Nursing Department Medical & Surgical Nursing course 2 2010-2011. Assessment of Clients with Integumentary Disorders. Presented By: Miss. Ahdab Eskan dar. Outlines. Introduction Integumentary system assessment Skin Functions Skin changes associated with aging Assessment techniques
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Medical & Surgical Nursing course 2
Assessment of Clients with Integumentary Disorders
Presented By: Miss. Ahdab Eskandar
An examination of the integument requires some understanding of the structure and function of the system. There also needs to be an awareness of the appearance of the skin, hair, nails, and mucous membranes in healthy and diseased states.
*The skin is the largest organ in the body:
12-15% of body weight, with a surface area of 1-2 meters.
*Skin is divided into three layers; the epidermis, the dermis, and the subcutaneous tissues.
The elastic fibers are replaced with collagen fibers, and sebaceous and sweat gland activity decreases. Capillary blood flow also decreases which slows wound healing. Fingernails usually thicken, become ridged and brittle, and grow more slowly.
Tineaversicolor, a common fungal infection, causes patches of either hyper- or hypo-pigmentation on the chest, upper back, and neck.
Pigmentation changes in nevi or moles may indicate carcinoma of the skin.
When preparing to assess the skin, wear gloves if the patient has any lesions, complains of itching skin, or if the mucous membranes are to be examined.
Dehydrated skin or the skin of the elderly patient will form a small tent shape before gradually assuming its normal position.
Testing Skin Turgor
press down on one of the patient’s nails until it pales. Release the nail and observe for the pink color to return. The normal color should return in less than 3 seconds.
Capillary refill can be affected by room and body temperature, vasoconstriction from smoking, or peripheral edema.
Checking Capillary refill
a sign of chronic tissue hypoxia, occurs when the angle between the fingernail and where the nails enters the skin increase.
Normal concave nail bases will create a small, diamond-shaped space when the nails of the index fingers of each hand are placed together.
Clubbed fingers are convex at the bases and will touch without leaving a space.
When fungal ,bacterial or viral pathogen is suspected as the cause of certain skin changes, confirmation by microscopic examination is necessary.
-Skin biopsy : such as punch , shave or excisional
-Skin testing: to identify allergy
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