integumentary system assessment

integumentary system assessment

an evaluation of the general condition of a patient's integument and of factors or abnormalities that may contribute to the presence of a dermatological disorder.
method The patient is asked to supply subjective information about itching, pain, rashes, blisters, or boils; whether the skin usually is dry, oily, thin, rough, bumpy, or puffy; or whether it feels hot or cold, peels, changes in color, or is marked with dark liver (aging) spots. Objective information is gleaned from inspecting the skin. Observations are made of the intactness, turgor, elasticity, temperature, cleanliness, odor, wetness or dryness, and color of the skin. Cyanosis of the lips, circumoral area, mucous membranes, earlobes, or nailbeds; jaundice of the sclera; paleness of conjunctivae; and distribution of pigment are noted. Evidence of rashes, edema, needle marks, insect bites, scabies, acne, sclerema, decubiti, uremic frost on the beard or eyebrows, or pressure areas over bony prominences is recorded. The nails are examined for brittleness, lines, a convex ram's horn or concave spoon shape, and the condition of surrounding tissue, including clubbing of the fingers and toes. The existence and characteristics of lesions such as maculae, papules, vesicles, pustules, bullae, hives, warts, moles, ulcers, scars, keloids, petechiae, lipomas, crusts of dried exudate, flakes of dead epidermis, excoriations, blackheads, and chancres are noted. The patient's exposure to parasites, to internal allergens in food and drugs, and to external allergens in cosmetics, soaps, topical medication, and plants, as well as a family history of allergies, is investigated, as well as currently used medication, creams, lotions, ointments, hygienic measures, and sexual practices. Diagnostic aids contributing to the evaluation are skin and lesion cultures, punch biopsies, skin tests for allergies, a lupus erythematosus preparation, and a blood culture.
nursing interventions The nurse conducts the interview to obtain subjective data on the patient's condition, makes the necessary observations, and assembles the background information and results of the diagnostic tests.
outcome criteria A well-conducted assessment of the patient's integument is a valuable aid in diagnosing a dermatological disorder or a disease with dermatological manifestations, such as palmar rash in syphilis.