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.

         

HEALTH ASSESSMENT ON CARDIOVASCULAR SYSTEM

HEALTH ASSESSMENT

ON

CARDIOVASCULAR

SYSTEM

PATIENT PROFILE

Name                                                 :          

Age                                                     :          

Sex                                                      :          

IP No                                                  :          

Unit                                                    :          

Ward                                                 :

Date of Admission                          :

Religion                                             :          

Marital Status                                  :          

Educational                          :

Reason for hospitalization           :

Present Medical History

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

Character                 :           Describe signs and symptoms

Onset                         :           When did it begins

Location                    :           Where it radiates

Duration                   :           How long does it lost?

Severity                     :           How bad it is

Pattern                      :           What makes better what makes it worse?

Associated factors  :          What other symptoms occurs with it.

Describe about chest pain   -        Pain/No Pain

When it starts / Type of Pain /

Rate the pain on pain scale

Perspiration / Palpitation / tiredness / Fatigue

Dyspnea       :           shortness of breath/ orthopnoea

Visual Analogue Scale

Shortness of breath 100mm

No shortness of breath

Subjective symptom:

On a scale 0 – 4

No distress                          0         1         2          3         4

Much distress                      0         1         2          3         4

Poor appetite                      0          1          2          3          4

Worn out                              0          1          2          3          4         

Suffocation                          0          1          2          3          4         

Tightness                              0          1          2          3          4         

Congestion                           0          1          2          3          4         

A feeling of panic               0          1          2          3          4         

New York Heart Association Classification

0       -  Not at all breathless

1       -  Breathless on heavy exercise (climbing 2 or 3 floors or waling    

    quickly)

2       -  Breathless on moderate excursion

3       -  Breathless on mild excursion

4       -  Breathless on minimal excursion

5       -  Breathless on minimal excursion

Past Health History:

Heart defect / mummer / Rheumatic heart disease / Previous history of cardiac surgery / intervention previous ECG / Blood test lipid profile / previous history of medication

Family History:

Family History of Hypertension / Myocardial infarction / coronary heart disease / elevated cholesterol level / Diabetes.

Life style and health care practices:

·        Smoking history

·        Packs per day

·        Years of smoking

·        Coping of stress mechanism

·        Alcohol consumption in a day / week

·        Exercise type of excessive

·        Describe the daily activity / change in the past 5 – 10 years / limitation in the performance of daily activity.

·        History of sexual activity

·        Number of pillows used for sleep Nocturnal

·        Anxiety regarding heart disease

·        Importance of having healthy heart

HEAD TO FOOT ASSESSMENT

General appearance          :           Thin / Moderate built / obese

Height                                    :           in cm

Weight                                  :           in kg

Head

Face                           :           Symmetrical / Asymmetrical

Edema                       :           Present / Absent

Eye                           :          

Eye brow                  :           Equal distribution of hair/

                                                Sparingly distributed /

                                                Absent

Eye lashes                 :           Equal distribution of hair/

                                                Sparingly distributed /

                                                Absent

Conjunctiva             :           Pale / yellow / pink / per orbital cyanosis

Eye lids                      :           Able to open & close / ptosis

Pupils                        :            PERLA

Eye

Position                     :           Above the level of outer cantus /

                                                At the level of outer canthus /

                                                Below the level of outer canthus

Drainage                   :           Present / Absent

Nostrils                      :           Patent / Obstructed

Septum                     :           Centre / deviated

Discharge                 :           present / absent

Mouth

Lips                             :           Dry / Moist / cyanosis

Gums                         :           Health / Swollen / gingivitis

Odour                        :           Present / Absent

Throat                       :           Normal / inflamed

Neck

Trachea                     :           Midline / deviated

Retraction                :           Present / Absent

Upper Extremity

ROM                          :           Full / Limited

Abdomen

Inspection                :           Shape / Scar / Lesion

Auscultation            :           Bowel sound / Present /

                                                Absent / Borborgymi

Percussion                :           Tymphony / resonant / dull

Palpation                  :           Organomegali / tenderness

Lower Extremity

ROM                          :           Full / limited

Capillary refill          :           <3 seconds / >3 seconds

Genitalia

External                     :           Drainage / edema

                                                Inflammation / odour

 

REVIEW OF SYSTEM

Preparing the patient for cardiac assessment

            Explain and expose only the area to be evaluated.

