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Zorluk: OrtaTechniques of Physical Assessment

A nurse is performing a comprehensive physical assessment on a 72-year-old client admitted to the medical-surgical unit with suspected dehydration and generalized fatigue. Which action by the nurse demonstrates the correct execution of physical assessment principles?

  1. Assessing for fluid volume deficit by gently pinching the skin over the client's clavicle to observe for tenting.Cevap
  2. B
    Performing deep palpation of the abdominal quadrants prior to auscultation to identify areas of underlying tenderness.
  3. C
    Delegating the initial baseline measurement of the client's pupillary light reflex to the unlicensed assistive personnel (UAP).
  4. D
    Attributing the client's sudden onset of profound confusion to the expected physiological cognitive decline associated with aging.

Cevap

The correct action is assessing for fluid volume deficit by gently pinching the skin over the client's clavicle to observe for tenting.
In older adults, the skin loses elasticity and subcutaneous fat, making the back of the hand an unreliable site for assessing hydration. The correct technique for assessing skin turgor in an older client is to pinch the skin over the clavicle or sternum to accurately observe for tenting, which is a clinical indicator of dehydration.

Adım Adım Çözüm

1
Analyze the client's demographic profile (72 years old) and the clinical presentation (suspected dehydration).
The nurse must select physical assessment techniques that account for age-related physiological changes.
Standard assessment sites, such as the back of the hand, become unreliable in older adults due to the natural loss of skin elasticity and subcutaneous fat.
2
Evaluate the correct technique for assessing tissue turgor in the geriatric population.
The skin over the clavicle or sternum is the most reliable site for assessing turgor in older clients.
The skin over the chest remains relatively taut despite aging, making it an accurate indicator of true fluid volume deficit (tenting).
3
Rule out assessment approaches that violate procedural standards, delegation rules, or physiological principles.
Abdominal palpation must follow auscultation, initial assessments cannot be delegated, and sudden confusion must be treated as acute delirium rather than normal aging.
Adhering strictly to established nursing protocols ensures accurate data collection and protects the client from harm.

Anahtar Kavram

Physical Assessment Techniques in the Older Adult
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Konular

Techniques of Physical Assessment

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