unbroken. Localized erythema, blanchable (turns light with pressure, then back to skin color).

Question 77

Stage 2

Answer 77

partial thickness, loss of epidermis +/- dermis. Looks like an abrasion or open blister

Question 78

Stage 3

Answer 78

full-thickness, extends into the subcutaneous tissue. Looks like a crater, may see subcutaneous tissue.

Question 79

Stage 4

Answer 79

full-thickness, involves all skin layers and extends into supporting tissue; muscle, tendon, bone may be exposed, black or brown necrotic tissue (eschar).

Question 80

Non-blanchable rashes (petichae, purpura), bruises at multiple stages of healing without explanation, and pressure injury require immediate nursing inquiry and/or intervention

Answer 80

Non-blanchable rashes (petichae, purpura) may signal a bleeding disorder, such as thrombocytopenia (abnormal clotting) or septicemias (infection in the blood stream). These are considered serious rashes that must be medically investigated.
Already discussed the importance of identifying alteration in skin integrity for older adults and immobile patients, as well as bruises in multiple stages of healing with no rational explanation. Documentation is key!

Question 81

Documentation for Skin

Answer 81

use the Braden Scale, FH Wound Assessment & Treatment flowsheet to document

Question 81

What do you know about these abnormal skin patterns?

Answer 81

Congenital dermal melanocytosis (also known as “Mongolian spots) – can be a normal skin condition and is quite common, especially in infants and young children of indigenous, black, east Indian, or Hispanic descent. Be cautious not to assume this is bruising, unless there is other indications for suspicion of abuse. If in doubt, always elicit another provider’s experienced opinion.

Lyme disease – the most common vector-borne disease in Canada. Has a characteristic bulls-eye pattern. Health promotion opportunities for people who engage in outdoor activities in heavily wooded areas in the Spring and Summer months.

Question 82

Care Plan

Answer 82

Framework to think critically & make reasonable decisions.
To identify & treat potential or actual health problems.
Orderly & systematic.
Assists in comprehensive, individualized approach to care.

Question 83

Care planning

Answer 83

1. Identify abnormal subjective and objective data (place this in your care plan template).
2. Plan your priorities of care by determining which abnormal data is the most critical.
3. Choose ONE nursing diagnosis related to your abnormal assessment findings. Etiology or cause of the nursing diagnosis must be within the domain of nursing practice & a condition that responds to nursing intervention.
4. Choose a goal of care that is specific, measurable, achievable, relevant, time-bound. This must be patient-centered. A broad statement that describes the desired change in a client’s condition or behaviour. Expected outcomes are the expected favourable and measurable results of nursing care.
5. Determine 2 or 3 interventions that are appropriate for the problem and are nursing-focused. This is any treatment, based on clinical judgement & knowledge, to enhance client outcomes. Should be evidence-informed.
6. Evaluate – what kind of response do you expect and how do you assess for it? Measures the client’s response to nursing actions and the client’s progress toward achieving goals. Evaluation is conducted to determine whether expected outcomes have been attained, NOT whether nursing interventions have been completed.

Question 84

The Neck & Regional Lymphatic System

Answer 84

Major neck muscles:
- Sternomastoid – for head rotation and flexion
- Trapezius – moves the shoulders and extends/turns the head.

Both are innervated by cranial nerve XI, which we will learn how to assess in the neurologic system.

Thyroid gland – important endocrine gland with a rich blood supply on either side of the trachea.

Both the head and neck have a rich supply of lymph nodes, which are a major part of the immune system. Lymph nodes filter the lymph and engulf pathogens, preventing harmful substances from entering circulation. Enlarged lymph nodes may signal an ongoing immune response to fight infection.
Thyroid is a major endocrine glad responsible for cellular metabolism; normally not palpable behind the trachea.