integumentary assessment

Integumentary Assessment

Kozier Ch 30

What are the Functions of the Integumentary System?

Functional Review

• Protector and barrier between internal organs and external environment

• Barrier against foreign body intrusions – against invading bacteria and foreign matter

• Transmits sensation – nerve receptors– allows for feelings of temperature, pain, light

touch and pressure

Skin Functions

• Regulates body temperature– regulates heat loss

• Helps regulate fluid balance – absorbs water – prevents excessive water & electrolyte loss. – Slow loss up to 600 ml daily by evaporation

• Immune Response Function– inflammatory process

Skin Functions

• Vitamin production – exposure to UV light allows for the conversion

of substances necessary for synthesizing vitamin D

– Necessary to prevent osteoporosis, rickets

Skin Assessment

• Visual inspection

• Palpation

• Olfactory senses

• Adequate lighting

• Remove necessary clothing while providing respect and privacy

• Appropriate client positions p.568

Visual inspectionSkin color:

• Palor

• Cyanosis

• Jaundice

• Erythema

• Hyperpigmentation

• Hypopigmentation – vitiligo

Visible changes if the Skin

• Changes in skin color texture – Eczema, infections

• Assess the vascularity & hydration of skin• Edema – swelling, pitting edema

1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm p.579

• Nails – configuration, consistency, color p.579

• Hair – color and distribution, aloplecia, location

Gerontology Considerations

Watch for significant changes in aging:• Decrease immunity functions• Susceptibility to infections• Poor nutrition• Decrease collagen production – loss of

subcutaneous• Thinning of epidermal skin layers• Increase skin problems

• Taking more medications• Excessive environmental exposure

• Dryness, wrinkling

• Uneven pigmentation

• Various proliferative lesions

Gerontology Considerations

Assessing light to dark skin

Description Light skin Dark skin

Cyanosis - bluish Bluish tinge Ashen gray

Pallor - paleness Loss of rosy glow Ashen gray (drk skin)

Yellowish brown (brown skin)

Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema

Petechiae – small size pinpoint ecchyumosis

Purplish pinpoints

Usually invisible; check oral

Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

Assessing light to dark skin

Description Light skin Dark skin

Jaundice - yellow Yellow sclera, skin, fingernails, soles, palms, oral mucosa

Reliable on sclera, hard palate, palms and soles.

Ecchymosis – large diffused bluish black

Purplish to yellow-green

Difficult to see, check mouth or conjunctiva

Brown-Tan – cortisol deficiency, increased melanin production

Bronze; Tan to light brown

Easily masked.

Assessing Lesions

• Vary in size, shape and cause

• Primary vs. Secondary

• Erruptions: cysts, wheals, bullous, pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules

• Discoloration: macules (café-au-lait),

Disorders Affecting the Skin

Skin Lesions p.755

• Etiology– Infections –herpes, impetigo, HIV, melanoma– Toxic chemicals: skin irritation– Physical trauma: burns, lacerations– Hereditary factors– External factors: allergens, contact dermitis– Systemic diseases: measles, lupus, nutritional

deficiency

Skin Lesions• Nursing Process Care:

– Assessment: descriptions; pt. history, causative factors

– Evaluation of skin – identify problem– Nursing Diagnosis – Interventions for skin care to promote healing

and prevent further injury– Pain management & comfort– Infection control– Nursing evaluation & reassessment

Systemic Skin Diseases: Skin Disorders in Diabetes

• Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin.

• Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels.

Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections

Fungal infections of the Skin

• Tinea Pedis (athlete’s foot)

• Tinea Corporis (ringworm of the body)

• Tinea Capitis (scalp ringworm)

• Tinea Cruris (ringworm of the groin)– Jock itch jock, common in diabetes.

• Tinea Unguium (ringworm of the nails)– onychomycosis

Parasitic Infections

• Pediculosis capitis - lice

• Pediculosis corporis/pubis

• Sarcoptes scabiei – scabies– Raised burrows found between fingers, wrists,

elbows, nipples, feet, groin, gluteal folds, penis, scrotum

– Poor hygienic living conditions– Increase; contagious– Secondary lesions: vesicles, papules, crust,

excoriations

Parasitic Infections– Appear 4 wks after exposure – Elderly patients from long term facilities– Lindane, crotamiton (Eurax), permethrin

Nursing Diagnosis

• Skin Impairment r/t:• GOAL:

– Protect the skin

– Prevent secondary infections

– Promote healing

Skin Care

Review of wound dressings

Wound Dressings

• Occlusive – airtight cover applied to skin lesions

• Wet –(obsolete) wet compresses applied on acute weeping, inflamed lesions

• Moisture-retentive –more efficient wet drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. – Avoids maceration , less infections,

scarring & reduces pain.

Wound Dressings• Hydrogels – polymers with 90% water

content

– superficial wounds, abrasions, skin graft sites, draining venous ulcers

• Hydrocolloids –impermeable to water, O2

– Remain intact during bathing.

– Produce foul-smelling yellowish covering

– May leave on wound for 7 days

– Promote debridment & granulation tissue

Wound Dressings

• Foam – hydrophilic absorption and hydrophobic backing to prevent leaking of exudate– Nonadherent; require secondary dressing– Used over bony areas and weeping wounds

• Calcium alginates – absorbent fiber packing made from seaweed.– Absorbes exudate, best for macerated

wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent