Health Assessment NCM 101 PDF

NCM 101 HEALTH ASSESSMENT LEC - PROF. SAMACO ______________________________________________________________________________________________________________ PRELIMS OUTLINE...

NCM 101 HEALTH ASSESSMENT LEC - PROF. SAMACO ______________________________________________________________________________________________________________ PRELIMS OUTLINE Dermis I. Assessing Skin, Hair, and Nails The inner layer of the skin, the dermal papillae connects the A. Overview of the Anatomy dermis to the epidermis. B. Collecting Subjective Data: The The dermis is a well-vascularized, connective tissue layer Nursing Health History containing collagen and elastic fibers, nerve endings, lymph C. Self-Assessment vessels. It is also the origin of sebaceous glands, sweat D. Collecting Objective Data: Physical glands and hair follicles. Assessment E. Nursing Diagnoses Sebaceous Glands F. Abnormalities of the Skin Are attached to the hair follicles and therefore are present G. Stages of Pressure Ulcer over most of the body, excluding the soles and palms. H. Primary Skin Lesions Secretes an oily substance called sebum that waterproofs I. Secondary Skin Lesions the hair and skin. J. Nail Abnormalities II. References Sweat Glands Eccrine and apocrine glands are two types. The Eccrine glands: are located over the entire skin. The ASSESSING SKIN, HAIR, AND NAILS primary function is secretion of sweat and thermoregulation, which is accomplished by evaporation of sweat from the skin OVERVIEW OF THE ANATOMY surface. The Apocrine glands: are associated with hair follicles in Structure and Functions: The integumentary system the axillae, perineum, and areolae of the breasts. The consists of skin, hair, and nails, which are external glands are small and non-functional until puberty. structures that serve a variety of specialized functions. The interaction of sweat with skin bacteria produces a characteristic body odor. In women apocrine secretions are linked with the menstrual cycle. Subcutaneous Tissue Located beneath the dermis. A loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles. Stores fats as an energy reserve, provides insulation to conserve internal body heat. Serves as a cushion to protect bones and internal organs Skin and contains vascular pathways for the supply of nutrients The largest organ of the body. and removal of waste products to and from the skin. It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, Hair ultraviolet radiation, and dehydration. Consists of keratinized cells found over much of the body Plays vital role in temperature maintenance, fluid and except for the lips, nipples, soles of the feet, palms of the electrolyte balance, absorption, excretion, sensation, hand, labia minora, and penis. immunity, and vitamin D synthesis. Hair develops within a sheath of epidermal cells called the It is composed of three layers: the epidermis, dermis, and hair follicle. subcutaneous tissue. There are two general types of hair: vellus and terminal. Vellus hair (peach fuzz) is short, pale, fine, and present Epidermis over much of the body. Terminal hair (particularly scalp and The outer layer of the skin is composed of four layers eyebrows) is longer, generally darker, and coarser than namely: stratum corneum, stratum lucidum, stratum vellus hair. Puberty initiates the growth of additional terminal granulosum, and stratum germinativum. hair in both sexes on the axillae, perineum, and legs. The outermost layer consists of dead, keratinized cells that Hair color varies and is determined by the type and amount are insoluble in water. of pigment (melanin and pheomelanin) production. A The epidermis, hair, nails, dental enamel, and horny tissues reduction in production of pigment results in gray or white are composed of keratin. hair. Completely replaced every 3 to 4 weeks. The innermost layer is the stratum germinativum, the only Nails layer that undergoes cell division and contains melanin The nails, located on the distal phalanges of fingers and (brown pigment) and keratin forming cells. toes, are hard transparent plates of keratinized epidermal Melanin is the major determinant of skin color. cells that grow from the cuticle. 