assessment of integumentary system.docxbBbbaj
- 1. SUSHRUSHA INSTITUTE OF NURSING SCIENCES, DAUND. CLINICAL TEACHING ON ASSESSMENT OF INTEGUMENTARY SYSTEM SUBMITTED TO, SUBMITTED BY, Mrs. Archana Salvi Ms. Anuradha S. Wanve Associate Professor F.Y. M.Sc. Nursing SIONS, Daund. SIONS, Daund.
- 3. GENERAL OBJECTIVE:- At the end of this clinical teaching students will be able to gain in depth knowledge about assessment of integumentary system and will be able to apply the same in their clinical practices. SPECIFIC OBJECTIVES:- Student will be able to_ a) define skin and integumentary assessment. b) describe the scientific principles of integumentary assessment. c) demonstrate procedure for assessment of integumentary system.
- 4. SR. NO. SPECIFIC OBJECTIVE TIME DURATION CONTENT TEACHER/LEARNER ACTIVITY AV AIDS EVALUATION 1. 2. Introduction of assessment of integumentary system. Definition of skin and integumentary assessment. 2 min 3 min ASSESSMENT OF INTEGUMENTARY SYSTEM INTRODUCTION: - Skin disorders are encountered frequently in nursing practice. The skin is a reflection of a person’s overall health, and alterations commonly correspond to disease in other organ systems. Skin-related disorders account for up to 10% of all ambulatory patient visits. In certain systemic conditions, such as hepatitis and some cancers, dermatologic manifestations may be the first sign of the disorder. So its very essential to know the assessment of integumentary system. DEFINITION OF SKIN: - “Skin is the body's outer covering, which protects against heat and light, injury, and infection.” DEFINITION OF INTEGUMENTARY ASSESSMENT: - “Integumentary is a systematic examination of different areas of skin.” Teacher introduces the topic assessment of integumentary system. Teacher defines the skin and integumentary assessment. White board Students understood the introduction of assessment of integumentary system. Students understood the definition of skin and integumentary assessment.
- 5. 3. describe the scientific principles of integumentary assessment. 6 min SCIENTIFIC PRINCIPLES OF BLOOD COLLECTION 1.ANATOMY AND PHYISIOLOGY: - Structure: The skin has a surface area of about 1.5 to 2 m2 in adults and it contains glands, hair and nails. There are two main layers: • epidermis • dermis Between the skin and underlying structures there is a layer of subcutaneous fat. The epidermis is the most superficial layer of the skin and is composed of stratified keratinised squamous epithelium which varies in thickness in different parts of the body. It is thickest on the palms of the hands and soles of the feet. There are no blood vessels or nerve endings in the epidermis. The dermis is tough and elastic. The structures in the dermis are: blood vessels, lymph vessels, sensory (somatic) nerve endings, sweat glands and their ducts, hairs, arrector pili muscles and sebaceous glands. Function: Protection Regulation of body temperature Control of body temperature Formation of vitamin D Sensation Teacher describe the scientific principles of integumentary assessment. Handout Student understood the scientific principles of integumentary assessment.
- 6. 4. demonstrate procedure for 25 min Excretion Absorption -The skin contains numerous nerves be careful during selection of the site to avoid injury to these areas. -The knowledge of the anatomy and physiology of the body is essential for the safe integumentary assessment. 2. MICROBIOLOGY: - -Wash hands thoroughly before and after the procedure to avoid cross infection. -Articles required for intravenous infection should be sterile and it should be sterilized by autoclaving. 3. PHARMACOLOGICAL: - -Nurse must know about the antidote and bioavailability of the injectable drug. 4. PSYCHOLOGY: - -Explain the procedure thoroughly to the patient to win the confidence and get the co- operation. -Proper positioning will help to relax the patient while intravenous injection. -Maintain privacy if require. INTEGUMENTARY ASSESSMENT: - Nursing action before procedure: - Teacher demonstrates procedure for assessment of integumentary system. Students understood the integumentary assessment.
- 7. assessment of integumentary system. 1.Identify the patient. 2.Prepration: - It include a) Preparation of self: - -Perform hand hygiene. -Put on gloves. b) Preparation of articles: - -Arrange all the articles in clean tray. c) Preparation of patient: - -Inform the patient and explain all procedure to patient. -Provide proper position to patient i.e, sitting or lying position. -Explain the patient that movement of the extremity should be minimal. c) Preparation of environment: - -Provide calm environment. -Maintain adequate lighting in room. -Provide privacy. Nursing action during assessment: - 1.Assessing General Appearance: The general appearance of the skin is assessed by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility, and the condition of the hair and nails. Skin turgor,
- 8. possible edema, and elasticity are assessed by palpation. 2. Skin color: varies from person to person and ranges from ivory to deep brown to almost pure black. The skin of exposed portions of the body, especially in sunny, warm climates, tends to be more pigmented than the rest of the body. The vasodilation that occurs with fever, sunburn, and inflammation produces a pink or reddish hue to the skin. Pallor is an 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. Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclera and mucous membranes. -Erythema: is redness of the skin caused by the congestion of capillaries. In light-skinned people, it is easily observed at any location where it appears. -Rash In instances of pruritus (i.e, itching) the patient should be asked to indicate which areas of the body are involved.
