Assessment of the Integumentary System and Oral Cavity FA 22 - Tagged.pdf

Assessment of the Integumentary System and Oral Cavity Lakeland Community College NURS 1090  Unit Outcomes Demonstrate the ability to assess the integumentary system including oral cavity, skin, hair, and nails Identify physical assessment changes in the older adult. Perform a total physical...

Assessment of the Integumentary System and Oral Cavity Lakeland Community College NURS 1090  Unit Outcomes Demonstrate the ability to assess the integumentary system including oral cavity, skin, hair, and nails Identify physical assessment changes in the older adult. Perform a total physical assessment  Assessment of the Integumentary System Health History oHistory of skin conditions oSun exposure oHistory of tattoos, piercings, or brands oEnvironmental exposure oFamily history  Assessment of the Integumentary System— Health History Hair Nails (fingers and toenails) Change in growth or loss of hair over head Changes to shape, or body color, texture Use of hair (breaking, thick) products/color Nail care practices Scalp: lesions, flaking History of systemic Risk for nail/foot illnesses problems Physical Assessment of Skin, Hair, and Nails General guidelines Inspection and palpation Check in skin folds Check both the front and the back of the patient as well as under the clothing for a thorough assessment **Room must have good lighting Skin Folds  Assessment: Skin Color Normal: Brown, black, pink, ivory Abnormal: pallor, cyanosis, jaundice, erythema Darker skin: ◦ May need to inspect areas of lighter pigmentation such as lips, nail beds, palms Discoloration Hypo/hyper pigmentation Skin alterations  Jaundice Cyanosis https://www.nlm.nih.gov/ Medicineco.blogspot.com  HYPERPIGMENTATION HYPOPIGMENTATION  Palpation Skin Temperature: Palpate with back of hand Should be warm, not hot Look for symmetry Skin Moisture: Note if moist or excessively dry Normal skin should be dry Palpation Texture: smooth or rough, soft, thickened Odor: Normal = without foul odors Foul odors may indicate poor hygiene, infection  Skin Turgor *Refers to elasticity of skin Some loss of skin elasticity is an expected part of aging Assessing: ◦Lift and release a fold of skin on an extremity ◦Skin should return to flat position quickly when gently pinched up ◦Tenting: delay in skin returning to normal position— what does this indicate (Pearson, Volume 3, p. 82) Assessing Skin Turgor Poor Skin Turgor (Tenting)  Alterations in Skin Integrity Bleeding or trauma Ecchymosis – area of purplish discoloration due to bleeding under the skin (bruise) Color: can indicate age Bluish or purplish discoloration – fades to green or yellow over time Ecchymotic areas do not blanch Note: Size, location, shape can indicate cause Ecchymosis  Erythema Generalized Localized Skin Alterations/Skin Lesions Any unusual finding of the skin surface Note color, location, texture, size shape Is it flat or raised? Is it solid or fluid filled? Measure size  Flat Skin Alterations Freckles Petechiae: small hemorrhages resulting Some rashes from fragile capillaries Petechiae Wheal Palpable Irregular borders Edematous Hive, insect bite Fluid-filled Lesion: Vesicle ◦ Filled with serous fluid ◦Herpes simplex, chickenpox, blisters Fluid-filled Lesion: Pustule Contains pus Varies in size ◦Acne ◦Skin infections Fluid-filled Lesion: Cyst Semi-solid material In or under skin Encapsulated  Additional Types of Skin Lesions (see next slides) Excoriation: superficial abrasions often due to friction or scratching itchy areas Scars: flat, irregular area of connective tissue after lesion/wound has healed Keloids: abnormally enlarged scars, not flat Tattoos, piercing Rash: an eruption of multiple lesions or bumps on the skin Note color, location, size of area Distribution or shape: Discrete, linear, grouped, generalized Excoriation Keloid Examples of Rashes Documentation: Try to get exact size and shape ◦ diagram body marks on “man” outline ◦ show front and back  Documentation, cont Points to note on the diagram ◦ Alterations in skin integrity ◦ Surgical sites and dressings ◦ Scars: location, reason, and date ◦ Ostomies ◦ Edema ◦ Tubes: IV sites, dialysis access ◦ Piercings, tattoos ◦ **Use accurate terms Sample Documentat ion for Skin Assessment  Expected Age-Related Changes in the Older Adult: Skin Color ◦ Paleness in white