Health Assessment

• Integumentary: Skin, Hair and Nails is a topic prepared for EC DON BSN 1-D by Virginia B.
• The course learning outcomes for Health Assessment include identifying pertinent history questions, obtaining a client history, performing a physical assessment, documenting pertinent assessment findings, identifying actual/potential health problems related to physical assessment, recognizing developmental and cultural variations of the different assessment systems, and differentiating between normal and abnormal assessment findings.
• Auscultation is performed by placing a stethoscope, or a medical instrument used for listening to the internal sounds of the body, flat on the body at different locations that correspond to different organs in the body.
• The history of present health concern includes information about the client's Chief Complaints, Family History, Lifestyle and Health Practices, Past Health History, and other relevant information.
• Chief Complaints (reason) can include Pain, Fever, Numbness, Rash, Nodule, Fainting, etc.
• There are 5 types of percussion:
• How much stress do you have in your life?
• Do skin problems limit any of your normal activities?
• How do you cut your nails?
• How much fluid do you drink each day?
• What kinds of foods do you consume in a typical day?
• Describe any skin disorder that prevents you from enjoying your relationships
• The learning objectives for Health Assessment include recalling the topics in previous subjects/topics like Anatomy and Physiology, recognizing the normal and deviations in doing health assessment of the Skin, Hair and Nails, demonstrating the process of health assessment of the Skin, Hair and Nails, and appreciating the application of health assessment of the Skin, Hair and Nails.
• Do you have any body piercings?
• Do you perform skin self-examination once a month?
• Do you have any tattoos?
• Do you spend long periods of time sitting or lying in one position?
• Do you have a history of smoking and/or drinking alcohol?
• Insect/animal bite is a risk for complications (RC).
• Allergic reaction is a risk for complications (RC).
• Burns are a risk for complications (RC).
• Septicemia is a risk for complications (RC).
• Ischemic skin ulcers are a risk for complications (RC).
• Skin lesion is a risk for complications (RC).
• Hemorrhage is a risk for complications (RC).
• Hypovolemic shock is a risk for complications (RC).
• Skin infection is a risk for complications (RC).
• Graft rejection is a risk for complications (RC).
• Skin rash is a risk for complications (RC).
• Steps in Health Assessment include washing hands/hand hygiene, making the patient feel comfortable, asking the client to gown, getting vital signs, conducting a preliminary interview/history taking/data gathering, assembling equipment/materials, doing the health assessment procedure, recording the findings, and analyzing data to determine/formulate a nursing diagnosis.
• Diseases and disorders of the body part/s to assess like the skin, hair and nails may be local or caused by an underlying systemic condition.
• To perform a complete and accurate assessment, it is important to collect data through interview, inspection, palpation, and percussion.
• Interview in health assessment includes chief complaints, describing the sign or symptom, onset, location, duration, severity, and pattern.
• Inspection in health assessment is a visual examination of the patient; palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain.
• Percussion in health assessment is a method of tapping body parts with fingers, hands, or small instruments as part of a physical examination; it is done to determine the size, consistency, and borders of body organs and the presence or absence of fluid in body areas.
• History of Family Health Concern: Sample Questions include whether anyone in the client's family has had a recent illness, rash, or other skin problem or allergy, and if they have a family history of keloids.
• Daily routine for skin, hair, and nail care is an important part of lifestyle and health practices.
• History of Present Health Concern: Sample Questions include whether the client has noticed any change in their ability to feel pain, pressure, light touch, or temperature variations, and if they have any birthmarks or moles that have changed color, size, or shape.
• Reduction in production of pigment results in gray or white hair.
• History of Lifestyle and Health Practices: Sample Questions include whether the client sunbathes, how much sun or tanning-booth exposure they get, what type of protection they use, and if they are regularly exposed to chemicals that may harm the skin.