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Nursing Fundamentals Exam 2 Notes OLOL Nurs 2750.docx

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Fundamentals Exam 2 Chapters: 4, 5, 27, 28, 31, 32, 39, and 48 Protection & Adaptation – Integumentary System Overview  The skin is the body’s largest organ, comprising 15% of the total bod... y weight.  The skin (1) acts as a protective barrier against disease-causing organisms, (2) is a sensory organ for pain, temperature, and touch, and (3) synthesizes vitamin D.  Injury to the skin poses risks to safety and triggers a complex healing response.  Knowing the normal healing pattern will assist in recognizing alterations that require intervention. Integumentary System  Refers to skin, hair, scalp, nails  Begin with health history (subjective data)  Followed by the physical examination (objective data) – visible surfaces  Sight, smell, and touch – inspection and palpation  Patient’s health status – oxygenation, circulation, nutrition, local tissue damage, and hydration Integumentary Assessment  Adequate lighting  Equipment - gloves, penlight, and small centimeter ruler  Room temperature  Inspection  Skin odors Subjective Data  Health History Questions – Table 31-7, 31-10, 31-11 o Past history of skin disease, allergies, hives, psoriasis, or eczema? o Change in pigmentation or color? o Change in mole size, shape, color, tenderness? o Excessive dryness or moisture? o Pruritus or skin itching? o Excessive bruising? o Rash or lesions? o Medications: prescription and over-the-counter? o Hair loss? o Change in nails’ shape, color, or brittleness? o Environmental or occupational hazards? o Self-care behaviors?  Additional history for infants and children o Does child have any birthmarks? o Any change in skin color as a newborn?  Physiologic jaundice?  Cyanosis? o Does child have any rash or sores? o Does child have diaper rash? o Does child have any burns or bruises?  Where?  How did it happen? o Has child been exposed to:  Contagious skin conditions: scabies, impetigo, lice?  Communicable diseases: measles, chicken pox, scarlet fever?  Toxic plants: poison ivy? o Does child have habits such as nail biting or twisting hair? o What steps are taken to protect child from sun exposure?  Additional history for adolescents o Skin problems such as pimples, blackheads?  Additional history for aging adults o What changes have you noticed in your skin in last few years? o Any delay in wound healing? o Any change in feet: toenails; bunions, wearing shoes? o Falling: bruises, trauma? o History of diabetes or peripheral vascular disease? [Show More]

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