Assessing The Integumentary

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Assessing the Integumentary System
Mrs.Helena R.Joseph,M.Sc(N), Associate Professor, Medical Surgical Nursing Department
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Mrs. Mahdia Samaha Kony 9/13/2013
Composition of the integumentary system

Skin Hair Nails Is the largest organ of the body and the easiest of all systems to assess
Anatomy and Physiology Review

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Epidermis
Covers, protects, and waterproofs. Contains four main layers: Stratum corneum: Keratinized layer. Prevents loss or entry of water; protects against pathogens and chemicals. Stratum lucidum: Found only on palms of hands and soles of feet; protects against UV sunrays to prevent sunburn. 1.Stratum granulosum 2.Stratum germinativum. The innermost layer of epidermis, is the only layer that undergoes cell division & contains melanin & keratin-forming cells.
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Epidermis
The epidermis, hair, nail, dental enamel, & horny tissues are composed of keratin. It is replaced every 3-4 weeks. Skin color depends on: 1. The amount of melanin & carotene" yellow pigment" contained in the skin 2. The volume of blood containing hemoglobin 3. The oxygen-binding pigment that circulates in the dermis.
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Dermis
Contains collagen, reticular, and elastic fibers. Adds strength and elasticity to skin. Contains papillary layer, reticular layer, sweat glands, sebaceous glands, cholesterol, and arterioles. Papillary Layer: Contains capillaries that supply the stratum germinativum; also contains nerve endings, touch receptors, and fingerprint pattern; double layer on hands and feet. Reticular Layer: Contains connective tissue with collagen and elastic fibers, blood and lymphatic vessels, nerves, free nerve endings, fat cells, sebaceous glands and hair roots, deep pressure receptors, and smooth muscle fibers.
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Dermis
Sweat Glands (Sudoriferous):Most numerous on palms of hands and soles of feet. Two types are eccrine and apocrine glands. Eccrine Glands: Respond to external temperature and psychological stress. Found over most of body but most numerous on palms of hands and soles of feet; secrete sweat, which helps regulate body temperature and, to a lesser degree, excretes wastes such as urea.
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Dermis
Apocrine or Odoriferous Glands: Found in axilla and genital area. Respond to stress; secrete pheromones, a substance with a barely perceptible odor; when apocrine secretions react with bacteria, body odor results. Ceruminous glands are a type of apocrine gland found in the external ear canal. They secrete cerumen, which prevents drying of the ear drum and traps foreign substances.
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Sebaceous Glands: Produce sebum, which lubricates and protects skin and hair. Cholesterol: Converts to vitamin D when exposed to UV lights. Arterioles: Dilate when hot to increase heat loss and constrict when cold to conserve heat. Constrict in response to stressful situations to shunt blood to vital organs.
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Hypodermis/Subcutaneous
Connective Tissue: Connects skin to muscles; contains white blood cells. Adipose Tissue: Contains stored energy, cushions bony prominences, provides insulation.
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The Hair
The hair is also made up of keratinized cells. 1. Vellus, which is short, pale,and fine hair, is located over all of the body. 2. Terminal hairs, which are dark and coarse, are found on the scalp, brows, and, after puberty, on the legs, axillae, and perineum. Hair provides protection by covering thescalp and filtering dust and debris away from the nose, ears, and eyes.
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The Nails
Nails are made up of hard, keratinized cells and grow from a nail root under the cuticle. The nail bed, or epithelial layer of skin: vascular supply gives the nail a pink color The lunula, the proximal part of the nail. The nailbeds . The purpose of the nails is to protect the distal portions of the digits and aid in picking up objects
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Relationship of the Integumentary System to Other Systems

ENDOCRINE Thyroid affects growth and texture of skin, hair and nails. Hormones stimulate sebaceous glands. Sex hormones affect hair growth and distribution, fat and subcutaneous tissue distribution and activity of apocrine sweat glands. Adrenal hormones affect dermal blood supply and mobilize lipids from adipocytes.
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URINARY Kidneys remove waste and maintain normal pH. Skin helps eliminate water and waste. Skin prevents excess fluid loss. DIGESTIVE Skin synthesizes vitamin D for calcium and phosphorous absorption. Supplies nutrients while skin stores lipids.
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CARDIOVASCULAR Mast cell stimulation produces localized changes in blood flow and capillary permeability. CV system provides nutrients and removes wastes. Delivers hormones and lymphocytes. Provides heat for skin temperature. SKELETAL Skin synthesizes vitamin D needed for calcium and phosphorus absorption. Skeletal system provides a framework for skin.
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LYMPHATIC/IMMUNE Skin is first line of defense. Langerhan cells and macrophages resist infection. Mast cells trigger inflammatory responses. Lymphatic system protects skin by sending more macrophages and lymphocytes when needed. RESPIRATORY Provides oxygen to and removes carbon dioxide from integumentary system. Color of skin and nails can reflect changes in respiratory system.
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MUSCULAR Skin synthesizes vitamin D needed for calcium absorption for muscle contraction. Gives shape to and supports skin. Contraction of facial muscles allows communication through expressions. NEUROLOGICAL Sensory receptors in dermis to touch, temperature, pressure, vibration and pain. Provides communication with external environment. Controls blood flow and sweating through thermoregulation.
Mrs. Mahdia Samaha Kony
9/13/2013
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Symptom Analysis
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Change in Mole or Lesion