            Wear examination gown. Explain procedure.

Equipments:

·        Stethoscope

·        Small pillow

·        Penlight or movable examination light

·        Watch

·        Centimeter ruler – 2

·        Centimeter tape

·        Stethoscope

·        Tourniquet

·        Gauze or tissue

·        Water proof pen

·        Blood pressure cuff

Cardiac land mark:

1.     Aortic area

2.     Pulmonic area

3.     Mid pericardial area (Erb’s point)

4.     Tricuspid area

5.     Mitral area

Carotid inspection:

            Pulsation / Cardiac land mark

Palpation:

            For pulsation / thrills / Leaves

Auscultation:

            Auscultate carotid artery –

No blowing / Swising / or other sound

Pulse equality or unequal

Pulse amplitude sound

            0          =          absent

            1+       =          weak

            2+       =          normal

            3+       =          increased

            4+       =          bounding

Auscultate pericardium

            At the apex / sinus arrhythmia

Bradycardia -           < 60 beats / minute

Tachycardia -           > 100 beats / minute

Premature ventricular contraction / Arterial fibrillation / arterial flutter. Pulse rate deficit.

S₁        -           lub      -           loudest at the apex

S₂        -           dub     -           loudest at the base

Accentuated / diminished / varying / split sound

Extra sounds:

            Ejections sound / click /

S₃        -           physiologic / pathologic

S₄        -           physiologic / pathologic

Murmurs:

Ø Innocent physiologic mid systolic murmur /

Ø Pathologic midsystolic / pan systolic / diastolic murmur

Ø Auscultation on change of position

HISTORY OF PRESENT HEALTH CONCERN

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

Character                             :

Onset                         :

Location                                :

Duration                               :

Severity                                 :

Pattern                                  :

Associated factors :

Present Medical History

·        Change in color, temperature, or texture change in skin.

·        Pain or cramping pain (aching / stabbing)

·        How often

·        Wake up from sleep

·        Leg veins ropelike, bulging, contorted

·        Any sores or open wounds, Location and pain

·        Any swelling legs or feet. Time of swelling worst. Pain with swelling.

·        Swollen glands or lymph nodes. Tender, soft or hard.

·        Sex history.

Past Medical History

·        Problems in the circulation of arms and legs.

·        Any heart blood vessel surgeries or treatment.

Family History

            Family history of diabetes / hypertension / coronary heart disease / elevated triglyceride levels.

Life style and health practices

·        Smoking

·        Pack per day

·        Year of smoking

·        History of exercise FITT

·        Use of transdermal contraceptives.

·        Describe the degree of stress

·        Problems with circulation

·        Leg ulcers, varicose veins – feeling about

·        Medication history

·        Support hose          

APMS:

Physical assessment:

Inspection

Ø Observe arm size and venous pattern look for edema.

Bilaterally equal / No edema. Lymph edema

Ø Observe coloration of the hands and arms-

Bilateral coloration symmetrical. Pallar, cyanosis, redness.

Palpation

·        Finger hands­­                        ­­- Temperature – warm / cool

·        Capillary refill time              - 1- 2 seconds

        >2 seconds.

