Integumentary System: Assessing the SKIN Spring 2012 1
Jun 03, 2015
Integumentary System: Assessing the
SKIN
Spring 2012 1
Functions of the Skin
Spring 2012 2
1. Protects Against Trauma2. Protects Against Ultraviolet
Radiation3. Support Structure4. Maintains Body Temperature
Functions of Skin
5. Involved with Absorption and Excretion6. Involved with Immunity7. Synthesizes Vitamin D8. Helps Maintain Fluid Balance9. Provides Sensation with the External
Environment
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Structures of Skin
1. Epidermis2. Dermis3. Subcutaneous Tissue4. Epidermal Appendages:
– Hair– Nails– Sebaceous Glands
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Risk Factors
• . . . . . .• . . . . . .• . . . . . .• . . . . . • . . . . .
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SECONDARY SKIN LESIONS1. Crust *2. Scale3. Fissure4. Erosion5. Ulcer6. Scar 7. Excoriation8. Keloid9. Lichenification
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Descriptions of Lesions *
• Size• Shape• Color• Texture• Surface relationship• Exudate• Tenderness or pain
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Skin Assessment:
• Approach
• Inspection
• Palpation
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Examination
• General Inspection :– General pigmentation– Texture– Temperature– Moisture– Mobility– Turgor– Vascularity or bruising– Edema– Lesions or discoloration
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Adult
–Normal Variations:• Striae• Vitiligo• Moles• Freckles • Birthmarks
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Warning Signs of Cancer
• A = Asymmetry• B = Boarder irregular• C = Color variation• D = Diameter >6mm• E = Elevation & Enlargement
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Abnormal Skin Findings
• Central Cyanosis
• Peripheral Cyanosis
12Spring 2012
• Pallor:
• decreased Hgb-, decreased perfusion• Also on conjunctiva
and mucus membranes
Examination
• Palpate skin for temp, moisture, mobility and turgor
• Hair Distribution• Nail
– Thickening or hypertrophy– Thinning or Brittleness– Spoon Shaped– Pitting of Nail– Pigmented Bands– Splinter Hemorrhages
13Spring 2012
Vascular Lesions:
1. Petechiae2. Ecchymosis3. Purpura4. Hematoma5. Venous Star6. Telangiectasis7. Spider Angioma8. Erythema
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Pitting Edema *
• 1+ < 0.25 inch (4.32mm) depression
• 2+ 0.25 - 0.5 inch (12.7mm)
• 3+ 0.5 - 0.75 inch (19 mm)
• 4+ 0.75 - 1 inch or more (25 mm)
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Pitting Edema *
• 1+ < 0.08 inch (2mm) depression __________
• 2+ 0.16 inch (4mm) ___________
• 3+ 0.24 inch (6 mm)
• 4+ >0.32 inch (8 mm)
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Aging Adult Health History1. Increased Risk of Damage2. Delayed Wound Healing3. Pruritis
1. Skin Turgor2. Lentigo (macule)3. Cutaneous Tags4. Cherry Angioma (red papule)5. Seborrheic keratoses / Actinic keratoses
Spring 2012 17
Older Adult
Approach:• Skin atrophies• Increase amount of pigmentation esp. in sun
exposed areas• Isolated areas of hypo pigmentation• Skin becomes drier and flattens, often
becoming paper like• Elasticity decreases and wrinkles develop
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Older Adult
• Decreased melanocyte function causes gray hair and pale skin
• Decreased axillary, pubic & scalp hairWomen: facial hair Men: nasal hair
• Nails grow more slowly, become thicker & more brittle, yellowish
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Older Adult• Temp/ moisture , mobility
– Increased dryness (xerosis)– Thinning of the skin– Hanging skin
• Hair:– Graying, thin texture– Symmetric balding may occur in men
• Facial & Body hair– Men increased coarseness
• Nail– Thickening, increases brittleness, deformity
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Cultural Considerations
• The oral mucosa is best for assessing color changes in dark-skinned persons
• Assessing the sclera for jaundice, rather than the skin in Asians
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Health Promotion• Immunizations• Sun Exposure & Protection• Skin Cancer • Teach client:
– skin self assessment– Toenail trimming – Ingrown toenail care
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