Noticing examples.docx

**Noticing** **To assess the lymphatic system, a nurse often uses palpation.** **How to use this skill and why it is so important to the assessment of the lymphatic system:** Prior to palpation, say to the client "let me know if you have any pain or tenderness when I touch you." Use the finger p...

**Noticing** **To assess the lymphatic system, a nurse often uses palpation.** **How to use this skill and why it is so important to the assessment of the lymphatic system:** Prior to palpation, say to the client "let me know if you have any pain or tenderness when I touch you." Use the finger pads of two to three fingers and move them in a circular motion. Use a light touch with gentle pressure so that you don't forcefully push the node inwards. After you palpate in one spot, shift your fingers to a new spot within the same area, because there are strands of lymph nodes in each area. This should be done about two to three times in each area. Typically, you palpate bilaterally at the same time and compare the right side to the left side. Conclude by asking the client if they had any pain or tenderness Provide information about the body's ability to regulate fluid and waste also if there is any swelling for lymphoedema or other causes like cellulitis. **Give 5 examples of questions a nurse may ask a client when assessing their lymphatic and immune system:** When did the swelling start? Have you noticed any lymph nodes (or lumps) on your head, neck, under your arms, or in your groin area? Have you noticed any changes in your skin? (You might ask about specific changes like those in the column to the left). Do you have any chronic conditions or diseases that affect your lymphatic system? If have answered yes, then ask about other symptoms, particularly if have answered about noticeable lymph node changes or skin changes, or if you suspect a lymphatic condition. **List the characteristics to note when inspecting the hair.** OBJECTIVE DATA Should be shiny, clean and untangled. Hypothyroidism can cause very thin and brittle hair Distribution: Facial and body Colour: Varies, severe protein deficiency (Kwashiorkor) can appear faded, reddish or bleached. Quantity: Thick, thin, balding (Alopecia) **What does the nurse look for when inspecting the nail bed?** OBJECTIVE DATA Inspect nail plate shape, angle between the finger nail and nailbed, nail texture, colour and intactness of surrounding skin. Normal: convex 160 degrees.