Health Assessment Nur 211 Integument System Fall 2004

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Health AssessmentNur 211Integument SystemFall
2004

• Curlissa Mapp RN, MSN

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Skin and Epidermal Appendages
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Function of the Skin

• Protection
• Prevents Penetration
• Perception
• Temperature Regulation
• Identification
• Communication
• Wound Repair
• Absorption and excretion
• Production of Vitamin D

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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

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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)

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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)

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Subjective Data of Health History (contd)

• 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?

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Physical Assessment

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

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Techniques used in skin assessmentInspection
and Palpation

• Inspection
• general to specific
• drape
• begin with exposed areas
• compare
• -anatomical areas
• -sun exposed non-exposed areas
• cleanliness

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Techniques used in skin assessmentInspection
and Palpation

• Palpation
• Exposed areas first
• Compare
• Fingertips for general differences/moisture
• Dorsa (back) of hand, temperature

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Inspect and Palpate Skin

• Color
• Temperature
• Moisture
• Texture
• Thickness
• Edema
• Mobility Turgor
• Vascularity or Bruising
• Lesions

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Inspect and Palpate the Hair

• Color
• Texture
• Distribution
• Lesions

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Inspect and Palpate the Nails

• Shape and Contour
• Consistency
• Color

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Special Considerations in Assessment of skin,
nails and hair

• Infant
• Adolescents
• Pregnant female
• Aging Adults
• Cultural

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Abnormal Findings

• Pallor
• Cyanosis
• Erythema
• Purpura
• Ecchymosis
• Petechia
• Jaundice

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Abnormal Findings Lesions

• Macule
• Patch
• Wheal Nodule
• Vesicle
• Pustule
• Cyst
• Scale

• Crust
• Excoriation
• Scar
• Keloid
• Fissure/Ulcer

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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

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Interaction with other Body System

• Urinary- skin
• Neurological- sensation, touch, temperature, skin
  vessels
• Endocrine- Diabetes, Thyroid
• Immunological- allergies, rashes, itching

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Documentation of Findings

• Describe
• Size
• Color
• Exudate
• Shape
• Texture

• Tenderness
• Blanching or pulsation of vascular lesion
• Pattern, configuration, distribution