Page 397 - Saunders Comprehensive Review For NCLEX-RN

discussions during the interview are realistic.
Thought Processes and Perceptions: The way the client thinks and what the
client says should be logical, coherent, and relevant; the client should be
consistently aware of reality.

Box 12-3

Characteristics of Skin Color

Cyanosis: Mottled bluish coloration
Erythema: Redness
Pallor: Pale, whitish coloration
Jaundice: Yellow coloration

Box 12-4

Assessing Capillary Filling Time

1. Depress the nailbed to produce blanching.
2. Release and observe for the return of color.
3. Color will return within 3 seconds if arterial capillary perfusion is normal.

Table 12-2

Pitting Edema Scale

*
“Measurement” is in quotation marks because depth of edema is rarely actually measured but is included as a
frame of reference.

Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St.
Louis, 2013, Mosby. Description column data from Kirton C: Assessing edema,
Nursing 96 26(7):54, 1996.

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