skin ◦ Decreased vascularity of dermis ◦ Decline of melanocytes ◦ Uneven pigmentation ◦ Brown spots (age spots) ◦ Caused by clusters of melanocytes ◦ More apparent on sun exposed skin ◦ Senile purpura ◦ red, purple, or brown areas seen on legs and arms ◦ Due to blood leaking from fragile capillaries Brown spots (age spots) Senile Purpura  Expected Age-Related Changes in the Older Adult: Skin Decrease in function of sweat (eccrine) and oil (sebaceous) glands ◦ Decreased perspiration ◦ Decreased sebum production in hair and skin ◦ Drying of skin, rough areas Elasticity, turgor ◦ Decreased elasticity ◦ Loss of collagen and elastic fibers ◦ Decreased turgor - tenting ◦ Loose folds and wrinkles  Expected Age-Related Changes in the Older Adult: Skin Texture ◦ Slowed proliferation of epidermal cells and vitamin D production ◦ Decreased subcutaneous tissue ◦ Decreased vascularity of dermis Leads to: ◦ Thin, more transparent skin ◦ Risk for skin tears, pressure ulcers, injury, infection ◦ Slow wound healing THINNING OF SKIN SKIN TEAR Hair Assessment Color: natural; artificial; age related change Texture: excessively dry or brittle? Distribution: over head and body: should be evenly distributed for patient's gender ◦ Alopecia: hair loss/asymmetrical baldness ◦ Hirsutism: increased growth of coarse hair on face/trunk ◦ Male pattern hair growth in women Is the grooming appropriate?  Health History: Hair Change in growth or loss of hair over head or body Use of hair products/color Scalp: lesions, flaking History of systemic illnesses Alopecia Male Pattern Baldness Hirsutism Inspection and palpation of hair and scalp: (Use gloves) Lumps or lesions: head should be rounded without pronounced depressions Pressure areas: behind ears and back of head Scars: surgical; trauma Scalp should not be excessively dry No flaking or crusting Note evidence of flaking, sores, lice Expected Age-Related Changes in the Older Adult: Hair Decreased density and rate of hair growth ◦ Thinning on head and body Loss of hair on head and body Decreased number of melanocytes in hair ◦ Grayness Nails Health History Nails (fingers and toenails) Changes to shape, color, texture (breaking, thick) Nail care practices Risk for nail/foot problems Nails (Assess both hands and feet) Color: Normal is pink in light skinned patients Dark skinned patients may have brown or black pigmentation Note if pale, dusky, cyanotic, yellow Shape: Normal is convex Nail texture: Normal is smooth Note excessive thickness or thinness, discolored or detached nail  Nail Angle (Pearson, Volume 3, p. 64) Angle of the nail base Normal: less than 180 180° or greater associated with long-term lack of oxygen Clubbing of Fingernails: ◦ change in shape ◦ may be related to heart or pulmonary conditions  Expected Age-Related Changes in the Older Adult: Nails NAILS Slow growth of nails Decreased peripheral circulation ◦ Brittle ◦ Longitudinal ridges ◦ Thickening ◦ Yellowing Assessment of the Oral Cavity Health History Oral cavity ◦ Natural teeth or prosthetics ◦ Dry mouth ◦ Lesions of lips or mucus membranes ◦ Difficulty chewing or swallowing ◦ Use of tobacco products/alcohol  Oral Assessment Lips Outline and movement, symmetry Color: uniform pink to brown, depending on ethnicity Note color alterations, lesions, and drooling  Oral Assessment Tongue, mucosa, and back of throat ◦ Patient should be able to extend tongue and move side to side ◦ Mucosa should be pink and glistening, smooth and moist ◦ Use a tongue blade and penlight to assess. Oral Assessment Teeth Normal healthy teeth: smooth, white, shiny Inspect for evidence of hygiene and care Gingiva: Normal is pink and glistening. Note if receding, bleeding, pale Missing/decayed teeth, implants ◦ Prosthetics: dentures or partials? ◦ If not fixed, remove carefully, inspect gum tissue  Oral Assessment Voice: hoarseness, volume ◦ A patient that is hard of hearing may have an abnormally loud tone of voice Halitosis: bad breath or taste Xerostomia: Excessive dryness What can these alterations reflect? Gingivitis Xerostomia www.aafp.org www.hometreatment.net  Decreased saliva and enzyme production – xerostomia (dry mouth) Expecte d Age- Related Decreased number of taste buds Changes in the Older Inadequate oral hygiene Adult: Halitosis Oral Cavity Periodontal disease, gingivitis Edentulism – tooth loss Less efficient chewing Lab Competency