NUR 230 Notes
NUR 230 Notes NUR 230
Popular in Health Appraisal Across the Lifespan
verified elite notetaker
Popular in Nursing and Health Sciences
HSC 180 - 1
verified elite notetaker
This 14 page Class Notes was uploaded by Issy Notetaker on Friday September 18, 2015. The Class Notes belongs to NUR 230 at Ball State University taught by Marjorie Pyron in Fall 2015. Since its upload, it has received 39 views. For similar materials see Health Appraisal Across the Lifespan in Nursing and Health Sciences at Ball State University.
Reviews for NUR 230 Notes
Report this Material
What is Karma?
Karma is the currency of StudySoup.
Date Created: 09/18/15
Jarvis Book Objectives Clinical Lecture Chapter 12 0 Purpose 0 Protection IgA Perception of touch pain temp pressure Regulation of temperature and hydration Communication Absorbing Produce Vitamin D Support circulatory system Notes status of vascular system nutrition 02 stats hygiene and chronic disease 0 Skin 0 Largest organ 20ftquot2 6 pounds 0 Guards and Adapts Epidermis 0 Thin Tough Tightly bound cells Protective of underlying layers and organs lnner Basal Cell layer New cells formed Keratin Melanocytes Melanin Same amount of cells different production rates 0 Horny Cell Layer Dead keratin cells Constantly shed and replaced 0 Completely every 4 weeks 0 Avascular Nourished by dermis 0 Color Melanin Carotene and Vascular bed Dermis o Supportive Layer 0 Collagen o Resist tearing o Tough o Nerves sensory receptors blood vessels and lymphatic system Subcutaneous o Adipose tissue 0 Stores fat for energy 0 Cushioning 0 Increased mobility 0000000 0000 Hair 0000 O O 0 125000 on scalp w loss of 45 a day ability to grow 30 feet Keratin Shaft Root Bulb matrix Cyclic growth pattern Arrector Pili mm Creates goose esh or raising hairs on neck Vellus Fine and Faint Terminal Darker and Thicker on scalp and eyebrows other grows in after pube y Not needed for protection Consider culture Color style and design Sebaceous Gland O O O Sebum through hair follicles Lubricates w oil to prevent water loss Everywhere hair is Sweat Glands O O Nails 0 o o o Eccrine Coiled tubules opening directly on skin surface Dilute saline is produced Apocrine Thick milky secretion Open on hair follicles Activate during puberty Emotional and sexual stimulation Muslq odor Decrease w age Hard plates of keratin Clear Longitudinal Ridges Pink and clear at cuticle Function of Skin 0 0000000 0 Protection Prevents Penetration Perception Temperature regulation ldenU cann Communication Wound Repair Absorption and Secretion Produces Vitamin D Developmental Considerations 0 Infants and Children Hair follicle develop after 3 months in womb Lanugo Fine downy After birth Ianugo is replaced w vellus Vernix Caseosa is present at birth 0 Thick cheesy sebum and shed epithelial cells Helps w hydrating the skin Newborn skin smooth thin elastic More permeable Temperature regulation is ineffective Growth causes thickening Puberty Changes 0 Hair growth 0 Increased oil production 0 Increased fat deposits 0 Pregnant Women 0 Aging Increased pigment in nipple and vulva Linea Nigra develops in many women Stretch marks develop Striae Gravidarum Fat deposits are created Adult Lose in elasticity Thins and attens Wrinkling occurs Lose in fat Shearing and tearing occur more frequently 0 Increased risk for skin breakdown Glands decrease in number Less temperature regulation Decrease in vascularity Hair thins and decreases Loss of selfesteem occurs Decrease mm tone Decrease in subcutaneous fat Senile Purpura discoloration caused by trauma looks like a bruise CultureGenetics Melanin production rates produce different skin tones Skin cancer risk increases w age and is highest among whites Gene can UV exposure is important 0 O O O O Tanning bed and sunburns increase risk Skin conditions among African Americans Keloids Post in ammatory Hypopigmentation or hyperpigmentation Pseudofolliculitis Melasma o SLE is higher in African American Women and have more severe levels 0 Hair of African Americans is in a wide variety of textures Subjective 0 Past History of Skin disease Treatments Allergies Birthmarks Tattoos Ask if