NSB103 Health Assessment PDF

NSB103 Health Assessment ASSESSM EN T O F TH E IN TEGUM EN TARY SYSTEM Associate Professor Christina Parker  Learning This Week ØOverview of the Integumentary System...

NSB103 Health Assessment ASSESSM EN T O F TH E IN TEGUM EN TARY SYSTEM Associate Professor Christina Parker  Learning This Week ØOverview of the Integumentary System Ø Assessment of skin Ø Maintaining skin integrity Ø Person Centred Care Ø Clinical Reasoning Cycle en-la-computadora-portatil-grande_1253706.htm  Overview of the Integumentary System Functions of the Integumentary system Ø Involved in: Ø Protection Ø Thermoregulation and sensation Ø Communication Ø Metabolism Ø Elimination Layers of the skin Largest organ in the human body Lets review the Integumentary system  Purpose of integumentary system: comprises the skin and its appendages e.g hair and nails. Aim of assessment: Integumentary System To differentiate between different skin problems To identify patterns that may help with diagnosis, and to assess the impact of any problem on a patient Neonatal Skin Purpose of skin: Thermoregulation Fluid and electrolyte balance Synthesis of Vitamin D Fat storage and insulation Excretion Protection from microorganisms Tactile stimulation for mother and baby attachment (Hughes 2011; Verklan & Walden 2010) Ø Skin development commences at 7 days after conception Ø Largest organ in the body Ø 50% adult thickness (Hughes 2011) Neonates skin is ØThinner ØMore fragile ØLess oily ØProduces less melanin ØLess resistant to bacteria ØReacts to environmental substances ØHeat rash ØCradle cap ØEczema  Skin Changes Associated with Ageing Type of Problem Ø Decreased sensory perception Ø Increased dryness Ø The skin becomes thinner and less elastic Ø Decreased vitamin D synthesis Ø Reduction in immune response Ø Decrease in temperature control or thermoregulatory functioning Ø Vascularity or blood supply of the skin is diminished Ø Hormonal changes Ø Changes in hair colour and balding Ø The amount of subcutaneous tissue decreases  Skin Changes Associated with Ageing: Intrinsic Ageing Ø Ethnicity (differences in skin pigmentation) Ø Anatomical variations (body site) Ø Hormonal changes in cutaneous tissues (oestrogen deficiency- collagen, skin thickness) https://www.youtube.com/watch?v=HMaWYBlo2Vc Skin Changes Associated with Ageing: Extrinsic Ageing Lifestyle influence Ø Temperature and humidity Ø Smoking Ø UV exposure https://www.google.com/ Skin Changes Associated with Ageing Think about someone close to you that is older Activity: and notice the changes to What changes are there? their skin that is different to yours. * If you don’t have Could these be due to Could these be due to someone close to you, intrinsic changes (what extrinsic changes (what watch the television and might these be)? might these be)? look for someone that is older and review their skin  Gather the Relevant Information Ø Past Medical History Ø Medications (topical, systemic, over-the-counter) Ø Exposure to environmental or occupation hazards Ø Substance abuse https://www.shutterstock.com/image-photo/gather-information Ø Recent physiological or psychological stress Ø Hair, nail and skin care habits Ø Skin self-examination Ø Problems with the skin  Focused Skin or Integumentary System Assessment ØReview baseline assessment data ØPerform hand hygiene ØComfort/Privacy/Explain procedure ØExpose each body region from head to toe ØInspect and palpate skin, hair, and nails noting: ØGeneral odour; Temperature; Moisture and turgor; Capillary refill time ØInspect and palpate for signs of pressure injury or skin lesions, noting: ØNon-blanchable redness; localised heat; oedema and induration ØObserve any wounds, dressings, drains and invasive lines, Fundamentals of Nursing Clinical Skill 17.8: Focused Skin or noting: Integumentary Assessment ØWarmth; Redness; Swelling; Exudate or odour ØDetermine frequency of skin assessment based on patients condition Skin Integrity Assessment Why should we assess? Ø Often gives indications of other conditions Ø Risk assessment for wound types Ø Lack of mobility Ø Hospitalised and residential aged care facilities When should we assess? Ø All patients should have skin integrity assessed on admission and at regular intervals Prepare the Environment Ø Ensure the room is quiet, private and has a stable temperature. This helps to reduce anxiety Ø Ensure adequate lighting so that you can see the colour of the skin or any skin changes Ø Ensure adequate exposure of the skin, especially areas not usually inspected such as the buttocks, axillae (armpits), back of thighs or feet. Skin Integrity Assessment: Inspection Inspect skin for: Ø Skin colour Ø Bleeding Ø Lesions Inspect hair for: Ø Hair distribution, colour and quantity (thick, thin, balding) Estes et al, 2016, p. 221 Inspect nails for: Ø Nail length, colour, configuration, symmetry and cleanliness  Skin Integrity Assessment: Palpation Palpation Palpation of the hair Ø Skin temperature Ø Texture Ø Skin moisture Ø Skin texture Ø Tenderness Ø Oedema Palpation of the nails Ø Skin changes Ø Texture Ø Skin turgor (resilience and Ø Elasticity of tissue) Estes et al, 2016, p. 221 Skin Integrity Assessment Observe any wounds, dressings, drains or invasive lines for: Ø Warmth Ø Redness Ø Swelling Ø Exudate or odour  It is estimated that 70% of older people have skin problems including wounds such as skin tears, leg ulcers and pressure injuries. Common Venous leg ulcer – A full-thickness defect of the skin of the lower leg that persists due to venous disease of the lower leg (Australian Wound Management Integumentary Association Inc. & New Zealand Wound Care Society Inc., 2011). issues relevant Arterial ulcers – A full thickness defect of the skin of the lower leg that persists due to peripheral arterial disease (Coleman, 2020). to the older person Diabetic foot ulcer – A full thickness defect of the skin of the foot of a person with diabetes mellitus, usually accompanied by neuropathy and /or peripheral arterial disease in the lower extremity (van Netten et al., 