Final answer:
The nurse should document the observation of yellow staining as jaundiced. Jaundice is related to the accumulation of bilirubin, a breakdown product of hemoglobin, which can signify a liver-related condition or increased red blood cell breakdown.
Step-by-step explanation:
When a nurse observes yellow staining in the sclera of the eyes, soles of feet, and palms of hands, these findings should be documented as jaundiced. Jaundice, also known as icterus, is caused by the accumulation of hemoglobin degradation products, particularly bilirubin. It indicates that there may be an underlying condition affecting the liver's ability to process bilirubin, such as liver disease, hepatocellular damage, biliary obstruction, or hemolytic anemia.
The bilirubin that causes jaundice is a result of the breakdown of red blood cells. In normal conditions, bilirubin concentration is low, but if liver function is compromised or if there is an increased breakdown of red blood cells, bilirubin accumulates in the body, leading to the characteristic yellowing of the skin and sclera. This condition warrants a further medical evaluation to identify and treat the underlying cause.