{"id":1092,"date":"2022-12-12T11:53:40","date_gmt":"2022-12-12T16:53:40","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/starting-your-assessment\/"},"modified":"2024-05-03T15:28:03","modified_gmt":"2024-05-03T19:28:03","slug":"starting-your-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/starting-your-assessment\/","title":{"raw":"Starting Your Assessment","rendered":"Starting Your Assessment"},"content":{"raw":"The integumentary system has fundamental characteristics that you will notice immediately. With more experience, you will learn what to consider during your subjective and objective assessment. See Table 2<\/strong> for descriptions of clinical manifestations related to integumentary issues.\r\n\r\nTable 2:<\/strong> Clinical manifestations of integumentary issues.\r\n
\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
 \r\n\r\nManifestation<\/strong><\/td>\r\n \r\n\r\nConsiderations<\/strong><\/td>\r\n \r\n\r\nExamples<\/strong><\/td>\r\n<\/tr>\r\n
 \r\n\r\nPattern\/distribution<\/strong>\r\n\r\nIs there a pattern to what you are seeing?<\/td>\r\n \r\n\r\nIntegumentary issues are rarely random or evenly distributed across the body. Consider the pattern or distribution of the integumental variation.<\/td>\r\n \r\n\r\nRashes that are ring-shaped, linear, or clustered around a blood vessel.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nMorphology<\/strong>\r\n\r\nWhat is the structure\/constitution of what you are seeing?<\/td>\r\n \r\n\r\nConsider whether it is presented discretely (singular; e.g., a lesion, growth, tumour), as a grouping\/cluster (e.g., infestation, rash), or confluent (small lesions [pb_glossary id=\"1440\"]coalescing[\/pb_glossary] into a larger lesion).<\/td>\r\n \r\n\r\nPus-filled blisters, movable, squishy lumps, [pb_glossary id=\"1442\"]vesicular[\/pb_glossary].<\/td>\r\n<\/tr>\r\n
 \r\n\r\nLocation\u00a0<\/strong>\r\n\r\nWhere is the variation located on the body?<\/td>\r\n \r\n\r\nConsider nearby anatomical landmarks and other considerations such as moisture, heat, and other exposure (e.g., urine, stool, saliva) in the region.<\/td>\r\n \r\n\r\nRashes around the mouth, around genitalia, limited to the trunk, or on the bottom of feet and palms of hands. Skin breakdown over bony prominences or under compression stockings.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nTexture<\/strong>\r\n\r\nWhat is the texture of the variation?<\/td>\r\n \r\n\r\nConsider whether the variation is dry or wet, scaling or crusted.<\/td>\r\n \r\n\r\nLesions that have crusts, rashes that are scaly in appearance or flaking.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nSymmetry\u00a0<\/strong>\r\n\r\nIs the integumentary variation distributed symmetrically?<\/td>\r\n \r\n\r\nExamine the symmetry of the variation. Is it distributed evenly on the body? Is there an asymmetrical distribution? Is there a generalized variation or is it localized to a specific region?<\/td>\r\n \r\n\r\nRashes that only appear on one side of the body. Skin eruption that is generalized all over the body. Itchiness that is localized to one region of the body.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nColour<\/strong>\r\n\r\nWhat colour is the variation?<\/td>\r\n \r\n\r\nThe colour of the variation (whether generalized or localized to a specific variation) is meaningful. Note the colour and any changes in colour.<\/td>\r\n \r\n\r\nCentralized cyanosis. Erythemic rash.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nSensation\u00a0<\/strong>\r\n\r\nIs the client experiencing any loss of sensation or [pb_glossary id=\"1438\"]dysesthesia[\/pb_glossary]?<\/td>\r\n \r\n\r\nNumbness or tingling could be the result of innervation of the integument.<\/td>\r\n \r\n\r\nNumbness in extremities. Tingling at the site of a vesicle. Burning sensation associated with a rash.<\/td>\r\n<\/tr>\r\n
 \r\n\r\nOther\u00a0<\/strong>\r\n\r\nIs the skin weeping? Is blood involved? Consider any odour, size, and changes.<\/td>\r\n \r\n\r\nConsider other issues related to the integument, e.g., is the client experiencing fever, nausea, vomiting, anorexia, fatigue? (these types of issues can sometimes suggest a systemic cause).<\/td>\r\n \r\n\r\nWeeping: Crusting, hyperkeratosis, or scale.\r\n\r\nBlood vessels: Visible blood vessels, increased superficial vasculature (telangiectasia).\r\n\r\nOdour: Foul-smelling ulcers may be infected.\r\n\r\nTime: What did it look like when it started? Did it change?\r\n\r\nSize: Petechiae (< 2 mm), purpura (>2 mm), and ecchymosis (1\u20132 cm).<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n
\r\n

Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n
\r\n\r\nAlways assess levels of acuity related to the integument. Certain conditions require immediate attention, while others may require prompt or gradual interventions. Necrosis<\/strong> (black tissue) is a form of tissue death that is typically associated with a pathological process and requires immediate intervention. Factors that can lead to necrosis include prolonged compression, bacterial infection, injury, disease, and environmental conditions. Necrotic tissue cannot be revived and normally requires debridement (removal).<\/span>\r\n\r\nDepending on the severity, clients with acute trauma to the integument, burns, or frost exposure<\/strong> may require urgent intervention. Lacerations and burns can rid the body of fluids and may require immediate fluid replacement (with intravenous). Any infections that spread quickly<\/strong> also require immediate intervention. Understanding the cues that prompt critical interventions is an important nursing skill.<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n
\r\n

Contextualizing Inclusivity<\/strong><\/span><\/h2>\r\nPersons experiencing homelessness have a higher prevalence of skin infections and non-melanoma skin cancers compared to the general population (Adly et al., 2021). They may find it difficult to access clean water, sanitation, and hygiene facilities. Use a person-centred and non-judgmental approach to help clients manage integumentary conditions. For example, you could link clients to organizations that provide clean clothing, water, and sanitation if needed. As a nurse, you should use a critical lens to identify health inequities, and this includes advocating for systemic changes to improve health conditions for all.<\/span>\r\n\r\n<\/div>\r\n

References<\/span><\/h2>\r\nAdly, M., Woo, T. E., Traboulsi, D., Klassen, D., & Hardin, J. (2021). Understanding dermatologic concerns among persons experiencing homelessness: A scoping review and discussion for improved delivery of care. Journal of Cutaneous Medicine and Surgery. 25(6): 616-626.<\/span>","rendered":"

The integumentary system has fundamental characteristics that you will notice immediately. With more experience, you will learn what to consider during your subjective and objective assessment. See Table 2<\/strong> for descriptions of clinical manifestations related to integumentary issues.<\/p>\n

Table 2:<\/strong> Clinical manifestations of integumentary issues.<\/p>\n

\n\n\n\n\n\n\n\n\n\n\n\n
 <\/p>\n

Manifestation<\/strong><\/td>\n

 <\/p>\n

Considerations<\/strong><\/td>\n

 <\/p>\n

Examples<\/strong><\/td>\n<\/tr>\n

 <\/p>\n

Pattern\/distribution<\/strong><\/p>\n

Is there a pattern to what you are seeing?<\/td>\n

 <\/p>\n

Integumentary issues are rarely random or evenly distributed across the body. Consider the pattern or distribution of the integumental variation.<\/td>\n

 <\/p>\n

Rashes that are ring-shaped, linear, or clustered around a blood vessel.<\/td>\n<\/tr>\n

 <\/p>\n

Morphology<\/strong><\/p>\n

What is the structure\/constitution of what you are seeing?<\/td>\n

 <\/p>\n

Consider whether it is presented discretely (singular; e.g., a lesion, growth, tumour), as a grouping\/cluster (e.g., infestation, rash), or confluent (small lesions

 <\/p>\n

Pus-filled blisters, movable, squishy lumps,

 <\/p>\n

Location\u00a0<\/strong><\/p>\n

Where is the variation located on the body?<\/td>\n

 <\/p>\n

Consider nearby anatomical landmarks and other considerations such as moisture, heat, and other exposure (e.g., urine, stool, saliva) in the region.<\/td>\n

 <\/p>\n

Rashes around the mouth, around genitalia, limited to the trunk, or on the bottom of feet and palms of hands. Skin breakdown over bony prominences or under compression stockings.<\/td>\n<\/tr>\n

