Exam 2 PA

How do you perform assessment of mental status?

By observing and asking questions; collecting subjective then objective data

What is level of consciousness?

Is the person alert and awake with eyes open?

Is the patient looking at the examiner?

Is the client responding appropriately?

Response to stating patient's name

Alert/awake

eyes open, looking at nurse, responds appropriately

Lethargic (abnormal)

opens eyes, answer questions, and falls back asleep

Obtunded (abnormal)

Opens eyes to loud voice, responds slowly with confusion, unaware of environment

Stuporous (abnormal)

awakens to vigorous shake or painful stimuli, then returns to unresponsive sleep

Comatose

remains unresponsive to all stimuli; eyes remains closed

What is the order of best to worst LOC?

lethargic -> obtunded -> stupor -> comatose

Glasgow Coma Scale

eye opening, verbal response, motor response

Decorticate

flexion, rigidity, abnormal flexion

rigid posture of flexed arms, clenched wrists/fists, and extended legs

sign of severe brain damage (brain tumor/stroke/drug abuse/ brain bleed)

PULLING IN CORE (CORETICATE)

Decerebrate

extension away from body, abnormal extension

rigid posture of stiff, extended arms, pronated forearms, extended legs

sign of deeper brain tissue

Flaccidity

Relaxed; flabby; having defective or absent muscular tone

No movement response

Posture normal & abnormal

Normal: relax, shoulders back, both feet stable

Abnormal: tense, rigid, slumped, asymmetrical

Gait normal & abnormal

Normal: smooth, coordinated, fluid movements; client alters position occasionally

Abnormal: uncoordinated, staggering, shuffling, stumbling

Movement normal & abnormal (schizophrenia or anxious)

Normal: smooth, coordinated, fluid; alters position occasionally

Abnormal: jerky, uncoordinated; tremors, tics, fast or slow movement. Bizarre movements with schizophrenia; tense, fidgety, and restless behavior in anxious clients

Dress normal & abnormal

Normal: clothes fit in our appropriate for occasion and weather

Abnormal: clothes are XL or small/ inappropriate for occasion.

Hygiene normal & abnormal

Normal: skin clean, nails clean and trimmed

Abnormal: dirty, unshaven; dirty nails; foul odors

Facial expression normal & abnormal

Normal: good eye contact, matches mood. smiles/frowns appropriately

Abnormal: poor eye contact, mask like expression, extreme anger/happiness. Facial expression does not match mood

Speech normal & abnormal

Normal: speech is in a moderate tone, clear, with moderate paste and culturally appropriate

Abnormal: slow repetitive, loud, rapid, disorganized, slurred, garbled dysarthria- distorted speech sounds

dysphasia- having trouble getting the words out

Mood questions

How are you feeling?

What are your plans for the future?

Normal vs abnormal mood

Normal: responds appropriately expressing feels appropriate to situation, expresses god feelings about self, others, and life; verbalizes positive coping mechanisms

Abnormal: Expressing feelings inappropriate to the situation like extreme anger or euphoria. Dissatisfaction with self, others, and life in general; verbalizes negative coping mechanisms; prolonged negative feelings- depression

elation and high energy scene- manic phases

excessive worry- OCD

eccentric mood not to relevant to situation- schizphrenia

How do you assess orientation?

Person: What is your name?

Place: Where are you?

Time: What time is it? What month are we in? What is today's date?

Event: Do you know why you are here? What brought you in today?

normal orientation

client is able to answer all questions; Alert and orientated x_

abnormal orientation

client is unable to answer some or all of questions. Alert and orientated x_, confused to_

(5-1) Dementia (duration, onset, attention, attention, memory, alertness, thinking/judgement)

Duration: Chronic condition that does not resolve over time

Onset: Chronic onset

Attention: generally normal attention

Memory: recent and remote memory impaired

Alertness: generally normal alertness

Thinking/judgement: may have word finding difficulties, judgement may be poor

Delirium (duration, onset, attention, attention, memory, alertness, thinking/judgement)

Duration: hours-weeks in duration

Onset: acute onset

Attention: impaired/fluctuating attention

Memory: recent and immediate memory impaired

Alertness: fluctuates between lethargic and hypervigilant

Thinking/ judgement: disorganized thinking, slow or accelerated

Depression (duration, onset, attention, attention, memory, alertness, thinking/judgement)

