Quiz #1 Flashcards
(97 cards)
1
Q
What is the purpose of a nursing assessment? Identify from your readings five reasons to complete an assessment.
A
- Emotional, intellectual, physical, psychosocial, spiritual, cultural components of evaluation
- Address patient need (chief complaint, yearly physical screening..)
- Health history, current status, nursing diagnosis, clinical judgements, expected outcomes, evaluation.
- Gather data -> develop -> create care plan -> manage patient concerns -> evaluate nursing care
- Confirm + identify diagnosis (DX); make judgements/decisions care -> EVALUATION - Applying social and cultural considerations (boils trust, connection, respect)
Added notes:
- Baseline Data; supplement, confirm or repute a previous finding.
Settings: Environment includes:
- Privacy (curtain)
- Comfort (lighting,
- Proper equipment
- Proper positioning
- Proper organization/sequence of exam
- Physiological + physical safety
- Proper infection control.
2
Q
What do the terms “acute” and “stable” refer to? How do these concepts relate to the frequency and type of assessments nurses complete?
A
Acute: dynamic health problem, acutely ill patient that requires intervention
1. Primary assessment:
- Done in ED
- General survey, focused assessment
- Can be every couple hours, completed every shift (primary assessment head-to-toe)
Stable: A patient who’s health status is stable and consistent. Health status is not acute
- Something unusual? -> focus assessment
- Annual physical exam, screening assessment + primary care exam.
- Can be done annually or can be screening assessment + can be completed at primary care visit.
3
Q
Describe primary, secondary, and tertiary sources of health assessment data.
A
Primary: their description of the presenting problem, medical history and narratives of health experiences.
Secondary: nursing notes/charting, physician progressive notes and medical administration record. It’s important to acknowledge that clients are dynamic and chart data records allows history but dosent always reflect current health status.
Tertiary: it provides information to client frame of reference such as relevant literature and nursing experience.
- Understanding commonalities among clients with similar physical and emotional response.
4
Q
Identify three relational practice and communication principles to use when conducting assessments.
A
- A thorough examination of purpose and steps of each assignment
- let client prepare and lets them know what to expect - Allow/help client feel confident to ask question sand to mention discomfort
- Convey an open professional approach while remaining calm and relaxed.
- still demeanour will inhibit reaction + too cause will fail to assure the client.
5
Q
Identify four ways to keep your patient safe and physically comfortable during an assessment.
A
- Ask for consent and check in to make sure client is comfortable
- Use relational practice skill like “SOLAR” to make your patient feel heard
- Describe the procedure to your patient to make them feel included
- Try to keep their equipment warm and make sure they are comfortable
6
Q
Identify three ways you will attend to infection control practices when assessing a patient.
A
- Proper hand hygiene
- Proper disposal of soiled material
3.using PPE when necessary
7
Q
Identify eight principles and/or organizational tips nurses apply when completing assessments.
A
- Compare both sides of body for symmetry
- If they are seriously ill assess the systems more at risk for being abnormal
- if the patient gets fatigued offer rest periods
- Preform painful procedures at the end
- Record assessments in specific terms on a physical assessment form/nurses notes
- Use common and accepted medical terms to keep things short
- Use quick notes during assessment and compete them after
- The physical assessment forms allow the info to be written in the same order it’s was gathered.
8
Q
Identify and describe five particular techniques nurses use during assessments.
A
- Inspection – use vision and hearing to distinguish normal vs. Abnormal findings
- Palpation – using hands to touch body parts in order to make sensitive assessments
- Percussion – tapping body with fingers to produce vibration through body tissue
- Auscultation – listening to sounds of the body to detect variations of normal
- Olfaction – smell can distinguish normal vs abnormal body orders
- body, urine, wounds breath, etc.
9
Q
Differentiate between subjective and objective data.
A
Subjective: what the patient is telling you, saying they feel pain, not having an answer for what’s going on.
Objective: things you can observe, is confirmed from results and matches patinet’s symptoms, from test results/vita.
10
Q
Differentiate between physical and screening assessments.
A
Physical: hands on assessment with patient
Screening: mammogram, BSE, prostrate exam, stool/bowel Ca
11
Q
List three or four additional assessments a nurse includes in a holistic assessment (i.e., cultural assessment).
A
- Cultural
- Family
- Psychosocial (mental)
12
Q
Differentiate between and summarize the main types of health assessments used by nurses.
A
- Primary survey:
- structural assessment helps nurse recognize and act on signs of clinical detoriation
- airway, breathing, circulation, disability, exposure
- collects data in order of importance
- rapid response system - General survey
- information about characteristics of an illness, pt. Hygiene, emotional state, recent changes in weight, and developmental status - Focused assessment
- survey/assessment about a specific body system/health concern
- related to specific signs or symptoms that are presenting - Head-to-toe (10 min)
- assesses several body systems
- Provides overview of pt. Health
- Collected data can influence the need for further examination - Complete health assessment (45-60 min)
- simulator to head to toe
- more comprehensive
- includes objective and subjective assessment of all body systems.
