Podcast
Questions and Answers
What is the purpose of saying 'let me know if you have any pain or tenderness when I touch you' before palpation?
What is the purpose of saying 'let me know if you have any pain or tenderness when I touch you' before palpation?
- To inform the client of the procedure
- To assess the client's pain tolerance
- To alert the client of potential discomfort during palpation (correct)
- To ensure the client's comfort during the assessment
What is the recommended touch and pressure when palpating the lymph nodes?
What is the recommended touch and pressure when palpating the lymph nodes?
- Light touch with gentle pressure (correct)
- Firm touch with heavy pressure
- Rapid touch with varying pressure
- Deep touch with moderate pressure
What is the purpose of palpating bilaterally?
What is the purpose of palpating bilaterally?
- To assess the lymph nodes on one side only
- To palpate the lymph nodes in a circular motion
- To assess the lymph nodes in a single area
- To compare the right side to the left side (correct)
What is an example of a question a nurse may ask a client when assessing their lymphatic and immune system?
What is an example of a question a nurse may ask a client when assessing their lymphatic and immune system?
What is a characteristic of healthy hair?
What is a characteristic of healthy hair?
What is a possible cause of very thin and brittle hair?
What is a possible cause of very thin and brittle hair?
What is an example of a characteristic to note when inspecting the hair?
What is an example of a characteristic to note when inspecting the hair?
What is a possible cause of faded, reddish, or bleached hair?
What is a possible cause of faded, reddish, or bleached hair?
Study Notes
Lymphatic System Assessment
- Palpation is used to assess the lymphatic system, and the nurse should inform the client to report any pain or tenderness during the process.
- Use the finger pads of two to three fingers, moving in a circular motion with light touch and gentle pressure, to avoid forcefully pushing the lymph node inwards.
- Palpate in one spot, then shift fingers to a new spot within the same area, as lymph nodes are present in strands throughout the area.
- Palpate bilaterally, comparing both sides, and ask the client about any pain or tenderness.
- Assess the body's ability to regulate fluid and waste, noting any swelling, lymphoedema, or cellulitis.
Client Assessment Questions
- When did the swelling start?
- Have you noticed any lymph nodes or lumps on your head, neck, underarms, or groin area?
- Have you noticed any changes in your skin?
- Do you have any chronic conditions or diseases that affect your lymphatic system?
- If yes, ask about other symptoms, particularly if noticeable lymph node changes or skin changes are present.
Hair Inspection Characteristics
Hair Characteristics
- Should be shiny, clean, and untangled
- Hypothyroidism can cause brittle, thin hair
- Distribution: Facial and body hair
- Color: Varies, with severe protein deficiency (Kwashiorkor) causing faded, reddish, or bleached hair
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Description
Learn how to assess the lymphatic system using palpation technique. Understand the importance of gentle touch and communication with the client during the process.