Duration: can last weeks to months or years

Onset: often abrupt onset

Attention: distractible but minimal impairment of attention

Memory: islands of intact memory

Alertness: Alert

Thinking/judgement: thinking intact though with themes of helplessness or self-depreciation

Geriatric variations in mental status

-confused in new or acute setting causing slow thought/responses to ANO questions (person/place/time)

-decreased ability to recall directional

-slight decline in short- term memory

-likes to reminisce and tends to wander from topic being discussed

-may have hesitation with short -term memory

-clients >80 should be able to recall 2-4 words after 5 minutes

Subjective vs objective data for SHN

Subjective: reason for visit

hx of present illness

past medical hx

family hx

lifestyle and health practices: specifically hygiene habits, sun/tanning exposure, chemical exposure

Objective:

inspection

palpation

Epidermis function and layers

superficial, thinner layer of skin

composed of keratinized stratified squamous epithelium

Function: waterproof barrier and creates our skin tone

Layers (bottom to top):

stratum basale -> stratum spinosum ->stratum granulosum -> stratum lucidum -> strum corneum

Dermis function and components

a layer of dense irregular connective tissue lying deep to the dermis.

Function: support the epidermis and enable the skin to thrive

Components: hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels, nerves, blood vessels

sebaceous glands

attached to hair follicles over most of the body, except soles and palms

they secrete an oily sebum that waterproofs the hair and skin

Sweat (sebum glands)

Eccrine glands: located over the entire skin

secrete sweat and affect thermoregulation by evaporation of sweat from the skin surface

Apocrine glands; associated w/ hair follicles in the axillae, perineum, and arolae of breasts

small and nonfunctional until puberty when they secrete milky sweat

Subcutaneous layers

continuous sheet of areolar connective tissue and adipose tissue between the dermis of the skin and the deep fascia of the muscles

Vellus (peach fuzz)

short, pale, and fine over much of the body

provides thermoregulation by wicking swear away from the body

Terminal (scalp and eyebrows)

longer, darker, and coarser than vellus hair

provides insulation and allows for self-expression

Nail body

extends over the entire nail bed and has a pink tinge as a result of blood vessels underneath

Lunula

The crescent-shaped area at the base of the human fingernail.

In what order will the nurse use assessment techniques to assess skin, hair, and nails?

Interview

Inspection (looking and smelling)

Palpation

What is the nurse looking, smelling, and feeling for?

1) inspect for generalized color, color variation

2) note odors/strong odors of perspiration of foul odor may indicate sweat gland disorder

3) odor may indicate infections

4) body odor may signify need for education

How does the nurse assess for skin color?

Using inspection

Normal: lightskin- light to dark pink; dark skin- light to dark brown

Abnormal: pallor, flushed, cyanosis

How does the nurse assess for skin texture?

palpate

normal: smooth and soft

abnormal: rough, thick, dry-hypothyroidism

How does the nurse assess for skin temperature?

feel with back of hand

normal: warm & dry

abnormal: cool-shock, hypotension, arterial insufficiency, very warm-fever, hyperthyroidism

How will the nurse assess for skin turgor?

pinched up skin on sternum or under clavicle

normal: returns immediately to normal position

abnormal: 30s or longer to return to normal can indicate dehydration

How will the nurse assess for skin edema?

pressing firmly for 5-10s over tibia and ankle

normal: no swelling or edema

abnormal: swollen,

shallow to deep pitting,

ascites generalized edema in CHF,

kidney disease,

unilateral,

localized edema is seen in peripheral vascular problems such as venous stasis, obstruction, or lymphedema

How will the nurse assess for skin integrity?

pay attention to pressure point areas

normal: intact, no reddened areas

abnormal: skin breakdown

primary or secondary lesions

vascular lesions

skin cancer

How will the nurse assess for skin lesions?

detected, inspect and palpate for size, location, mobility, consistency, and pattern (circular, clustered, or straight-lined)

normal: silver-pink stretch marks (striae), moles (nevi), freckles, birthmarks

abnormal:

primary- arise from normal skin owing to disease or irritation

secondary- arise from changes in primary lesions

vascular- seen w increased venous pressure, aging, liver disease, or pregnancy

Table 10-1/ skin types

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

stage 3 pressure injury

fulll thickness skin loss with adipose tissue, granulation tissue, undermining, and tunneling

stage 4 pressure injury

full thickness loss of skin with extensive destruction, tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed

