N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide It is important to compare all findings with the previous findings to determine if there are changes to any abnormal abdominal findings. Record and report any significant deviations from the normal. In many agencies, there may be diagrams for documenting areas of abdomen abnormalities. 2.13 Extremities There is no special equipment needed for the extremity exam. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled,and upon completion of the exam. • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Heart disease o Varicosities o Hypertension o Exercise patterns o Signs or symptoms of disease (swelling, redness, pain at rest or with ambulation, etc.) • Assess peripheral pulses: Palpate pulses bilaterally at wrists, femoral area, inner aspect of ankles, behind the knee, and dorsalis pedis (top of foot). o Normal: Symmetrical; full and strong pulsations o Deviations from normal: Asymmetrical; absence pulse; weak, thread-like, or diminished pulses; increased pulsevolume • Assess peripheral veins. o Normal: When the arm or leg is dependent, veins bulge; when the arm or leg iselevated, veins collapse o Deviations from normal: Distended veins that do not collapse when extremityis elevated; hard, distended vein in the calf • Assess peripheral perfusion. o Normal: Skin moist and pink; temperature in bilateral extremities consistent and symmetrical; no edema; skin resilient; capillary refill with immediate return of color in compressed nail bed

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