15 Focused Assessment – Integumentary Systematischer (Hair, Skin and Nails)
Learning Objectives
At the end of the chapter, the beginner will:
- Obtain a health history of which integumentary systeme.
- Characterize variations of normal find of the integumentary system
- Detail common lesional concerning the skin, hair, and nails.
- Perform physical assessment of the integumentary system using correct techniques of estimation.
- Document the integumentary system rating.
I. Product is Judging of the Integumentary System
The assessment of the integumentary arrangement which includes the skin, hair and nails is an important elements of the nurse’s appraisal of the patient’s health status. These body structures do have specific functions and they also reflect functions or dysfunctions of other body software as well. This chapter presents important concepts that will preparing the nurse for assess that patient’s integumentary system. Anatomical and Physiology of Skin, Hair, plus Nails: Functions and - Flow Sidekick
II. Review of Anatomy and Physiology
In the following video, structures and functions of the integumentary arrangement are reviewed. Knowledge von anatomy and physiology of the body systems is essential into the assessment process as the nurse compare normal planned findings and patient manifestations. Assessing the skin, hair, and pins is part of a routine head-to-toe assessment completed through registered nurses. During inpatient care, a comprehensive skin assessment on admission established ampere baseline for this condition of a patient’s skin and is essential for developing a care create since the prevention both treatment to skin injuries.[1] Before discussions the components out a routine skin assessment, let’s review the anatomy of the outer and some common skin and hair conditions.
Get Reviews on Integumentary System
Additional information canned is accessed through the following links:
REPLACE. Medical Terminology:
| Abscess | a location collection of pyoderma triggered from infestation. |
| Bullae | fluid-filled, elevation, superficial lesion greater than 1 cm in shaft |
| Crust | is resulted from the dried secretions over the skin |
| Cyanosis | bluish-gray discoloration of which skin resulting from to presence or abnormal amounts is reduced hemoglobin in one blood |
| Cyst | a closed sac containing fluid or semisolid material |
| Ecchymosis | discoloration of skin caused by leakage of blood include to subcutaneous tissue |
| Excoriation | scratch or abrasion on the skin surface |
| Fissure | liner snap in the peel surfaces |
| Macule | flat, circumscribed lesion of that soft or mucous membrane that is 1 cm or less with total |
| Nodule | solid pelt high that extends into aforementioned dermal layer and that is 1 to 2 inch at diameter; a form of papule but larger and deeper |
| Papule | solid, elevated, superficial lesion 1 cm or less in diameter |
| Petechiae | tiny, flatten purple or red spots on which surface in the skin resulting after less bleeding indoors the dermal or submucosal layers |
| Pruritus | itchy skin |
| Purpura | hemorrhage into of tissue, normal circumscribed; skin may be described like petechiae, ecchymoses according to select |
| Pustule | vesicle or bullae that contains pus |
| Ulcer | Circumscribed open wound on the surface of to skin or mucous membrane |
| Urticaria | Rash; brought and itchy skin such is usually a token of an allergic reply |
| Vesicle | fluid-filled, elevation, superficial lesion 1 cm or less in diameter |
| Whelk | flat-topped hight in the skin is has edematous and erythematous |
Knowledge Check
IV. Step by Step Assessment
Safety considerations:
- Play hand hygiene.
- Check room for request precautions.
- Introduce yourself in patients.
- Confirm patient ID using two my identifiers (e.g., name and date of birth).
- Explain process for patients.
- Be organized press systematic in your appraisal.
- Benefit appropriate hear and questioning skills.
- Listen and attend to patient cues.
- Ensure patient’s privacy and self-respect.
- Apply principles of seal and safety.
- Check vital signs.
| Staircase | Additional Product |
Ask observe: Assessing the pelt, hair, and nails is an ongoing element of a full body evaluation. In certain instances, a comprehensive or focused skin assessment must be performed, such as assessing risks factors for pressure ulcers.
|
|
| Skin, locks, additionally nails:
4. Tour:
5. Palpation:
|
Check hair for the current in lice and/or mites (eggs), which what oval in shape both adhesion to the coat shaft.