13
Q
Compare and contrast the Nursing Process (ADPIE) with Tanner’s (2006) Thinking Like a Nurse model.
A
ADPIE:
- Implementation
- Linear
- More patient friendly when explaining cure
- STABLE beginnings
Tanner:
- More complex and more in depth
- More specific reflection
- Acute + advanced
Similarities:
- Follow same rubric
Assess = noticing
Dx/Plan = interpreting
Intervention = responding
Evaluation = reflection
14
Q
When is a complete health history is utilized by the health care team?
A
- When patients are admitted to the unit (within the 4 hours!)
- It is a “form” that is 2pgs that prompts the procedures needed, organized, least invasive -> more invasive (trauma informed care)
15
Q
How is this useful for the nurse/health care team for the care of the well patient?
A
Baseline: It is used to assess overall health status, health maintenance goals, and health-promoting practices, such as exercise pattern, diet, risk and harm reduction, and preventive behaviours such as immunization status, age-appropriate health screening, limiting screen and sedentary time, or helmet use during sports activities.
16
Q
How is this useful for the nurse/health care team for the care of the ill patient?
A
- It includes a detailed and chronological record of the health problem.
17
Q
What are the systems you will assess as part of this health history review of systems?
A
- Biographical data: the patient’s name, age and birthdate, birthplace, other recent countries of residence, sex, gender, relationship status, and usual and current occupation or daily activity pattern (an illness or disability may have prompted a change in occupation or usual patterns of activity). And sometimes preferred language.
- Reason for seeking care: a brief, spontaneous statement in the patient’s own words that describes the reason for the visit.
- Current health or history of current illness:
Healthy patient: a short statement about the general state of health.
Ill Patient: a chronological record of the reason for seeking care, from the time the symptom first started until now. Isolate each reason for care identified by the patient. - Past health history: Past health events may have residual effects on the current health state. Also, patients’ previous experience with illness may give clues as to how they respond to illness and to the significance of illness for them. Ex. Childhood illness, accidents or injuries, serious or chronic illness, hospitalizations, operations, immunizations, allergies, and current medications.
- Family health history: the ages and health, or the ages at and cause of death, of blood relatives, such as parents or other primary caregivers, grandparents, and siblings.
- Review of systems: The order of the examination of body systems is approximately head to toe.
(a) to evaluate the past and current health state of each body system,
(b) to double-check in case any significant data were omitted in the Current Illness section, and
(c) to evaluate health promotion practices. - Functional assessment (including activities of daily living [ADLs]): you measure a patient’s self-care ability in the areas of general physical health or absence of illness; activities of daily living (ADLs), such as bathing, dressing, toileting, eating, and walking; instrumental activities of daily living (IADLs), which are activities needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, and managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.
- self concept
- sleep and rest
- nutrition and elimination
-Interpersonal relationships
-Spiritual resources
-Coping and stress management
-Tobacco use history
-Alcohol
-Substance use
-Environmental hazards
-Intimate parter violence
-Occupational health
18
Q
describe the difference between a sign and a symptom and give one example for each.
A
Symptom: what the patient is feeling but we are not able to see or measure (subjective) eg. Stomach ache or pain from 1-10
Sign: a measurable or visible outcome of a health abnormality that health care workers can detect (objective) ex. Increased heart rate or a broken bone
19
Q
- Identify two or three things to consider when assessing pain in older persons.
A
- Pain is not a natural occurrence of aging, although there are risks of experiencing more pain
- Take time when planning pain assessment (patient-centred care)
- Fear of becoming “addicted”
- Fall risk/sedation
1) Older persons who are able to express themselves can use self-report pain scales. In addition, assessment should include how the pain is affecting function, sleep, appetite, activity, mood, and relationships with others (Booker & Haedtke, 2016).
Practise person-centred care and take the time required when explaining a pain-assessment scale.
2) Pain is not a natural occurrence of aging, although older persons are at risk for experiencing more pain-producing conditions.
3) Nonverbal older persons experiencing pain are at high risk of inadequate analgesia (Allione, Pivetta, Pizzolato, et al., 2017). Ensure that your assessment is thorough and evaluate a patient’s response critically.
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Q
- Identify two or three things to consider when assessing pain in children.
A
- Children w/ verbal skills an rate their pain on their face scale and numeric 0-10 used @ age 7
- FLACC
- May have misconceptions about the cause of pain or fear of consequences ex. Needle
- Culture
1) Some children are reluctant to report pain because they have misconceptions about the cause of their pain or they fear the consequences (e.g., another painful procedure or an injection).
2) Infants and children experience pain but respond to it differently than adults. Infants and children who do not have the ability to self-report their pain are at risk of having their pain go unrecognized. A valid observational pain assessment tool such as the Face Legs Activity Cry Consolability–revised (FLACC-r), the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), or the COMORT/COMFORT scale (Andersen, Langius-Eklof, Nakstad, et al., 2017) should be used.
