Week 6 - Tissue Integrity Flashcards
Is the integumentary assessment separate of the health assessment? (2)
no, it is integrated into the complete examination of a patient
- we palpate and inspect
What are the physiological functions of the skin? (6)
- protection
- prevention of penetration
- temperature regulation
- wound repair
- absorption and excretion (transdermal)
- production of vitamin D
What are the embody (social) functions of the skin? (2)
- Perception
- communication
- identification
Different layers of skin diagram
Name some subjective data findings for the integumentary system. (12)
- previous history os skin disease
- hives, psoriasis, eczema, allergies (manifests as rash) - Change in pigmentation
- Change in mole (size or colour)
- Excessive dryness or moisture (thyroid conditions)
- Pruritus
- Excessive bruising
- Rash or lesion (O/N, B/W)
- Medications
- Hair loss
- Chnage in nails (clubbing)
- Environmental or occupational hazards
- Self-care behaviours
Name 10 objective assessments for the integumentary system.
- Colour of skin
- thickness of skin
- palpate temperature of skin
- Consider moisture of skin
- texture
- palpate for edema
- palpate mobility and turgor
- Inspect vascularity and bruising
- Note the presence of any rash or lesions
What should you note about a patient’s skin colour? (7)
Widespread changes
- pallor (white): not enough blood
- erythema (red): temp. inflammation
- Cyanosis (blue): lack of O2
- Jaundice (yellow): Liver
Areas of darker pigmentation - freckles, moles, birthmarks
Areas of lighter pigmentation - vitiligo: absence of melanin pigment
What should you consider regarding thickness of the skin? (2)
- any calloused areas
- in the skin thin or shiny?
ie diabetes
How should you palpate for temperature? (2)
- hypothermia or hyperthermia
- use back of your hand
How should you assess moisture of the skin? (3)
- diaphoresis or profused perspiration (at rest)
- dryness
- dehydration (oral mucous membranes)
How should you assess for texture of the skin?
smooth, firm, with even surface
What is edema (swelling)?
- fluid that accumulates in the intracellular spaces
How should you palpate for edema?
- imprint your thumb firm against the ankle malleolus or the tibia
What is unilateral edema?
- local or peripheral cause
What is bilateral edema, or generalized edema (anasarca)? (2)
- central problem
- edema all over, or both L+ R
What is the +3 score of pitting edema? (3)
- deep pitting
- indentation remains for a short time
- swelling of leg
