Week 9

Assessment of Integumentary System

(Skin)

Learning Objectives

1. Describe and list factors that affect tissue integrity.

2. Explain common physical assessment procedures used to evaluate tissue integrity of patients across the lifespan.

3. Identify priority tissue integrity assessment findings.

4. Differentiate normal tissue integrity assessment findings from abnormal findings.

5. Explain the process for assessment of tissue integrity.

Why is this a system?

What does it do for us?

The skin is the body's largest

organ, covering the entire body.

Our skin serves as a protective shield against:

HeatLight InjuryInfection

Skin also: Regulates body temperature Stores water and fat

Is a sensory organ

Prevents water loss

Prevents entry of bacteria

Inspection of the Skin:Nurses conduct an

examination of the skin as part of a routine

assessment, during regular care, and as

needed.

During a bed bath is a good time fully

assess the patients skin.

Remove all barriers unless contraindicated: i.e. wound

dressing

Location sizeobjective descriptionskin temperature

Assess and Document:

Also inspect and document any scars reported or noted.

A scar can indicate a healed surgical wound or

injury.The nurse should make

note of this.

Everted:Turned inside out; turned

outward

Everted Umbilicus: Indicates increased

pressure in the abdomen

Palpation of the skin:

Does it feel dry, moist, rough, smooth, bumpy, etc?

Do you feel swelling, edema, coolness, heat, is the area

warmer than surrounding skin?

Skin should feel warm and dry

with good color; not pale.

Healthy Skin

Unhealthy Skin

Before and after Meth

Basic Assessment Interview Questions

•Have you ever had any skin problems?

•If yes, was this acute and/or chronic?

•Do you have any bruises, sores, ulcers or rashes on your body and are they slow to heal?

•Do you have any skin pain, burning or itching?

More Interview Questions

•Do you sunbathe or have a history of sunbathing?

•Do you work outdoors?

•How does your skin react to sun exposure?

•How do you care for your skin?

•Sensitivities or allergies?

•Tattoos and/or piercings?

Considerations as the nurse…

•Is the patient nutritionally challenged?

•Is the patient immobile?

•Does the skin appear paper-like or fragile?

Sun bathing and sunburn is considered a risk

Sunburn Blisters and Damaged Peeling Skin

1. Outer Skin Layer2. Middle Skin Layer3. Deep Skin Layer4. First Degree Burn5. Second Degree Burn6. Third Degree Burn

Poison Ivy is an allergic reaction.(Oily sap called urushiol triggers an allergic

reaction when it comes into contact with skin, resulting in an itchy rash, which can appear

within hours of exposure or up to several days later.)

Black henna tattoo reaction; scarring

Skin Ulcer

Venous Stasis Ulcers: The result of venous blood collecting

and stagnating in the lower leg (Inadequate venous return).

Necrotic Ulcer

Necrotic Toes

What causes this? Decreased/impaired tissue

perfusion.

Diabetics are at high risk for slow healing wounds due to vascular changes leading to arteriosclerosis (thickening,

loss of elasticity, and calcification of arterial

walls).

Odor:Does the wound site have an

odor?

Pressure Ulcer: (decubitus ulcer) This is

preventable by repositioning the patient every two hours.

Varicella Rash(Chicken Pox)

Psoriasis Rash

Dry, Scaly Skin

Age Spots:(Liver Spots)

Age Spots:(Liver Spots) Part of the

skin’s normal aging process. Appear as flat gray, brown or black spots. They vary in size and usually appear on the face, hands, shoulders

and arms; areas most exposed to the sun.

Wound Types

Contusions: Bleeding under or within layers of

skin

Abrasion:Surface scrape, open wound

Laceration:Tissues torn apart, open wound;

edges often jagged

Puncture or Penetrating: Penetration of skin and

underlying tissues; open wound

Burns

Surgical Incision

Wound Measurement Guide: Assess if the wound is

getting larger, smaller, healing, etc.

Abscess: A swollen area within body tissue, containing

an accumulation of pus.

Candida:Yeast/fungal infection

Skin breakdown under breasts: Skin must be kept clean and

dry.

Port-Wine Stain Birthmark

Infants and children have sensitive skin…

• The younger the more sensitive the skin is

• Protect from sunburn

• Protect from rashes and irritation

Mongolian Spot Birthmark: A dense collections of

melanocytes(not a bruise)

Older adults have sensitive skin: Skin changes associated with aging include less elasticity, decreased subcutaneous tissue.

These factors put them at increased risk for tears, pressure ulcers, and skin breakdown.

Aging skin characteristics include decreased collagen, elasticity, tone.

Elderly skin is fragile, paper-thin, and tears easily.

Edema Scale

Nursing Goals Include:

• Frequent and thorough skin assessment and interventions

• Promote wound healing

• Prevent skin breakdown and/or additional wounds

Injury to skin, and breaks in the skin put the patient at risk for

what kinds of problems?

• Infection at the site, also systemic infection • Loss of fluid • Burns, internal injury, temperature regulation problems (Severe sunburn: fever and chills)

Bowel Sounds: When bowel sounds are

hypoactive and not easily heard, you must listen for 5 minutes to each quadrant before deciding that bowel

sounds are absent.

True or False?

Ask the patient what time of day they normally move

their bowels. (We attempt to work with the time

schedule they are used to; not have them adjust to the

facility’s time schedule.)

Constipation

Passing gas indicates bowel motility and passing gas is

taking place.

End of Week 9