BSN211 Clinical Health Assessment - Integumentary System PDF

BSN211 Clinical Health Assessment - Theory Integumentary System Assessment Skin, Hair, and Nails 2024/2025 Week 3  Learning Objectives By the end of this lecture the student will be able to: Review the structure and function of the skin, na...

BSN211 Clinical Health Assessment - Theory Integumentary System Assessment Skin, Hair, and Nails 2024/2025 Week 3  Learning Objectives By the end of this lecture the student will be able to: Review the structure and function of the skin, nails and hair. Obtain subjective data related to Integumentary system. Discuss objective data collection of skin, hair and nails. 2 Structure of the Skin 3  Functions of the Skin Protection Prevention of penetration Temperature regulation Identification Communication Wound repair (Wound Healing) Absorption and Excretion Production of Vitamin D 4  Subjective Data 1. Previous history of skin disease? Any previous skin disease or problem? How was it treated? Any family history of allergies or allergic skin problem? Any known allergies to drugs, plants ,animals? Any birth marks, tattoos? 5  Subjective Data 2. Change in pigmentation Hypopigmentation: loss of the pigmentation- “Vitiligo” Hyperpigmentation: increase in color Generalized change: systemic illness, pallor, jaundice, cyanosis 3. Change in mole: color, size, shape 6  Subjective Data 4. Excessive dryness or moisture Seborrhea: oily skin Xerosis: dry skin 5. Pruritus = itching 6. Medications 7  Nursing Diagnosis Example Disturbed body image related to change in pigmentation as evidenced by patient's expression of concern or discomfort 8  Objective Data Color (Inspection) Observe general Pigmentation Benign pigmentation include: Freckles Moles Birthmarks Observe widespread color changes: Pallor, erythema, cyanosis and jaundice Transient or expected or due to pathology. 9  Pallor- White Skin Color change: Pallor- white skin Loss of redness from oxygenated hemoglobin, skin replaces the color with collagen (connective tissue) Sign of anxiety, fear, stress, anemia- vasoconstriction Severe anemia. Dark skinned- appear gray (lips, mucous membranes, nails) Check conjunctiva and nail beds for assessing anemia. 10 Pallor- White Skin 11  Nursing Diagnosis Example Impaired tissue perfusion related to decreased blood flow and oxygenation as evidenced by pallor 12  Erythema: Red Skin Color change: Erythema- red skin From excess blood (hyperemia) in dilated superficial capillaries. Often associated with fever, local inflammation and emotional reactions blushing in vascular flush area (neck, cheeks, upper chest). 13  Erythema: Red Skin Color change: Erythema- red skin More blood to vessels - increases temperature In dark skinned - palpate skin for warmth, tightly pulled skin. 14  Nursing Diagnosis Example Disturbed skin integrity related to inflammation and increased blood flow as evidenced by erythema 15  Cyanosis: Bluish Skin Color change: Cyanosis - bluish skin Signifies decreased perfusion, reduced oxygenation. Seen in lips, nose, cheeks, ears and oral mucous membrane. Occurs with hypovolemic shock, heart & respiratory problems. Dark-skinned: Difficult to observe. Other clinical signs of hypovolemic shock: Changes in level of consciousness and respiratory distress. 16 Cyanosis: Bluish Skin Cyanosis 17  Nursing Diagnosis Example Impaired gas exchange related to decreased oxygen saturation as evidenced by cyanosis 18  Jaundice- Yellow skin Color change: Jaundice- yellow skin Increased amounts of bilirubin in the blood. First noted in the junction of the hard and soft palate in the mouth and in the sclera. Then overall body. Occurs with hepatitis, cirrhosis, sickle cell anemia and transfusion reaction. 19  Nursing Diagnosis Example Impaired bilirubin metabolism related to hepatic dysfunction as evidenced by clinical presentation and laboratory findings 20 External Variables Influencing Skin Color 21  Vascularity or bruising: Vascularity or bruising: Observe for bruises or needle marks, document presence of tattoos. Bruising: Multiple bruise (ecchymosis) above knees or elbows should raise concern about physical abuse. Different colors- Different stages of healing: 1. Red- immediately after trauma (24 hrs.). 2. Blue to purple. 3. blue- to green. 4. Yellow. 5. Brown to disappearing. 22 Vascularity or bruising: 23  Temperature: palpation Temperature: palpation Note your own temperature and use dorsa (back of hand) to palpate the patients. Temperature change: Hypothermia: - Generalized coolness in shock, and surgery. - Localized coolness in peripheral arterial insufficiency (limb in cast or with IV infusion). Hyperthermia: - Generalized with increase metabolic rate (fever) - localized with infection or trauma. 