dryness irritation itching or rashes 0 Change in Pigmentation Overall or Localized 0 Change in Mole Color Size Shape Sudden Appearance tenderness Bleeding 0 Excessive Dryness or Moisture o Pruritus Skin itching 0 Excessive Bruising o Rash or Lesion SOLDCART Did it spread Associated Symptoms Coping Stress o Medications some cause side effects that show up in skin rashes or dryness Some make sunburn more likely to occur 0 Hair Loss Gradual vs Sudden 0 Change in nais Shape Color Brittleness 0 Environmental or Occupational Hazards Dyes toxic Substances 0 Patient Centered Care What does pt do to care for skin hair and nails 0 Additional for InfantsChildren Birthmarks Change in color as a newborn Rashes or Sores Diaper Rash Burns or Bruises Exposure to contagious skin diseases Communicable diseases Habits Nail biting Protection steps 0 Additional for Adolescent Skin problems OLDCARTS 0 Additional for Aging Changes in past few years Delay in healing Pain Change in feet Fas History of chronic illness How do you care for skin 0 Objective 0 Prep Consciousy attend to characteristics Know normal coloring Incorporate into the Complete Physical Assessment Regional is when looking into one area Try to control external variables 0 Inspect and Palpate Skin Color 0 General Pigmentation even and Consistent o Darker in sun exposed areas 0 Common abnormalities Freckles Mole Junctional Nevus and Compound Nevus Birthmarks Reliable areas under tongue buccal mucosa palpebral conjunctive sclera Widespread Color Change 0 Pallor RedPink tones are lost White color Peripheral Vascular constriction Yellowish brown ashen grey Inspect nail beds 0 Erythema Intense Red Expected w fever in ammation emotional reactions 0 Cyanosis Blueish Color Lips Nose Cheeks and Ears Nonspeci c Dif cult to observe in dark skinned people 0 Jaundice Yellowish color Not normal First noted in hard and soft palate junction and sclera Temperature Hypothermia Hyperthermia Moisture Diaphoresis Profuse perspiration Dehydration Texture Firm smooth even surface Thickness Thin but thick of callus areas Edema Fluid accumulating in interstitial space 0 Press thumb into skin and if pit stays present grade 1 4 0 Normal skin color Mobility and Turgor Pinch under clavicle Shows elasticity Vascularity and Bruisingquot Charry Angiomes commonly appear 0 Normally no venous dilations Note tattoos Lesions Color Past and present Elevation Flat raised indented Pattern distinct grouped Annular Con uent Shape Size In cm Exudate color oder Papate blanch or stretch w pressure Use Woods Light Discrete Distinct individual lesions Grouped Cluster of lesions Annular circular Begins in middle and spreads outward Con uent Lesions run together Primary Lesions De ne o Macule Patch Papule Plaque Nodule Wheal Urticaria Vesicle Bulla Pustule o Cyst 0 Inspect and Papate Hair Color Varies Graying begins around 305 and is genetic Quantity of hair Texture Fine Thick Straight Curly Kinky SHINEY Distribution Vellus coats body 0 Terminal is colored ls balding occurring Hirsutism Hair growth on facial area in women or increase in body hair Lesions Separate an lift hair 0 Inspect and Papate Nails Shape and Contour Slightly curved or at smooth an rounded folds and edges 0 Pro le Sign Angle of nail base 160 degrees base is rm 0 Clubbing is an angle of 180 degrees determined by diamond sign Consistency Smooth and regular uniform thickness rmly adheres to base and bed Color See trough plate and pink bed OOOOOOOOO 0 Cap Re ll Depress nail edge and release 0 Note time to regain all color should be 12 seconds Note if pitting peeling or ridges are present or redness swelling or exudate Vertical Ridges rt aging kidney disease iron de ciency anemia Beau39s Lines Pitting w psoriasis Spoon Shaped Ironde ciency anemia Fungal infection is under the nail and hard to treat turn nail yellow hard and thick lngrown toenails 0 Promoting Health and Self Care Teach SelfExam ABCDE Rule 0 Asymmetry 0 Border Irregular 0 Color Variations 0 Diameter Larger than 6mm 0 Elevation Enlargement Welllit room Full length mirror Educate about harmful effects of tanning and excessive sun exposureburns Avoid 10am2pm sun