NR 414

•During procedures that require intentional perforation of the client’s skin

• •When the skin’s integrity is broken as a result
• of trauma, surgical incision or burns

-During procedures that involve insertion of catheters or surgical instruments into sterile body cavities

• -Annular
• -Confluent
• -Discrete
• -Grouped
• -Gyrate
• -Target, or Iris
• -Linear
• -Polycyclic
• -Zosteriform

• –A—asymmetry
• –B—border
• –C—color
• –D—diameter
• –E—elevation and enlargement

• -Shape and Contour
• -Profile Sign-clubbing?
• -Consistency
• -Color
• -Capillary Refill Time (CRT)

• 1. Protection: physical, chemical, thermal and light
• 2. Prevents penetration & loss of fluids
• 3. Perception: touch, pain, temperature, pressure
• 4. Temperature regulation via sweat & adipose layer
• 5. Identification
• 6. Communication
• 7. Wound repair
• 8. Absorption and excretion
• 9. Production of Vitamin D

• -—Continues for 6 months or longer
• -Types are malignant (cancer related) and nonmalignant
• -—Does not stop when injury heals

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

• -Visceral pain
• -Deep somatic pain
• -Cutaneous pain
• -Referred pain

• -—Abnormal processing of pain message
• -Most difficult type of pain to assess and treat
• —-Damaged/dysfunctional/injured nerve fibers

• -—Temp:decrease fevers, increase risk hypo/hyperthermia, decrease sweating
• -—Pulse: Normal range, but often irregular
• -Respirations: decrease Tidal Volume 
• -BP: Systolic generally increases with age

—

• -I, the systolic pressure
• -IV, muffling of sounds
• -V, the diastolic pressure

• -—Cardiac output
• -—Peripheral vascular resistance
• -—Volume of circulating blood
• -—Viscosity
• -—Elasticity

Systolic BP - Diastolic BP

Left ventricular contaction

• -—Oral
• -Electronic (via central line)
• -—Axillary
• -—Rectal
• -—Tympanic membrane
• -—Temporal

• -May examine alone without parent or sibling
• -Give feedback that they are developing normally
• -Do not treat like a child or adult
• -Focus on health teaching
• -Examine genitalia last and quickly

• -Clean the equipment
• -Set Clean vs. dirty area for handling equipment
• -Prevent Nosocomial infections
• -Wash hands
• -Wear gloves
• -Follow Standard precautions
• -ObserveTransmission-based precautions

The abdomen,

• Inspect
• Osculate 
• Palpate 
• Percuss

• •Inspection
• •Palpation
• •Percussion
• •Auscultation

• •Resonant= clear, hollow
• •Hyperresonant=booming
• •Tympany= musical & drum like
• •Dull= muffled thud
• •Flat= absolute dullness

-Purpose- to assess underlying structures

• •Map location and size of organs
• •Signal density of a structure by a characteristic note
• •Detecting superficial abnormal mass
• (penetrate ~5cm deep)
• •Elicit pain if underlying structure is inflamed
• •Elicit deep tendon reflex using percussion hammer

• -To assess-
• •Texture
• •Temperature
• •Moisture
• •Organ location/size
• •Swelling, vibration or pulsation 
• •Rigidity or spasticity
• •Crepitation
• •Presence of lumps or masses
• •Presence of tenderness or pain

• -˜Refer to established outcomes
• -Evaluate individual’s condition and compare actual outcomes with expected outcomes
• -˜Summarize results of evaluation
• -˜Identify reasons for failure to achieve expected outcomes
• -˜Take corrective action to modify plan of care
• -˜Document evaluation in plan of care

• -˜Determine patient readiness
• -˜Review planned interventions
• -˜Collaborate with other team members
• -˜Supervise by delegating appropriate responsibilities
• -˜Counsel person and significant others
• -˜Involve person in health care
• -˜Refer for continuing care
• -˜Document care provided

• -˜Establish priorities
• -˜Develop outcomes
• -˜Set time frames for outcomes
• -Identify interventions
• -˜Document plan of care

• -˜Identify expected outcomes
• -˜Individualize to patient
• -˜Ensure outcomes are realistic and measurable
• -˜Include a time frame

• -˜Interpret data
• -Identify clusters of cues
• -Make inferences
• -˜Validate inferences
• ˜-Compare clusters of cues with definitions and defining characteristics
• -˜Identify related factors
• -˜Document the diagnosis

