Nursing Department Medical & Surgical Nursing course 2 2010-2011 Assessment of Clients with Integumentary Disorders Presented By: Miss. Ahdab Eskandar
Outlines • Introduction • Integumentary system assessment • Skin Functions • Skin changes associated with aging • Assessment techniques • ABCD for skin cancer • Summary
Introduction 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.
Integumentary System *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.
Integumentary System • The basic cell type of theepidermis is the keratinocyte, which contain keratin, a fibrous protein. Basal cells are the innermost layer of the epidermis. • Melanocytes produce the pigment melanin, and are also in the inner layer of the epidermis. • The dermis is a connective tissue layer under the epidermis, and contains nerve endings, sensory receptors, capillaries, and elastic fibers.
Follicles and Glands • Hair follicles are lined with cells that synthesize the proteins that form hair. • A sebaceous gland (that secretes the oily coating of the hair shaft), capillary bed, nerve ending, and small muscle are associated with each hair follicle. If the sebaceous glands becomes plugged and infected, it becomes a skin blemish (or pimple).
Glands • The sweat glands open to the surface through the skin pores:- • Eccrine glands are a type of sweat gland linked to the sympathetic nervous system; they occur all over the body. • Apocrine glands are the other type of sweat gland, and are larger and occur in the armpits and groin areas; these produce a solution that bacteria act upon to produce "body odor"
Hair and Nails • Hair :The hair shaft extends above the skin surface, the hair root extends from the surface to the base or hair bulb. Genetics controls several features of hair: baldness, color, texture. • Nails: consist of highly keratinized, modified epidermal cells. The nail arises from the nail bed, which is thickened to form a lunula (or little moon).
Skin Functions • Maintaining an internal environment by acting as a barrier to loss of water and electrolytes • Protection from external agents that could injure the internal environment • Regulation of body heat • Acting as a sense organ for touch, temperature, and pain. • Self-maintenance and wound repair • Production of vitamin D • Delayed hypersensitivity reaction to foreign substances
Age Related Changes of the Integumentary System • The older person’s skin is wrinkled and has a loss of resiliency. The skin becomes thinner, drier, less elastic, and more fragile as subcutaneous fat diminishes. 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.
A careful skin assessment can alert the examiner to cutaneous problems as well as systemic diseases
Assessment Techniques • History taking (through interview): • Demographic data • Family history and genetic risk • Medication history • Diet history • Socioeconomic status • Current health problem • Personal history • Physical assessment (through inspection ): • Color • Temperature • Turgor • Moisture • Oder • Scars • Lesions • Birth marks • Masses • Nails • Hair
Assessment • Head • Hair: Determine any recent color changes (to include the use of dyes or other chemicals), texture, abnormal loss or growth distribution, lesions of scalp, and baldness.
Assessment • History: • Changes in pigmentation may indicate conditions such as vitiligo, Addison’s disease or uremia. 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.
Assessment • History: • Rashes/Pruritus: The examiner should ask how long the area has been present, whether it itches, and whether it appeared abruptly or seemed to start in a specific area and spread. Patient input as to possible causative factors of any rashes should be ascertained. For example if it came as (side effect from medication )
Assessment • History: • Bruising/Bleeding: The patient should be questioned as to any history of unusual bruising or bleeding which could indicate a problem with clotting disorders. Bleeding from moles should be also be noted as this could indicate cancer of the skin.
Assessment • History: • Nevi/Moles: The patient should be asked if there has been any changes in the size or shape of existing nevi or moles. • Dryness/Sweating: Problems with dry skin or excessive sweating may indicate endocrine disorders such as hypothyroidism. Excessive sweating at night may be indicative of tuberculosis.
Assessment • History: • Previously Diagnosed Skin Diseases: It is important to assess previously diagnosed skin disorders such as eczema to provide baseline information.
Assessment • Physical Assessment • Physical assessment of the skin begins with a general inspection followed by a detailed examination. 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.
Physical Assessment • Color: Note the color of the skin first. Depending upon the person’s race the skin should be flesh-toned appropriate for the person. • Jaundicecan indicate biliary tract disease or a liver problem; pale yellow skin can indicate a renal problem. • A flushed, red face can indicate excessive ETOH intake, fever, localized inflammation, or even embarrassment.
Physical Assessment • Temperature : Use the back of the hand to assess skin temperature for coolness or warmth. • Turgor :When pinched between the thumb and index finger for a few seconds, normally hydrated, taut skin will snap back into place when released. Dehydrated skin or the skin of the elderly patient will form a small tent shape before gradually assuming its normal position.
Physical Assessment • Moisture: Dry skin can be caused by irritating soap, excessive bathing, or hypothyroidism; dry skin is normally found in elderly people. • Odor: Note any unusual body odor, smell of ETOH, and breath odor. • Scars: Assess for cause, location, appearance (color and size), and degree of tenderness.
Physical Assessment • Lesions: Lightly palpate any lesions to detect tenderness, firmness, and depth. Measure length, width, and depth also. • Primary lesions are those originally produced by trauma or other stimulation • Secondary lesions result from some alteration, usually traumatic, to the primary lesion
Physical Assessment • Birthmarks/Moles: Note location, color, shape, and size. Assess with the following four warning signs (ABCD) that might indicate the presence of skin cancer: • A Asymmetry of shape • B Border irregularity • C Color variation within one lesion • D Diameter greater than 5 mm
Physical Assessment • Masses: Note location, size, depth, and presence of tenderness. • Fingernails/Toenails: Check for nail bed color, clubbing, and assess capillary refill. Chronic renal problems can cause the lower half of the nail bed to turn white while the top half remains pink.
Nails • To assess capillary refill: 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.
Nails • Finger clubbing: 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.
Diagnostic Assessments • Laboratory test : When fungal ,bacterial or viral pathogen is suspected as the cause of certain skin changes, confirmation by microscopic examination is necessary. • Others: -Skin biopsy : such as punch , shave or excisional -Skin testing: to identify allergy
Finally • outcome criteria A well-conducted assessment of the patient's integument is a valuable aid in diagnosing a dermatologic disorder or a disease with dermatologic manifestations, such as palmar rash in syphilis.
Summary • Anatomy structure • History taking • Physical assessment • Diagnostic assessment
References • Medical & Surgical Nursing critical thinking for collaborative care Volume 2 By Ignatavicius and Workman- chapter 69 page from 1556 • Text book of Medical & Surgical Nursing By Brunner & Suddarth`s 10 edition- chapter 55 page from 1638 • : http://medical-dictionary.thefreedictionary.com/integumentary+system+assessment* • http://www.ehow.com/how_7534311_perform-health-assessment-pressure-ulcer.html#ixzz1KrjFNic9