Illinois Central College Health Assessment RNRS 210: Illinois Central College Health Assessment RNRS 210 Fall 2011 Integumentary System: Integumentary System Skin, Hair, Nails and Glands Objectives: Objectives Discuss the structures and functions of the skin, hair and nails. Identify teaching opportunities for integumentary health promotion and risk reductions. Collect subjective data relating to various skin lesions and risk factors for altered skin integrity (e.g., cancer, pressure ulcer). Collect objective data on the skin, including turgor, temperature, color and moisture. Differentiate normal from abnormal skin conditions, including the location, size, distribution, and configuration of any lesions'. Objectives continued: Objectives continued Use subjective and objective data from integumentary assessment to analyze findings and plan interventions. Document and communicate integumentary data using appropriate medical terminology Individualize assessment of integumentary system, considering the patient’s condition, age, gender, and culture. Use integumentary assessment data to identify diagnoses and initiate a plan of care. Integumentary System: Integumentary System Largest body system Consists of skin, hair, nails, and sweat glands. Provides vital information about a patient’s health status. Plays a major role in the protection of the body and immune system. Anatomy: Anatomy Identify the structures and function of the integumentary system Skin-Structure and Function Overview: Skin-Structure and Function Overview Three distinct layers and separate functions Epidermis Dermis Subcutaneous Hair: Hair Two types Vellus and terminal Hair-continued: Hair-continued Vellus Fine Short Hypo pigmented Located all over the body Terminal Darker and coarser Varies in length Generally found on the scalp, brows and eyelids Nails: Nails Formed in the epidermal layer Comprised of hardened keratin Grows at various rates Sweat Glands: Sweat Glands Function to maintain normal body temperature Eccrine glands: cover most of the body. Apocrine glands: located in the axillae and genital areas. Sebaceous glands: located throughout the body except the palms and soles. Skin-History: Skin-History Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or increased pigmentation? What aggravates the problem? What relieves it? Describe any birthmarks, tattoos, or moles you now have? Have you noticed any changes in size? Do you have difficulty controlling body odor? Have you noticed a difference in the amount of sweat you are producing? Lifestyle Considerations: Lifestyle Considerations Pregnant Women Newborns and Infants Children and Adolescents Older Adults Cultural Considerations Healthy People Goals 2020: Healthy People Goals 2020 Goals Reduce the rate of melanoma cancer deaths Increase the proportion of people using protective measures Patient Education Topics Teach the patient early signs of melanoma Teach the patient to use sunscreen with an SPF of 15 or higher, avoid peak exposure, wear sun protective clothing, and avoid UV light. Skin Cancer: Skin Cancer Perform a self check continuously. . .report any changes to your physician or health care provider immediately Reduce sun exposure Use SPF 15 minimal sunscreen when exposure is anticipated Avoid sunburns Have an annual skin cancer check by a professional Get a balanced diet, rich in B3 The Examination of the Skin: Collecting the Objective Data: The Examination of the Skin: Collecting the Objective Data Prepare the patient—Ask the patient to remove most clothing, provide a gown and adequate draping. Let the patient know that you must inspect and palpate the skin over various parts of the body. Gather the equipment—You will need good lighting, a centimeter ruler, a penlight, gloves and appropriate materials for draping your patient Remember these key points when examining the skin, hair and nails: Remember these key points when examining the skin, hair and nails Inspect the skin for color, temperature, moisture, and texture Check skin integrity Be alert for skin lesions—each lesion must be measured and documented in a scientific and precise fashion Evaluate hair condition and any unusual growth Note nail bed condition Use the Basic Techniques of Physical Examination: Use the Basic Techniques of Physical Examination Inspection Palpation Percussion—skip this with the skin Auscultation—Skip this one too!! Inspection: Inspection Make a visual “sweep” of the skin on the patient’s body As other parts of the body are examined more closely, take care to inspect the skin again more closely Look for symmetry and differences in the skin of various body areas Be alert for special conditions that require attention as the examination progresses Exposure of the Skin is Necessary: Exposure of the Skin is Necessary Adequate exposure of your patient’s body is a necessity Use drapes to cover areas you are not currently assessing Remove draping as you progress through the exam On hospitalized