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ARIZONA COLLEGE NUR 216 - Full Body Assessment

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Full Body AssessmentCare of the skinAnatomy and PhysiologyIntegumentary system - consist of the skin, hair, nails, sweat and sebaceous glands2 layers: epidermis - thicker, outer layer contains melanin and sheds every 3-4 weeks dermis - thinner, inner layer contains blood and lymphatic vessels, nerves, base of hair follicles, sebaceous and sweat glandsFunction of the SkinProtection - bodies 1st line of defenseSensation - heat, cold, pressure, touch, and painRegulation - maintain fluid and electrolyte balance by preventing fluid losssweat glands - concentrated in axilla and external genitaliaSecretion/excretion - sweat glands secrete fatty acids and proteins and excrete urea, NaCl, and H2OVitamin D formation - cholesterol changed to vitamin D on exposure to UV light from the sunFactors Affecting the SkinHealth Statusdampness, dehydration, nutritional status, insufficient circulation, skin disease, jaundice, lifestyle and personal choicesDevelopmental Stageinfants with fragile skin, grows and skin become more resistant to injury and infectionBathing morbidly obese patients BMI >30skin assessment is essential, pay attention to skin foldsinterventions include: hygiene, moisture, pressure and friction, and nutritionNursing ProcessAssessmentsubjective data - ask patient about bathing, skin care practices, past or current skin problems, allergic skin reactions, prescriptions or herbal remediesobjective data - inspect area of the skin observe for: rashes, lumbs, lesions, cracking changes in skin color: pallor, erythema, jaundice, cyanosisNursing Diagnosiscommon skin problems include:pruritus - scratching and breaks in skindry skin - crack, burn, or itchexcoriation - loss of superficial layers of the skinabrasion - rubbing away of the epidermal layer, especially over bony prominences caused by frictionpressure injury - lesions caused by tissue compression and inadequate perfusionacne - inflammation of the sebaceous glands that is common in young adultsburns - injury caused by thermal, electrical, chemical, or radioactive agentsNursing ProcessPlanning InterventionFor impaired skin integrity-bathing, cutaneous stimulation, perineal care, pressure management, wound careFor risk for impaired skin integrity-bed rest care, circulation precautions, pressure ulcer prevention, and positioningPlanning Outcomeoral hygiene, tissue integrity, wound healing, immobility consequencesCommon foot problemscorn - cone shaped thickening of epidermis by continuous pressure over bony prominencescalluses - usually over weight bearing part of the foot eg. heel, soles, or plantar surfacetinea pedis - also called athlete's foot, fungal infection aggravated by moisture symptoms: itching, burning, blisters, scalding, and crackingingrown toenail - grows inward into soft tissue , nail may need to be surgically removedfoot odor - produced when microbes grow on the feet interact with perspirationplantar wart - painful growth caused by virus, develop under pressure pointspressure injuries - lesions caused by unrelieved pressure that impairs the circulationbunion - progressive disorder that begins with the enlargement of the 1st metatarsal joint at the base of big toeCare of the feetNursing ProcessAssessmentcolor and temperature of feet give data about circulation and oxygenation of patientNursing Diagnosisfeet can be affected by malformations, injury, improper footwear, and medical conditionPlanning Outcomesavoid trimming calluses, wear shoes that fit properly, inspect feet regularlyPlanning Interventionsteach patient about self care -important for diabetic patients or patients with poor peripheral circulation -patients with neuropathy may not experience pain from a foot injuryNursing AssessmentAssessmentsubjective data - usual nail care practice, history of nail problemsobjective data - shape, contour, and cleanliness, manicured and trimmed, unclean or rough fingernails, harbor dirt and bacteriaNursing Diagnosisrisk for impaired tissue integrity or risk for infectionsPlanning Outcomerelated to circulation, infection, tissue integrity, or wound healingPlanning Interventioneducate patient on nail inspections, trim with clipper, remove hangnails, use moisturizer, etcCare of the nailscomposed of epithelial tissuehealthy = clean, pink, smooth, convex, and evenly curvedmaintain integrity of mucous membranes, teeth, and gums -prevent tooth loss and gum diseaseimportant to have -routine dental checkups -adequate nutrition -daily mouth careRisk factors -history of periodontal disease-lack of money or insurance- pregnancy - hormones increase vascularity and cause gums to become puffy easily bleed-poor nutrition or eating habits-medications or medical treatmentsOral hygieneCommon problemsdental caries - caused by failure to remove plaqueplaque - invisible bacterial film that builds up on the teeth, destroys tooth enameltartar - causes deterioration of the supporting structures that hold teeth in the gums and bone bone tissueperiodontal disease - major cause of tooth lossgingivitis - inflammation of the gum tissue surrounding the teethhalitosis - also known as bad breath, results from poor oral hygiene, eating habits, tobacco use, dental caries, infectionsstomatitis - inflammation of the oral mucosacaused by bacteria, trauma, irritants, nutritional deficiencies, and infectionglossitis - inflammation of the tongue, caused by deficiency in vitamin B12, folic acid, and ironcheilosis - cracking or ulceration of the lips, reddened fissures at the angle of the mouth, caused by deficiencies in vitamin B-complexoral malignancies - lumps, ulcers, white or red patches, bleeding, pain, persistent sores, or numbnessNursing ProcessAssessmentsubjective data - asking patient about hygiene practices, tobacco and alcohol useobjective data - inspect lips, oral mucosa, ms, and tongueNursing Diagnosis-risk of infection related to mouth lesion-imbalanced nutrition related to lack of teeth-impaired oral mucous membrane integrity-pain related to mouth lesionsPlanning Outcome-demonstrate correct techniques for brushing and flossing-make preventive dental visit every 6 monthsPlanning Intervention-provide supplies or complete care as necessaryaccessory structure to skin vellus hair - short fine, present much of the body terminal hair - coarser, darker and longer hair located: scalp, eyebrows, axillaw, perineum, and legshelps: maintain body temperature, tactile sensation receptor for tactile sensation, and

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