3) Parents are helpful when assessing their child’s pain and planning pain-relief therapies. Most parents know how their child exhibits pain and which pain-relief interventions have been successful.
4) Children with verbal skills can rate their level of pain on the FACES Scale, FACES Pain Scale– Revised, pain rating scale, or Numeric Rating Scale (0–10). The Numeric Rating Scale (0–10) can be used in children over the age of 7 years. With children, 0 = no pain. However, there is no consensus on what 10 should mean. “Most hurt” or “worst hurt you can imagine” are suggestions for defining “10” (Castarlenas, Jensen, von Baeyer, et al., 2017). The absolute value of a pain-intensity score is not as important as the changes in scores in each individual child. In clinical use with children, a change in pain of 2 of 10 (i.e., a change of one face) represents the least change that can be considered clinically significant when using a FACES Scale–Revised (Tsze, Hirschfeld, von Baeyer, et al., 2015).
5) • Pharmacological pain support is safe and effective in pediatric patients when the dose is calibrated according to the child’s weight; however, recent evidence cautions that this practice may be inappropriate for obese children (Vaughns, 2017).
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Q
2) Why are infants, children and older persons at risk for under-treating pain?
A
- Some ages and conditions common in infants, children and older persons inhibit them from describing or express themselves and their symptoms.
- Verbal communication, unable to self-report
- Dependency
- Infant: patents advocate
- Children: self/parents advocate
- Older adults: self/caregiver (LOC -rushed assessment)
22
Q
3) Name two tools used to quickly assess pain across the lifespan (besides the 0-10 Pain Scale).
A
1) For patients with dementia or those who have no verbal skills, use observational pain assessment scales such as the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-II) and the Pain Assessment in Advanced Dementia scale (PAINAD)
- Assess physical, behavioural, and emotional signs and symptoms of pain:
a. Moaning, crying, whimpering, groaning, vocalizations b. Decreased activity
c. Facial expressions (e.g., grimace, clenched teeth)
d. Change in usual behaviour (e.g., less active, irritable) e. Abnormal gait (e.g., shuffling) and posture (e.g., bent,
leaning)
f. Guarding a body part
g. Diaphoresis
h. Changes in sleep patterns
- FACEs pain scale/visual analogue scale (gives a picture and simple description – children)
- Descriptor scale (describes pain – older adults)
- OPQRSTV pain mnemonic (guidelines for questions)
2) Assess characteristics of pain. Follow employer policy regarding frequency of assessment. Use the OPQRSTUV pain assessment.
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Q
a. Compare and contrast acute pain and chronic pain. What do you imagine are the differing signs and symptoms of these two experiences?
A
Acute: a response to and experience of unpleasant stimuli. It motivates lasts from hours to days or a month after the precipitating event. It resolves as tissue healing occurs behaviours to avoid potential or actual tissue damage. It is recent in onset and is self-limiting,
Chronic: Chronic pain is defined as pain that lasts longer than 3 months or past the time of normal tissue healing. It can impact the person’s physical, psychological, and social well-being.
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Q
b. What effect does acute and/or chronic pain have on quality of life and ADL’s/iADL’s?
A
- Adequate pain relief allows patient to participate in activities of daily living (ADLs).
- Pain can prevent people from assessing ADL/iADL
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c. Compare and contrast an “initial pain assessment” to a “brief pain inventory”. Which assessment guide/tool is most appropriate for acute pain? Why or why not?
initial pain assessment:
O: onset - When did the pain start?
- To identify onset of pain (when active, or resting) or whether pain is acute/chronic.
P: provocative/palliative - Does your pain increase with movement or activity? Are the symptoms relieved with rest? Were any previous treatments effective?
- To identify quality of pain and differentiate between nociceptive and neuropathic pain mechanisms.
- To identify alleviating and aggravating factors.
- To evaluate effectiveness of current treatment.
Q: quality of the pain - What does your pain feel like? What words describe your pain?
- To identify mechanism of pain (terms such as “throbbing,” “aching,” “shooting,” and “dull” may provide clues).
R: region of the body/radiation - Where is your pain? Does the pain radiate, or move to other areas?
- To identify one or more areas of the body that are affected by pain, inasmuch as there may be several.
S: severity of pain -How would you rate your pain on an intensity scale?
- To identify intensity (refer to various intensity scales).
- To identify degree of impairment and effect on quality of life or ability to perform activities of daily living (ADLs).
T: treatment/timing - What treatments have worked for you in the past? Is it a constant, dull, or intermittent pain?
- To identify treatments which have been successful in the past.
- To identify the timing of the pain so that treatment can be focused on spikes in pain.
U: Understanding of pain - What do you believe is
- causing the pain?
- To understand patient history of pain.
- To be able to set achievable pain and function goals when reviewing the plan of care.