·        Radial pulse                          - 2+ /Increased / bounding / diminished

·        Ulnar pulses                         - not deductable / inelastic

·        Brachial pulses                    - equal / strength / symmetric

·        lymph Node                         - not palpable / palpable

·        Allens test                             - coloration 3-5 seconds / > 5 seconds / pale

LEGS

Color              -                      pink / brown / pallor / Rubor cyanosis /

            rusty brownies pigmentation

Distribution

Of hair                       -           even distribution / loss of hair

Lesion or ulcers       -           free of ulcer / ulcer with smooth

                                                Ulcer with irregular edges

Edema

·        1+       -           slight pitting

·        2+       -           deeper than 1+

·        3+       -           deep + extremity looks larger

·        4+       -           very deep gross edema extremity

·        Bilateral / Unilateral

Temperature of the feet and legs

            Warm / coolness / increased temperature

Superficial inguinal lymph nodes

            Non tender / lymph node larger than 2 cm /

Femoral pulses                    :           strong / equal / weak /

Auscultation                                   :            No sound / bruits /

Popliteal pulses                   :           Palpable / not palpable /

Dorsalis pedis                      :           Bilateral / weak / absent /

Posteriortibial pulses         :           Present / Bilateral / weak / absent /

Varicosities &

Thrompophlebitis  :           No varicosity / varicose veins / bulging /    

                                                            Nodular /

Homan’s sign                       :           Negative / Positive /

Special Test for aterial venous insufficiency

Position change

            Test                :           pink / light pale / pallor coloration > 15 seconds

Trendlenberg

            Test                :           Fill from below / fill from above

CENTRAL NERVOUS SYSTEM:

Level of consciousness         : Alert and awake/ Letharg/Obtunded/Stupor/Coma.

Dress and Grooming             : Neat/ Meticulous grooming.

Facial expression                    : Good eye contact/ Poor eye contact.

Speech                                      : Moderate tone/ Slow / Repetitive.

Head ache                                : Present Absent.

RESPIRATORY SYSTEM:

Symmetry of chest wall          : Symmetrical / Asymmetrical.

Rate/ Rhythm/Pattern            : Resonant/ Hyper resonant.

INTEGUMENTARY SYSTEM:

Color of the skin                    : White skins/Darker skins/ Pallor/ Cyanosis.

Skin capillary refill                 : Pink tone return immediately,

/ < 3 seconds   >3 Seconds.

Distribution of hair                : Hair covers the scalp/ Hair loss.

MUSCULO SKELETAL SYSTEM:

Gait                                           : Posture erect/ UN even weight bearing.

ROM                                         : Full ROM against resistance/ Pain / Spasms

Swelling                                   : No bulge/ Bulge of fluid.

Size / Shape / Deformities   : Symmetric without deformities/ Redness/ heat/

                                                   Swelling / Deformities.

Muscle strength                     : Complete absence of contraction (0)/ Normal

                                                       Strength (5)/ (Scale 0 – 5)

GENITO URINARY SYSTEM:

Urethral discharge                 : Free of discharge/ a yellow discharge.

Inguinal hernia                        : Bulging or mass not seen/ A bulge or mass seen

VITAL SIGN:

Temperature                           :

Pulse                                         :

Respiration                              :

B.P                                             :

Pain scale :                       Numerical pain scale

                                               

                              0      1     2       3        4        5      6      7      8         9      10

NUTRITIONAL ASSESSMENT

A.    Diet history

-          Ask about a history of nausea, vomiting and abdominal pain

-          Ask about increase or decrease in food or fluid intake

Excessive thirst                            :           (present in Diabetes insipidus)

Salt craving                                  :           (present in Adrenal hypo function)

Increase in hunger & thirst        :           (present Diabetes mellitus)

Rapid change in weight :           Diabetes mellitus / Thyroid problems

B.    ANTHROPOMETRIC MEASUREMENTS

Height                                              :           in cm

Weight                                             :           in kg

BMI                                                   :           Weight in Kg

                          M2

Normal limits                                  :           20 – 25

Overweight                                      :           25 - 29.9

Obese (class I)                                 :           30 – 34.9

Moderately obese (class II)           :           35 – 39.9

Extremely obese (class III)             :           > 40

Ideal body weight                           :           Current weight

                                                                      ---------------------    X  100

                                                                      Ideal body weight

Mild obesity              :    20 – 40 %

Moderate obesity     :    40 – 100 %

Morbid obesity         :     > 100%

Waist Hip Ratio                               :           Waist in inches          Female  : 0.8 (normal)

                                                                       Hip in inches           Male      : 1 (normal)