Nursing Assessment: Integumentary System – Flashcards
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The Integumentary System
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Largest body organ and is composed of skin, hair, nails, glands.
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What are the functions of skin?
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- Prevents loss of body fluids - Protects deeper tissues - Helps regulate body temperature - Provides locations for sensory reception of touch, pressure, temperature, pain, wetness, tickle, etc. - Assists in vitamin D synthesis - Plays a minor excretory role
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Why is the integument assessment important?
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- Provides a clear sense of the patient's overall health - Changes in skin, hair, and nails may be the first indicator that a person's health is declining - Identifies subtle changes in color, texture, moisture, or temperature as well as unusual markings or areas of injury
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Skin changes related to aging (7)
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1) Decreased turgor 2) Thinning 3) Dryness 4) Wrinkling 5) Vascular lesions 6) Increased skin fragility 7) Benign neoplasms
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Assessment of Integumentary System- Subjective Data
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- Paste health history indicates previous trauma, surgery, or disease that involves the skin. (ex. Cyanosis, respiratory disorder) - Medications - Surgery or other treatments (ex. biopsy, cosmetic surgery) - Health practices related to integumentary system (ex. hygiene, sun protection) - Nutritional-metabolic pattern, changes in the skin, hair, nails and mucous membranes and whether they are related to dietary changes. - Elimination pattern, ask patient about conditions of the skin such as dehydration,edema, and pruritus (itching). - Activity-Exercise pattern, environmental hazards (ex. carcinogens, allergens) - Sleep-Rest pattern, disturbances in sleep caused by a skin condition -Cognitive-Perceptual pattern, patient's perception of the sensations of heat, cold, pain, and touch. -Self-perception-self concept pattern, feelings related to the patient's skin condition. -Role-relationship pattern, how the skin condition affects relationships with family members, peers and work associates. -Sexuality-reproductive pattern, effect of the patient's skin condition on sexual activity -Coping-Stress Tolerance pattern, the role that stress may play in creating or exacerbating the skin condition. Value-Belief pattern, cultural or religious beliefs that could influence the patient's self-image.
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Assessment of Integumentary System- Objective Data
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Physical Examination - INSPECTION
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Begin inspection of patient
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- Begin by inspecting all exposed areas of the patient's skin - Pay particular attention to areas associated with the patient's chief complaint and other clinical findings - Look for skin pigmentation, complexion, areas of skin breakdown, lesions, rashes, and wounds - Inspect any area that may be excoriated or infected from incontinence, heavy perspiration, and lack of exposure to air * Beneath the breast, in the axillae * Between the thighs, in the gluteal fold * abdominal apron
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Palpation
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1) Warm your hands 2) If you expect the patient may have an infection that can be transmitted via the skin or if any body fluid is present, wear gloves 3) Palpate temperature of the skin with the back of the hand *Compare bilaterally *Can use your own skin temperature as a comparison if necessary *Using tips and pads of fingers, palpate for areas of increased roughness or smoothness *Palpate for dry and patchy areas; may need to use the back of your hand or fingers ~ Can't do this if you are wearing gloves *If a lesion is present, gently palpate the borders to see if it is raised or flat
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Skin Tugor
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Fullness or elasticity of the skin Assessed on the sternum or under the clavicle -Normal turgor *Elasticity of the skin *When picked up in a fold-returns to shape when released -Dehydrated patients *Elasticity is decreased *Returns to normal slowly
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Skin-Normal Findings
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-Skin color even over body (race specific) *Ranging from pinkish white to various shades of brown *Dark-skin patients -Palms, hands, mucous membranes will show color alterations -Warm -Turgor good (no tenting) -No unexplained lesions
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Cyanosis (Grayish-blue tone)
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*Nail beds ear lobes lips, mucous membranes, palms and soles *Dark skin-ashen or gray color-conjunctiva of eye, mucous membranes (hard palate), and nail bed *Hypoxemia
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Ecchymosis (Bruise)
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*Dark red, purple, yellow or green *Dark skin- deeper bluish or black tone *Bruising from anticoagulant therapy, clotting disorder, or trauma
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Erythema
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*Reddish tone *Dark skin- deeper brown or purple skin tone *Polycythemia, localized infection, burns
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Jaundice
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*Yellowish color *Sclera, fingernails, palms of hands, mucous membranes *Dark Skin- yellowish-green color, sclera of eye *Hepatic disease
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Pallor
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*Pale skin color, white or ashen *Lips, nail beds, mucous membranes *Dark skin- underlying red tone is yellowish brown skin or ashen or gray. *Anemia, hypotension
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Petechiae
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Small reddish-purple pinpoints
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Rash
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Small reddish pinpoint
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Scar
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*Abnormal formation of connective tissue at site *Post surgery or injury *Initially pink -Fades to white *Dark skin- keloid
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Nevus of Ota
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*Darker skinned patients. -slate-grey or blue-grey birthmark normally found on the forehead and face around eye area.
