General Survey/Skin/Nutrition study. Regardless of your specialty or practice setting, each of your patient encounters should begin with a brief study of the overall characteristics of the individual, which is referred to as the general survey (Jarvis, 2016). It is this brief overview that provides you with the first impression of your patient and enables you to quickly gauge his or her level of distress thus allowing you to prioritize your care delivery more efficiently. The general survey begins the minute you walk into the room and includes not only the patient but his or her surroundings as well. So what kinds of things can we assess simply by observing our patients?
- Distress level—Are they breathing, is it labored, are they grimacing or displaying other outward signs of distress?
- Physical appearance—Are they clean, dressed appropriately for the weather, displaying any obvious injuries?
- Behavior—Is it appropriate for the situation and for their age?
- Age—Do they look their stated age?
- Nutritional status—Thin, obese, cachexic
- Skin—Scars, discolorations, jaundice, ashen, obvious open areas, signs of abuse
- Mobility—ROM, gait, assistive devices
- Environment—Safety hazards, equipment, odors, and so on.
With consistent use of this sequential and evidenced-based approach to patient assessment during each patient encounter, nurses are better equipped to recognize early signs of decline (Considine & Currey, 2015).
Reflect on your last patient admission. What was the first thing you recall noticing when you first entered the patient’s room? How did these findings help you to prioritize your care?
Assessing the Integumentary System
The skin, hair, and nails make up the integumentary system. The integumentary system protects the body from excessive heat, ultraviolet rays, trauma, and it acts as a barrier for protection against infection.
Identification and reduction of risk factors related to skin disorders, including skin cancer, are among the objectives for Healthy People 2020 (DHHS, 2014). Melanoma, the third most common skin cancer, is more dangerous to younger populations and is caused by exposure to ultraviolet rays including sun, tanning beds and tanning lamps (CDC, 2015). Other risk factors for skin cancer include a history of prolonged sun exposure, skin cancer and environmental exposure to chemicals such as coal tar and radiation.
Common client complaints include itching, rashes, lesions, hair loss, hirsutism, and changes in nail growth or color. Any one of these problems may be related to a variety of medical, environmental, or lifestyle factors, therefore we need to ask the right questions to get good information that will help the healthcare team plan treatment and care. What questions would you ask these people?
Asking the Right Questions: Skin, Hair, and Nails
- The client comes in complaining of uncontrollable itching all over his or her body.
- The client comes in complaining of hair loss.
- While conversing with your client, you discover that her nails are now very brittle and break often.
Many assessment skills are second nature to us and come from the use of our senses. This is especially true when we think of skin, hair, and nails. Whenever we meet a stranger for the first time, or someone we know well, we take a mental inventory of how that individual appears.
You may come across a variety of lesions when you assess your client’s skin. A good rule of thumb for assessing lesions is to remember ABCDE.
Color and Configuration
Diameter and Drainage
Evolution or progression of the lesion
Hair and Nails
Take note of patterns of hair loss and growth. If a client complains about an itchy scalp, flaking, or sores, drill down a bit further and use inspection to investigate what the scalp looks like. While looking at the scalp, ask the client if there have been any changes in shampoo or soap, new stresses, or unusual environmental exposure. When examining the scalp, you should palpate the scalp and note any irregularities such as depressions or elevations on the scalp which could be due to trauma from accident or injury, for example, during a sports events or recreational activity. In the older adult, falls with injuries such as head trauma are of major concern.
A nail assessment may not be as obvious but it is extremely important. Nails should be examined for any cyanosis, spooning, clubbing or discoloration. A client’s nail health gives us insight into overall grooming and general health. The nails are a good indicator of a number of systemic illnesses.
Because skin and hair disorders affect physical appearance, be sensitive to these insecurities as you assess the patient. Reflect on how best to address such problems that affect the client’s quality of life and how to offer suggestions about ways to improve these situations.
Cultural and Life Span Considerations
Children’s dry skin should be monitored. Information should be provided to parents as to when to seek the assistance of the healthcare provider or when mild lotions can be used. Tattoos and body piercings are very popular with adolescents and young adults. This once culturally-based practice is becoming more common and poses a significant health risk for skin and systemic infections.
Aging skin takes more time to repair due to increased dryness and elasticity. All clients should be taught how to do a self-examination on their skin with the help of both a full-length and hand-held mirrors.
Jarvis (2016) defines nutritional status as being the balance between nutrient intake and nutrient requirements. Optimal status is achieved through the consumption of sufficient nutrients necessary to support the daily needs of the body as well as any increase in metabolic demands that may occur as the result of growth, pregnancy, or illness. Much like the skin, the nutritional status of an individual can provide a glimpse into their overall wellbeing and can be impacted by economic, cultural, psychosocial, developmental, and physical factors.
Nutritional assessments are noninvasive, easy to complete, and inexpensive and can range from a simple nutritional screening aimed at identifying individuals at risk for nutritional deficits and increasing in depth and complexity up to the comprehensive nutritional assessment which encompasses a dietary history, clinical information, physical examination, anthropometric measures, and laboratory tests.
Patients displaying alterations in nutritional status can be present in all clinical settings. While the causes may vary those at highest risk of developing malnutrition in the clinical setting include the elderly, surgical patients, and those requiring extended stays and are most commonly attributed to metabolic responses to trauma, disease pathology, ill health contributing to the inability to perform self-care, and poor meal provision (Langley-Evans & King, 2014).
Your Turn! to participate in regards to General Survey/Skin/Nutrition study
Take a moment to visit the CDC website at https://nccd.cdc.gov/NPAO_DTM/ (Links to an external site.) to explore the nutritional statistics specific to your state. What factors specific to your community do you think might be contributing to these numbers?
Steps to Conducting a Nutritional Assessment
- Obtain a health history relevant to nutritional status.
- Elicit dietary history if indicated.
- Inspect skin, hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems for clinical signs and symptoms suggestive of nutritional deficiencies.
- Measure height, weight, BMI, WC, and other anthropometric parameters as indicated.
- Review relevant laboratory tests.
- Offer health promotion teaching.
Summary in regards to General Survey/Skin/Nutrition study
This week, we began with a general assessment and began our in-depth look at nutrition and our first body system, the skin. As we progress through the coming weeks, we will use a systematic approach to explore the physical assessment process as it relates to each of the body systems.
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