Asepsis, Skin, Head, & Neck

Elizabeth Bruderle
Villanova University

Asepsis

Definition: Absence of disease producing microorganisms (Pathogens)

Types: Medical and Surgical
Describe degree of asepsis
Describe type of technique

Medical Asepsis/Clean technique

Goal: Decrease number of organisms; e.g. Handwashing (Clean)
Asepsis

Surgical Asepsis/Sterile Technique
Goal: Eliminate organisms and spores;
e.g. Operating Room (Sterile)

Contamination: Break in aseptic technique
Unclean/Dirty: Pathogens present
e.g. soiled bandage
Unsterile: Touched by unsterile object
e.g. sterile glove touched by ungloved hand 

Skin: Integumentary System

Anatomy and Physiology

Stratified layers
Epidermis: 2 layers
Dermis
Subcutaneous Tissue

Appendages
Sweat glands: Apocrine and Eccrine
Sebaceous glands
Hair
Nails

Developmental variations

Newborn: acrocyanosis, desquamation, milia, lanugo, vernix caseosa
Adolescent: secondary sex characteristics,
acne vulgaris
Elderly: benign skin lesions, changes in epidermis, dermis, subcutaneous tissue, hair, & nails
Health teaching: Skin cancer 

Factors that Affect Skin Integrity: Nurse assesses patient for risk factors and initiates interventions: Who is at risk?

Circulation
Mobility
Nutritional status
Neurological status
Developmental level 
Knowledge
Bowel/bladder function: moisture

Assessment: Skin, Hair, & Nails

What techniques/equipment will you use?
What concerns need to be addressed?
History questions:
Past history/ Family history
Present status
Current problems/changes: include description, contributing factors, methods of relief
Risk Factors & Health Teaching 

Skin: Integumentary system
Specific History Questions:

burns, infectious diseases, itching, rashes, bug bites, allergic reactions, moles, changes in color/texture of skin, changes in moles, bleeding, bruising, exposure to sun, level of sun protection used

Physical Exam

Skin

Inspect and Palpate, Head to Toe:
color, integrity, lesions, hygiene, pigmentation, foreign bodies, turgor, moisture, temperature, texture, edema
Inspect and Palpate Lesions:

Structure: size, shape, elevation or depression 
Classification: primary, secondary, vascular

Hair:

Inspect and Palpate
distribution, quantity, quality, color, texture, hygiene, parasites

Nails: 

Inspect and Palpate
color, shape, contour, texture, hygiene,
nail bed, nail adhesion, cuticles, capillary refill (brisk/delayed)
Documentation: Assessment & Health Teaching

Head and Neck

Developmental Variations

Infant: molding. fontanelles, sutures, short neck 
Adolescent male: cricoid cartilage enlarges
Adult/Elderly: ROM may be limited

Assessment
What techniques/equipment will you use?
What concerns need to be addressed?

Assessment of Head

History Questions
Birth trauma, injuries, headache, seizures, syncope
Describe attributes of symptoms, e.g. onset, frequency, related symptoms, precipitating factors, methods of relief
Identify risk factors
Provide relevant health teaching

Physical Exam

Size of head: normocephaly vs. micro, macro, hydrocephaly 

Shape of head
Facial Landmarks:

Palpebral Fissures (ptosis, exopthalmos)
Nasolabial Folds
Symmetry of facial features
Fasiculations

Documentation: include findings, risk factors, and health teaching

Assessment of Neck

History Questions
Infections, fever, hoarseness, masses, dysphagia, stiffness, surgery, pain, stress, radiation, travel

Physical Exam

Inspect: symmetry, ROM, scars, masses
Palpate: thyroid, trachea, cervical lymph nodes
Auscultate: thyroid, carotid arteries for bruits

Cervical Lymph Nodes
Classification: preauricular, posterior auricular, occipital, tonsillar/parotid, submaxillary, submental, posterior cervical, superficial cervical, deep cervical, supraclavicular
Should be non-palpable, non-tender (may find small, mobile, non-tender nodes in healthy individuals)
Describe: location, size, shape, mobility, consistency, tenderness