Transcript Health Assessment Nur 211 Integument System Fall 2004

Health Assessment
Nur 211
Integument System
Fall 2004
Curlissa Mapp RN, MSN
Skin and Epidermal
Appendages
Function of the Skin
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Protection
Prevents Penetration
Perception
Temperature Regulation
Identification
Communication
Wound Repair
Absorption and excretion
Production of Vitamin D
Main Symptoms of Disease of
Skin, Hair and Nails are:
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Rash or skin lesion
Changes in skin color
Itching (Pruritus)
Changes in Hair
Changes in Nail
Subjective Data of Health
History: Skin
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Any previous skin disease or problem? Any family history of
allergies or allergic skin problems? Any known allergies to drugs,
plants or animals? Any birthmarks or tattoos?
Any change in skin color or pigmentation? Was color change
generalized (all over body) or localized (in one area)?
Any change in a mole: color, size shape, sudden appearance of
tenderness, bleeding or itching? Any “sores” that do not heal?
Any change in temperature, moisture or texture of your skin? Any
excess dryness? Is this seasonal or constant?
(Jarvis, 2004)
Subjective Data of Health
History: Skin
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Any skin itching? Where is the itching? When did it start? Is this mild
or intense?
Any excess bruising? Where on the body? How did this happen? How
long have you had it?
Any skin rash or lesion? Onset. When did you first notice it? Where
did it start? Describe the color. Is it raised or flat? How long have you
had it? Anyone at home or work with similar rash? Have you been
camping, have a new pet, tried a new food or drug? What home care
have you tried? Any itching, fever?
What medications do you take? Prescription and over-the counter?
(Jarvis, 2004)
Subjective Data of Health
History (cont’d)
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Any recent hair loss? Was it a
gradual or sudden onset?
Symmetrical? Associated with
fever, illness, increased stress?
Any unusual hair growth? Any
recent change in texture,
appearance?
Any change in nails: shape,
color, brittleness? Do you tend
to bite or chew your nails?
(Jarvis, 2004)
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Any environmental or
occupational hazards? Any
hazard related problems with
occupation, hobbies. How much
sun exposure do you get from
outdoor work, leisure activities,
sunbathing, tanning salons?
Recently been bitten by insect:
bee tick, mosquito?
Any recent exposure to plants,
animals in yard work, camping?
What do you do to care for your
skin, hair, nails? What
cosmetics, soaps, chemicals do
you use?
Physical Assessment
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Equipment:
Strong Direct Lighting
Small Centimeter ruler
Penlight
Gloves
Magnifying glass
Techniques used in skin assessment:
Inspection and Palpation
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Inspection
general to specific
drape
begin with exposed areas
compare
-anatomical areas
-sun exposed; non-exposed areas
cleanliness
Techniques used in skin assessment:
Inspection and Palpation
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Palpation
Exposed areas first
Compare
Fingertips for general differences/moisture
Dorsa (back) of hand, temperature
Inspect and Palpate Skin
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Color
Temperature
Moisture
Texture
Thickness
Edema
Mobility & Turgor
Vascularity or Bruising
Lesions
Inspect and Palpate the Hair
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Color
Texture
Distribution
Lesions
Inspect and Palpate the Nails
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Shape and Contour
Consistency
Color
Special Considerations in
Assessment of skin, nails and hair
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Infant
Adolescents
Pregnant female
Aging Adults
Cultural
Abnormal Findings
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Pallor
Cyanosis
Erythema
Purpura
Ecchymosis
Petechia
Jaundice
Abnormal Findings: Lesions
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Macule
Patch
Wheal Nodule
Vesicle
Pustule
Cyst
Scale
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Crust
Excoriation
Scar
Keloid
Fissure/Ulcer
Interaction with other Body
System
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Respiratory- Bluish discoloration,
cyanosis
Cardiovascular- Changes in skin color,
temperature, necrosis
GI- Jaundice (sclera, conjunctiva), skin;
dietary lipids (xanthomas); vitamin
deficiency skin, hair, nails
Interaction with other Body
System
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Urinary- skin
Neurological- sensation, touch,
temperature, skin vessels
Endocrine- Diabetes, Thyroid
Immunological- allergies, rashes, itching
Documentation of Findings
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Describe:
Size
Color
Exudate
Shape
Texture
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Tenderness
Blanching or
pulsation of vascular
lesion
Pattern,
configuration,
distribution