Health Assessment Nur 211 Integument System Fall 2004 Curlissa Mapp RN, MSN

Health AssessmentNur 211Integument SystemFall 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 Production of Vitamin D

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

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)

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)

Subjective Data of Health History (cont’d) 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?

Physical Assessment

Equipment: Strong Direct Lighting Small Centimeter ruler Penlight Gloves Magnifying glass

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

Techniques used in skin assessment:Inspection and Palpation

Palpation• Exposed areas first• Compare• Fingertips for general

differences/moisture• Dorsa (back) of hand, temperature

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

Inspect and Palpate the Hair

Color Texture Distribution Lesions

Inspect and Palpate the Nails

Shape and Contour Consistency Color

Special Considerations in Assessment of skin, nails and hair

Infant Adolescents Pregnant female Aging Adults Cultural

Abnormal Findings

Pallor Cyanosis Erythema Purpura Ecchymosis Petechia Jaundice

Abnormal Findings: Lesions Macule Patch Wheal Nodule Vesicle Pustule Cyst Scale

Crust Excoriation Scar Keloid Fissure/Ulcer

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

Interaction with other Body System

Urinary- skin Neurological- sensation, touch,

temperature, skin vessels Endocrine- Diabetes, Thyroid Immunological- allergies, rashes,

itching

Documentation of Findings Describe:• Size• Color• Exudate • Shape• Texture

• Tenderness• Blanching or

pulsation of vascular lesion

• Pattern, configuration, distribution