V: values - What is your acceptable level for this pain? Is there anything elsethat you would like to say about your pain? Are there any other symptoms related to the pain?
- To understand and discuss other stressors, spiritual pain.
Brief pain inventory: The patient rates the pain within the previous 24 hours, using graduated scales (0 to 10); indicates how much relief the patient has had; and describes how the pain interferes with areas such as general activities, mood, walking ability, work, and sleep
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a. What is the relationship between anxiety/ fear and pain?
People are fearful of mowing they will experience pain and therefore become anxious.
Chronic pain can result in fear and anxiety of ADLs + iADLs
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b. When assessing a person in pain, why does a nurse take a health/illness history and a history of the type of medications/therapies they have tried?
To see if they are taking any medications or have any health conditions or incidents that might be related to the pain.
To know what hasn’t/isn’t working in relation to therapies and medications.
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7) Identify two or three person-centred principles to follow when assessing pain.
- Patient advocacy
- Patient empowerment
- Compassion + respect
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8) What is nociceptive pain and what are the words used to describe this sort of pain.
Nociceptive pain: caused by tissue injury or damage. It is well-localized and often described as aching, sharp or throbbing.
Nociceptive pain can be further classified as somatic or visceral.
Somatic pain can be superficial (superficial somatic or cutaneous pain), derived from skin surface and subcutaneous tissues, or deep (deep somatic pain), derived from joints, tendons, muscles, or bone. Visceral pain originates from the larger interior organs (e.g., kidney, intestine, gallbladder, and pancreas). The pain can stem from direct injury to the organ or from stretching of the organ as a result of tumour, ischemia, distension, or severe contraction.
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9) What is neuropathic pain and what are the words used to describe this sort of pain.
Neuropathic pain: caused directly by a lesion or a disease affecting the somatosensory nervous system. Sensation of pinpricks, cold, loss of sensation
Neuropathic pain can result from damage to the nerve pathway at any point along the nerve, from the terminals of the peripheral nociceptors to the cortical neurons in the brain. Examples of neuropathic pain may include pain caused by direct nerve trauma (spinal cord injury), infectious diseases (herpes zoster, human immunodeficiency virus [HIV] infection), or metabolic problems (diabetes), or it may be medication-induced (chemotherapy, antiretroviral therapy).
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10) What other words are used to describe pain?
• Aching.
• Throbbing.
• Cramping.
• Gnawing.
• Heavy.
• Hot or burning.
• Sharp.
• Shooting.
• Stabbing
• Ripping
• Grinding
• Poisoned
- Observed, noticed, inspected
- Palpated…
- Odour noticed
- ANS calculated
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11) Identify objective assessment findings a nurse might observe, inspect, or palpate associated with pain? (What does it look like when someone is in pain? Does a person in acute pain look the same as a person in chronic pain?)
Assess physical, behavioural, and emotional signs and symptoms of pain:
a. Moaning, crying, whimpering, groaning, vocalizations b. Decreased activity
c. Facial expressions (e.g., grimace, clenched teeth)
d. Change in usual behaviour (e.g., less active, irritable) e. Abnormal gait (e.g., shuffling) and posture (e.g., bent,
leaning)
f. Guarding a body part
g. Diaphoresis
h. Changes in sleep patterns
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12) Identify primary, secondary, and tertiary sources of data when assessing pain?
Primary: collecting data from patient
Secondary: data found in chart, diagnostic imaging + test, lab reports
Tertiary: data from literature (medical + pharmacological) that relates to patient’s condition (Our experiences)
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Pharmacologic?
a. Pharmacologic – relating to the branch of editing concerned with the uses, effects and modes of action of drug
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b. Analgesic?
– the action of a drug relieving pain
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c. Multimodal analgesia?
– several different modes of activity or occurrence + the action of a drug relieving pain
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Adjuvants or coanalgesics?
- A substance that enhances the body’s immune response to an antigen/ a group of pharmaceuticals with pharmacological characteristics that were not primarily intended for pain relief but were found to have therapeutic properties when used independently or in conjunction with opioids.
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e. Non-pharmacologic
- the management of pain without medications.
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14) Provide examples of non-pharmacologic interventions to treat pain.
- Hypnosis
- Physical therapy
- Comfort therapy
- Neurostimulation
- Hot and cold application (cold for neurologic)
- Kitsons fundamentals of care: clean, dry, warm, position, rested, decrease noise, listen, collaborate, positioning
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15) Prepare for documenting your pain assessment in class. Consider List four tips for documenting a pain assessment.
Tip 1: Document the SEVERITY level of pain.
Tip 2: Document what causes VARIABILITY of pain.
Tip 3: Document the MOVEMENTS of the patient at pain onset.
Tip 4: Document the LOCATION of pain.
Tip 5: Document the TIME of pain onset.
Tip 6: Document your EVALUATION of the pain site.