• -˜Collect data
• -Review of clinical record
• -Interview
• -Health history
• -Physical examination
• -Functional assessment
• -Cultural and spiritual assessment
• -Consultation
• -Review of the literature

• ˜Assessment
• ˜Diagnosis
• ˜Outcome identification
• ˜Planning
• ˜Implementation
• ˜Evaluation

• Observed when inspecting, percussing, palpating, and auscultating patient during
• physical examination

• –Gradual onset
• –More common in elderly
• –Causes: Alzheimer’s,Parkinson’s, CVA, HIV, head trauma

• –Acute onset
• –Young or old
• –Causes: infection, intoxication, withdrawal, hypoxia, F&E imbalance, post head trauma, postop

• Differentiated crying by 4 weeks
• Cooing at 6 weeks
• One word sentences at 1 year
• Multi-word sentences by 2 years

Statements from the patient that are not verifiable. 

• JOMACS
• J-Judgement
• O-Orentation
• M-Memory
• A-Appearance 
• C-Calculation 
• S-Speech 

Person, place, time and purpose 

• ABCT
• –Appearance

–Behavior

–Cognition

–Thought processes

• •a significant behavioral or psychological pattern associated with: distress or
• disability and has a significant risk of pain, disability, or death, or a loss
• of freedom.

–Organic disorder: brain disease of known specific organic cause

–Psychiatric mental illness: no organic etiology established

•a person’s emotional and cognitive functioning.

• –Optimal functioning aims toward
• simultaneous life satisfaction in work, caring relationships, and within the self
• –Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally

• R= Realize that you must know the heritage of yourself and your patient.
• E= Examine the patient within the cultural context.
• S= Select questions that are simple and speak them slowly.
• P = Pace questioning throughout the exam.
• E = Encourage patient to discuss meaning of health and illness with you.
• C = Check patient’s understanding and acceptance of recommendations.
• T = Touch the patient within the
• boundaries of his or her heritage.

• Meditating
• Exercising/physical fitness
• Sleep habits
• Vaccinations
• Willingness to undergo physical examination
• Pilgrimage
• Truthfulness about how patient feels
• Maintenance of family viability
• Hoping for recovery
• Coping with stress
• Genetic screening and counseling
• Living with a disability 
• Caring for children

• •Understanding and attending to
• total context of patient’s
• situation including:

• -Immigration status, Stress factors, Social factors, & Cultural similarities and
• differences

• •Applying underlying background
• knowledge necessary to provide the best possible health care

• •Possessing basic knowledge of and
• constructive attitudes toward diverse cultural populations

• The loss of the person’s balance, within one’s
• being—physical, mental and/or spiritual—and
• in the outside world—natural, communal, and/or metaphysical

• The balance of the person, both within one’s
• being—physical, mental and/or spiritual—and
• in the outside world—natural,communal, and/or metaphysical, is a complex, interrelated phenomenon

• Nutrition
• Oxygenation
• Infection
• Age
• Chronic health condition
• Medications
• Smoking

• Pain Scale
• When
• Alleviating factors
• Stop, look, and listen
• Before, during, and after
• Medication and results

• -Least to most contaminated 
• -Clean to dirty
• -Top to bottom 

Remove dead tissue and debris, which impedes healing

• Impaired Tissue Integrity
• Risk for Infection
• Pain
• Disturbed Body Image
• Deficient Knowledge (wound care)

• -Serous
• -Sanguineous
• -Serosanguineous
• -Purulent

Typically need to be buried before sundown 

• Wound dimensions (size and depth)
• Tunneling and undermining
• Bed texture
• Bed moisture
• Wound odor
• Margins and surrounding skin
• Pain?

Debridement

• -Immobility
• -Limited activity levels
• -Incontinence
• -Impaired nutritional status
• -Infection
• -Anemia
• -Diminished sensations
• -Altered level of consciousness
• -Cachexia(emaciation)
• -Friction and shear injury
• -Obesity
• -Hydration
• -Aging skin
• -Medications that delay healing
• -Decreased blood flow to lower extremities

Numeric value for 6 risk factors related to impaired skin integrity

Total score <18 = risk

• 6 risk factors:
• Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction & Sheer

–A—asymmetry

–B—border

–C—color

–D—diameter

• –E—elevation
• and enlargement