Assessing the Integumentary System Checklist PDF

Preview

Summary

Health Assessment in Nursing Return Demonstrations...

Description

Assessing the Integumentary System Definition: Assessment of the integumentary system is a very crucial part of every medical health assessment. It involves a careful and thorough assessment of the skin, the largest organ of a human’s body. This involves the observation of the skin’s color, temperature, texture,and general appearance which can provide important information about a patient’s overall health condition. This is basically the system that is most easy to examine for it can directly be seen and observed. Objectives: 1. To be able to identify any problems/abnormalities related to the patient’s skin. 2. To differentiate the patient’s general skin appearance to what we know is normal. 3. To be able to describe the overall skin condition of the patient and identify the need for nursing care. Safety/Security Measures: 1. Proper hand hygiene 2. Use the right tools and equipment and always follow correct procedures. 3. Wear proper/appropriate clothing (PPE) Pre-procedural Preparations: 1. Wash hands 2. Introduce yourself to the client and identify client’s identity. Explain what you are going to do, why it is necessary, and how the client can cooperate. 3. Gather the necessary equipment. 4. Provide Privacy Equipment: Examination gloves, Millimeter Ruler, Magnifying glass Procedure

Normal Findings/Abnormal Findings

Inquire if client has any history of the following:  Pain or itching 

Presence and spread of any lesions, bruises, abrasions, or pigmented spots



Skin problems



Associated clinical signs



Problems in other family members



Related systemic conditions



Use of medications, lotions, or home remedies



Excessively dry or moist feel to the skin



Tendency to bruise easily



Any association of the problem to a season of the year

Rationale: To collect information about the patient’s past and current health history and identify any health associated problems. Current problems may be a recurrence of previous ones. Reference: Health Assessment in Nursing book (sixth edition)

No history of pain or itching. No presence of bruises, lesions, abrasions, or pigmented spots. Allergic to chicken. No problems in other family members. No related systemic conditions. Use of medications, lotions and home remedies are confirmed. No experiences of having excessively dry or moist skin. No tendency to bruise easily. No association of the problem to a season of the year.

Able to perform

Unable to perform

1.

Inspect skin color. Rationale:

To identify signs of jaundice, pallor, cyanosis, and even skin cancer.

The patient has a fair skin color without prominent discoloration. No signs of abnormalities such as skin cancer, jaundice, cyanosis, and other skin related problems.

Reference:

Health Assessment in Nursing book (sixth edition), (page 258 of unit 3)

2.

Inspect uniformity of skin color. Rationale:

To identify any skin pigmentation disorders.

Patient’s skin color is uniform and fair except in areas which are mostly exposed to sun/sunlight. Nonetheless, patient has no signs of skin pigmentation disorders.

Reference:

Chapter 30 of Health Assessment Pearson (www.pearson.com)

3.

Assess edema, if present. Rationale:

Edema may cause skin stretching to a point of pruritus and discomfort.

There are no edema or any swelling present on the patient’s skin.

Reference:

Edema: Common Risk Factors and Complications by woundsource editors (November, 2019)

4.

Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or draining. Describe lesions according to location, distribution, color, configuration, size, shape, type, or structure. Assess for Malignant Lesions A=symmetry B=Border of irregularity C=Color variation D=Diameter> 0.5 cm Rationale:

Some skin lesions may lead to skin cancer. Reference: Health Assessment in Nursing (sixth edition), (page 260 of unit 3)

No lesions palpated

5.

Observe and palpate skin moisture. Palpate for tenderness and surface characteristics of any lesions. Rationale:

Skin moisture can be a good indicator of a patient’s health condition. Excessive moisture or excessive dryness may indicate serious health problems.

The patient’s skin moisture is observed to be at a normal level. No skin tenderness palpated. No signs of abnormalities such as hyperthermia and dehydration.

References:

Health Assessment in Nursing (sixth edition), (page 261 of unit 3) Health Assessment - Pearson (www.pearson.com)

6.

Palpate skin temperature. Compare the client’s two feet and the two hands using the dorsal part of the nurse’s hand Rationale:

The patient has a uniform temperature within a normal range. No signs of hypothermia and hyperthermia.

To detect any signs of hypothermia and hyperthermia. This will also be a good indicator of the patient’s overall health condition. References:

Health Assessment in Nursing (sixth edition), (page 261 of unit 3) Health Assessment -Pearson (www.pearson.com)

7.

Note skin turgor by lifting and pinching the skin on an extremity.

Patient’s skin turgor is normal. Skin springs back to its original position within a second Rationale: or two. No signs of dehydration and edema observed. To assess skin elasticity and detect any signs of dehydration and edema. References:

Health Assessment in Nursing (sixth edition), (page 261 of unit 3) Health Assessment -Pearson (www.pearson.com)

8.

Check for blanching of vascular lesions Rationale:

Blanching helps identify good blood flow. Deep vascular lesions may need treatment with surgery or laser treatment.

No vascular lesions present.

Reference:

Skin Care & Pressure Sores Part 3: Recognizing and Treating Pressure Sores (http://sci.washington.edu/info/pamphlet s/SCI_skin3.pdf) 9.

Document findings in the client record. Draw the location of skin lesions on body surface diagrams. Rationale:

General findings of the assessment done should always be documented in a health record chart to keep record for current and future references and further evaluation.

Patient’s overall skin condition is normal with no signs of abnormalities and skin disorders.

(own formulated rationale based on my understanding)

EXPERT PROFICIENT COMPETENT MARGINAL

Remarks:

CLINICAL INSTRUCTOR: MS. JENICA EUGENIO

DATE: FEBRUARY 15, 2021...