History And Physical Assessment Of Integumentary System

By:Mr. M . Shiva Nanda

Reddy

Introduction:• Skin disorders are encountered

frequently in nursing practice.• Skin-related disorders account for up to

10% of all ambulatory patient visits . • In certain systemic conditions, such as

hepatitis and some cancers, dermatologic manifestations may be the first sign of the disorder.

• So its very essential to know the assessment of integumentary system.

Subjective Data / History Collection:• Present health history:

Specific information about the onset, signs andsymptoms, location, and duration of any pain, itching, rash, or other discomfort experienced by the patient need to be collected.

Past Health History:-• Past health history of trauma, surgery, or

disease that involves the skin• Determine if the patient has noticed any

dermatologic manifestations of systemic problems such as jaundice (liver disease), delayed wound healing (diabetes mellitus), cyanosis (respiratory disorder), or pallor (anemia).

Medications:

• A thorough medication history is important, especially in relation to vitamins, hormones, antibiotics, corticosteroids, and antimetabolites because these may cause side effects that are manifested in the skin.

• If a medication is used, record the name, length of use, method of application, and effectiveness.

Surgery or Other Treatments.

• Determine if any surgical procedures, including cosmetic surgery, were performed on the skin.

• Note any treatments specific for a skin problem (e.g., phototherapy) or for a health problem (e.g., radiation therapy).

• In addition, document any treatments undergone primarily for cosmetic purposes.

Health Perception–Health Management Pattern• Question the patient about health

practices related to the integumentary system, such as self-care habits related to daily hygiene.

• Document the frequency of use and sun protection factor (SPF) of sunscreen products.

• Assess the use of personal care products (e.g., shampoos, moisturizing agents, cosmetics).

• Note any medications used for treating hair loss.

Family history:

• Obtain information about any skin diseases, including congenital and familial diseases (e.g., alopecia, psoriasis) and systemic diseases with dermatologic manifestations (e.g., diabetes, thyroid disease, cardiovascular diseases, immune disorders).

• In addition, note any family and personal history of skin cancer.

Psoriasis

Nutritional history:

• A diet history reveals the adequacy of nutrients essential to healthy skin such as vitamins A, D, E, and C; dietary fat; and protein.

• Note any food allergies that cause a skin reaction.

Elimination Pattern.

• Ask the patient about conditions of the skin such as dehydration, edema, and pruritus (itching), which can indicate alterations in fluid balance.

• If urinary or fecal incontinence is a problem, determine the condition of the skin in the anal and perineal areas.

Activity-Exercise Pattern

• Obtain information about occupational hazards in relation to exposure to known carcinogens, chemical irritants, and allergens.

Sleep-Rest Pattern:

• Question the patient about disturbances in sleep patterns caused by a skin condition.

• For example, pruritus can be distressing and cause major alterations in normal sleep patterns.

Cognitive-Perceptual Pattern:

• Determine the patient’s perception of the sensations of heat, cold, pain, and touch.

• Assess and record any joint pain.• Assess the mobility of the joints,

since the patient’s skin condition may cause alterations in mobility.

Role-Relationship Pattern.

• Determine how the patient’s skin condition

affects relationships with family members,

peers, and work associates.

Objective Data / Physical Examination

• Assessment of the skin involves the entire skin area, including the mucous membranes, scalp, hair, and nails.

• The skin is a reflection of a person’s overall health, and alterations commonly correspond to disease in other organ systems.

• Inspection and palpation are techniques commonly used in examining the skin.

Principles when assessing the skin are as follows:

• Have a private examination room of moderate temperature with good lighting.

• Ensure that the patient is comfortable and in a dressing gown that allows easy access to all skin areas.

• Be systematic and proceed from head to toe.• Compare symmetric parts.• Perform a general inspection and then a lesion-specific

examination. • Use the metric system when taking measurements.• Use appropriate terminology and nomenclature when

reporting or documenting.

Inspection.

• The general appearance of the skin is assessed by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility, and the condition of the hair and nails.

Palpation

• Skin turgor, possible edema, and elasticity are assessed by palpation.

Gradings of pitting edema

• Skin color varies from person to person and ranges from light pink to deep brown to almost pure black.

• The skin of exposed portions of the body, especially in sunny, warm climates, tends to be more pigmented than the rest of the body.

• The vasodilation that occurs with fever, sunburn, and inflammation produces a pink or reddish colour to the skin.

• Pallor is an absence of or a decrease in normal skin color and vascularity and is best observed in the conjunctivae or around the mouth.

• The bluish hue of cyanosis indicates cellular hypoxia and is easily observed in the extremities, nail beds, lips, and mucous membranes.

• Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes

Erythema• Erythema is redness of the skin caused by

the congestion of capillaries.• In light-skinned people, it is easily observed

at any location where it appears.• it may be difficult to detect erythema in dark

skinned persons as the skin turns to purple grey due to increases blood supply.

Erythema

Pallor

Jaundice

• Cyanosis

Cyanosis• Cyanosis is the bluish discoloration that results from a lack

of oxygen in the blood.

• It appears with respiratory or circulatory compromise.

• Cyanosis manifests as a bluish hue to the lips, fingertips,

and nail beds.

• To detect cyanosis, the areas around the mouth and lips

and over the cheekbones and earlobes should be

observed

Color Changes

Observe for hypopigmentation (ie, decrease in the melanin of the skin, resulting in a loss of pigmentation) and hyperpigmentation (ie, increase in the melanin of the skin, resulting in increased pigmentation).

ASSESSING SKIN LESIONS

• Skin lesions are the most prominent characteristics of dermatologic conditions.