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1. According to the BCCNM, what are 10 things a nurse knows before performing any medication-related activity?
- Client name and second client identifier
- Medication ( Therapeutic use/indications, Expected effects, Dosage(s), Precautions Contraindications Form (e.g. tablet, liquid), and route for administration, Interactions, Side effects and Adverse effects.
- Dose
- Time and frequency
- Route
- Reason for administration to the client
- Monitor the client’s response to the medication
- Recognize and manage intended and adverse outcomes of the medication.
- Nurses administer, dispense, or prescribe medications only for clients under their care, except in an emergency.
- Nurses assess the appropriateness of the medication for the client before administering, dispensing, or prescribing a medication.
- Nurses assess and respect the client’s values, beliefs, personal preferences, language, learning needs, abilities, mental state, and level of understanding, to support the client (or their substitute decision-maker) to be an active participant in making informed decisions about the medication.
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2. According to the BCCNM, what are eight things a nurse teaches clients (or their substitute decision-maker) about the medication they are receiving?
- The reason the client is receiving the medication, The expected action of the medication,
- The duration of the medication therapy,
- Specific precautions or instructions for the medication,
- Potential side-effects and adverse effects (e.g. allergic reactions) and action to take if they occur,
- Potential interactions between the medication and certain foods, other medications, or substances,
- Handling and storage requirements,
- Recommended follow-up.
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3. Medications have three names. State what they are and provide a brief description.
1) The chemical name: describes the drug composition and molecular structure, such as N-acetyl-para-aminophenol, commonly known as Tylenol.
2) The generic name: is the name that is listed in official publications such as the Health Canada's Drug Product Database or the RxTx Database (formerly the Canadian Compendium of Pharmaceuticals and Specialties [CPS]).
3) A medication trade name or brand name: is used to market the medication. The trade name has the symbol TM at the upper right of the name, indicating a manufacturer trademark of the name (e.g., TempraTM, TylenolTM).
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4. Why are medication names a source of medication errors for nurses? Identify an action you can take to prevent you making a medication error resulting from confusion about the medication name.
similar names and spelling, such as Celebrex for arthritis and Celexa for depression; Lamictal for epilepsy and Lamisil for fungal infections; Losec for ulcers and Lasix for fluid retention. Another measure to help address the confusion around medications having similar names includes the use of TALL-man lettering (ISMP, 2016). This measure uses capital letters in specific parts of a word and helps distinguish dissimilarities in medication names; for example, TEGretol (for seizures) can be confused with TRENtal, which is prescribed for intermittent claudication; but the TALL-man letters emphasize the difference in the medication name.
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5. What is a medication “classification”?
indicates the effect of a medication on a body system, the symptoms the medication relieves, or the desired effect of the medication.
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6. What “forms” do medications come in? Why?
The form of the medication determines its route of administration. The composition of a medication influences its absorption and metabolism. Many medications are made in several forms, such as tablets, caplets, or suppositories. When administering a medication, be certain to use the proper form.
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7. Pharmacokinetics is the study of absorption, distribution, metabolism, and excretion of a medication. Explain these four terms.
Absorption: is the passage of medication molecules into the blood from site of administration
Distribution: distributed to tissues depending on the route it takes it can go to different areas of the body.
Metabolism: after medication reaches its site of action is metabolized into less active form “broken bone”
Excretion of a medicine: process of what medication leaves the ody through lungs, exocrine glands, bowel, kidneys, and liver.
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8. Why does age, sex, and illness of the liver, kidney, lungs, and intestines matter when thinking about pharmacokinetics?
- Older adults may be at risk for toxicity if their organs cannot metabolize medication effectivity
- Site of excretion can increase level of intensity of medication and/or toxicity
- These organs are sensitive and need to be considered durring usage of any medication.
- Women have smaller organs
- Organ function decreases with age
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9. Identify the 10 “rights” of medication administration.
10. 1. Right patient
11. 2. Right dose
12. 3. Right medication 4. Right route
13. 5. Right time
14. 6. Right education 7. Right to refuse
15. 8. Right assessment 9. Right evaluation
16. 10. Right documentation
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17. Identify the seven components of a medication order.
• Patient's full name: The patient's full name distinguishes the patient from other persons with the same last name. In an acute care setting, patients may also be assigned a special identification number (e.g., a medical record number) to help differentiate patients with the same names. This number may be included on the order form.
• Date and time the order is written: The day, month, year, and time must be listed. Designating the time that an order is written helps to clarify when certain orders are to stop automatically. If an incident occurs involving a medication error, documentation is easier when this information is available.
• Medication name: The prescriber will order a medication by its generic or trade name. Correct spelling is essential to prevent confusion with medications with similar spelling.
• Dose: The amount or strength of the medication is included.
• Route of administration: The prescriber uses accepted abbreviations to indicate the medication routes. Accuracy is important because some medications can be administered by more than one route.
• Time and frequency of administration: Nurses need to know when to initiate medication therapy. Orders for multiple doses establish a routine schedule for medication administration.
