NRS 312 Study Guide - Final Guide: Dietary Supplement, Far (Album), Blood Pressure
Week 2
Nursing Dx: Impaired Tissue Integrity
• Damage to the mucous membrane, cornea, integumentary system, muscular fascia,
muscle tendon, bone cartilage, joint capsule, and/or ligament
Nursing Dx: Impaired Skin Integrity
• Altered epidermis and/or dermis
Nursing Dx: Risk for Disuse Syndrome
• Vulnerable to deterioration of body systems as the result of the prescribed or unavoidable
musculoskeletal inactivity, which may compromise health
Nursing Dx: Self-Care deficit:
• Impaired ability to perform or complete bathing, dressing, feeding, or toileting activities
for self
Assessment Techniques
• Objective Assessment:
• Obtain subjective assessment: Asking questions. Simple gathering information from the
patient.
o Inspection: Look before you touch. Determine percautions.
o Palpation: wrong: aggressive, hurtful. Ask questions. Light palpation (what we
are licensed for. Use progressive touch. Start in less non invasive part of the body.
Tell you patient what you are doing and why to make them comfortable.
Important for older adults with cognitive impairment
o Percussion: not used that often in nursing assessment. Used without non
dominant hand. Taping with fings. To see if there is a mass, fluid filled. Or
hallow. Tempatic sound in the hollow parts. Dull sound over masses
o Auscultation : use of a stethoscope. Bowel, heart, lungs, abdomen. Bowel and
lungs use the diaphragm ( high pitched. ) heart and vascular system are high
pitched and require the bell ( low pitched)
o Olfaction: wound infections have smell. Yeast infections in palces that have skin
folds.
• Integumentary Assessment:
o Occurs simultaneously with assessment of hygiene, peripheral vascular system,
etc
o Integrated throughout
o Bilateral comparisons are necessary
o Assessment techniques: Subjective assessment, inspection and palpation
o Assess during times when they are not just laying in bed. Make sure there is
noting of skin break down
find more resources at oneclass.com
find more resources at oneclass.com
o If we note one side is warm and red or discolered we ant to check the other
extremity.
• Inspection and patient history
o Aging skin and how it is more susceptible. Nothing to be too concerned about
unless you are doing cancer screenings. Look at other discolorations in skin.
Cherries melanomas.
o Petechia: micro hemorages under skin layer. Common when people take blood
thinners. Straining and coughing.
o Ecchymosis: bruising. Purple skin.
o Purpura: purple discoloration with skin.
o Hematoma: raised skin caused by collection of blood.
• Signs of Aging Skin
o Decrease sensitivity to Hot or Cold (burns from heating pads?)
o Decrease sweat production
o Decrease oil production
o Decrease SQ Fat layer
o Decrease Thinner skin, increase fragility, fragile blood vessels caused by meds
o Wound healing up to 4x slower
o Greater than 90% older adults have some type of skin disorder.
• Inspection
o Pallor: associated with poor perfusion/ischemia. Absence of color tone
o Cyanosis: Late sign of 02/hypoxemia. Lips turn blue. Distal extremities. Late
sign of low oxygenation in blood flow
o Circumral Cyanosis: blueing around the lips and or mouth. Different in kids.
Peds can get blue lips quickly. We are going to focus on adults. We want to pay
attention to early signs of poor oxygenation. Low reading of pulse oximitor,
altered level of consciousness, Blood pressure
• 5 Classic Signs of Infection:
o Redness
o Swelling
o Temperature/Heat
o Pain
o Limited Movement
• Rash- Maceration
o Sitting in moisture or in contact for a long time. Wound edges become paler. Try
to keep it dry. Special absorbent dressing. Wound dressing needs to be changed
more frequently
• Pressure Ulcers
o Stage one: Damage to the blood vessels before the skin breaks down. Redness
over a boney prominence. Non blanchable. Absence of warmth. Patient complains
of discomfort or pain.
o Stage two: loss of dermis, shallow wound. Drainage from the wound. Want to see
the wound bed. Shallow partial thickness. Loss of dermis.
o Stage 3: full loss down to subcontaneous fat. Tunneling or underlining. Under the
wound there are edges that can dig deep in the body.
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Nursing dx: impaired tissue integrity: damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle tendon, bone cartilage, joint capsule, and/or ligament. Nursing dx: impaired skin integrity: altered epidermis and/or dermis. Nursing dx: risk for disuse syndrome: vulnerable to deterioration of body systems as the result of the prescribed or unavoidable musculoskeletal inactivity, which may compromise health. Impaired ability to perform or complete bathing, dressing, feeding, or toileting activities for self. Assessment techniques: objective assessment, obtain subjective assessment: asking questions. Simple gathering information from the patient: inspection: look before you touch. Start in less non invasive part of the body. Tell you patient what you are doing and why to make them comfortable. Important for older adults with cognitive impairment: percussion: not used that often in nursing assessment. To see if there is a mass, fluid filled. Dull sound over masses: auscultation : use of a stethoscope.
