Skin Communication Nursing Process
This chapter covers skin communication nursing process.
What are the three layers of the skin
When assessing skin, what alterations in condition are you looking?
Color
Thickness
Texture
Turgor
Temperature
Hydration
Examples of color changes in the skin are:
Cyanotic – blueish color indicating poor O₂ circulation.
Smurf blue – methhemoglobinemia
yellow-gray –
Dusky (blueish-gray) –
Jaundice – accumulation of billirubin
Mottled (blotchy – pale/red/blue) – poor perfusion
Flush – normal color but face becomes red
Pale – lack of blood circulation
Ruddy (Erythema) – Redness of the skin.
Eschar – Black, necrotic tissue.
Petichiae – A small purplish spot on a body surface, such
as the skin or a mucous membrane, caused
by a minute hemorrhage
What can thickness changes in skin imply?
Keloids – Hypertrophic scarring that extends beyond
the borders of the initial injury.
Langerhans Cells – Attach themselves to antigens that invade damaged skin.
Lichenification – Thickening and roughening of the skin with
increased visibility of skin furrows from
chronic rubbing.
Precursor – A substance, cell, or cellular component from which another substance, cell, or cellular component is formed especially
by natural processes.
Stratum germinativum – Inner cellular keratin layer of the epidermis, that contains melanocytes.
Stratum corneum – Outer horny layer of dead keratinized cells
** ONLY THE HEELS & PALMS SHOULD BE THICK
What does skin Texture imply during assessment?
Lumpy
Smooth
Rough
Moles, lesions, etc
How is Turgor assessed and why?
Grasping the skin on the sternum, forehead, or top of the hand and gently pulling up.
After letting go of the skin, the skin should “snap” back into place within three seconds.
Skin that remains elevated or “tented” may be due to age related
changes, dehydration, or a combination of both
What is venous thrombosis
WARM body temperature
What is arterial thrombosis
COLD body temperature
Hydration concerns for the skin
Normally, your patient’s skin should be dry with only a slight amount of moisture. Overly moist skin may be due to environmental conditions, anxiety, obesity, hyperthyroidism, fever, or diaphoresis
What is Dependent Rubor?
A redness or purple color of a leg when it is in the dependent or lowered position. If the leg blanches on elevation it may be a sign of lower leg ischemia
Why is it important to assess the Nails?
The appearance of the patient’s nails may provide information about systemic illnesses and yield information about their self care abilities or behaviors:
•Clubbed nails may indicate chronic hypoxia. Bases are flat or rounded, not concave.
° Inadequate nutrition – lines (grooves) going across nails horizontally.
•Cyanosis: May be present in the nail bed, indicating poor
perfusion and possible underlying vascular insufficiency. Nicotine staining can be seen in the nails.
Observe for infections of the nails or nail bed
Condition of what areas greatly impacts patient’s ability for self-care?
Feet – bear weight or ambulate
Hands – dexterity
Nails – infection
What are the purposes of a bath in the hospital?
Cleanses the skin
Acts as skin conditioner
Relax the patient
Promotes circulation
Encourages musculoskeletal exercises
Stimulates rate & depth of respirations
Promotes comfort through muscle relaxation and skin stimulation
Improves self-image
Helps build stronger nurse-patient relationship
What are the types of baths
Complete bed bath –
nurse washes entire body. usually comatose or critical care patients
Partial bath –
only areas that cause discomfort or odor if left unwashed
Sponge bath at sink –
pt. sits in chair at sink and nurse helps with areas pt. can”t reach
Bag bath – commercially prepared & disposable
Shower – full self-care
Assessment for Hygiene
Self-care ability
* encourage self-care
skin
feet & nails
Oral cavity
hair & hair care
Eyes, ears & nose
Nursing diagnosis for Hygiene
Through assessment hygiene status and patient self-care ability has been identified and it must be determine if patient has an actual problem or is at risk for problem and in need of hygiene diagnosis.
Common NANDA International diagnostic Identification for patient situation:
Activity intolerance
Ineffective health maintenance
Risk for infection
Impaired physical mobility
Bathing self-care deficit
Dressing self-care deficit
Nursing process: Planning for Hygiene
Develop individualized plan of care
– Techs may be involved in planning
Use concept map (may be helpful)
Set realistic goals
Collaborate with other health care providers
-dentistry
-podiatry
Nursing process for Hygiene: Implementation
Health promotion – teaching patient
Reinforce infection control
* use a mirror to help patient see
How can you maintain comfort in patient room?
Room temp (68°-74°)
Clean equipment
Water, phone, tissue, & other personal items within reach
Nursing process in Hygiene: Evaluation
Observe patient reaction after hygiene measures
– comfortable
-relaxed
Assess condition of skin, mouth, hair after interventions
What is the hallmark of the Nurse’s role?
Health Assessment & Physical Examination
** CANNOT delegate assessment to anyone!
Nurse should be very proficient in assessment skills
Reasons for physical examination are:
– Triage for emergency care (making clinical judgements)
° Gather baseline data
– routine screening to promote wellness
° Identify nursing diagnosis
– determine eligibility for health insurance, military, new job
° evaluate the outcome of care
– admit patient for long-term care
How can nurse show respect for cultural differences?
Acknowledge health beliefs (what family can afford too)
Use of alternative therapies
Nutritional Habits
Family relationships (who makes decisions in family)
Use of personal space
What is most important about INSPECTION of a patient?
PAYING ATTENTION TO DETAIL!
– size, shape, color, symmetry, position, abnormalities
Make sure lighting is adequate and low level of noises
Expose areas you need to examine so that clearly visible while still respecting patient privacy
When palpating the skin, what should the nurse pay attention to?
