erythema
white skin is redness of the skin produced by capillary congestion
objective data
measurable data, for example vital signs
after completing an initial assessment on a pt, the nurse charts, vital
...
erythema
white skin is redness of the skin produced by capillary congestion
objective data
measurable data, for example vital signs
after completing an initial assessment on a pt, the nurse charts, vital signs as temp of 100.1 oral, apical HR 98 irregular, RR 24 shallow, B/P 128/90, pulse ox of 90% on RA, what are you worried about
oxygenation, infection, activity intolerance, capillary refill greater than 3 seconds
during assessment of the lower extremities of a male patient the nurse is unable to palpate the dorsalis pedis pulse, what action should the nurse take first
reposition the fingers and assess again
what is a Doppler?
is a test that uses high frequency sound waves (ultrasound) to measure the amount of blood flow through your arteries and veins, usually those that supply blood to your arms and legs
an example of objective data obtained during the physical assessment includes
audible and auscultated inspiratory wheeze, 2x2 cm stage 1 pressure ulcer on right ankle, crackles that clear with cough
audible vs. ausculated
auscultated is hearing through stethoscope while audible is heard within the room
what does clears with cough mean
hear normal sounds after patient coughs
level of consciousness
objective data, alert, lethargic, stuporons, and comatose
orientation x 4
person, place, time, situation
a mother is at the clinic with her 2 year old son, "he wont go to sleep at night and during the day he has several fits" I get so upset when this happens, the nurses best verbal response would be
to clarify and get more information, fits?, tell me
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