Skin Communication Nursing Process

Skin Communication Nursing Process

This chapter covers skin communication nursing process.


What are the three layers of the skin

Image: 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


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