Integumentary System Assessment

Integumentary System Assessment and Interventions

• Physical Assessment - Inspect and palpate skin, hair, and nails from head to toe.

  • Skin: Assess color, temperature, moisture, texture, thickness, vascularity, bruising, mobility, and turgor.
  • Hair: Inspect and palpate scalp and hair for surface characteristics, distribution, texture, quantity, and color. Inspect facial and body hair.
    • Surface characteristics: Should be smooth without flaking, scaling, redness, or lesions.
    • Shiny and soft: Hair should appear shiny and soft.
    • Quantity and quality: Note any balding patterns or hair loss.
    • Texture and color: Assess texture and color.
  • Nails: Inspect nails for shape, contour, color, consistency, thickness, and cleanliness.
    • Edges: Note if edges are smooth and rounded.
    • Shape and contour: Nails should appear flat and slightly rounded.
    • Consistency: Inspect for grooves, depressions, pitting, and ridges.
    • Color: Pink in light-skinned individuals, yellow/brown with vertical lines in dark-skinned individuals.

• Equipment:

  • Strong direct lighting
  • Small centimeter ruler
  • Penlight
  • Gloves
  • Stethoscope (for auscultation)

• Age-related Changes:

  • Slower wound healing
  • Increased risk of skin breakdown in older adults
  • Skin thinning
  • Difficulty regulating temperature
  • Wrinkling/loss of elastin and collagen
  • Reduced muscle tone

• Cultural Considerations:

  • Blanching (turning white) may not occur in darker-skinned individuals.
  • Skin color cannot be used to assess for pressure injuries in dark-skinned individuals.
  • Melanoma is 20 times more common in white individuals than black individuals and 4 times more common in Hispanic individuals.

• Skin Color Variations:

  • Light Skin:
    • Pallor: White or pale.
    • Erythema: Red or bright pink.
    • Cyanosis: Dusky blue.
    • Jaundice: Yellow sclera (whites of the eyes) and hard palate of the mouth.
  • Dark Skin:
    • Pallor: Yellow-brown or grey.
    • Erythema: Purplish tint.
    • Cyanosis: Dark, dull, lifeless.
    • Jaundice: Yellowing of the hard and soft palate and palms of the hands.

• Selected Integumentary Variations:

  • Acne: Inflammatory papulopustular skin eruption, often on the face, neck, shoulders, and upper back.
  • Psoriasis: Chronic skin disease resulting in scaly, itchy patches.
  • Alopecia: Partial or complete hair loss.
  • Eczema (Dermatitis): Inflammation of the skin characterized by itchiness, redness, and a rash.

• Normal Integumentary Findings:

  • Striae: Silver or pink stretch marks.