Health Assessment
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| show | Epidermis, Dermis, & Beneath these layers is a third layer, the subcutaneous layer of adipose tissue.
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| show | The outer layer of skin. This layer is thin but tough. Its cells are bound tightly together into sheets that form a rugged protective barrier.
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| Dermis: | show 🗑
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| Subcutaneous Layer: | show 🗑
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| show | Hairs are threads of keratin. The hair shaft is the visible projecting part, and the root is below the surface embedded in the follicle.
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| show | Nails are hard plates of keratin on the dorsal edges of the fingers and toes.
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| show | These glands produce a protective lipid substance, sebum, which is secreted through the hair follicles. Sebaceous glands are everywhere except the palms and soles. Most abundant in the scalp, forehead, face, and chin.
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| show | There are two types: Eccrine glands and Apocrine glands
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| Eccrine Glands: | show 🗑
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| show | produce a thick, milky secretion and open into the hair follicles. They are located mainly in the axillae, anogenital area, nipples, and naval.
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| show | Provides barrier, Regulates body temperature, Synthesizes vitamin D, Sensory perception, Provides nonverbal communication, Provides identity, Allows wound repair, Allows excretion of metabolic waste
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| Functions of the Skin: (continued) | show 🗑
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| show | skin allows cell replacement of surface wounds.
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| Absorption and Excretion: | show 🗑
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| show | the skin is the surface on which ultraviolet light converts cholesterol into Vitamin D.
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| Skin and the Aging Adult: | show 🗑
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| Skin and the Aging Adult cont: | show 🗑
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| Skin and the Aging Adult cont: | show 🗑
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| show | Rash, Non-healing lesions, Moles, Lesions, Bruising, Hair loss, Previous history of skin disease, Family history of skin disease, allergies, birthmarks, tattoos, Lifestyle and personal habits, Medications prescribed and OTC
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| Subjected Data (cont) - for states problem: | show 🗑
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| History for the Aging Adult: | show 🗑
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| show | Does the child have any birthmarks? Was there any change in skin color as a newborn?Any jaundice? Which day after birth? Any cyanosis? Under what circumstances?
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| show | Rash? Related to new foods, formula, chocolate, cow’s milk, eggs?
Ask about origin of any bruises/burns. Use sunscreen?
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| show | Inspect and palpate the skin: Observe color and pigmentation: freckles, nevus, birthmarks. Color changes: pallor, erythema, cyanosis, jaundice.
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| Physical Exam - Objective Data: (cont) | show 🗑
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| show | Moisture: Look for diaphoresis-increased perspiration. Look for excess dryness, dehydration-check oral mucous membranes, mobility and skin turgor.
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| show | Texture and thickness: Normal skin feels smooth and firm and with an even surface.
Also check for Edema and bruising. Check for lesions.
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| Lesions: if lesions are present: | show 🗑
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| show | Braden Scale – see page 162
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| show | the immediate result of a specific causative factor, lesions develop on unaltered skin.
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| show | Color change, flat, less then 1 cm.- freckles, petechiae, measles, scarlet fever.
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| Papule: | show 🗑
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| Patch: | show 🗑
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| Plaque: | show 🗑
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| show | Solid elevated lesion >1cm
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| show | >then a few cm, firm or soft, deeper into the dermis.
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| show | Superficial, raised,transient,and erythematous. Slightly irregular shaped, fluid filled-mosquito bite, allergic rxn.
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| show | example: hives, intensely pruritic, reaction.
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| Cyst: | show 🗑
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| show | Elevated cavity containing clear fluid, up to 1 cm-herpes, varicella.
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| Bulla: | show 🗑
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| show | Elevated turbid (pus) fluid filled cavity-acne, impetigo.
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| show | Resulting from a change in primary lesion.
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| show | Thickened dried out lesion-yellow, brown or honey colored.
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| show | Flakes, dry or greasy, silvery or white, shedding of dead excess keratin cells.
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| show | Linear crack with abrupt edges.
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| show | Scooped out shallow depression.
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| show | Deeper depression extending into the dermis.
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| show | Self inflicted abrasion, superficial, crusted.
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| Scar: | show 🗑
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| Atrophic Scar: | show 🗑
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| Lichenification: | show 🗑
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| Keloid: | show 🗑
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| show | Inspect, palpate, note any lesions, teach self examination ABCDE
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| show | color, general pigmentation, abnormal color changes.
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| Palpate: | show 🗑
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| Note any lesions: | show 🗑
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| show | Inspect and Palpate Hair: texture, distribution, scalp for lesions, flakes, lice, nits. Inspect body, axillae and pubic hair. Inspect and Palpate Nails: shape and contour, consistency, color.
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| show | often regarded as 5th vital sign.
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| Acute Pain: | show 🗑
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| show | pain lasting more than 1 month.
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| Assessing the patient's pain: | show 🗑
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| Types of Pain: | show 🗑
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| show | pain related to tissue damage.
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| show | pain resulting from direct injury to the peripheral or central nervous system.
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| Psychogenic and Idiopathic Pain: | show 🗑
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| show | Appropriate pain assessment is important to assure quality pain care. It may be challenging with pediatric patients and cognitively impaired older adults.
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| Pain Assessment and Management: (cont) | show 🗑
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