exposure prime times 0 Use SPF 15 AT LEAST 0 Use sunscreen when overcast Some meds increase sunlight sensitivity Fluids maintain hydration to help keep skin intact Moisturizer should be applied 0 Developmental 0 Infants Skin Color and General Pigmentation Black babies might develop a darker tone later Mongolian Spot Hyperpigmentation in Asian Black American Indian and Hispanic Newborns Caf Au Lait Spot Round patch of light brown pigmentation Skin Color Change Erythematous o Beefy red ush for rst 24 hours 0 Harlequin Color change When laying on side half red and top is white 0 Erythema Toxicum Rash Cyanotic Conditions o Acrocyanosis bluish around lips hands and ngernails o Cutis Marmorata Mottling in trunk in response to cooler temperatures Physiologic Jaundice common developing after 34 day Carotenemia YellowOrange in light skinned people Moisture Perspiration occur after 1 month Texture Milia or tiny papules on cheeks and forehead Thickness Thin and thicker layers of subcutaneous fat Mobility and Turgor Test over abdomen Vascularity and Bruising Stroke Bite is normal and fades Hair Newborn is covered Nails May be blue but will turn pink 0 Adolescents Acne is common 0 Pregnant Women Striae appear Linea Nigra BrownBlack line midline Chloasma Irregular hyperpigmentation Vascular Spiders Lesions w tiny red centers 0 Aging Adult Color and Pigmentation Senile lentigines Liver Spots Keratoses Seborrheic Keratosis thickened pigmentation areas Actinic Kertosis redtan scaly plaques Moisture Dry Skin is common Texture Acrochordons Skin Tags Sebaceous Hyperplasia Thickness Thins and fat diminishes Hair Growth rate decreases Nails Growth rate Decreases and nails may thicken Mobility and Turgor Decreased and Elasticity is less Abnormalities Freckles Note how they are and amount Junctional Nevus MOLE Size Elevation Color Compound Nevus Vitilago Educate about sunburns risk and sunscreen use education to coverup Jaundice Late stage will show in eyes common in newborns bc immature liver liver damage is usual cause yellowing of skin Xerosis Excessively dry skin Need prescription of super strength lotion Edema O O O O 0 Mostly in low extermities Found commonly in people who stand on their feet all day o If healthy the swelling will go down in an hour Pitting is serious and causes complications w circulation Lymph node removal and cardiac surgery put a person at a higher risk 0 Osteomyleitis Infection of the bone started as edema and swelling in the ankle 0 Children Mongolian Spots Common and go away with age more common in African American Milia Like pimples should be taught to not pop Caf au Lait Birthmarks Erythema Toxicum Will go away education should be toward maintaining good hygiene 0 Aging Adult Cherry Angiomas Skin Tags Senile Lentigines Liver Spots Keratosis Not cancerous Should monitor for measurement elevation Actinic Petechiae Broken blood vessels Purpura Look like bruises common on hands Chapter 20 c Any disease impairing vascular system impairs 02 and nutrient delivery along with removal of wastes Arteries Carry blood to tissues contains 02 0 High Pressure 0 Heart beats cause expanding and recoiling to pulse blood through and arefeltat Temporal Carotid Arm Brachial Radial Ulnar Leg Femoral Popliteal Dorsalis Pedis PosteriorTibial 0 Supply 02 and nutrients to tissues 0 lschemia l de cient supply O Veins O O O Obstruction is the cause Peripheral Artery Disease Noncoronary arteries arteries in limbs Absorb C02 and Waste More Closer to skin and accessible Jugular Arm Super cial and Deep Leg Flow from super cial into deep 0 Deep 0 Femoral and popliteal Super cial 0 Great and Small Saphenous Perforators Venous Flow 0 O O O 0 Low Pressure Pumped by Contraction of Skeletal MM Pressure gradient from breathing Intraluminal Valves Larger and hold more of blood volume 60 Capacitance Vessels Problems w Elements of pumping cause risk for venous disease Varicose Veins cause valves to stop working properly and lead to pooHng Lymphatic Carries lymph uid Clear containing water and blood cells 0 O 0 Separate Vessel System Retrieves interstitial uid and pumps into venous system Collect in R and Thoracic Duct