24  Moisture : palpation Moisture: Observe skin for change in moisture, and palpate! Moisture change: Diaphoresis: Perfuse perspiration, accompanies an increased metabolic rate, in heavy activity or fever Dehydration: Dry skin and mucous membranes, cracked lips, fissures in the skin. 25  Texture & Thickness : palpation Texture: Observe skin for smoothness with even surfaces Thickness: Observe for thickened skin Thickness change: Callus: circumscribed overgrowth of epidermis, skin adapted to excessive pressure (weight bearing, friction) 26  Edema: Palpation Edema: Fluid accumulation in intercellular spaces Types of Edema:- - Imprint your thumbs firmly against ankle, malleolus or tibia 1- Non-pitting edema: no dent or mark after applying thumb pressure. 27  Edema: Palpation 2- Pitting Edema: if pressure leaves dent (hollow). - Scale to grade pitting edema: 1+ Mild pitting, slight indentation. 2+ Moderate pitting, indentation subsides rapidly. 3+ Deep pitting, indentation remains for short time, leg looks swollen. 4+ Very deep pitting, indentation lasts a long time, leg is very swollen. 28  Edema: Palpation Checking for Bilaterally pitting pretibial edema edema 29  Mobility and Turgor: palpation Mobility and Turgor: Mobility: is the skin’s ease of rising and Turgor is the ability to return to place = elasticity. To check: Pinch up a large fold of skin on the anterior chest under the clavicle. 30  Mobility and Turgor: palpation Mobility and turgor changes: Poor mobility: Scleroderma “hard Skin” and in edema. Poor turgor: dehydration, weight loss. Skin “stands” by itself. 31  Lesions Equipment Gloves Magnifier glass Lesions Traumatic or pathological changes in previously normal skin structures. Inspect and Palpate: use gloves, assess depth, temperature, gently scrape, assess surrounding skin. 32  Lesions Describe skin lesions according to: 1. Color 2. Elevation: flat or raised 3. Location and distribution: localized or generalized. 4. Size: use ruler and measure in cm 5. Pattern or shape- Configuration: arrangement in relation to each other. 6. Exudate: note color and / or odor. 33  Lesions Describe skin lesions according to: 7. Primary or secondary lesion: Primary lesions: develops on unaltered skin, present at onset of disease. Secondary lesions: changes over time due to disease progression, treatment or manipulation (scratching, picking, rubbing). 34  Lesions: ABCDE Lesions Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE: Asymmetry Border irregularity Color variation Diameter greater than 6mm Elevation or Enlargement 35  Lesions: ABCDE Additional Symptoms - Lesion Rapidly changing lesion. A new pigmented lesion. Development of itching, burning, or bleeding in a mole. Any of these signs should raise suspicion of malignant melanoma and warrant referral. 36 Classification of Skin lesions according to Configuration 1. Annular, or circular, begins in center and spreads to periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea). 2. Linear, a scratch, streak, line, or stripe. 3. Confluent, lesions run together (e.g., urticaria [hives]). Refer table 12-3: common shapes and configuration of lesions 37  Classification of Skin lesions according to Configuration 4. Discrete: individual lesions that remain separate 5. Zosteriform, linear arrangement along a unilateral nerve route (e.g., herpes zoster). 6. Grouped: clusters of lesions (e.g., vesicles of contact dermatitis). Refer table 12-3: common shapes and configuration of lesions 38  Objective Data: Primary skin lesions PRIMARY skin lesions: The immediate result of a specific causative factor; primary lesions develop on previously unaltered skin. Types of PRIMARY skin lesions (refer to table 12-4) 1. Macule: Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, measles, scarlet fever. 2. Patch: Macules that are larger than 1 cm. Examples: Mongolian spot, vitiligo, measles rash. 39  Objective Data: Primary skin lesions 3. Papule: Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in epidermis. Examples: elevated nevus (mole), wart (verruca). 40  Objective Data: Primary skin lesions 4. Nodule: Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi. 41  Objective Data: Primary skin lesions 4. Wheal: Superficial, raised, transient, and erythematous; slightly irregular shape. Examples: mosquito bite, allergic reaction. 5. Urticaria (Hives): Wheals coalesce to form extensive reaction, intensely pruritic. 42  Objective Data: Primary skin lesions Types of PRIMARY skin lesions (refer to table 12-4) 6. Cyst: Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen. 43 Objective Data: Secondary skin lesions Secondary skin lesions :Resulting from a change in a primary lesion from the passage of time; an evolutionary change. NOTE: Combinations of primary and secondary lesions may coexist in the same person. 44 Objective Data: Secondary skin lesions 1. Crust: The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus). Examples: impetigo (dry, honey- colored), weeping eczematous dermatitis, scab after abrasion. 