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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. Protection Prevents Penetration Perception Temperature Regulation Identification Communication Wound Repair Absorption and excretion

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Health Assessment Nur 211 Integument System Fall 2004

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  1. Health AssessmentNur 211Integument SystemFall 2004 Curlissa Mapp RN, MSN

  2. Skin and Epidermal Appendages

  3. Function of the Skin • Protection • Prevents Penetration • Perception • Temperature Regulation • Identification • Communication • Wound Repair • Absorption and excretion • Production of Vitamin D

  4. Main Symptoms of Disease of Skin, Hair and Nails are: • Rash or skin lesion • Changes in skin color • Itching (Pruritus) • Changes in Hair • Changes in Nail

  5. Subjective Data of Health History: Skin • 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)

  6. Subjective Data of Health History: Skin • 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)

  7. 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) 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? Subjective Data of Health History (cont’d)

  8. Physical Assessment • Equipment: • Strong Direct Lighting • Small Centimeter ruler • Penlight • Gloves • Magnifying glass

  9. Techniques used in skin assessment:Inspection and Palpation • Inspection • general to specific • drape • begin with exposed areas • compare -anatomical areas -sun exposed; non-exposed areas • cleanliness

  10. Techniques used in skin assessment:Inspection and Palpation • Palpation • Exposed areas first • Compare • Fingertips for general differences/moisture • Dorsa (back) of hand, temperature

  11. Inspect and Palpate Skin • Color • Temperature • Moisture • Texture • Thickness • Edema • Mobility & Turgor • Vascularity or Bruising • Lesions

  12. Inspect and Palpate the Hair • Color • Texture • Distribution • Lesions

  13. Inspect and Palpate the Nails • Shape and Contour • Consistency • Color

  14. Special Considerations in Assessment of skin, nails and hair • Infant • Adolescents • Pregnant female • Aging Adults • Cultural

  15. Abnormal Findings • Pallor • Cyanosis • Erythema • Purpura • Ecchymosis • Petechia • Jaundice

  16. Macule Patch Wheal Nodule Vesicle Pustule Cyst Scale Crust Excoriation Scar Keloid Fissure/Ulcer Abnormal Findings: Lesions

  17. Interaction with other Body System • Respiratory- Bluish discoloration, cyanosis • Cardiovascular- Changes in skin color, temperature, necrosis • GI- Jaundice (sclera, conjunctiva), skin; dietary lipids (xanthomas); vitamin deficiency skin, hair, nails

  18. Interaction with other Body System • Urinary- skin • Neurological- sensation, touch, temperature, skin vessels • Endocrine- Diabetes, Thyroid • Immunological- allergies, rashes, itching

  19. Describe: Size Color Exudate Shape Texture Tenderness Blanching or pulsation of vascular lesion Pattern, configuration, distribution Documentation of Findings

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