and empty into subclavian veins Func ons Conserve Fluid and plasma proteins Part of immune system Absorb lipids from small intestines Lymph Nodes Clumps of lymphatic tissues that lter uid Exposing uid to B and T lymphocytes Super cal Nodes Cervical Head and Neck Axillary Nodes Breast and Upper Arm Epitrochlear Node Hand and Lower Arm lnguinal Node Groin Related Organs Spleen Destroy old RBCs Produce Antibodies Store RBCs Filter microbes Tonsils Thymus Develops T Cells in children 0 Developmental O 0 Infants and Children By 6 system is fully developed Surpasses adults and then atrophies Nodes are large in children Pregnant Low BP increases venous pressure Edema results 0 Aging Adult Arteriosclerosis Hardening of vessels 0 Rise in systolic BP Atherosclerosis Fatty build up PAD Underdiagnosed Large cause of morbitiy and mortality 0 Women develop later than men 0 Associated w CAD only 7080 Diagnosed are treated Enlargement of calf vein 0 Risk for DVT o DVT risks Bed rest Sitting for large amount of time Heart failure 0 Results in PE is not treated Ml treatment 0 Early mobilization Low dose anticoagulant Fewer number of Lymph tissue CultureGenetics O PAD is a CAD risk Screening and treatment are key Smoking and obesity increases risk NonHispanic black have highest risk factors Subjective O O O Leg painCramps SOLDCART Skin Changes in Arms or Legs Swelling in Arms or Legs When Lymph Node Enlargement Chest pain SOB Coughing Where when and what activities induce these Fatigue O O O O Medications Smoking History Family note what side of family Diabetes HD Hyperlipidemia Hypertension Personal these affect circulation Objective 0 O 0 Prep Exercise eating habits caffeine alcoholdrug use Examine arms at the beginning during vital signs Legs after abdominal in supine and standing Inspect and Papate Arms Hold in hands and inspect color temp texture ect Look for clubbing by pro ling nger Check Cap re ll Note scars on hands and arms Papate Radial and Brachial Pulse Check Epitrochlear lymph nodes Modi ed Allen Test is used to evaluate adequacy of collateral circulation Inspect and Papate Legs Note color texture temperature Hair on toes indicated proper swelling Bend knee and assess for tenderness Papate Femoral Popliteal Dorsalis Pedis and Posterior tibial arteries 0 Grade force Check for edema by pressing on tibia or medial malleolus for 5 seconds o If pitting occurs grade it Color Changes Raise legs 30 cm an have pt shake feet to rid of venous blood and check color o If really paleD Problem 0 Have person sit and dangle feet over edge count time to re ll color 0 Test leg strength and sensation Doppler Ultrasonic Probe Detects weak peripheral pulse Ankle Brachial Index 0 R Highest R ankle pressureHighest Arm Pressure 0 L Same but for left Wells Score for DVT Development InfantsChildren 0 Pulse should be Bilaterally Nodes can be palpates 0 Pregnant Women Expect bilat pitting in lower extremities 0 Aging DP and PT pulses are harder to nd Edema Pitting 04 0 0 No pitting o 1 Mild pitting 2 mm disappears rapidly o 2 Moderate pitting 4mm Disappears in 1015 seconds 0 3 Moderately severe pitting 6 mm lasts 1 minute leg looks swollen o 4 Severe Pitting 8mm lasts 2 minutes leg looks veryy swollen Expected nding immediate rebound Arterial Insuf ciency 0 Normal Transports 02 lled blood 0 Caused by 02 De cit 0 55 Lower legFoot pain 0 1 hour onset Numbness tingling quotCrampingquot quotFeeling Coldquot 0 Relievers Rest Dangling o Aggravators Activity Elevation Venous Insuf ciency 0 Normal Transports de02 blood an wastes o Caused by metabolic waste build up 0 55 Lowerleg pain 0 Intense Sharp 0 1 hour onset Red swollen warm Aching feeling of fullness o Relievers Elevation Lying Walking 0 Aggravating Prolonged sittingstanding lschemia De cient 02 suppled blood to tissues 0 Apparent in exercise bc body needs more 02 ODVT Occluded vessel from thrombus In ammation Blocked venous return Cyanosis Edema Treatment is urgent or PE will occur Causes Bed rest Varicose Veins Trauma Infection Cancer Oral contraceptives Cyanosis Edema SS Increased Warmth and Swelling Redness Cyanosis Tender palpation lntense sharp mm pain Homan Sign