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

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Visual inspection
Skin 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 2+ 4 mm 3+ 6 mm 4+ 8 mm
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Nails configuration, consistency, color 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

Gerontology Considerations
Taking more medications Excessive environmental exposure Dryness, wrinkling Uneven pigmentation Various proliferative lesions

Assessing light to dark skin

Description Light skin Dark skin

Cyanosis - bluish
Pallor - paleness

Bluish tinge

Ashen gray

Loss of rosy glow Ashen gray (drk skin) Yellowish brown (brown skin) Visible redness Purplish pinpoints Diffused; rely on palpation of warmth or edema Usually invisible; check oral Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

Erythema - redness Petechiae small size pinpoint ecchyumosis

Assessing light to dark skin

Description Jaundice - yellow Light skin Dark skin Yellow sclera, Reliable on sclera, hard skin, fingernails, palate, palms and soles. soles, palms, oral mucosa Purplish to yellow-green Bronze; Tan to light brown Difficult to see, check mouth or conjunctiva Easily masked.

Ecchymosis large diffused bluish black Brown-Tan cortisol deficiency, increased melanin production

Assessing Lesions
Vary in size, shape and cause Primary vs. Secondary Erruptions: cysts, wheals, bullous, pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules Discoloration: macules (caf-au-lait),

Disorders Affecting the Skin

Skin Lesions
Etiology

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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 (athletes 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