integumentary assessment
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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