Skin cancer is the most common type of cancer, and changes in a mole (nevus) or skin lesion can often evoke fear in the patient. Types of skin cancer: Basal cell Squamous cell carcinomas, which affect the epidermal keratinocytes Melanoma which affects the melanocytes of the basal layer of the epidermis. Sun exposure is a risk factor in all types
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Nonhealing Sore or Chronic Ulceration

A nonhealing wound or chronic irritation is often associated with an underlying disease. The most common types of nonhealing wounds or chronic skin ulcerations are caused by vascular disease or pressure or by diabetes. Pruritus : is severe itching. May be localized or generalized Caused by a dermatologic problem or underlying systemic problem. Pruritus is often accompanied by a rash. Itching, when not associated with a rash, may be indicative of significant systemic disease or simply dry skin.
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Causes of pruritis
External stimuli, such as: heat dryness Inflammation Vasodilatation
Psychological factors, such as depression, can influence the perception of itching, which explains the varied responses to it
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Rashes
Like itching, may be localized or generalized, acute or chronic, Caused by an obvious dermatologic problem or an underlying systemic problem. Seasonal Skin Disorders Seasonal skin problems include those caused by temperature fluctuations, air humidity, and exposure to contaminants.
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Seasonal Skin Disorders

Spring: Chickenpox, Acne flare-ups Summer: Contact dermatitis, Tinea, Candida, Impetigo, Insect bites Fall: Senile pruritus/winter itch, Pityriasis rosea, Urticaria, Acne flare-ups Winter: Contact dermatitis of hands, Senile pruritus/winter itch, Psoriasis, Eczema
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Hair Changes
Hair loss (alopecia) is probably the most distressing change in hair that can occur because of its cosmetic effect. Alopecia not only refers to scalp hair but also to body hair. Scalp hair grows about 0.25mm/d, and about 70- 100 strands of hair are lost per day. Hair loss can occur for many reasons. Alopecia classification: Alopecia scaring (resulting from injury such as burns, radiation, or traction with irreversible damage to the hair follicles) Nonscarring (resulting from hormonal changes, medications, infectious diseases, or thyroid disease, in which the follicles remain intact with a potential to reverse the process).
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Nail Changes
Changes in the nails also often reflect an underlying systemic problem Changes in color and texture are frequent complaints.
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Assessing Lesions
Primary lesion is one that appears in response to some change in the internal or external environment of the skin and is not altered by trauma. Secondary lesions result from changes in primary lesions. They either add to or take away from an existing primary lesion.
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Pressure Ulcers
Pressure ulcers are a type of secondary lesion caused by unrelieved pressure. Assessment begins with identifying those at risk for pressure ulcer development and developing a plan to prevent pressure ulcer formation. If a pressure ulcer develops, assessment focuses on staging pressure ulcers and developing and evaluating pressure ulcer treatment plans.
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Clinical Description of Lesions