• Signature of prescriber: The prescriber's signature makes the order a legal request.
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What are developmental changes that occur during pregnancy
- change in hormone levels results in increased pigmentation in the areolae and nipples, vulva, and sometimes in the midline of the abdomen (linea nigra) or in the face (chloasma).
- Hyperestrogenemia probably also causes the common vascular spiders and palmar erythema. Connective tissue becomes increasingly fragile, which results in striae gravidarum, which may develop in the skin of the abdomen, breasts, or thighs.
- Metabolism is increased in pregnancy; as a way to dissipate heat, the peripheral vasculature dilates, and the sweat and sebaceous glands increase secretion.
- Fat deposits are laid down, particularly in the buttocks and hips, as maternal reserves for the nursing baby.
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What developmental changes during infancy and children?
- hair follicles develop in the fetus at 3 months' gestation;
- by midgestation, most of the skin is covered with lanugo
- present at birth is vernix caseosa, the thick, cheesy substance made up of sebum and shed epithelial cells.
- sebaceous glands decrease in size and production and do not resume functioning until puberty.
- newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of an adult, and so the infant is at greater risk for fluid loss.
- Temperature regulation is also ineffective.
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What developmental changes occur during adolescence
- sebaceous glands resume functioning due to puberty.
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What developmental changes occur for older adults? Safety considerations?
Integumentary changes:
- The aging skin loses its elasticity; it folds and sags
- Sweat glands and sebaceous glands decrease in number and function, leaving the skin dry.
SAFETY considerations:
- The epidermis's outer layer, the stratum corneum, thins and flattens allowing chemicals easier access into the body
- The loss of collagen increases the risk for shearing and tearing injuries.
- Decreased response of the sweat glands to thermoregulatory demand also puts older adults at greater risk for heat stroke.
- An accumulation of factors increases older adults' risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging (e.g., less nutrition, limited financial resources), the increasingly sedentary lifestyle, and the chance of immobility.
- subsequent cell replacement is slower, and wound healing is delayed.
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Identify 3-4 elements of an integumentary assessment that you think are the most important things to remember (HINT: think “health promotion” and SAFETY).
1. Pressure injuries Never rub vigorously and reduce moister on skin when
2. Never rub vigorously and reduce moister on skin when
3. Compliment patient on what they are doing good at and highlight areas of improvement
4. Identify any precautions-open sores, wounds, dressings, etc..
5. Skin is a clue, specifically the liver, kidneys, nourishment, anemia, hydration
6. Smoking, sun-exposure, moles, (athletes, farmers, athletes, etc)
7. Hair loss – skin conditions
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What are normal findings to find during pregnancy?
- Striae are jagged linear “stretch marks” coloured silver to pink that appear during the second trimester on the abdomen, breasts, and sometimes thighs. They occur in half of all pregnancies. They fade after delivery but do not disappear
- Vascular spiders occur in two-thirds of all pregnancies, primarily in Canadians of European descent. These lesions have tiny red centres with radiating branches and occur on the face, neck, upper chest, and arms.
- Spider veins
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What are normal findings during adolescents?
- Acne is the most common skin problem of adolescence.
- Pubic + axillary hair
- Sebaceous gland-excretion-body odour
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What are normal findings in infants and children?
- The café au lait spot is a large round or oval patch of light brown pigmentation (hence, the name, which means “coffee with milk”), which is usually present at birth. Most such patches are normal.
- Erythema toxicum is a common rash that appears in the first 3 to 4 days of life. Sometimes called the “flea bite” rash or “newborn rash,” it consists of tiny, punctate, red macules and papules on the cheeks, trunk, chest, back, and buttocks
- Jaundice
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What are normal findings for older adults?
- Senile Lentigines. Called “liver spots,” these are small, flat, brown macules that are common variations of hyperpigmentation (Fig. 13.21). These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsa of the hands. They are not malignant and necessitate no treatment.
- Keratoses. These lesions are raised, thickened areas of pigmentation that look crusted, scaly, and warty.
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What are abnormal findings during pregnancy
Chloasma
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What are abnormal findings during adolescents?
Acne lesions
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What is abnormal findings for infants and children?
- Jaundice (pathological)
- Burns/bruising
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What are abnormal findings for older adults?
- Abnormal moles
- Crumbling toenails
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When assessing the integumentary system, what are some subjective assessment questions a nurse can ask? What are some objective assessments a nurse would inspect, observe, and/or palpate? What are some words used to describe the symptoms and signs of integumentary assessment findings?
• Subjective assessment questions:
- Do you have a history of skin disease?
- Are you taking any medications?
- Are there any skin hazards that are work or one related?
• Objective assessment observations/palpated findings:
- Skin: Colour tan-pink, even pigmentation, with no nevi. Warm to touch, dry, smooth, and even. Turgor good, no lesions.
