Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide • Assess skin color and uniformity of color. o Normal: Color will vary by ethnicity from brown to pink to yellow to olive tones. If abnormal color is suspected, it is often helpful to inspect the color of other family members. Coloring should be relatively uniform across the body except in areas of lighter pigmentation such as the palms, lips, fingers, andtoenails. o Deviations from normal: Paleness, cyanosis, excessive redness (erythema), and jaundice are concerns. So are areas of increased or decreased color (hyperpigmentation or hypopigmentation). • Assess any swelling (edema) of the skin. o Normal: No edema. o Deviations from normal: Any amount of edema should be described by location, shape, color, and temperature. The amount of edema can be assessed by pressing the area with a finger. If the skin remains indented, the edema should be documented based on the followingscale: § 1+ indentation up to 2mm § 2+ indentation of 2-4 mm § 3+ indention of 5-7 mm § 4+ indentation of more than 7mm • Assess the moisture of the skin. o Normal: Depending on the temperature in the room, the patient's skin may be moist. In a normal room temperature, the skin may be moist in the armpits and in skin folds. o Deviations from normal: This includes excessive moisture or dryness. • Assess the temperature of the skin. o Normal: In the absence of a fever, the feet and hands should be evaluatedto ensure that the temperature is the same on both sides of the body. o Deviations from normal: Any generalized hypothermia or hyperthermia should be described. Any local hypo or hyperthermia should be described (location and any associated signs or symptoms). • Assess the turgor of the skin. • Assess and palpate any lesions to describe, location, color, configuration, shape, size, and type. o Normal: Freckles, birthmarks and some small nevi are normal. o Deviations from normal: Any disruption in skin. Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal skin findings. Record and report any significant deviations from the normal. In many agencies, there may be diagrams for documenting skin abnormalities. 2.2 Neurological Equipment needed for the neurological exam will be determined by the kind of exam being done

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