SKIN

• INTEGUMENTARY SYSTEM - consist oh the skin, hair and nails. which are the external structures.
• SKIN - largest organ in the body, act as physical barrier protecting underlying tissues from micro organism, physical trauma, ultraviolet radiation and dehydration.
• SKIN - thicker on the palms of the hands and soles of the feet.
• SKIN VITAL ROLES -

  • TEMPERATURE MAINTENANCE
  • FLUID AND ELECTROLYTE BALANCE
  • ABSORPTION
  • EXCRETION
  • SENSATION
  • IMMUNITY
  • VIT. D SYNTHESIS
• EPIDERMIS - the outermost layer of the skin on your body, protects body from harm and keeps body hydrated.
• DERMIS - composed of proteins and mucopolyssacharides, serve as supporting matrix of the nerve tissue.
• SUBCUTANEOUS TISSUE - loose connective tissue that include fat cells, blood vessels, nerve and the remaining parts of sweat glands and hair follicles.
• PROPER ASSESSMENT - information obtain provide clues to client overall level of functioning concerning on hair, skin and nails.
• PROPER ASSESSMENT - ask question in a straight forward manner.
• PROPER ASSESSMENT - keep in mind that a non-judgemental and sensitive approach is needed if the client has abnormalities that may be associated with poor hygiene or unhealthful behaviors.
• SUBJECTIVE DATA COLLECTION -

  • USE COLDSPA TO EXPLORE SYMPTOMS
  • CHARACTER
  • ONSET
  • LOCATION
  • DURATION
  • SEVERITY
  • PATTERN
  • ASSOCIATED FACTORS
• SUBJECTIVE DATA COLLECTION -

  • ARE YOU TAKING ANY MEDICATIONS
  • PERSON HEALTH HISTORY
  • FAMILY HISTORY
• SUBJECTIVE DATA COLLECTION -

  • LIFESTYLE AND HEALTH PRACTICES
  • DO YOU SPEND LONG PERIODS OF TIME SITTING OR LYING POSITION?
  • DO YOU HAVE ANY BODY PIERCING?

  SUBJECTIVE DATA COLLECTION -
• SUBJECTIVE DATA COLLECTION -

  • DO YOU HAVE ANY TATTOOS?
  • WHAT IS YOUR DAILY ROUTINR FOR SKIN, HAIR AND NAILS?

  SUBJECTIVE DATA COLLECTION -
• PHYSICAL ASSESSMENT -

  • inspect skin color, temperature, moisture and texture
  • check skin integrity
  • be alert for skin lesions
  • evaluate hair condition, loss or unusual growth
  • note nail bed condition and capillary reliff
• PALLOR - loss of color (maputla) arterial insufficiency, decreased blood supply and anemia.
• CYANOSIS - may cause white skin to appear blue-tinged.
• JAUNDICE - characterized by yellow skin tones.
• ERYTHEMA - redness in skin or mucous membrane caused by hyperemia (increased blood flow)
• ACANTHOS NIGRICANS - darkening of the skin in the body folds, creases, especially in the neck, groin and axilla.
• NORMAL SKIN INTEGRITY -

  • skin is intact, and there are no reddened areas.
• NORMAL SKIN INTEGRITY -

  • in the obese client, carefully inspect skin on the limbs, under breast and in the groin where problems are frequent due to perspiration and friction.
• ASSESSMENT TOOL FOR BED SORE -

  • BRADEN SCALE
  • PUSH TOOL
  • PRESSURE ULCER STAGE