Size: Major determinant of correct category for primary lesions. Pigmented lesions are typically 0.5 cm. If larger, consider potential for malignancy. Depth of pressure ulcers is major determinant of assigned grad Shape Macules, wheals, and vesicles are circumscribed. Fissures are linear. Irregular borders are associated with melanoma.
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Color
Variegated-colored lesions may signal melanoma. Pustules are usually yellow-white. New scars are red and raised; old scars, white or silver. Petechiae are red. Purpura are red to purplish. Vitiligo is white Texture Macules are smooth. Warts are rough. Psoriasis is scaly.
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Surface Relationship Flat (nonpalpable): Macules, patches, purpura, ecchymoses, spider angioma, venous spider. Raised (palpable) solid: Papules, plaques, nodules, tumors, wheals, scale, crust. Raised (palpable) cystic: Vesicles, pustules, bullae, cysts. Depressed: Atrophy, erosion, ulcer, fissures. Pedunculated: Skin tags, cutaneous horn
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Exudate
Clear or pale, straw-yellow exudate: Serous oozing/weeping from noninfected lesion. Thicker, purulent discharge: Infected lesion. Clear serous exudates: Vesicles, as seen with herpes simplex; or bullae, larger than vesicles, as seen with second-degree burns. Yellow pus exudates: Pustules, as seen with impetigo or acne. Tenderness or Pain associated with a lesion depends on the underlying cause. May be associated with bullae from a burn or ecchymoses (bruise).
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Petechiae or Purpura Extravasations of blood into skin. Caused by steroids, vasculitis, systemic diseases. Does not blanch.
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Vascular Lesions
Ecchymosis Extravasation of blood into skin layer. Caused by trauma/injury. Does not blanch.
Petechiae or Purpura Extravasations of blood into skin. Caused by steroids, vasculitis, systemic diseases. Does not blanch.
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Vascular Lesions
Venous Star Blue color. Irregular-shaped, linear, spider. Does not blanch. Caused by increased pressure on superficial veins. Telangiectasia Red color. Very fine and irregular vessels. Blanches. Seen with dilation of capillaries.
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Vascular Lesions
Spider Angioma Red color, type of telangiectasis. Looks like a spider, with central body and fine radiating legs. Blanches; seen in liver disease, vitamin B deficiencies, idiopathic origin. Capillary Hemangioma Red color. Irregular-shaped macula patch.
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Primary Lesions
Flat, Nonpalpable Macule:< 1 cm Patch: >1 cm
Vitiligo
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Primary Lesions
Palpable, Raised, but Superficial Papule: <1 cm Kaposis sarcoma Psoriasis
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Primary Lesions
Raised, Superficial, Temporary Examples: Allergic reaction Hives (urticaria) Insect bite Palpable, Solid With Depth Into Dermis Examples: Bartholins cyst Erythema nodosum Lipoma Nodule:<2 cm If fluid filled and encapsulated, called a cyst Cyst Tumor: >2 cm
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Primary Lesions
Vesicle (serous):<1 cm Palpable, Fluid Filled Examples: Blister Contact dermatitis Herpes simplex Bulla (serous):> 1 cm Examples: Blister Burn Contact dermatitis
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Primary Lesions
Pustule(pus filled) Examples: Acne vulgaris Impetigo
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Secondary Lesions
Lichenification: Thickening and Scaling With Increased Skin Markings Examples: Contact dermatitis Eczema Lipoma Psoriasis
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Secondary Lesions
Scales: Shedding, Dead Skin Cells; Scales Can Be Either Dry or Oily, Adherent or Loose, Variable in Color Examples: Psoriasis
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Secondary Lesions
Crust: Dried Exudates Examples: Dried herpes simplex Impetigo
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Secondary Lesions
Scar: Replacement Connective Tissue Formations Examples: Surgical site Trauma site
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Secondary Lesions
Keloid: Hypertrophic scarring because of excess collagen formation; raised and irregular Examples: Surgical site Tattoo
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Secondary Lesions: Secondary lesions that take away

Excoriation: Abrasion or other loss that Does not extend beyond the superficial epidermis Examples: Atopic dermatitis scratch marks Insect bite Scabies Vascular rupture site
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Secondary lesions that take away

Erosion: Loss of superficial epidermis Examples: Abrasion Candidiasis erosion Fragile skin Impetigo
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Fissure: Linear breaks in the skin with well-defined borders, may extend to the Dermis Examples: Athletes foot Cheilitis Hand dermatitis (chapped hands) Syphilis
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Ulcer: Irregularly shaped loss extending to or through the dermis; may be Necrotic Examples: Pressure ulcer
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Atrophy: Thinning of skin with transparent appearance and loss of markings Examples: Aging Arterial insufficiency Topical corticosteroids
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Common Abnormalities
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Acne Vulgaris
9/13/2013
Caused by sebaceous gland overactivity with plugging of hair follicles and retention of sebum, resulting in comedones, papules, and pustules. Onset is typically at puberty, but acne may last into advanced age. Greater incidence in males. Aggravated by: 1. Emotional distress 2. Greasy topical applications (cosmetics) 3. Medications (oral contraceptives, lithium, phenobarbital).
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ASSESSMENT FINDINGS
Pimples present as papules or pustules. Cysts may develop and leave extensive scarring. Most common on face, back, and shoulders. Bacillus is cause. Lesions may be sore and painful.
9/13/2013
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Basal Cell Carcinoma