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Primary Skin Lesions
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Develop on previously unaltered skin -Macule -Papule -Vesicle -Plaque -Wheal -Pustule -Bulla
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Macule
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*Flat circumscribed area without elevation -Freckle, flat pigmented moles
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Papule
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*Raised circumscribed area <1cm in size -Acne
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Vesicle
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*Raised collection of fluid < 1 cm -Chicken pox
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Plaque
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*Elevated circumscribed, superficial solid lesion >0.5 cm - psoriasis
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Wheal
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* Firm, edematous, irregularly shaped area, diameter variable *Flattened collection of fluid 1 mm to several centimeters -Insect bite, TB test
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Pustule
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*Vesicle or bulla filled with pus > 1 cm -Acne Vulgaris
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Bulla
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*Fluid filled vesicle > 1cm -Second degree burn
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Secondary Skin Lesions
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Lesions that change with time or occur because of factors such as scratching or infection. - Fissure - Scale - Scar - Ulcer - Atrophy - Excoriation
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Fissure
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*Linear crack in the skin -Athlete's foot -Cracked lips -Anal fissures
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Scale
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*Flake of exfoliatee epidermis -Dandruff, dry skin
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Ulcer
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*Deep loss of skin surface that may bleed -Stasis ulcer -Pressure ulcers, cold sores, canker sores
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Atrophy
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*Depression of skin resulting from thinning of the epidermis or dermis - aged skin, striae
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Excoriation
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*Area in which epidermis is missing, exposing the dermis - abrasion, scratch
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Nodule
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*Raised solid mass that extends into the dermis. *1-2 cm -Pigmented nevi
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Tumor
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*Solid raised mass that extends into the dermis *> 2 cm -dermatofibroma
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Cyst
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*Mass of fluid filled tissue that extends to the subcutaneous tissue or dermis *1 cm
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Erosion
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*Non-bleeding loss of superficial dermis -Chickenpox rupture
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Crust
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*Dried residue from blood or pus -Impetigo
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Hair
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*Normal hair findings *Hair distributed evenly over scalp and body -Exception in men with male pattern baldness or thinning *Hair color consistent across scalp -Be aware of cultural use of hair coloring -Be aware of normal graying *Scalp is free of injury, lesions, scaling, infection, and infestation
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Hair- Abnormal findings
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*Decreased hair growth -May indicate decreased circulation *Patchy baldness with breakage of hair shaft at surface (alopecia areata) *Hair loss from wearing tightly bond hairstyles traction alopecia *Hair loss from habitual pulling (trichotillomania) *Hirsutism ( excessive hair) from hormonal dysfunction, hereditary factors, or certain medication -Altered hair color, possible malnutrition, pernicious anemia, or nerve injury *Dry, brittle hair may indicate malnutrition, or hypothyroidism. Increased silkiness and thinning of the hair may indicate hyperthyroidism *Scalp eruption may indicate psoriasis or seborrheic dermatitis *Excoriated of scalp, eyelids, and pubic areas*
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Nails
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*Nails are an extension of the epidermis, so their shape, color, texture and condition may be affected by disease *Assess the bare nail -Note shape, color, opacity -Feel surface to determine smoothness and areas of unevenness -Check for horizontal or longitudinal ridges, opaque white spots, -and small splinter hemorrhages -Inspect for clubbing or spooning -Assess capillary refill
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Nails-Normal findings
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*Smooth, round, fairly translucent nail plate that is firmly attached to the nail bed -Dark-skinned patients normally have pigmented spots or bands on their nail plates *Curvature should be convex with an angle of about 160 degrees between the nails and skin at the nail base *Surface should feel smooth, even and hard with smooth, rounded edges *Nail beds pinkish, and firm. Cap refill < 3 sec *Cuticles smooth, flat and unbroken
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Nails-Abnormal findings