How does the nurse assess for hair color?

normal: ask about a change in color yielding to more inform

abnormal: patchy gray areas seen in nutritional deficiences

copper-red hair (AA)- severe malnutrition

How does the nurse asses for amount and distribution in hair?

normal: observing a head of hair on patient

abnormal:

alopecia- loss of hair suddenly

hirsutism- increase in facial hair in females as seen in Cushing syndrome

seen infections, nutritional deficiencies, hormonal disorders, some types of chemo, or radiation therapy; patchy loss w scale infection and lupus erythematous

How des the nurse assess for hair texture?

normal: fine to coarse, pliant

ask about a change in texture

abnormal: change in texture, brittle. dull/dry hair in hypothyroidism and malnutrition

How does the nurse assess for parasites?

normal: none

abnormal: lice, eggs attached to hair shaft severe itching

How does the nurse inspect for scalp texture?

symmetry: smooth and form

asymmetrical: bumpy, scaly, excoriated

dermatits- scaly, dry flakes

fungal infection- gray scaly patches

dandruff psoriasis

How does the nurse assess for scalp lesions?

normal: NONE

abnormal: open or closed lesions

How does the nurse assess for nail color?

normal: pink nail bed

dark skin- may have small or large pigmented streaks/freckles

abnormal: hypoxia-cyanosis

anemia- pale

fungal infection- yellow discoloration

trauma- splinter hemorrhages (vertical)

acute trauma-beau's lines (horizontal)

psoriasis- yellow or pitting

How does the nurse assess for nail shape?

normal: round nail with 160 degree nail base

abnormal: hypoxia-clubbing (enlargement of ends of fingers and downward sloping, 180 degree or more nail beds)

iron deficiency anemia- spoon shape

How does the nurse assess for nail texture?

normal: hard and immobile

abnormal: decreased ciculation-thickened

How does the nurse assess for nail condition?

normal: smooth pink firm

dark skin- may be thick

abnormal:

infection- paronychia (inflamed)

infection or trauma- oncholysis (detached nail plate

Braden Scale

Pressure ulcers

lower the number, higher the risk

4-23

less than 17 = risk for pressure ulcers

non-palpable lesion (macule)

flat and colored (freckle, petechiae, ecchymosis)

Palpable lesions with fluid (bulla/vesicle)

elevated and filled with fluid (blister)

palpable lesions (papule)

elevated and superficial (wart)

cyst

Encapsulated fluid-filled or semi-solid mass (epidermoid cyst)

tumor (nodule)

elevated and firm, has the dimension of depth (lipoma)

wheal

A localized area of edema (insect bite/hives)

pustule

elevated and filled with pus (acne)

crust

dried pus or blood

keloid

hypertrophied scar

geriatric variations in the skin

thinning epithelium

wrinkles, decreased turgor, and elasticity

dry, itchy skin due to decrease in elasticity of eccrine and sebaceous glands

prominent veins due to thinning epithelium

Seborrheic (Senile) Keratosis

tan or black macular papular-lesions on neck, chest or back)

senile lentigines

liver spots/ age spots: flat brown maculae on hands, arms, neck, and face

cherry angiomas

small, round, red elevated spots

senile purpura

vivid purple patches

acrochordons

soft, light pink to brown skin tags

geriatric variations in the hair

- Loss of pigment; fine, brittle texture

- Alopecia, especially in men; sparse body hair

- Coarse facial hair, especially in women

- Decreased axillary, pubic, and extremity hair

geriatric variations in the nails

-thickened, yellow, brittle nails

-ingrown toenails

pallor (cultural variations)

-dark skin: loss of underlying red tones

-brown skin: appears yellow brown

-black skin: appears ashen grey

-light skin: absence of underlying tones, skin turns white

erythema (cultural variations)

-dark skin: increased temp to palpation

-light skin: redness

ecchymosis (cultural variations)

-dark skin: red to purple, dark brown, or black bruise and area may be tender to touch. Look for a bump under the skin As it heals may turn yellow, brown, green.

