Integumentary Assessment PDF

Integumentary assessment (Skin, Hair, and Nails) Dr/ Fatma Mohamed Abdl hamid Lecturer of medical surgical nursing Integumentary assessment (Skin, Hair, and Nails) The skin, nails, hairs, glands, and associated nerve endings make up the integumentary system. Skin The skin acts a...

Integumentary assessment (Skin, Hair, and Nails) Dr/ Fatma Mohamed Abdl hamid Lecturer of medical surgical nursing Integumentary assessment (Skin, Hair, and Nails) The skin, nails, hairs, glands, and associated nerve endings make up the integumentary system. Skin The skin acts as a physical, biochemical, and immunological barrier between the outside world and the body. The Major Functions of the Skin:  Perceiving touch, pressure, temperature, and pain via the nerve endings  Protecting against mechanical, chemical, thermal, and solar damage  Protecting against loss of water and electrolytes  Repairing surface wounds through cellular replacement  Synthesizing vitamin D  Allowing identification through uniqueness of facial contours, skin and hair color, and fingerprints  Regulating body temperature Layers of the skin A. Epidermis B. Dermis C. Subcutaneous tissue The Major Functions of the Cutaneous Glands  o Excreting uric acid, urea, ammonia, sodium, potassium, and other metabolic  wastes  o Regulating temperature through evaporation of perspiration on the skin surface  o Protecting against bacterial growth on the skin surface  o Softening, lubricating, and waterproofing skin and hair  o Resisting water loss from the skin surface in low-humidity environments  o Protecting deeper skin regions from bacteria on the skin surface Provides the body with external protection, regulates temperature, and is a sensory organ for pain, temperature, and touch. Assessment of the skin reveals the patient‘s health status related oxygenation, circulation, nutrition, local tissue damage, and Hydration. The examination begins with a generalized inspection using a good source of lighting, preferably indirect natural daylight. Assessment of the skin involves inspection and palpation. Use the olfactory sense to detect unusual skin odors; these are usually most evident in the skinfolds or in the axillae. Pungent body odor is frequently related to poor hygiene, hyperhidrosis (excessive perspiration) Is most often daily and when the patient is  Newly admitted  Moved to a different level of care  Transferred  Discharged Survey skin at 3-year intervals for patients 20 to 40 years of age and annually for patients older than 40 years. For those older than age 50 or with dysplastic nevi or history of melanoma, encourage monthly self-examination and do regular clinical screening. The skin is the largest organ of the body comprising 15 percent of total body weight. Teach the ABCDE screen for dysplastic  nevi/melanomas: Asymmetry, irregular Borders, variation in Color, Diameter 6 mm, and Evolution or change in size, symptoms, or morphology. Hair Hairs are formed by follicles of specialized epidermal cells buried deep in the dermis. Nails o These are sheets of keratin that are continuously produced by the matrix at the proximal end of the nail plate.  Dermatological history History of presenting illness When was the problem first noticed? How have things changed since? Has it been a continuous or intermittent problem? Where did it start? Has it spread—is it still spreading? If spreading, is it spreading from the edge or appearing in crops? What is the distribution of the problem? Is there any discharge, bleeding, or scale? Is there pain, itch, or altered sensation? Has it started to resolve? Are there any obvious factors that either trigger or relieve the problem? Ask especially about the following: UV light (sunlight) Foods Temperature Contact with any other substances  What has it been treated with—was the treatment effective? Are there any systemic symptoms such as fever, headache, fatigue, anorexia, weight loss, or sore throat? PMH Are there previous skin problems? Does the patient have diabetes, connective tissue disease, inflammatory bowel disease, asthma? What does the patient use on their skin—e.g., soaps, creams, cleansers, aloe or other plant products? Allergies Remember to ask about the nature of any allergic reaction. Drug history Which drugs is the patient taking and for how long? Skin assessment includes Skin color Lesion Moisture Temperature Turgor Texture Edema Pallor is the result of inadequate circulating blood or hemoglobin andsubsequent reduction in tissue oxygenation.  In clients with dark skin, it is usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the Buccal mucosa  In brown-skinned clients, pallor may appear as a yellowish brown tinge  In black-skinned clients, the skin may appear ashen gray.  Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet. Vitiligo, seen as patches of hypo pigmented skin, is caused by the destruction of melanocytes in the area. Albinism is the complete or partial lack of melanin in the skin, hair, and eyes. Dark-skinned clients normally have areas of lighter pigmentation, such as the palms, lips, and nail beds. Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin. Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or venous abnormalities Skin lesion is an alteration in a client‘s normal skin appearance. Primary skin lesions are those that appear initially in response to some change in the external or internal environment of the skin Primary skin lesions are basic and simple Secondary skin lesions are those that do not appear initially but result from complications of primary skin lesions such as trauma, or infection Nurses are responsible for describing skin lesions accurately in terms of location (e.g., face), distribution (i.e., body regions involved), and configuration (the arrangement or position of several lesions) as well as color, shape, size, firmness, and texture o Any raised lesion or lump should be inspected and palpated o Note position, distribution, color, shape, size, surface, edge, nature of the surrounding skin, tenderness, consistency, temperature, and mobility o Ulcers should be examined just like any other skin lesion, noting the position, distribution, color, shape, size, surface, edge, nature of the surrounding skin, tenderness, consistency, and temperature. Primary lesions are flat or raised. Flat: You cannot palpate the lesion with your eyes closed. Macula: Lesion is flat and 1 cm. Raised: You can palpate the lesion with eyes closed. Raised without fluid Papule: Lesion is raised, 1 cm, but not fluid filled Raised with fluid Vesicle: Lesion is raised, 1 cm, and fluid filled Pustule: Lesion is raised, >1 cm, and fluid (pus) filled Cyst: Larger is raised, >1 cm, and fluid filled Raised with solid or semi solid mass Nodule: Lesion is raised, >1 cm, and solid or hard mass Cyst A 1-cm (0.4 in.) or larger, elevated, encapsulated, fluid filled arising from the subcutaneous tissue or dermis. epidermoid cysts, Nodule, Tumor Elevated, solid, hard mass that extends deeper into the dermis. Nodules have a circumscribed border and are 0.5 to 2 cm. squamous cell carcinoma, fibroma. Tumors are larger than 2 cm and may have an irregular border. malignant melanoma, hemangioma Macule, Patch Flat, un elevated change in color. , measles, petechiae, flat moles. Some skin color abnormalities Jaundice: a yellow tinge to the skin; best appreciated at sclera Carotenemia: a yellow–orange tinge to the skin that is similar to that of jaundice but the sclera are spared Hemochromatosis: slate-gray skin coloration Addison’s disease: darkened scars and skin  creases on the palms and soles–also darkening of mucosa Albinism: a lack of pigmentation with white skin  and pink irises Assessment of Hair & Nails  Thick hair E.g.: scalp hair, pubic hair.  Normal hair is strong and evenly distributed.  Assessing a client‘s hair includes inspecting the hair, considering developmental changes and ethnic differences, and determining the individual‘s hair care practices and factors influencing them. o Much of the information about hair can be obtained by questioning the client.  o In people with severe protein deficiency (kwashiorkor), the hair color is faded and appears reddish or bleached, and the texture is coarse and dry.  o Some therapies cause alopecia (hair loss), and some disease conditions and medications affect the coarseness of hair. For example, hypothyroidism can cause very thin and brittle hair. Important hair disorders and signs Male-pattern baldness Hair is lost first from the temporal regions, frontal area, and the crown. Alopecia areata is associated with autoimmune disorders. Sharply defined, non-inflammatory bald patches appear on the scalp. Alopecia totalis is loss of hair from all areas of the scalp. Alopecia universalis is loss of all body hair. Scarring alopecia: Inflammatory lesions causing hair loss include burns, and infection.  Nails are inspected for nail plate shape, angle between the fingernail and the nail bed, nail texture, nail bed color, and the intactness of the tissues around the nails The nail plate is normally colorless and has a convex curve. The angle between the fingernail and the nail bed is normally 160 degrees  Clubbed nails may indicate chronic hypoxia. Bases are flat or rounded, not concave. Cyanosis: May be present in the nail bed, indicating poor perfusion and possible underlying vascular insufficiency. Important nail disorders and signs Splinter hemorrhages are tiny, longitudinal streak hemorrhages under the nails caused by microemboli or trauma. Pitting involves tiny indentations in the surface of the nail. It is a feature of psoriasis and less commonly eczemaplanus, and alopecia areata. Onycholysis is is premature lifting of the nail. Leukonychia is white discoloration of the nail. It is a sign of low albumin or chronic ill health. Beau’s lines are transverse depressions in the nail. They coincide with arrested nail growth during a period of acute illness. Paronychia is infection of the skin adjacent to the nail, causing pain, swelling, redness, and tenderness. Koilonychia is spooning (concave indentation) of the nail. It is associated with severe iron deficiency. Clubbing: increase curvature of the nails leads to a loss of the diamond-shaped Onychomycosis is fungal nail infection causing the nail to become thickened, opaque, crumbly, and yellow.