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*Brittle, thinning, peeling nail plates -Nutritional or circulatory deficiencies or damage from external chemicals *Cracks or fissures in nails -Malnutrition *Thickened nails *Trauma, decreased circulation, fungal infection *White nail plates -Hypoalbuminemia *Pale nail plates -Anemia *Greenish-black nail plates -Fungal or bacterial infection (pseudomonas) *Yellow nail plates -Psoriasis, respiratory disease, cigarette smoking, staining from nail polish *Spoon shaped nails -Iron deficiency *Poor adhesion of nails to nail bed or pitting nail plate -Psoriasis *Rough, jagged, or bitten nails -Poor hygiene, habit, nervousness/stress *Clubbing -Cardiopulmonary disease
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Age Related Changes
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*Thinning of skin (decreased sub q fat) *Dryness of skin and hair *Fragility of skin *Seborrheic keratosis -Slightly raised tan to black, warty lesions, covered with a greasy crust that leaves a raw pulp when removed *Cherry angiomas -Small tumor consist of blood or blood vessels *Skin tags *Actinic keratosis -Slowly developing, localized thickening of skin from sun exposure, pre-malignant
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Common Assessment Abnormalities
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*Alopecia -Loss of hair *Angioma -Tumor of blood or lymph vessel *Vitligo -White depigmented area *Telangiectasia -Visible dilated, superficial cutaneous, small blood vessels *Varicosity -Increased prominence of superficial veins
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Cultural Considerations
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*Pallor -Dark-skinned patients Mucous membranes Ash gray color *Cyanosis -Dark-skinned patients Lips and tongue are gray Palms, soles, conjunctivae and nail beds appear bluish tinge *Inflammation -Dark-skinned patients Palpate for warmth Darker than normal skin tone *Jaundice -Dark-skinned patients Oral mucosa Hard palate for yellow discoloration Many dark-skinned patients have a normal yellowish hue to the conjunctiva Palms and soles may appear yellow if callused
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Braden Scale
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Used for predicting Pressure Ulcer Risk Includes: -Sensory Perception -Moisture -Activity -Mobility -Nutrition -Friction and Shear
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Diagnostic Test (4)
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*Punch biopsy -Small circular instrument or punch ranges from 2-6 mm -Local anesthesia -Plug of tissue is removed -May be closed with 1-2 stitches *Shave biopsy -Removal only of the portion of the skin that is raised -Local anesthesia -Scalpel is moved parallel to the skin -No suturing necessary *Excisional biopsy -Removal of entire lesion -Larger or deeper specimens -Sutured *Patch test -Allergy testing -Allergic reaction from contact with the responsible allergen
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Nursing Diagnosis
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*Skin integrity, impaired *Skin integrity, risk for impaired *Protection, Ineffective *Body temperature, imbalanced, risk for *Sleep pattern, disturbed *Body image, disturbed *Self-Esteem
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The primary function of the skin is a. insulation b. protection c. sensation d. absorption
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B
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Age-related changes in the hair and nails include (select all that apply) a. oily scalp b. scaly scalp c. thinner nails d. thicker, brittle nails e. longitudinal nail ridging
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B, D, E
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When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding a. joint pain b. the use of moisturizing shampoo c. recent changes in wound healing d. self-care habits related to daily hygiene
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C
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During the physical examination of the patient's skin, the nurse would a. use a flashlight in a poorly lit room b. note cool, moist skin as a normal finding c. pinch up a fold of skin to assess for turgor d. perform a lesion-specific examination first and then a general inspection
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C
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The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals b. papules c. pustules d. plaques
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A
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To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is a. palpation b. inspection c. percussion d. auscultation
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A
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Individuals with dark skin are more likely to develop a. keloids b. wrinkles c. skin rashes d. skin cancer
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A
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On inspection of a patient's dark skin, the nurse notes a blue-grey birthmark on the forehead and eye area. The assessment finding is called a. vitiligo b. intertrigo c. telangiectasia d. Nevus of Ota
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D
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Diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained b. a more definitive diagnosis is needed c. percussion reveals an abnormal finding d. treatment with prescribed medication has failed
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B
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SPF-sun protection factor
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The SPF measures the effectiveness of a sunscreen in filtering and absorbing UV radiation.