- Hair: Even distribution, thick texture, no lesions or pest inhabitants.
- Nails: No clubbing or deformities. Nail beds pink with prompt capillary refill.
• Symptoms words:
- Itchy
- Hot-
• Signs words:
- Annular: also called circular; begins in centre and spreads to peripher. Examples: tinea corporis (ringworm), tinea versicolor, pityriasis rosea.
- Confluent: Lesions that merge together Example: urticaria (hives)
- Discrete: Distinct, individual lesions that remain separate Example: molluscum
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1. Where do pressure injuries usually appear?
- on the skin over a bony prominence when circulation is impaired. This occurs when a person is confined to bed or is immobilized.
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2. Name four common sites where pressure injuries develop.
A. heel,
B. ischium,
C. sacrum,
D. elbow,
E. scapula,
F. vertebra
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3. Identify four risk factors for developing pressure injuries.
- impaired mobility, thin fragile skin of aging, decreased sensory perception (which causes inability to perceive pain accompanying prolonged pressure), impaired level of consciousness (which causes inability to respond to pain), moisture from urine or stool incontinence, excessive perspiration or wound drainage, shearing injury (being pulled down or across in bed), poor nutrition, and infection. Learning about risk factors and the prevention of pressure injury is far more easily accomplished than is the treatment of existing wounds. However, once the pressure injury occurs, they are assessed by stage, depending on
- the pressure ulcer depth:3
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4. Identify actions nurses take to prevent pressure injuries.
- Pressure are assessment (neurological conditions, mobility impairment, nutritional status, posture, level of consciousness, deformity, sensory impairment, previous pressure damage, pain status, psychological factors, social factors, cognition, medication and continence.)
- Risk assessment
- Prevention strategies Check SSKIN:
1. Surface - equipment/support surfaces to relieve pressure and prevent skin damage should be used and evaluated regularly to review their effectiveness.
2. Skin - https://www.magonlinelibrary.com/doi/full/10.12968/bjon.2018.27.18.1050
3. Keep moving
4. Incontinence and moisture
5. Nutrition and hydration.
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1. What are the six categories of the Braden Scale?
- Sensory perception, moisture, activity, mobility, nutrition, friction and repair.
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2. What is “friction” in relation to the integumentary system?
- Friction is the force of rubbing two surfaces against one another.
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3. What is “shear”?
- Shear is a gravity force pushing down on the patient's body with resistance between the patient and the chair or bed
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What are musculoskeletal developmental changes expected durring pregnancy?
- Increased levels of circulating hormones (estrogen, relaxin from the corpus luteum, and corticosteroids) cause increased mobility in the joints.
- Increased mobility in the sacroiliac, sacrococcygeal, and symphysis pubis joints in the pelvis contributes to the noticeable changes in maternal posture.
- Mom’s center of gravity shifts forward, in turn, creates strain on the low back muscles, which in some women is felt as low back pain during late pregnancy.
- Nerve pressure creates aching, numbness, and weakness in the upper extremities in some women.
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What are musculoskeletal developmental changes expected for infants and children?
- By 3 months' gestation, a “scale model” of the skeleton that is made up of cartilage has formed. During succeeding months in utero, the cartilage ossifies into true bone and starts to grow. Bone growth continues after birth—rapidly during infancy and then steadily during childhood—and during adolescence.
- Long bones increase in width or diameter by deposition of new bony tissue around the shafts.
- Lengthening occurs at the epiphyses (growth plates).
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What are musculoskeletal developmental changes expected during adolescence?
- adolescent growth spurt: muscles respond to increased secretion of growth hormone, to adrenal androgens, and, in boys, to further stimulation by testosterone. Muscles vary in size and strength in different people.
- The most common cause of childhood musculo-skeletal pain is termed “growing pains,” a noninflammatory pain syndrome affecting children mainly between the ages of 3 and 12 years.
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What are musculoskeletal developmental changes expected for older adults? Safety considerations?
Musculoskeletal changes:
- Bone remodelling is a cyclical process of loss of bone matrix (bone resorption) and new bone growth (deposition). Deposition predominates until skeletal maturity at 25 to 35 years, when bone mass reaches its peak.4 After age 40, resorption occurs more rapidly than deposition.
- Long bones do not shorten with age; decrease in height results from shortening of the vertebral column caused by loss of water content and thinning of the intervertebral discs, which occurs more in middle age.
SAFETY considerations:
- Loss of subcutaneous fat leaves bony prominences more marked (e.g., tips of vertebrae, ribs, iliac crests) and body hollows deeper (e.g., cheeks, axillae).
- An absolute loss in muscle mass occurs; some muscles decrease in size, and some atrophy, which causes weakness.
- Muscle contours become more prominent, and muscle bundles and tendons feel more distinct.
