physical assessment of the skin, head, and neck
TRANSCRIPT
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PHYSICAL ASSESSMENT: THE INTEGUMENT
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THE INTEGUMENT
Includes:SkinHairNails
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THE SKIN, HAIR, AND NAILS
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SKIN
Assessment of the skin invloves inspection and palpation.
In some instances, the nurse may also use the olfactory sense.
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SKIN COLOR CHANGES
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PALLOR
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CYANOSIS
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CYANOSIS
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CYANOSIS
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JAUNDICE
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JAUNDICE
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ERYTHEMA
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BIRTHMARK
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VITILIGO
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ALBINISM
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ALBINISM
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EDEMA
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EDEMA
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SKIN LESIONS
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SKIN LESIONS
Can be primary or secondary Nurses are responsible for describing
skin lesions accurately in terms of location, distribution, and configuration.
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PRIMARY SKIN LESIONS
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MACULES
Flat, unelevated change in color 1mm-1cm, circumscribed Ex: Freckles, measles, petechiae
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PAPULE
Circumscribed, solid elevation of skin <1cm Ex: Warts, pimple, acne
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PLAQUE
Larger than 1 cm Examples: Psoriasis, rubeola
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NODULE/TUMOR
Solid, hard mass that extends deeper into the dermis
0.5 to 2 cm (Nodule), have circumscribed border
Ex: squamous cell ca, fibroma
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VESSICLE / BULLA
A circumscribed, round or oval, thin transluscent-filled mass with fluid or blood
Size: 0.5cm Ex: Herpes simplex, early
chickenpox, burn blister
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PUSTULE
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WHEAL
A slightly irregular, relatively transient, superficial area of localized skin edema.
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WHEAL
A slightly irregular, relatively transient, superficial area of localized skin edema.
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CYST
Mass arising from the dermis or subcutaneous tissue.
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SECONDARY SKIN LESIONS
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ASSESSING THE SKIN
In general, we assess the client’s skin for the following:ColorLesionsMoistureTemperatureTextureMobility and turgor
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ASSESSING THE SKIN ACROSS THE LIFESPAN
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INFANTS
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INFANTS
Physiologic Vs. Pathologic Jaundice
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INFANTS
Milia
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INFANTS
Vernix Caseosa
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INFANTS
Lanugo
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INFANTS
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INFANTS
Diaper Dermatitis
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INFANTS
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CHILDREN
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CHILDREN
Children have minor skin lesions on arms and legs due to high-activity level
Secondary skin lesion may occur frequently
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CHILDREN
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ELDERS
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ELDERS
Changes in white skin occur at an earlier age than in black skin
Common skin findings:WrinklesThin and dry skinPoor skin turgorSenile lentigines
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ELDERS
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ELDERS
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ELDERS
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ELDERS
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ELDERS
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ELDERS
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ELDERS
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THE NAILS AND HAIR
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THE HAIR
The hair, together with the nails, is differentiated tissue but continuous extension of the skin.
Hair is generally distributed over the body except in some areas
The amount and texture varies with age, sex, race, and body part
Types:VellusTerminal hair
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NORMAL HAIR
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ABNORMAL HAIR FINDINGS
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ABNORMAL HAIR FINDINGS
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HAIR ASSESSMENT PROCEDURES 1. Introduce self 2. Perform hand hygiene 3. Provide privacy 4. Inquire if the patient has any
history of using hair cosmetics and presence of any disease
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HAIR ASSESSMENT PROCEDURES 5. Inspect the hair for the ff:
EvennessThickness/thinnessTexture and oilinessInfections or infestationsAmount of body hair
Document findings
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THE NAILS
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THE NAILS
Nails are inspected for:Nail plate shapeAngleTextureNail bed colorIntactness of surrounding tissues
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THE NORMAL NAIL
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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ABNORMAL NAIL FINDINGS
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BLANCH TEST
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BLANCH TEST (CAPILLARY REFILL TEST)
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BLANCH TEST: AN EARLY INDICATOR OF SHOCK?
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ASSESSMENT OF THE NAILS
1. Introduce self 2. Observe infection control
procedures 3. Provide for privacy 4. Inquire for presence of certain
diseases
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ASSESSMENT OF THE NAILS
5. Inspect nails for:Nail plate shapeTextureColorSurrounding tissue
6. Perform blanch test 7. Document findings
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What are the Lifespan Considerations when assessing the nails?
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THANK YOU!
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