1  The nail body extends over the entire nail bed and has a pink tinge as a result of blood vessels underneath. The lunula is a crescent-shaped area located at the base of the nail. It is the visible aspect of the nail matrix. The nails protect the distal ends of the fingers and toes, enhance precise movement of the digits, and allow for an extended precision grip. COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY COLLECTING OBJECTIVE DATA: PHYSICAL ASSESSMENT Preparing the Client - Remove all clothing and jewelry and put on an examination gown. - Ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. - Have the client sit comfortably on the examination table or bed for the beginning of the examination. - During the skin examination, ensure privacy by exposing only the body part being examined. Make sure that the room is a comfortable temperature. Equipment - Examination light - Penlight - Mirror for client’s self examination of skin - Magnifying glass - Centimeter ruler - Gloves - Wood light - Examination gown or drape - Braden Scale for Predicting Pressure Sore Risk - Pressure Ulcer Scale for Healing (PUSH) tool to measure pressure ulcer healing SELF-ASSESSMENT: HOW TO EXAMINE YOUR OWN SKIN 2 3  NURSING DIAGNOSES Risk Diagnoses Risk for Impaired Skin Integrity related to excessive exposure to cleaning solutions and chemicals Risk for Impaired Skin Integrity related to prolonged sun exposure Risk for Imbalanced Body Temperature related to immobility, decreased production of natural oils, and thinning skin. Risk for Impaired Skin Integrity of toes related to thickened dried toenails Risk for Imbalanced Body Temperature related to severe diaphoresis Risk for Infection related to scratching of rash Risk for Impaired Nail Integrity related to prolonged use of artificial nails Risk for Imbalanced Nutrition: less than body requirements related to increased vitamin and protein requirements necessary for healing of a wound 4  Risk for Infection related to multiple body piercings Intact skin with nonblanchable redness of a localized area, Risk for Infection related to periodic skin tattooing usually over a bony prominence. Its color may differ from the surrounding area. The area may be painful, firm, soft, Actual Diagnoses warmer, or cooler. Ineffective Health Maintenance related to lack of hygienic care of the skin, hair, and nails Impaired Skin Integrity related to immobility and decreased circulation Impaired Skin Integrity related to poor nutritional intake and bowel/bladder incontinence Disturbed Body Image related to scarring, rash, or other skin condition that alters skin appearance Disturbed Sleep Pattern related to persistent itching of the skin Deficient Fluid Volume related to excessive diaphoresis secondary to excessive exercise and high environmental temperatures Stage II ABNORMALITIES OF THE SKIN Partial thickness loss of dermis Red-pink without slough. May also present as a ruptured, serum filled blister. Presents as a shiny or dry shallow ulcer Stage III Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. STAGES OF PRESSURE ULCER Stage IV Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Can extend into fascia, tendon, or joint capsule. Exposed one/tendon is visible. Stage I 5  Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/ or eschar (tan, brown, or black) in the wound bed. Wheal Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis, it does not contain free fluid in a cavity (e.g., vesicle). PRIMARY SKIN LESIONS Macule and Patch Small, flat, non palpable skin color change may be brown, white, tan, purple, red. Macules are less than 1 cm. Patches are greater than 1 cm. Examples: Freckles, Flat moles, petechiae. Pustule Pus-filled vesicle or bulla. Examples include acne, impetigo, furuncles, and carbuncles. Papule and Plaque Elevated, palpable, solid mass. Papules are less than 0.5 cm. Plaques are greater than 0.5 cm. Examples of papules include elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis (psoriasis vulgaris pictured below) and actinic keratosis. SECONDARY SKIN LESIONS Erosion Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area. Example: Stomatitis, commonly called a canker sore. Vesicle and Bullae Circumscribed elevated, palpable mass containing serous fluid. Vesicles are less than 0.5 cm. Bullae are greater than 0.5 cm. 6  Ulcer Yellow Nail Syndrome Skin loss extending past epidermis, with necrotic tissue loss. Yellow nails grow slowly and are curved. May be seen in Bleeding and scarring are possible. AIDS and respiratory syndromes. Paronychia Local Infection Scar Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Longitudinal Ridging Parallel ridges running lengthwise. May be seen in the elderly and some young people with no known etiology. Fissure Linear crack in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and an athlete's foot. Half-and-Half Nails Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease. NAIL ABNORMALITIES Koilonychia Spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease). III. REFERENCES Brosola, D. (2024). Assessing Skin, Hair, and Nails. Assessing Head, Face, and Neck. Powerpoint Presentation. Week 4 Notes. NU Manila. CREATED BY: DAVERIEL YKALINA 7