patients, bath time is an excellent opportunity to assess skin Look carefully at the areas of skin that are not usually exposed—buttocks, perineum, backs of thighs especially on elderly and bedridden patients What are you looking for?: What are you looking for? Pigmentation Abnormalities Lesions, birthmarks, integrity breaks Symmetry Bruising, redness, scars Palpation: Palpation Temperature Moisture Turgor Lesions: Lesions Term “lesion” is a catch all phrase Lesion may be primary or secondary Primary – appearing initially in response to some change in external or internal environment Secondary – do not appear initially, appear as result in modification of primary lesion Lesions: Lesions Describe lesions according to characteristics of: size, shape, color, texture, elevation, exudate (color, amount, odor, consistency), moisture, temperature, texture Describe according to distribution: localized, regionalized, generalized, relation to clothing Primary Lesions: Primary Lesions Macule Patch Papule Nodule Tumor Wheal Vesicle Bulla Pustule Secondary Lesions: Secondary Lesions Scale Crust Fissure Erosion Ulcer Scar Atrophy Secondary lesions: Secondary lesions Bleeding, Ecchymosis, & Vascular lesions: Bleeding, Ecchymosis, & Vascular lesions Petechiae Purpura Ecchymosis Spider angiomas Venous stars Cherry angiomas Petechiae Ecchymosis Spider angiomas Cherry angiomas Assessment of Skin: configuration and distribution: Assessment of Skin: configuration and distribution Arrangement of lesions Discrete Grouped Confluent Linear Annular Polycyclic Generalized Zosteriform Color alterations: Color alterations Hypopigmentation – decreased melanin in skin,ie: vitiligo (destruction melanocytes result white patches) Hyperpigmentation – increase in melanin in skin, maybe after a disease or injury Albinism – total absence of pigment Erythema – redness due to congestion of capillaries Cyanosis – dusky blue, due to increased unoxygenated hemoglobin Pallor –loss of color due to vasoconstriction or local arterial insufficiency Jaundice – yellow due to increased bilirubin, liver inflammation or hemolytic disease A very extreme case of warts, recently in the news: A very extreme case of warts, recently in the news Butterfly Rash- Typical of Lupus: Butterfly Rash- Typical of Lupus Nails: Nails Looking for adherence to the nail bed Lack of clubbing---what might clubbing indicate? Other abnormalities indicative of systemic disease—Beau lines, spoon nails, white banding, psoriasis This might also be an appropriate time in the exam to check capillary refill Make sure you inspect fingernails and toenails Nail Disorders: Nail Disorders Hair: Hair Inspect for symmetry and hair growth patterns Look at texture of hair Examine for cleanliness and presence of insects (lice) Palpate for dryness and texture Assessing Nevi—Suspecting Skin Cancer: Assessing Nevi—Suspecting Skin Cancer Rashes—Skin Conditions are Difficult to Diagnose Accurately: Rashes—Skin Conditions are Difficult to Diagnose Accurately Poison Ivy: Poison Ivy Note major conditions or pigmentation asymmetry: Note major conditions or pigmentation asymmetry Hyperpigmentation and pallor can often be noted more easily on the hands, feet, and face: Hyperpigmentation and pallor can often be noted more easily on the hands, feet, and face Asymmetry—Do you think it is always this obvious?: Asymmetry—Do you think it is always this obvious? Close up Thin fragile skin: Close up Thin fragile skin Lyme Disease: Lyme Disease Assessment of skin: summary: Assessment of skin: summary Skin, hair, nails, and mucous membranes may be assessed either as a separate entity or in conjunction with the systematic examination of each region of the body Observations should be organized under headings: Skin: color, lesions (size & shape), superficial vascularity, edema, physical characteristics (moisture, temperature, texture, turgor, mobility, elasticity, thickness), and odor Hair: coarseness, cleanliness, distribution, color Nails: color, lesions, texture, nail folds, size, shape, capillary refill Mucous membranes: color, moisture Documentation: Documentation Document your findings in an organized, head to toe fashion Know the difference between subjective (health history) and objective (physical examination) data Sample Documentation : Sample Documentation Skin: Ruddy, smooth, warm and dry. Flat brown lesion noted left neck measuring 1cm x 1cm. Occasional flat pinpoint dark nevi noted on trunk. Skin turgor appropriate. Hair: Thick, evenly distributed, light brown, clean and styled. Nails: well groomed, although short. Brisk capillary refill. No lesions or clubbing noted. Mucous membranes: light pink and moist. References: References D’Amico, D., Med, RN, & Barbarito , C., EdD , RN (Eds.).(2007). Health and physical assessment in nursing. Upper Saddle River, NJ: Person Prentice Hall. Jensen, S. (2011). Nursing Health Assessment: A Best Practice Approach . Philadelphia, PA. Lippincott Williams and Wilkins.