Temperature
Moisture
Texture
Turgor
Tenderness
Thickness
When palpating the abdomen, what should nurse examine?
Tenderness
Distention
Masses
Best way to palpate is?
Lightly – for superficial
Deeply – with two hands for deeper findings
What is percussion?
Tapping the body with fingertips to produce vibration
Nurses typically do not percuss
What is Auscultation?
Listening to sounds produced by the body with the aid of a stethoscope.
i.e: heart, lungs, GI
How can sense of Olfaction assist the nurse in assessment?
Identify nature and source of body odors
Help detect abnormalities
Used in conjunction with other measurements
In case of a fire, always remember RACE:
R = Rescue → remove all patients from danger
A = Activate Alarm
C = Confine → close doors to confine the fire
E = Extinguish → if possible
What are the most important roles of the nurse (5)
Caregiver
Advocate
Educator
Researcher
Leader
What are the 5 steps in the nursing process?
(1) Assessment
(2) Nursing Diagnosis
(3) Planning
(4) Implementation
(5) Evaluation
Define Assessment
Collects comprehensive data pertinent to the patient’s health and/or situation.
– info medical personnel can look at
– begins the moment you walk through the door
Can the RN provide subjective information about patient?
NO! Only the patient can give subjective info.
OBJECTIVE info is what the RN sees, hears, or smells
What is the Diagnosis phase?
Analyze the assessment and make a clinical judgement related to an ACTUAL or POTENTIAL health problem.
** Nurses have to be aware of potential risks based on health problems.
** Also collaborate with other specialists to manage the problem(s)
What are the three phases of a Nursing Diagnosis?
First info → Related to → as evidence by
WHAT is the problem?
WHY is it a problem?
WHAT is the evidence of that problem?
Ex:
“Acute pain → related to surgical incision → as evidence by patient report (or as evidence by crying)”
What are the OUTCOMES IDENTIFICATION?
This is the statement of how a patient’s status will change once interventions have been successfully instituted
Identify the expected outcomes when planning for the patient’s individual situation.
Interventions must be measurable criterion indicating that objectives have been met.
Define the PLANNING stage of the nursing process
Develops a plan that prescribes strategies and alternatives to attain expected outcomes.
– Prioritize strategies
– Goals (statement that describes the aim if the nursing care) should be short term and long term
Describe IMPLEMENTATION of the nursing process
The actions to facilitate positive patient outcomes
What three skills are needed in order to implement goals?
Cognitive
Personal
Psychomotor
Describe the EVALUATION phase of the nursing process
This describes how well the patients needs were met (or not met).
Done through reassessment
What percentage of all communication is nonverbal?
90%
What two characteristics should nurses always exude?
CARING
COMPETENCE
How is communication used in the Assessment phase of the nursing process?
Verbal interviewing and history taking
Visual and intuitive observation of nonverbal behavior
Visual, tactile, and auditory data gathering during physical examination.
Written medical records, diagnostic tests, and literature review.
Define REFERENT
The referent motivates one person to communicate with another.
Examples of referents: sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, etc.
Define SENDER in communication
The person who encodes and delivers the message.
Sender puts ideas or feelings into form that is transmitted and is responsible for accuracy and emotional tone of message content
What is the RECEIVER in the communication process?
The person who receives and decodes the message
** senders message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the message.
MESSAGE in communication process
Content of communication…. verbal, nonverbal & symbolic language.
CHANNELS in communication process
These are the means of conveying the message through visual, auditory, and tactile senses.
Facial expression = visual message
Spoken word = auditory
Touch = tactile
FEEDBACK in communication process
The message that the receiver returns. This indicates if receiver understood meaning of message. Sender can evaluate effectiveness of communication.
Explain the communication process briefly
The source has a message and encodes the message.
Message is sent through a channel
Receiver must first decode the message
Before message can be fully received
What are the 5 levels of communication in nursing?
Interpersonal
Interpersonal
Small group
Public
Transpersonal
Define Intrapersonal
a.k.a. SELF-TALK
Define Intrerpersonal
Occurs between two people or groups
– usually one on one conversation
Define Small Group Communication
Committee or a conference
Public Communication
Interaction of one person with a group of people
Transpersonal Communication
Within a person’s spiritual domain
Forms of Communication
Messages conveyed verbally and nonverbally, concretely and symbolically.
Expression through: Words, movements, voice inflection, facial expression, and use of space
Elements can work in harmony to enhance a message OR conflict with one another to confuse it.
Example Forms of Communication
VOCABULARY
What is the role of the nurse?
Nurse often the interpreter of medical terminology
Example Forms of Communication
DENOTATIVE AND CONNOTATIVE
What is the role of the nurse?
Denotative is the exact meaning
Connotative is shades of the meaning
Be selective in word choice and avoid easily misinterpreted words.
Example Forms of Communication
PACING
What is the role of the nurse?
Speak slowly and enunciate clearly!
Too fast = unintended messages
Too slow = impression of hiding the truth
Example Forms of Communication
INTONATION
What is the role of the nurse?
Tone of voice… be careful
Example Forms of Communication
CLARITY & BREVITY
What is the role of the nurse?
Simple – short – to the point
& possible repeated
Example Forms of Communication
TIMING & RELEVANCE
What is the role of the nurse?
When it is appropriate to discuss issues & what is most important at that time.
What are forms of Nonverbal Communication?
Personal Appearance
Posture and gait
Facial Expression
Eye Contact
Gestures
Sounds – sighs, moans, groans…
Territoriality & Space