Chapter Objectives:
- Obtain a health history of the integumentary system.
- Describe variations of normal findings of the integumentary system
- Describe common lesions of the skin, hair, and nails.
- Perform physical assessment of the integumentary system using correct techniques of assessment.
- Document the integumentary system assessment
I. Overview of Assessment of the Hair, Skin and Nails
The assessment of the integumentary system which includes the skin, hair and nails is an important element of the nurse’s assessment of the patient’s health status. These body structures do have specific functions but they also reflect functions or dysfunctions of other body systems as well. This chapter presents important concepts that will prepare the nurse to assess the patient’s integumentary system.
II. Review of Anatomy and Physiology
Knowledge of anatomy and physiology of body systems is essential to the assessment process as the nurse compare normal expected findings and patient manifestations. Open the following resources to review foundational concepts:
Anatomy and Physiology of the Integumentary System
III. Medical Terminology:
Open the link below and learn the definitions of the terms below:
Medical terminology: Integumentary System
Macule
Papule
Nodule
Cyst
Ecchymosis
Cyanosis
Excoriation
Fissure
Ulcer
Vesicle
Pustule
IV. Integumentary system focused Assessment
| This is usually not a specific step, but evaluating the skin, hair, and nails is an ongoing element of a full body assessment . In certain instances, a comprehensive or focused skin assessment must be performed, such as assessing risk factors for pressure ulcers.
Skin, hair, and nails:
|
Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes.
Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure. Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft. |
V. Documentation
VI. Related Laboratory Tests and Diagnostic Procedures
VII. Learning Activities: This video provides NCLEX style questions to assess your knowledge of integumentary system assessment:
https://www.youtube.com/watch?v=LGf0YXKzxWI
VIII. Citations and Attributions