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Identify 3-4 elements of musculoskeletal assessment that you think are the most important things to remembe
1. FALL RISK! Identify peoples that are at a higher risk for MSK injury
- old people, people with disabilities
2. Functional assessment to determine if change in musculoskeletal system impacts iADL
- Recommend equipment to assist w/ ADLs to promote autonomy
3. Inspecting and enclosing to palpate abnormal findings like inflamed joints, edema etc.
4. Identify peoples that are at a higher risk for MSK injury
- old people, people with disabilities
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What are abnormal findings during pregnancy?
- Relaxin increases mobility
- Train on lower back muscles
- Posture changes = lordosis, kyphosis
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What are abnormal findings during adolescents?
- Growth spurt
- Growing paints
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What are abnormal findings for children and infants?
- Rapid growth
- Growing pains
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What are abnormal findings for older adults?
- Decreased bone density
- Decrease in height
- Kyphosis
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What are normal findings for older adults?
- Osteoporosis
- Rheumatoid arthritis
- Bone cancer
- Decrease in muscle tone, bone density, contractures, join ROM
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What are normal findings during pregnancy?
- Lumbar lordosis
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What are normal findings during adolescents?
- Scoliosis
- Chronic poor posture
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What are normal findings for infants and children?
- One knee lower than the other (All is sign)
- Hip dislocation
- Weakness in shoulder muscles
- Positive trendelenberg: severe solution of the hip
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1. What is the purpose of heat and cold therapy?
- It causes the blood vessels to contract and reduce circulation, therefore decreasing pain. Removing the cold causes the veins to expand, increasing circulation. Heat therapy can be applied to assist circulation and the incoming flow of nutrients that can heal the injured tissues.
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2. What conditions are better suited to cold therapy?
- It is particularly effective when you are managing pain with swelling, especially around a joint or tendon.
- Acute: decrease inflammation, neuropathic
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3. Which conditions are better suited to heat therapy?
- Muscle pain or stiffness
- CHRONIC: wounds increase circulation
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4. Identify five safety guidelines for applying heat and cold therapy.
- Don’t apply heat for longer than 20 min at a time
- Don’t use heat if there is swelling
- Use cold first, then heat
- Don’t use heat if you have poor circulation or swelling (clarify)
- Never use heat on open wounds or areas with stitch’s
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5. Identify one or two lifespan considerations for using heat and cold therapy.
- Heat for older persons to reduce muscle stiffness
- Cold for swelling from any injuries (all ages)
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1. Identify two things a nurse is responsible for related to clinical calculations.
- Double checking all calculations
- Know standard units – mg -> g -> kg
- Convert available units of volume and weight to desire doses
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2. What should be administered first: “PO” medication, a “SL” medication, or a “buccal” medication?
- PO: taken by mouth
- SL: under the tongue
- Buccal: between Gum and cheek
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3. What is the purpose of enteric coated medications? Why do we not crush that type of medication? What would you do if your patient had difficulty swallowing whole medications (e.g., dysphagia) and their medication came in an “enteric coated” form?
- Prevents medications form being absorbed too quickly that’s why you don’t crush them.
- Enteric-coated preparations resist being dissolved by gastric juices. The enteric coating protects the stomach lining from irritation by the medication. These preparations are absorbed in the small intestine.
- Never crush or split an enteric-coated medication. Crushing or splitting these preparations causes the medication to be released too early; the medication may become inactive in the stomach or fail to reach the intended site of action.
- Enteric tube?
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4. Identify one or two reasons why it matters what time a medication is given.
- Give an oral medication with a meal if its absorption is enhanced by food in the stomach. Some medications must be taken between meals, 2 to 3 hours later.
- Medications that require exact timing include stat, first- time or loading doses, and one-time doses. Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive medications) at exact time prescribed (no later than 30 minutes before or after scheduled dose).
- Other meds they may bear on and that interaction
- Bladder, bowel, sleep
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5. Aspiration is an important safety consideration when administering oral medications. Recall from N142 assessment findings or things you would notice on a general survey & primary survey that would alert you to a swallowing risk.
- Dysphasia
- Assess swallowing ability
- Drooling, coughing, slurred speech, facial droop
- General/primary survey
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1. Which integumentary changes across the lifespan will affect the absorption of topical medications? Explain.
- Older adults: thin skin, dry skin, skin intact?
- reduction in gastric pH which, in the case of some drugs, affects the solubility and thus will influence the rate of absorption
- infants and children’s skin is highly absorbent
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2. Why is it important to clean the skin prior to administering topical medications?
- Cleaning removes microorganisms from reminding debris or any surface medication.
- Ensures complete medication absorption
- Skin encrustation/dead tissue harbour microorganisms which block medications contact with tissue/membrane
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3. Why is it important to wear gloves when administering topical medications? Is it always appropriate to wear gloves when applying lotions/topical medications? Come to class with questions to help you make appropriate decisions on the need to wear gloves or not.
- Gloves reduce the spread of microorganisms
- Prevent contact with prescription medication
- If both nurse/patient skin is intact and med is not prescribed
- No gloves necessary