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Actinic Keratosis
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*Also known as solar keratosis, consists of hyperkeratotic papules and plaques on sun-exposed areas. Actinic keratoses are premalignant skin lesions that effect nearly all of the older white population. *Most common of all precancerous skin lesions. *Irregularly shaped, flat, slightly eryhematous papule with indistinct borders and an overlying hard keratotic scale or horn.
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BCC- Basal Cell Carcinoma
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*Locally invasive malignancy arising from epidermal basal cells. *Most common type of skin cancer and also the least deadly. BCC usually occurs in middle-aged to older adults. *Pigmented with curled borders and an opaque appearance and may be misinterpreted as a melanoma. *tissue biopsy is needed to confirm diagnosis
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SCC- Squamous Cell Carcinoma
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*Malignant neoplasm of keratinizing epidermal cells. *Occurs on sun-exposed skin at the base of an actinic keratosis or other lesion. *SCC is less common than BCC * Can be highly aggressive, has potential to metastasize, and may lead to death if not treated early and correctly. * Skin biopsy is needed to confirm
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Malignant Melanoma
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*Tumor arising from melanocytes, which are the cells producing melanin. *Melanoma causes the majority of skin cancer deaths. *UV radiation from the sun is the main cause of melanomas * frequently occurs-women-lower legs and back, men-trunk, head, and neck * Stages 0-IV
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ABCDEs of Melanoma
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Asymmetry Border Color Diameter Evolving
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2 methods to determine thickness of tumor
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Breslow measurements indicates the depth of the tumor in millimeters. Clark level indicates the depth of invasion of the tumor, the higher the number, the deeper the melanoma,
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DN- Dysplastic nevi
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Atypical moles, are nevi that are larger than usual (> 5 mm across) with irregular borders and various shades of color.
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Psoriasis
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Common benign disorder Autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells.
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Curettage
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The removal and scooping away of tissue using an instrument with a circular cutting edge attached to a handle. Used for removing small, soft skin tumors and superficial lesions, such as warts, actinic keratoses, and small basal and squamous cell carcinoma.
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Cryosurgery
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Use of subfreezing temperatures to destroy epidermal lesions. Useful treatment for common benign, precancerous conditions, including common and genital warts, cutaneous tags, thin seborrheic keratosis, lentigines, actinic keratoses, and non-melanoma skin cancers.
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Lichenification
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Thickening of the skin as a result of the proliferation of keratinocytes with accentuation of the normal markings of the skin. Caused by chronic scratching and rubbing of the skin.
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Acne Vulgaris
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Inflammatory disorder of sebaceous glands. More common in teenagers but possible development and persistence in adulthood. Flare can occur with use of corticosteriods and androgen-dominant birth control pills and before menses.
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Cellulitis
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Inflammation of subcutaneous tissues.
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Impetigo
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Group A b-hemolytic streptococci. staphylococci, or combination of both. Associated with poor hygiene. Contagious.
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Herpes Zoster (shingles)
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Linear distribution along a dermatome of grouped vesicles and pustules on erythematous base resembling chickenpox. Usually unilateral on trunk, face, and lumbosacral areas. Burning, pain, and neuralgia preceding outbreak. Mild to severe pain during outbreak.
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Urticaria
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Usually allergic phenomenon. Erythema and edema in upper dermis resulting from a local increase in permeability of capillaries. Spontaneously occuring, raised or irregularly shaped wheals, varying size, usually multiple.
