ASSESSMENT OF INTEGUMENTARY SYSTEM

ASSESSMENT OF INTEGUMENTARY SYSTEM

PATIENT PROFILE

Name                                       :       

Age                                          :       

Sex                                          :       

IP No                                       :       

Unit                                          :       

Ward                                        :

Date of Admission                   :

Religion                                   :       

Marital Status                          :       

Educational                             :

Reason for hospitalization       :

PRESENT HISTORY

C.O.L.D.S.P.A

C       -        Character           

O       -        Onset                  

L        -        Location             

D       -        Duration             

S        -        Severity              

P       -        Pattern               

A       -        Associated factors

SKIN

Current skin problem

          Rashes / LesIon / Dryness / Oilness / Drainage / Bruising / Swelling / Pigmentation increased.

Aggravating factor     :

Relieving factor           :

Change in tattoo or birthmark – color / size / shape.

Change in pain perception / touch / temperature / itching / tingling / numbness.

Body odour: increased / decreased.

Perspiration: increased / decreased.

Hair and Nail:

Hair loss / change in hair condition

Hair loss: Patchy / Generalized

Nail changes: Colour / condition / appearance

PAST HEALTH HISTORY

History of – treatment / surgery / Allergic skin reaction / Medication.

History of – fever / nausea / vomiting / gastro intestinal or respiratory problem.

History of – Pregnancy / Irregular menstrual cycle.

FAMILY HISTORY:

          History of illness in the family – rashes / allergy / other skin problem / skin cancer.

LIFE STYLE & HEALTH PRACTICES:

          History exposure to – chemicals / paints / bleach / cleansing products etc.

          Routine skin care / hair care.

          Dietary History – History of food allergy / Fluid intake.

COLLECTING OBJECTIVE DATA:

PHYSICAL EXAMINATION:

Preparing the client:

          Prepare the client for skin, hair and nail examination ask the client to remove all clothing remove jewellery and wear examination gloves. 

Equipments:

Ø Examination lights

Ø Penlight

Ø Mirror for the clients self examination.

Ø Magnifying glass

Ø Centimeter ruler

Ø Gloves

Ø Woods light

Ø Examination gown drape

Temperature – warm / cold / increased / body temperature

Mobility and Turgor – Pinches easily and return to normal

                                           Loss of turgor / decreased mobility /

Edema – Normal skin rebound / no deepening

                    Edema scale – Trace

                                      1+

                                      2+

                                      3+

                                      4+

SCALP AND HAIR:

          Inspection and Palpation

Hair color – Pale / Black / Patchy grey hair / Copper red hair /

Cleanliness – Dry / oily / dandruff / Excessive scaliness / Raised lesion /

SKIN:

Inspection:

 General skin condition / evenly colored / Discoloration / Pale Albinism / Erythema / Cyanosis – central / Peripheral

Skin integrity:

          Intact / skin breakdown / skin lesion / striae / birthmark / scars.

Colour variation:

          Vitiligo / albinism / rashes / Butterfly rashes /

PALPATION:

Skin texture:

          Smooth / even / rough / Flaky / Dry skin / Very thin /

Skin Moisture:

          Moist / dry /diaphoresis

Hair distribution:

          Equal / unequal / excessive bald / hair loss / Hirsutism

          Hair loss – Equal / Unequal

NAILS

Inspect for

          Grooming – clean / Dirty / broken / jagged finger nails /

          Colour and markings – Pink / longititudinal / ridging / pigmented / Cyanotic / pain / Fungal infection

COMMON LABORATORY AND DIAGNOSTIC STUDIES

Wood’s light Examination:

          Wood light or long ulcer violet light is used mainly in the examination of epidermal pigmentary disorders and cutaneus infection, applying long UV light to the skin in dark room causes epidermal pigment to appear accentuated while dermal pigmentary disorder with normal epidermal finding are obscured.

Micro porium audounis         -        Bright blue green

Micro porium cannis             -        Bright blue green

Micro porium distortum         -        Bright blue green

Tinea tonsurans                    -        Non fluresant

Tinea versicolor                    -        Dull golden yellow

Bacterial

          Erythrasma          -        Brilliant coral, red pink

          Pseudomonas     -        Yellowish green

Surface microscopy:

                  Illuminated and evaluated with magnifier.

         Asymmetry, Border irregularity, color variation, Diameter, Elevation or enlargement.

Scraping:

          Scraping and examination

Culture:

          To identify microbes

Patch Testing:

          To diagnose the allergens

Biopsy:

          To identify the pathology

NUTRITIONAL ASSESSMENT

·       Follow any particular diet

·       History of allergy to any foods like sea foods, eggs, green leafy.

·       History of any new diet before.

·       Dinner outside the home.

·       Take normal nutritional.