Special Considerations in Patient Assessment and Documentation
Special Considerations in Patient Assessment and Documentation ( 6 Questions)
A nurse is performing a skin assessment on a client who has dark skin.
Which of the following techniques should the nurse use to detect cyanosis in this client?
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.
Inspect the nail beds and lips for a bluish hue.
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
Incorrect options:
B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.