• They vary in size, shape, and cause and are classified according to their appearance and origin.

Described the lesions clearly and in detail:• Color of the lesion• Any redness, heat, pain, or swelling• Size and location of the involved area• Pattern of eruption (eg, macular, papular, scaling, oozing)• Distribution of the lesion (eg, bilateral, symmetric, linear, Circular)

Classification of skin lesions:• Skin lesions may be primary or secondary skin

lesions.• Primary lesions are the initial lesions and are

characteristic of the disease itself. • Secondary lesions result from external causes, such

as scratching, trauma, infections, or changes caused by wound healing.

• Depending on the stage of development, skin lesions are further categorized according to type and appearance

Primary Skin LesionsMacule & Patch:

• Flat, nonpalpable skin color change (color may be brown, white, purple, red)

• Macule: <1 cm, circumscribed border• Patch: >1 cm, may have irregular border• Example: flat mole

Macule Patch

Papule & Plaque Papule

Elevated, palpable, solid mass Circumscribed borderPlaque coalesced papules with flat top Papule <0.5 cm Plaque >0.5 cm

Examples:

Papules: warts

Plaques: Psoriasis

papule

plaque

Nodule & TumorElevated, palpable, solid massExtends deeper into the dermis than a papule• Nodule: 0.5–2 cm; circumscribed• Tumor: >1–2 cm; tumors do not always have sharp bordersExamples:Nodules: LipomaTumors: Larger lipoma, carcinoma

Nodule

tumour

Vesicle & Bulla:

Circumscribed, elevated, palpable mass containing serous fluid• Vesicle: <0.5 cm• Bulla: >0.5 cmExamples:

Vesicles: Herpes simplex/zoster, chickenpox,second-degree burn (blister)Bulla: Pemphigus, large burn blisters

Vesicle & Bulla:

Wheal:Transient (temporary) elevated mass

which usually disappers in 24 hours.Borders often irregular Caused by movement of serous fluid

into the dermisExample: Insect bites

wheal

• Pustule

• Pus-filled vesicle or bulla• Example: Acne

pustule

Cyst• Encapsulated fluid-filled or semisolid mass• In the subcutaneous tissue or dermisExamples:

Sebaceous cyst

cyst

SECONDARY SKIN LESIONS

Erosion:

• Loss of superficial epidermis• Does not extend to dermis• Depressed, moist areaExamples:Ruptured vesicles, scratch marks

erosion

Ulcer:• Skin loss extending past epidermis• Necrotic tissue loss• Bleeding and scarring possibleExample: pressure ulcer

ulcer

Fissure

• Linear crack in the skin• May extend to dermisExamples:Cracked foot, lips

fissures

Scales•scales are secondary to desquamated, dead epithelium.

• Flakes may adhere to skin surface

• Color varies (silvery, white)

• Texture varies (thick, fine)

Examples:

Dandruff, psoriasis

scales

Crust

• Dried residue of serum, blood, or pus onskin surfaceExample:

Residue left after vesicle rupture

crust

Scar (Cicatrix):

• Skin mark left after healing of a wound or lesionExamples:Healed wound or surgical incision

scar

Keloid• Hypertrophied scar tissue• Secondary to excessive collagen formation during healingExample:Keloid of surgical incision

keloid

Atrophy

• Thin, dry, transparent appearance of epidermis

• Secondary to loss of collagen and elastin

• Underlying vessels may be visible

Examples:

Aged skin

Atrophy:

Lichenification:

• Thickening and roughening of the skin• May be secondary to repeated rubbing, irritation, scratchingExample:Contact dermatitis

Lichenification:

VASCULAR SKIN LESIONSPetechia:• Round red or purple macule• Small: 1–2 mm• Secondary to blood extravasation• Associated with bleeding tendencies

petechiae

Ecchymosis

• Round or irregular macular lesion• Larger than petechia• Secondary to blood extravasation• Associated with trauma, bleeding tendencies

Ecchymosis

Cherry Angioma:

• Papular and round• Red or purple• Noted on trunk, extremities• May blanch with pressure• Normal age-related skin alteration

Cherry angioma

Spider Angioma

• Red, arteriole lesion

• Central body with radiating branches

• Noted on face, neck, arms, trunk

• Associated with liver disease, pregnancy, vitamin B deficiency.

Spider angioma

Telangiectasia (Venous Star)• Shape varies: spider-like or linear

• Color bluish or red• Does not blanch when pressure is applied

• Noted on legs, anterior chest

• Secondary to superficial dilation of venous vessels and capillaries

• Associated with increased venous pressure states

Telangiectasia

Assessing Vascularity and Hydration

• A description of vascular changes includes location, distribution, color, and size.

• Common vascular changes include petechiae, ecchymoses, angiomas, and venous stars.

• Skin moisture, temperature, and texture are assessed primarily by palpation.

• The elasticity (ie, turgor) of the skin decreases normally with aging.

Assessing the NailsObserve the nails for the signs and symptoms of beaus lines( Transverse depressions), koilnychia (spoon shaped nails)and clubbing (the angle between the nail and the base of the nail will be greater than 180 degrees) and paronychia (inflammation of the skin around the nails).

Assessment Of Hair:• The hair assessment is carried out by

inspecting and palpating.• Gloves are worn, and the examination room

should be well lighted.• Separating the hair so that the condition of the

skin underneath can be easily seen.• The nurse assesses color, texture, distribution

and any abnormal lesions, evidence of itching, inflammation, scaling, or signs of infestation (ie, lice or mites) are documented

Natural hair color ranges from white to black.

Hair color begins to gray with age, initially appearing during the third decade of life, when the loss of melanin begins to become apparent.