An epidermoid cancer, one of the most common malignant skin diseases, but rarely metastatic. Typically has pearly, flesh-colored or transparent rolled border. Central area develops telangiectasia and may ulcerate. Variations can present with nodular, sclerotic, and/or pigmented appearance. Usually occurs on sun-exposed surfaces, especially the face.
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Contact Dermatitis
Localized skin irritation, inflammation, and pruritus from contact with an irritating substance. 1. Additive effect of multiple irritants (soaps, detergents, or chemicals) 2. Allergy to a specific agent (topical to a specific agent, topical medication, plant oils, or metals). 3. Secondary infections may occur at the site.
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ASSESSMENT FINDINGS
Edema may occur, with development of vesicles and bullae. Vesicles or bullae may rupture, causing crusting. Edema may be very significant, particularly when face or genitalia are involved. Person may have history of previous reaction to agent and recent exposure.
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Eczema/Atopic Dermatitis
Signs and symptoms: Redness Pruritus Scratching Skin lesions in a person with a predisposition to skin irritations
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ASSESSMENT FINDINGS
Red to red-brown, slightly scaly lesions. Skin markings common. Exudative As sites resolve, skin pigmentation is often permanently altered. Common sites include: Face and Neck Upper trunk Wrists and Hands Flexor surfaces (folds) of knees and elbows.
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ASSESSMENT FINDINGS
Person also often has asthma or allergic rhinitis; family history is often positive for asthma, rhinitis, eczema, or other allergy problems. Itching can be quite severe. Sites may develop secondary infection. May be triggered by changes in temperature, emotional stress, or food allergies.
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Herpes Simplex
A common, contagious disease caused by the herpes simplex virus type 1. More prevalent in women than in men.
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ASSESSMENT FINDINGS
Recurrent clusters of small vesicles on erythematous base. Sites burn and sting; neuralgia often occurs. Typically found on perineal and genital areas. May initially follow a minor infection. Later recurrences may be triggered by trauma, stress, or sun exposure. Often associated with lymphadenopathy of regional nodes.
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Herpes Zoster
Also called shingles; an acute, infectious disease caused by the varicella zoster virus. Postzoster neuralgia discomfort can last for months. Ocular involvement can lead to blindness.
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Pain along a nerve dermatome is often the first symptom. Discomfort followed in 2 to 4 days by erythematous area that develops papules or plaques followed by painful grouped vesicles unilaterally along the dermatome. Vesicles or bullae rupture with crusting. Most common sites are face and trunk. Most common in people over age 60 and those with impaired immunity.
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Psoriasis
A common dermatitis that has genetic causes and may begin at any age.
Silvery scales on bright red papules. Scales generally thick; area beneath bleeds if scale is removed. Usually occurs on extensor surfaces of knees, elbows, and scalp. Can occur elsewhere, including between buttocks.
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Psoriasis
Nails may develop a stippled, pitted appearance and separations. Itching may be mild or severe. A genetic predisposition is suggested by family history. May occur with arthritis.
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Tinea
Tinea Capitis A fungal infection of the scalp. Scaling, itching. Dry, brittle hair.
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Tinea Corporis
Ringworm, a fungal skin disease occurring anywhere on the body. Ring-shaped erythematous lesions on body. Central clearing. Advancing border with small vesicles. Pruritic. Most often on exposed surfaces.
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Tinea Cruris
Jock itch, a fungal skin disease occurring in the genital and anal areas in males. reddened areas. Central clearing. Severe pruritus. Intertriginous area in groin. When it occurs on scalp, proper term is tinea capitis.
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Tinea Pedis
Athletes foot, a fungal skin disease occurring in the foot. Tinea manum occurs on the palms. Exfoliating, fissuring, macerated area of erythema. Sites itch, burn, and/or sting. Tinea manum occurs in interdigital folds of fingers or on palms. Tinea pedis occurs in interdigital folds between toes or on soles of feet.
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Vitiligo
Characterized by white patches of skin surrounded by areas of normal pigmentation. Progresses slowly and is more common in dark-skinned people.
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Irregular areas of depigmentation. May have hyperpigmented border. Flat, nonraised, with smooth surface. Most common sites are face, hands, and feet. Probably autoimmune cause; also associated with various endocrine disorders.

Assessing The Integumentary

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1

Assessing the Integumentary System

Mrs.Helena R.Joseph,M.Sc(N), Associate Professor, Medical Surgical Nursing Department

Composition of the integumentary system

Anatomy and Physiology Review

Relationship of the Integumentary System to Other Systems

Relationship of the Integumentary System to Other Systems

Relationship of the Integumentary System to Other Systems

Relationship of the Integumentary System to Other Systems

Relationship of the Integumentary System to Other Systems

Mrs. Mahdia Samaha Kony

Change in Mole or Lesion

Nonhealing Sore or Chronic Ulceration

Seasonal Skin Disorders

Clinical Description of Lesions

Clinical Description of Lesions

Clinical Description of Lesions

Clinical Description of Lesions

Secondary Lesions: Secondary lesions that take away

Secondary lesions that take away

Secondary lesions that take away

Secondary lesions that take away

Secondary lesions that take away

Mrs. Mahdia Samaha Kony

Mrs. Mahdia Samaha Kony

Basal Cell Carcinoma

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