-light skin: black and blue bruise. As it heals may turn yellow, brown, green.

cyanosis (cultural variations)

-dark skin: lips and tongue ashen gray

-light skin: bluish tone

jaundice (cultural variations)

-dark skin: yellow color in sclera, oral mucus membranes hard and soft palates, palms and soles

-light skin: pale yellow to pumpkin generalize color

What are some risk factors related to pressure injuries?

-prolonged pressure due to immobility and decreased activity

-moisture on skin which could be related to diaphoresis or incontinence

-Risks: malnutrition, EtOH, tobacco use, dehydration, lack of sensory perception

-medical history of diabetes melitus (DM), peripheral vascular disease (PVD), cerebral vascular accident (CVA), spinal cord injury (SCI), and corticosteroid use.

What are some signs and symptoms of pressure injuries?

-an area of breakdown or lesions on the skin

-4 stages that reflect the amount of tissue injury and the degree of underlying structural damage

Medical treatment for pressure injuries?

-diagnosis (nursing assessment)

-possible culture of wound to determine presence of type of organisms present in wound

-supporting tests: hemoglobin/hematocrit levels, WBC, transferring levels, albumin and total protein levels, skin biopsy, blood culture

-may need surgical interventions to mechanically debride, may need skin/muscle flaps if very deep (may need drains)

-wound care

What are risk factors for skin cancer?

Repeated, intermittent sun exposure with sunburn beginning at early age; tanning booths; radiation;

genetics-fair skin, light eyes; immunosuppression; HPV; chemicals; actinic keratosis

change in mole/ long term skin irritation

What is primary prevention for skin cancer?

-avoid sun

-use sunscreen

-avoid radiation

What is secondary prevention for skin cancer?

-self assessment

-screen for skin cancer

-chemo prevention

What are example outcomes for impaired skin integrity?

-patient will participate in prevention measures throughout hospitalization

-patient will display wound healing by discharge

-patient will have no complications of wound healing throughout stay

-patient will return demonstrate the prescribed wound care by tomorrow

What are some interventions to assess for impaired skin integrity?

-inspect skin, particularly over bony prominences

-palpate areas on skin that show signs of breakdown

-assess location, size, depth, color of wound bed (pink, red, yellow, brown, black)

-determine location, size, depth, color of wound bed (pink, red, yellow, brown, black)

-determine drainage type, color, odor, consistency, amt

-assess peri-wound for redness, edema, indurations, tenderness, and breakdown of healed tissues to identify signs and symptoms of infection

-determine alterations in mobility, continence, self care

-review history of past skin problems

-evaluate skin care regimen/hygiene

-review lab results (H&H, BG albumin) and collect and send wound culture

What are some interventions to promote healthy/intact skin?

-handle gently

-clean/hygiene, peri care

-keep sheets dry and without wrinkles

-turn q2h

-pressure reducing devices (eggcrate, air mattress, special bed, gel pads, heel rolls)

-be careful w tape/no hot or cold; encourage mobilization

-provide optimum nutrition, protein to provide positive nitrogen balance, and vitamins ACDE

-wound care

What are some intervention for health promotion/wellness?

-prevention

-encourage regular exercise

-smoking abstinence or cessation

-keep nails short

-avoid sun

-proper fit of clothes and shoes

What are the mechanics of breathing?

Respiration

Ventilation

Inspiration

Expiration

What happens during inhalation and exhalation?

-the diaphragm presses the abdominal organs downward an forward (inhalation)

-the diaphragm rises an recoils to the resting position (exhalation)

What assessment techniques will the nurse use to assess the respiratory system?

1- Interview

2- Inspection

3- Palpation

4- Auscultation

What subjective data specific to the respiratory system should the nurse collect?

Reason for visit: what brought you in today?

History of Present Health Concern: difficulty breathing, shortness of breath (SOB), snoring

chest pain (COLDSPA)

cough (productive or not), sputum (color, amount, thick/thin)

Personal Health: allergies, asthma, bronchitis, emphysema, TB, lung cancer

Family History: allergies, asthma, lung cancer

Lifestyle and Health Practices: smoking (calculate pack year), travel to high risk areas for SARS or COVID-19, environmental exposure to asbestos or inhalants (chemicals, spray paint), sedentary lifestyle

How does the nurse calculate pack year?

# of packs per day x # of years smoked