45 Objective Data: Secondary skin lesions 2. Fissure Linear crack with abrupt edges; extends into dermis; dry or moist. Examples: cheilosis—at corners of mouth caused by excess moisture; athlete's foot. 46 Objective Data: Secondary skin lesions 3. Erosion: : Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis. 47 Objective Data: Secondary skin lesions 4. Ulcer: Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure injury. 48  Braden Scale for Pressure Ulcer Assessment Developed 1984 by Braden and Bergstrom Six elements that contribute to either higher intensity and duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development. 1. Sensory perception 2. Moisture 3. Activity 4. Mobility (ability to change own position) 5. Nutrition 6. Friction and shear activity Each item is scored between 1 and 4 guided by a descriptor. 49  Braden Scale for Pressure Ulcer Assessment The lower the score, the greater the risk. 15 + = low risk 13-14 = moderate risk 12 or less = high risk Below 9 = severe risk 50  Braden Scale Pressure Ulcer Assessment Criteria 1 2 3 4 Sensory Completely limited Very limited Slightly limited No impairment Perception Moisture Constantly moist Very moist Occasionally moist No impairment Walks Activity Bedfast Chairfast Walks occasionally frequently Completely Mobility Very limited Slightly limited No limitation immobile Probably Nutrition Very poor Adequate Excellent inadequate No apparent Friction & Shear Problem Potential problem None problem Score 6 24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Ulcer Risk Severe High Moderate Low 51 Objective Data: Secondary skin lesions 5. Scar: After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne. 52  Nursing Diagnosis Examples Risk for infection related to open skin lesions and immunosuppression. Impaired skin integrity related to external factors, altered tissue perfusion, and inadequate nutrition as evidenced by skin assessment. 53 Skin Self Examination 54 Skin Self Examination 55 Skin Self Examination 56  Hair Assessment Subjective Data Hair loss Any recent hair loss? Did it happen suddenly or slowly? Associated with fever, illness or stress? Any unusual hair growth? Any recent change in hair texture? Are changes correlated with life events (pregnancy)? 57  Hair Assessment Subjective Data Abnormal Findings: Alopecia: hair loss Causes of Alopecia include: Male pattern balding. Chemotherapy. Injury. Infection. Hirsutism: excessive facial hair in women Pediculosis: head and pubic lice 58  Hair Assessment Objective Data Change in Hair: Inspect and palpate hair and scalp. 1. Color: depends on melanin production (black to light blonde), reduced melanin production- gray hair. 2. Texture: fine, thick, straight, curly, or kinky. 3. Distribution: Is distribution conforms to normal male and female pattern (all over body & in genital area). 4. Lesions: separate the hair and lift it, if itching is reported, observe the scalp for (Seborrhea: dandruff). Hair should be clean and free of lesion. 59  Nails Assessment Subjective Data Nails: Any changes in nail color, consistency (uniformity), and shape? Ask about self-care practices and footwear. 60  Nails Assessment Objective Data Inspect and palpate: Nail surface Nail folds Nail edges Nail base (angle of nail base) 61  Nails Assessment Objective Data Change in Nails: Inspect and palpate Shape and Contour: nail surface normally slightly curved, the angle of nail base (160 degrees). 62  Nails Assessment Objective Data Shape and Contour: Abnormal Findings: Clubbing: rounded, nail base is enlarged, with a nail base angle exceeding 180 degrees (convex shape). May indicate chronic hypoxia. 63  Nails Assessment Objective Data Nail edges are smooth, rounded and clean. Borders are approximated, skin is without erythema, edema, and exudate. Note dirty nails, bitten nails, traumatized. 64  Nails Assessment Objective Data Consistency Surface is smooth and regular, not brittle Nail thickness is uniform. Nails adheres to nail bed, base is firm on palpation. Ridges: transverse grooves/lines may indicate a nutrient deficiency. 65  Nails Assessment Objective Data Color Nail bed pink and even. Dark skinned - brown black pigmented areas. White linear marking - accidental injury/abnormal marking. Inspect toenails: Separate toenails and note smooth skin in between. 66  Nails Assessment Objective Data Capillary refill Indicates status of peripheral circulation (vascularity) Depress the nail edge to blanch and release Note if the return color is instant or not within 1 or 2 seconds. 67  Nails Assessment Objective Data Abnormal Findings: Cyanotic nail beds: cardiovascular or respiratory dysfunction. Sluggish color return: Takes more then 1-2 seconds indicates cardiovascular or respiratory dysfunction. 68  Nursing Diagnosis Example Ineffective Tissue Perfusion related to low hemoglobin as evidenced by Capillary refill >3 seconds 69 70  References Jarvis, C (2016). Physical Examination and Health Assessment (7th ed.). Philadelphia: W.B. Saunders, USA. Jarvis, C (2012). Physical Examination and Health Assessment (6th ed.). Philadelphia: W.B. Saunders, USA. https://www.nursetogether.com/ 71