- 9. Pointing a penlight laterally across the skin may effectively highlight the rash. The differences in skin texture are then assessed by running the tips of the fingers lightly over the skin. The borders of the rash may be palpable. The patient’s mouth and ears are included in the examination. The patient’s temperature is assessed, and the lymph nodes are palpated. Cyanosis is the bluish discoloration that results from a lack of oxygen in the blood. It appears with shock or with respiratory or circulatory compromise. In people with light skin, cyanosis manifests as a bluish hue to the lips, fingertips, and nail beds. Other indications of decreased tissue perfusion include cold, clammy skin; a rapid, thready pulse; and rapid, shallow respirations. The conjunctivae of the eyelids are examined for pallor and petechiae (ie, pinpoint red spots that appear on the skin as a result of blood leakage into the skin). In a person with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, the areas around the mouth and lips and over the cheekbones and earlobes should be observed. 3. Assessing patients with dark skin: The color gradations that occur in people with dark skin are largely determined by genetic transmission; they may be described as light, medium, or dark. In people with dark skin,
- 10. melanin is produced at a faster rate and in larger quantities than in people with light skin. Healthy dark skin has a reddish base or undertone. The buccal mucosa, tongue, lips, and nails normally are pink. The degree of pigmentation of the patient’s skin may affect the appearance of a lesion. Lesions may be black, purple, or gray instead of the tan or red seen in patients with light skin. Dark pigment responds with discoloration after injury or inflammation, and patients with dark skin more often experience post inflammatory hyperpigmentation than those with lighter skin. The hyperpigmentation eventually fades but may require months to a year to do so. In general, people with dark skin suffer the same skin conditions as those with light skin. They are less likely to have skin cancer but more likely to have keloid or scar formation and disorders resulting from occlusion or blockage of hair follicles. 4. Assessing skin lesions: Skin lesions are the most prominent characteristics of dermatologic conditions. They vary in size, shape, and cause and are classified according to their appearance and origin. Skin lesions can be described as primary or secondary. Primary lesions are the initial lesions and are characteristic of the disease itself. Secondary lesions result from external causes, such as scratching, trauma, infections, or changes caused by wound
- 11. healing. Depending on the stage of development, skin lesions are further categorized according to type and appearance. A preliminary assessment of the eruption or lesion should help to identify the type of dermatosis and indicate whether the lesion is primary or secondary. 5. Assessing Vascularity and Hydration After the color of the skin has been evaluated and lesions have been inspected, an assessment of vascular changes in the skin is performed. A description of vascular changes includes location, distribution, color, size, and the presence of pulsations. Common vascular changes include petechiae, ecchymoses, telangiectases (ie, red marks on the skin caused by stretching of the superficial blood vessels), angiomas, and venous stars. Skin moisture, temperature, and texture are assessed primarily by palpation. The elasticity (ie, turgor) of the skin, which decreases in normal aging, may be a factor in assessing the hydration status of a patient. 6. Assessing the Nails and Hair: A brief inspection of the nails includes observation of configuration, color, and consistency. Many alterations in the nail or nail bed reflect local or systemic abnormalities in progress or resulting from past events. Transverse depressions known as Beau’s lines in the nails may reflect
- 12. retarded growth of the nail matrix because of severe illness or, more commonly, local trauma. Ridging, hypertrophy, and other changes may also be visible with local trauma. Paronychia, an inflammation of the skin around the nail, is usually accompanied by tenderness and erythema. The hair assessment is carried out by inspecting and palpating. Gloves are worn, and the examination room should be well lighted. Separating the hair so that the condition of the skin underneath can be easily seen, the nurse assesses color, texture, and distribution. Any abnormal lesions, evidence of itching, inflammation, scaling, or signs of infestation (ie, lice or mites) are documented. ASSIGNMENT: - Q. Enlist advantages and complications of integumentary assessment? SUMMERY: - In this CT, we have seen_ a) define skin and integumentary assessment. b) describe the scientific principles of integumentary assessment.
- 13. c) demonstrate procedure for assessment of integumentary system. CONCLUSION: - This topic helps student to improve their practical skill as well as knowledge regarding assessment of integumentary system and helps to apply these skills in clinical practice. BIBLIOGRAPHY: - 1.Sr. Nancy Principles and practice of nursing 6th edition Page no: - 210-211. 2. Annamma Jacob, clinical nursing procedures the art of nursing practice, 2nd edition, Page no: - 350-353. 3.Ross and Wilson (2003) “Anatomy and Physiology” 9th edition Published by Churchill living stone Philadelphia Page No: - 78-80.
- 14. REFERENCES: - 1. https://en.wikipedia.org/wiki/ assessment of integumentary system 2. https://www.slideshare.net/ mahesh0926/iv- assessment of integumentary system -133188009 3. https://www.slideshare.net/aparnaclaks hmi/ assessment of integumentary system