PHYSICAL ASSESSMENT- INTEGUMENTARY

ASSESSMENT: PART 2

•        Subjective Data / History Collection:

•        Present health history:

–       Specific information about the onset, signs, and symptoms, location, and duration of any pain, itching, rash, or another discomfort experienced by the patient need to be collected

–       Past Health History:

–       Past health history of trauma, surgery, or disease that involves the skin

–        Determine if the patient has noticed any dermatologic manifestations of systemic problems such as jaundice (liver disease), delayed wound healing (diabetes mellitus), cyanosis (respiratory disorder) or pallor (anemia).

•        Medications:

–        A thorough medication history is important, especially in relation to vitamins, hormones, antibiotics, corticosteroids, and antimetabolites because these may cause side effects that are manifested in the skin.

–        If a medication is used, record the name, length of use, method of application and effectiveness.

–       Surgery or Other Treatments.

–        Determine if any surgical procedures, including cosmetic surgery, were performed on the skin.

–       Note any treatments specific for a skin problem (e.g., phototherapy) or for a health problem (e.g., radiation therapy).

–        In addition, document any treatments have undergone primarily for cosmetic purposes.

•        Family history:

–       Obtain information about any skin diseases, including congenital and familial diseases

–        (e.g., alopecia, psoriasis) and systemic diseases with dermatologic manifestations

–        (e.g., diabetes, thyroid disease, cardiovascular diseases, immune disorders).

–       In addition, note any family and personal history of skin cancer

•        Nutritional history:

–        A diet history reveals the adequacy of nutrients essential to healthy skin such as vitamins A, D, E, and C; dietary fat; and protein.

–       Note any food allergies that cause a skin reaction.

•        Activity-Exercise Pattern:

–       Obtain information about occupational hazards in relation to exposure to known carcinogens chemical irritants, and allergens.

•        Cognitive-Perceptual Pattern:

–       Determine the patient’s perception of the sensations of heat, cold, pain, and touch.

–       Assess and record any joint pain.

–       Assess the mobility of the joints, since the patient’s skin the condition may cause alterations in mobility.

•        Physical Examination:

–       Have a private examination room of moderate temperature with good lighting.

–       Ensure that the patient is comfortable and in a dressing gown that allows easy access to all skin areas.

–       Be systematic and proceed from head to toe.

–       Compare symmetric parts.

–       Perform a general inspection and then a lesion-specific examination.

–       Use the metric system when taking measurements.

–       Use appropriate terminology and nomenclature” terminology” when reporting or documenting.

•        Inspect the skin:

–       The general appearance of the skin is assessed by observing the:

§  Color

§  General pigmentation

§  Areas of hypopigmentation or hyperpigmentation

§  Abnormal color changes

§   Skin color varies from person to person and ranges from light pink to deep brown to almost pure black.

§  The skin of exposed portions of the body, especially in sunny warm climates, tend to be more pigmented than the rest of the body.

•        Palpate the skin:

–        temperature

–       Moisture

–       Texture

–       Thickness

–       Edema

–       Mobility

–       Skin turgor

–       Vascularity or bruising

•        Note any lesion:

–       Color

–       Shape and configuration “order”

–       Location and distribution on the body

Inspect and palpate the hair:

–       Texture

–       Distribution

–       Any scalp lesions

•        Inspect and palpate the skull:

–       General size and contour.

–       Note any deformities, lumps, tenderness.

•        Inspect and palpate the nails:

–       Shape and contour:

§  Observe the nails for the signs and symptoms of beau’s lines (Transverse depressions)

–       koilonychia (spoon-shaped nails) and clubbing (the angle between the nail

–       and the base of the nail will be greater than 180 degrees) and paronychia (inflammation of the skin around the nails)

–       Consistency

–       Color

•        Inspect the face:

–       Facial expression

–       The symmetry of movement (carinal nerve VII “7” )

–       Any involuntary movements, edema, lesion.

•        Inspect and palpate the neck:

–       Active range of motion.

–       Enlargement of lymph nodes or thyroid gland.

•        Head and Neck Lymph Nodes:

–       preauricular

–       postauricular

–       occipital

–       tonsillar

–       submandibular

–       submental

•        Teach skin self-examination.

•        Abnormal findings:

–       Pallor’s: absence of or a decrease in normal skin color and vascularity and is best observed in the conjunctivae or around the mouth.

–       The bluish hue of cyanosis indicates cellular hypoxia and is easily observed in the extremities, nail beds, lips, and mucous membranes.

§  Cyanosis is the bluish discoloration that results from a lack of oxygen in the blood.

§   It appears with respiratory or circulatory compromise.

§   To detect cyanosis, the areas around the mouth and lips and over the cheekbones and earlobes should be observed

–       Jaundice: yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes

–       Erythema is the redness of the skin caused by the congestion of capillaries.

–       In light-skinned people, it is easily observed at any location where it appears.

–       It may be difficult to detect erythema in dark-skinned persons as the skin turns to purple-grey due to increases in blood supply.

• Color Changes:

–       Observe for hypopigmentation:

§   (i.e. decrease in the melanin of the skin, resulting in a loss of pigmentation)

–       Observe for hyperpigmentation:

§  (i.e. increase in the melanin of the skin, resulting in increased pigmentation).

–       Described the lesions clearly and in detail:

§  Color of the lesion

§  Any redness, heat, pain, or swelling

§  Size and location of the involved area

§  pattern of eruption (e.g., macular, popular, scaling, oozing)

§  Distribution of the lesion (e.g., bilateral, symmetric, linear, Circular)

·        Nostril patency:

–       Inspect & observe symmetry, inflammation & deformity.

–       In case of swelling or deformities of the nose, the nose is palpated gently for tenderness, swelling, and underlying deviations.

–       Normally the external nose is symmetrical, straight, non-tender, and without discharge.

–       Assess mucosa which is normally pink in color.

–       Yellowish or greenish discharge – means a sinus infection.

–        Pale mucosa with clear discharge – means allergy.

–       For a client with NGT, the nurse should routinely check for local breakdown of skin.

–       “Excoriation” of the nostril that characterized by redness and sloughing of the skin.

•        Functions of the nose:

–        Identify odors (upper 1/3 of septum)

–        Air passageway (obligate in newborns)

–        Air conditioning: humidify, warms/cools the air, cleans and filters the air of dust and most bacteria and voice resonance.

•        Inspect and Palpate:

–        External Nose.

–       Symmetric, in the midline, skin lesion, pain.