 <\/p>\n

Texture<\/strong><\/p>\n

What is the texture of the variation?<\/td>\n

 <\/p>\n

Consider whether the variation is dry or wet, scaling or crusted.<\/td>\n

 <\/p>\n

Lesions that have crusts, rashes that are scaly in appearance or flaking.<\/td>\n<\/tr>\n

 <\/p>\n

Symmetry\u00a0<\/strong><\/p>\n

Is the integumentary variation distributed symmetrically?<\/td>\n

 <\/p>\n

Examine the symmetry of the variation. Is it distributed evenly on the body? Is there an asymmetrical distribution? Is there a generalized variation or is it localized to a specific region?<\/td>\n

 <\/p>\n

Rashes that only appear on one side of the body. Skin eruption that is generalized all over the body. Itchiness that is localized to one region of the body.<\/td>\n<\/tr>\n

 <\/p>\n

Colour<\/strong><\/p>\n

What colour is the variation?<\/td>\n

 <\/p>\n

The colour of the variation (whether generalized or localized to a specific variation) is meaningful. Note the colour and any changes in colour.<\/td>\n

 <\/p>\n

Centralized cyanosis. Erythemic rash.<\/td>\n<\/tr>\n

 <\/p>\n

Sensation\u00a0<\/strong><\/p>\n

Is the client experiencing any loss of sensation or

 <\/p>\n

Numbness or tingling could be the result of innervation of the integument.<\/td>\n

 <\/p>\n

Numbness in extremities. Tingling at the site of a vesicle. Burning sensation associated with a rash.<\/td>\n<\/tr>\n

 <\/p>\n

Other\u00a0<\/strong><\/p>\n

Is the skin weeping? Is blood involved? Consider any odour, size, and changes.<\/td>\n

 <\/p>\n

Consider other issues related to the integument, e.g., is the client experiencing fever, nausea, vomiting, anorexia, fatigue? (these types of issues can sometimes suggest a systemic cause).<\/td>\n

 <\/p>\n

Weeping: Crusting, hyperkeratosis, or scale.<\/p>\n

Blood vessels: Visible blood vessels, increased superficial vasculature (telangiectasia).<\/p>\n

Odour: Foul-smelling ulcers may be infected.<\/p>\n

Time: What did it look like when it started? Did it change?<\/p>\n

Size: Petechiae (< 2 mm), purpura (>2 mm), and ecchymosis (1\u20132 cm).<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n

\n
\n

Priorities of Care<\/strong><\/h2>\n<\/header>\n
\n

Always assess levels of acuity related to the integument. Certain conditions require immediate attention, while others may require prompt or gradual interventions. Necrosis<\/strong> (black tissue) is a form of tissue death that is typically associated with a pathological process and requires immediate intervention. Factors that can lead to necrosis include prolonged compression, bacterial infection, injury, disease, and environmental conditions. Necrotic tissue cannot be revived and normally requires debridement (removal).<\/span><\/p>\n

Depending on the severity, clients with acute trauma to the integument, burns, or frost exposure<\/strong> may require urgent intervention. Lacerations and burns can rid the body of fluids and may require immediate fluid replacement (with intravenous). Any infections that spread quickly<\/strong> also require immediate intervention. Understanding the cues that prompt critical interventions is an important nursing skill.<\/span><\/p>\n<\/div>\n<\/div>\n

\n

Contextualizing Inclusivity<\/strong><\/span><\/h2>\n

Persons experiencing homelessness have a higher prevalence of skin infections and non-melanoma skin cancers compared to the general population (Adly et al., 2021). They may find it difficult to access clean water, sanitation, and hygiene facilities. Use a person-centred and non-judgmental approach to help clients manage integumentary conditions. For example, you could link clients to organizations that provide clean clothing, water, and sanitation if needed. As a nurse, you should use a critical lens to identify health inequities, and this includes advocating for systemic changes to improve health conditions for all.<\/span><\/p>\n<\/div>\n

References<\/span><\/h2>\n

Adly, M., Woo, T. E., Traboulsi, D., Klassen, D., & Hardin, J. (2021). Understanding dermatologic concerns among persons experiencing homelessness: A scoping review and discussion for improved delivery of care. Journal of Cutaneous Medicine and Surgery. 25(6): 616-626.<\/span><\/p>\n