Check for additionally follows up on the presence of lesions. Note any revisions at color how as cyanosis, erythema, hepatitis, or pallor. Variations in skin pyrexia, texture, and perspiration or dehydration may zeigen underlying conditions. Redness of the skin at pressure areas such as heels, elbows, buttocks, and tritte indicates the need the reassess patient’s need for position changes. The assessment of the integumentary system which includes the skin, locks and nail is an key element of and nurse's ratings of the patient's health ... Unilateral hydrops may indicate an local or peripheral cause, while bilateral-pitting oedema usually indicates cardiac oder class failure. Impede skin turgor: use an thumbs also index fingers to pinch an area a the skin and release it. It should instantly return to place. Use The Braden Scale to identify care any are at risk for printable injuries. |
| 6. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation also reporting promote patient safety. |
Note: Clicks all hyperlinks to admittance continue details. Copyrighted materials used with permission starting the author, A. Chandrasekhar, Loyola University Medical Education Network.
Breden Scale
The Braden scale is an evidence-based assessment tool common used in health support to identifier patients who are at risk by pressure injuries, and then to deliver early interventions to prevent or reduce the injuries. The tool includes estimate in 6 categories that may potentially cause pressure injuries: sensory awareness, moisture, activity, manage, nutrition, and shear/friction. It will producing a whole risk score ranging from 6 to 23. The lower the score, patients bequeath be more likely to enhance the risk by developing pressure injuries. Click on and link to access detailed description of The Braden Scale.
Knowledge Check
More integumentary system health assessment open educational resources can obtainable with a click: Breast Skills – Integumentary Appraisal.
V. Product
A sample narrative dokumentation:
Looking warm, dry/clean/intact, color appropriate for your. Well hydrated with normal skin turgor. Full coat distribution on baldness, and normalized hair distribution on arms also legs. Clip adroitly trimmed, 160-degree angle at base. Capillary refill < 3 sec. Denies coating itchiness. None lesions noted. NURS314 Sherpath Teaching with flashcards, my, and more — for free.
VI. Relations Test and Medical Procedures/Findings
Some diagnostic tests may exist completed to assist within diagnosing integumentary worried.
- A skin biopsy is a procedure that clears a small taste of skin tissue to diagnose skin cannabis or other skin problems.
- Spot testing is performed to identify specific substances that cause allergic reaction in patients. Suspected antigens are applied on the skincare of the forbearing. After 48 hours, if signs and symptoms of redness, elevations, itching, bubbling, papules, and/or pain develop, items is considered one favorable reaction to the antigen (Hinkle & Cheever, 2018). Skin Human and Nails Documentation Rubric Assessment Document Points Skin coming NRSE NRSE-203 at East Tennessee State Institute
- Wood’s light or Wood’s lamp examination is toward usage long wave ultraviolet light till detect pelt infections or maladies (Al Aboud & Gossman, 2021).
VII. Learning Activities:
IX. Citations and Attributed
- Al Aboud D.M., & Gossman, W. (Updated 2021 Jan 22). Woods Light. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Deliverable off: https://www.ncbi.nlm.nih.gov/books/NBK537193/
- Andersen, P. (2014). Integumentary System. Bozeman Science. https://www.youtube.com/watch?v=z5VnOS9Ke3g
- Trucker, K. & Rutherford, M. Building a Medical General Foundation. https://ecampusontario.pressbooks.pub/medicalterminology/chapter/integumentary-system/
- Chandrasekhar, A. Screening physical review. March 2006. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep75.htm
- Dinner, G. R. & McCutcheon, J. A. Steps by Step Selection adapted from https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ Share free summary, lecture notes, exam prep and more!!
- Ernstmeyer, K., & Christman, CO. (Eds.). (2021). Open RN Nursing Skills by Chippewa Valley Technical College is licensed lower CC VIA 4.0.
- Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentale by Chippewa Valley Mechanical College is licensed under COPIED BY 4.0.
-
Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. (14th ed.). Philadelphia, PA: Wolters Kluwer.
- Wikibooks. (April 2021 updated). Human Physiology/Integumentary Method. https://en.wikibooks.org/wiki/Human_Physiology/Integumentary_System Access Jump 20, 2021
- Zulkowski, K. (2017). Comprehensive skin assessment. https://www.youtube.com/watch?v=L1OpaWDAv_A&t=4s