2020). Moisture associated skin damage (MASD) (also known as perianal dermatitis, irritant dermatitis) and Incontinence associated dermatitis (IAD) – dermatitis that develops from chronic exposure to moisture, urine or liquid stool. Assessment for A skin tear is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be Skin Tears partial-thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures). Ø All patients should have a risk assessment for skin tears on admission Ø Risk factors include: limited mobility and use of wheelchairs or other mobility aids, cognitive impairment, poor nutrition, polypharmacy and sensory loss Ø A recognised skin tear assessment and classification system should be used (i.e STAR Classification System) Ø Assess the size of the skin tear and document the assessment Assessment for Skin Tears The ISTAP tool is another classification tool for Look this up and review Activity: skin tears that is now how it is different to the more commonly used in STAR classification QLD Health Facilities.  Assessment for Pressure Injury A pressure injury is a ‘localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction Ø All patients be assessed for their risk of developing pressure injuries on admission and following any change in health status Ø A pressure injury risk assessment tool should be used Ø Individuals found to be at risk of developing pressure injuries should have their skin assessed daily for signs of impaired skin integrity Ø Risk factors include: immobility or reduced physical mobility, loss of sensation, impaired cognitive state or level or consciousness, urinary or faecal incontinence, poor nutrition or recent weight loss, dry skin and acute or severe illness Ø A recognised pressure injury classification system should be used https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/ safety/PDF/Pressure-Injury-Staging.pdf Pressure Injury Risk Assessment Tools: Braden Pressure Injury Risk Assessment Tools: Waterlow Pressure Injury Risk Assessment Tools: Glamorgan Paediatric Scale Clinical Reasoning Cycle Subjective Objective Data Compare the data against normal parameters Identify Health Problems Realistic goals (collaborative)  Goal. To Chronic pain related to: increase Ø Break in skin integrity Impaired tissue integrity related tissue pain integrity by Chronic pain related to Ø Eczema to: enhancing ØBreak in skin integrity Ø Altered circulation circulation and ØEczema nutrition Ø Nutritional deficit or excess Goals: realistic, timely, achievable, Impaired skin integrity related to: Goal. To manage collaborative. Ø Pressure area wound Ø Leg ulcer Use the ‘related to’ factor to direct your goals and ultimately the intervention. Ø Surgery May need to address other health problems to solve one. E.g.. Appropriate wound management is necessary to address activity intolerance, pain and impaired immobility. Documentation Regularly Note any new Communicate assess and abnormal abnormal document findings or findings investigations https://nurseslabs.com/tips-improve-clinical-documentation/  Case Study Mr Brown, aged 78 years, is a widower and lives at home. His daughter lives nearby. Mr Brown usually uses a wheelie walker to mobilise because he often becomes unsteady on his feet. Since he was only going out to collect the mail he decided to leave it inside feeling confident that he wouldn’t be walking very far. On his way to the letter box he tripped and fell sustaining a large skin tea on his left arm. When he got back inside he applied some paper towel to stop the bleeding knowing that his daughter was coming over from morning tea and would be able to fix it up then. A few hours later, Mr Brown’s daughter arrived and decided to take her father to the doctor’s surgery because she wasn’t sure what to do. On arrival at the doctor’s surgery, Mr Brown was taken straight through to the treatment room to be seen by the Practice Nurse. This is not the first time that Mr Brown has sustained skin tears. What skin assessment would you do for this patient?  Consider the person and the context. Who is the person? Where are they living? Who supports them? What is their experience? Present, past, family history. Collect Cues and Information. Subjective and objective Data Processing the Information. Compare the data against normal parameters. Analyse, organise, categorising. Identify potential health issues/problems. Relate back to the data for relevance and direction. Set goals in collaboration with the person and their family Each goal is aligned with each potential health issue or problem.  References Australian Wound Management Association Inc. & New Zealand Wound Care Society Inc. (2011). Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers: Cambridge Publishing. Coleman, K. (2020). Wound Care: A Practical Guide for Maintaining Skin Integrity. Chatswood: Elsevier Health Sciences. Crisp, J., Taylor C., Douglas, C., Rebeiro, G., and Waters, D. (2017). Potter & Perry's Fundamentals of Nursing (5th Ed.) Sydney, Mosby Elsevier Estes, M., Calleja, P., Theobald, K., & Harvey, T. (2016). Health Assessment and Physical Examination. Australian and New Zealand (2nd Ed) Hughes, K. (2011). Neonatal skin care: Advocating good practice in skin protection. British Journal of Midwifery. 17 (120): 773-775 Levett-Jones, T. (2013) Clinical reasoning: learning to think like a nurse. Melbourne, Pearson Australia Lewis, P., & Foley, D. (2011). Weber & Kelly’s Health Assessment in Nursing. First Australian and New Zealand Edition. Sydney AUS: Wolters Kluwer: Lippincott Williams & Wuikins. Queensland Department of Health (2014). NSQHS Standard 8 Pressure injury Definitions Sheet, Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2009/01/Guidelines-HOSP.pdf van Netten, J., Bus, S., Apelqvist, J., Lipsky, B., Hinchliffe, R., Game, F.,... Schaper, N. (2020). Definitions and criteria for diabetic foot disease. Diabetes Metabolism Research and Reviews, 36(S1). doi:10.1002/dmrr.3268 Verklan, T. & Walden, M. (2010). Core Curriculum for Neonatal Intensive Care Nursing, 4th Ed. Saunders Elsevier. USA. 32