10.6 Applying the Nursing Process
Open Resources for Nursing (Open RN)
Assessment
Subjective Assessment
During a subjective assessment of a client’s integumentary system, begin by asking about current symptoms such as itching, rashes, or wounds. If a client has a wound, it is important to determine if a client has pain associated with the wound so that pain management can be implemented. For clients with chronic wounds, it is also important to identify factors that delay wound healing, such as nutrition, decreased oxygenation, infection, stress, diabetes, obesity, medications, alcohol use, and smoking.[1] See Table 10.6a for a list of suggested interview questions to use when assessing a client with a wound.
If a client has a chronic wound or is experiencing delayed wound healing, it is important for the nurse to assess the impact of the wound on their quality of life. Reasons for this may include the frequency and regularity of dressing changes, which affect daily routine; a feeling of continued fatigue due to lack of sleep; restricted mobility; pain; odor; and the side effects of multiple medications. The loss of independence associated with functional decline can also lead to changes in overall health and well-being. These changes include altered eating habits, depression, social isolation, and a gradual reduction in activity levels.
Table 10.6a Interview Questions Related to Integumentary Disorders
| Symptoms | Questions | Follow-up Questions |
|---|---|---|
| Current Symptoms | Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole? | Please describe. |
| Wounds | Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury?
If a wound is present:
|
Please describe.
Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the “Pain Assessment Methods” section of the “Comfort” chapter. |
| Medical History | Have you ever been diagnosed with a wound related to diabetes, heart disease, or peripheral vascular disease? | Please describe. |
| If chronic wounds or wounds with delayed healing are present: | ||
| Medications | Are you taking any medications that can affect wound healing, such as oral steroids to treat inflammation or help you breathe? | Please describe. |
| Treatments | What have you used to try to treat this wound? | What was successful? Unsuccessful? |
| Symptoms of Infection (pain, purulent drainage, etc.) | Are you experiencing any symptoms of infection related to this wound such as increased pain or yellow/green drainage? | Please describe. |
| Stress | Have you experienced any recent stressors such as surgery, hospitalization, or a change in life circumstances? | How do you cope with stress in your life? |
| Smoking | Do you smoke? | How many cigarettes do you smoke a day? How long have you smoked? Have you considered quitting smoking? |
| Quality of Life | Has this