Card Set Information

2012-02-04 06:00:04


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  1. Hello Mr. Jones. I'm Tom Wruble, a student nurse and I'll be doing a skin and respiratory assessment if that is OK with you?
  2. Draw curtain for privacy
  3. Wash hands
  4. Now can you tell me your birthday? ... The medical record number on your ID bracelet matches my information and it says you have no allerfies. Is that accurate? ...
  5. 1. Verbalize inspection of the skin for generalized color, color variation, and scars. Note that you are looking for lesions that may be Asymetrical, irregular Borders, variety of Colors, Diameter greater than 6 mm or Elevated and possibky dry.
  6. 2. Palpate both forearms for texture, temperature, moisture. Check one hand for turgor, and both lower legs for edema (scale 0: NONE, through 4+ by 2 mm, 2-4, 5-7, greater 7 mm
  7. 3. Verbalize Braden Score. Note that based on an analysis of SENSORY PERCEPTION, MOISTURE, ACTIVITY, MOBILITY, NUTRITION, and FRICTION/SHEAR, that a Braden Scale score of less than 18 is an indicatory of Risk for Pressure Ulcers.
  8. 4. Document findings of assessment. John has a grouping of acrochordons on his left neck/shoulder area, a scar on his hand...
  9. 5. Document 3 abnormal findings of skin assessment. 1) EDEMA, 2) RAISED MULTI-COLORED LESIONS WITH IRREGULAR BORDERS, 3) WARM AND MOIST ALL OVER
  10. 6. Document 3 normal geriatric variations of skin assessment. 1) PRESENCE OF ACROCHORDONS, 2) WRINKLES, 3) SENILE LENTINGINES
  11. 7. Document 3 potential nursing diagnoses related to skin assessment. 1) INEFFECTIVE HEALTH MAINTENANCE, 2) IMPAIRED SKIN INTEGRITY, 3) RISK FOR IMPAIRED SKIN INTEGRITY
  12. Respiratory Assessment
  13. 8. Verbalize inspection of the thorax. Looking for symetry of check front and back.
  14. 9. Palpate the anterior and posterior chest. Anterior: Listen to PT says 99 with the ball of hand on symetrical spots of upper chest, Posterior: with thumbs pinching flesh at T10, looking for symetrical expansion
  15. 10. Auscultate the: 1) anterior chest (8 areas), 2) posterior chest (10 areas), 3) lateral chest (5 areas each side)
  16. 11. Document findings of assessment. John should have very clear harsh hollow tubular sounds heard anteriorly and low, soft (wind in the trees) sounds in the vesicular area posterior
  17. 12. Document 3 abnormal findings of auscultation. 1) Rales - are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. 2) Rhonchi � low pitched, musical, snoring, adventitious lungs sounds caused by airflow obstruction from secretions. 3) Wheezing � high pitched, musical, squeaking adventitious lung sound.
  18. 13. Document 3 normal geriatric variations of respiratory assessment. 1) Lungs being more rigid leading to 2) decreased ability to cough and 3) decreased breath sounds
  19. 14. Document 3 potential nursing diagnoses related to respiratory assessment. 1) Ineffective airway clearance, 2) Impaird gas exchange, 3) Ineffective Breathing Pattern
  20. Call light, bed low, top rails up with permission, anything I can do?, wash hands