Assessing the Integumentary System PDF

Assessing the Integumentary System Largest organ of the body...

Assessing the Integumentary System Largest organ of the body Physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation (UVR), and dehydration Vital for: temperature maintenance Assessment of the Hair, fluid and electrolyte balance absorption and excretion Skin, Nails, Head & sensation immunity Neck vitamin D synthesis Varies among cultural and racial/ethnic groups Shermel Edwards-Maddox, PhD, RN, CNE, RN-BC Edited/Presented By: Rosalyn Heath-Pena, Doctoral Candidate, MSN, RN, NE-BC, CMSRN Structure and Function of the Skin, Hair & Nails Structures of the Head and Neck Head: consists of 22 cranial and Skin: epidermis, dermis, sebaceous facial bones glands, sweat glands, subcutaneous houses major sensory organs layers information processing center Hair: functions to preserve heat and protect from pathogens/irritants Neck: muscles, bone, blood Types: vellus vs terminal vessels, cartilage, lymph nodes, Nails: functions to protect and organs sensation: supports the skull and allows for movement Ex: nail body, lunula, cuticle Concerns of the Skin Abnormal color – systemic issue Pressure injuries Lesions/wounds Infection Fluid status (dehydration or excess fluid) Skin cancer  Skin Lesions Hair loss Concerns of Discoloration Skin Cancer the Hair Scaliness Risk factors: Infestations A lighter natural skin color. Skin that burns, freckles, reddens easily, or becomes painful in the sun. Blue or green eyes. Blond or red hair. Certain types and a large number of moles. A family history of skin cancer. A personal history of skin cancer. Older age.  Concerns of the Nails Concerns of the Head Infection Bacterial or fungal Abnormal shape or size Microcephaly Circulatory issues Acromegaly Respiratory issues Trauma Nutritional deficiencies Concerns of the Neck Performing the Health Assessment Respiratory Physical concerns characteristics Body functions Thyroid Appearance disorders Behavior Measurements Cancers of the Results of laboratory head/neck testing  Physical Assessment Preparing for the Physical Exam Techniques Comfortable, warm temperature Private area free of interruption Inspection Quiet area with adequate lighting Palpation Firm examination table or bed Percussion Beside table/tray to hold Auscultation equipment Assessment of the Skin Inspect general skin color and/or color variations Inspect for lesions and/or wounds Palpate for temperature, texture, Assessment of the Hair and moisture  Assessment of the Assessment of the Nails Head Inspect nail color and shape Abnormal finding: Paronychia (nail Inspect for size and infection – around the fingernail) contour Abnormal finding: Clubbing Inspect for scaliness or lesions Palpate to test capillary refill Palpate for deformities Color should return in less than 2 seconds or tenderness Assessment of the Neck Inspect skin color Inspect for symmetry Palpate for texture and lesions Palpate for skin turgor Palpate trachea for any deviation Palpate lymph nodes for tenderness Palpate the thyroid Size, symmetry, tenderness or nodules Documentation of Findings Always document normal and abnormal findings Report any concerns to the provider Use medical terminology Concise and clear Let’s Practice! Ms. Jones presents to the clinic with a red rash on her face. Use COLDSPA to elicit a history of her rash. Let’s Practice! Ms. Allen presents to the clinic with a swelling in the front of her neck. Use COLDSPA to elicit a history of her health Questions concern.