Lesson 1 Integument, Eyes, Ears

Integument system components

Skin, nails, hair, scalp, sweat and sebaceous glands

Integument system information

Shows overall health, hygiene and information on self-care activities; skin cancer awareness, prevention and identification

Health history questions - skin

Rashes, lesions, changes in color or itching; bruising or bleeding

Health history questions - allergies

Allergies to medications, plants, food; assess for hives, airway involvement, itching, tongue swelling

Health history questions - sun exposure

Exposure to sun and sunburn history

Health history questions - hygiene

Routine bathing habits

Health history questions - body modifications

Body piercings/tattoos

Health history questions - moles

Assess for presence and changes in moles

Health history questions - mobility

Degree of mobility

Health history questions - culture

Cultural practices related to hygiene and skin

Integument assessment beginning

Begin with general survey and move to physical assessment

Integument assessment techniques

Inspection and palpation; what you see and feel

Integument assessment privacy

Protect patient privacy; expose only the body part being examined

Integument assessment PPE

Wear gloves if lice or open sores

Inspection - color abnormalities

Erythema, cyanosis, jaundice, pallor

Inspection - vascularity

Ecchymosis, petechiae

Inspection - lesions

Assess for presence and characteristics of lesions

Nails inspection

Shape, angle, texture and color

Normal nail characteristics

Convex should follow natural curvature of finger; smooth, firm and nontender

Normal nail angle

Angle between nail and base is 160 degrees

Skin turgor test

Small fold of skin picked up and then released should return to normal shape

Dehydration skin turgor

Skin returns slowly

Decreased skin turgor in elderly

Normal finding with older patients as elasticity decreases and skin thins

Erythema

Redness

Ecchymosis

Collection of blood in subcutaneous tissue

Petechiae

Hemorrhagic spots/capillary bleeding

Cyanosis

Bluish or grayish color

Jaundice

Yellow color

Pallor

Paleness

Diaphoresis

Excessive perspiration

Turgor

Elasticity

Edema

Excess fluid

Head and neck assessment - risk factors

Identify changes in vision or hearing, history of allergies, chronic illnesses, exposure to harmful substances or smoking, history of infection or trauma

Head and neck assessment techniques

Inspection and palpation; assess visual acuity, extraocular movements, peripheral vision, hearing and sound conduction, thyroid gland and lymph nodes

Snellen E-chart distance

Patient stands 20 feet from chart

Snellen E-chart procedure

Read smallest line of letters first (possible); test both eyes and then one eye at a time

Snellen E-chart denominator

20 over the smallest line they can read (e.g., 20/20, 20/40)

Eye assessment components

External eye structures, symmetry and alignment, visual acuity, extraocular movements, peripheral vision

External ear assessment

Shape, size and lesions

Normal external ear characteristics

Smooth, symmetrical and proportional to head; painless

Nares assessment positioning

Tip patient head back slightly to visualize nares

Nares mucous membranes assessment

Color, lesions, exudate or growths

Normal nares characteristics

Moist and darker red than oral mucous membranes

Sinuses assessment

Gentle pressure on bony prominences of upper cheek

Normal sinuses

Not painful with palpation

Mouth and pharynx assessment

Lips, tongue, teeth, gums, hard and soft palate, salivary glands, tonsillar pillars and tonsils