Unit 10A Notes - Integumentary Assessment PDF

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Integumentary Assessment...

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Unit 10A: Integumentary Assessment Objectives        

Describe the anatomy and physiology of the integumentary system Explain the process of describing and classifying skin lesions Describe the characteristics of the most common integumentary chief complaints Discuss the system-specific history for the integumentary system Identify and describe common abnormalities found in the physical assessment of the integumentary system and discuss the pathophysiology of these problems along with risk factors Demonstrate and document an integumentary assessment Identify appropriate nursing interventions based on assessment of the integumentary system Describe changes in the physical assessment findings for different age groups

Structure of the Skin  

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Structures formed by tubular invagination of epidermis down to underlying dermis Skin is o Waterproof o Protective o Adaptive o Helps protect against the environment o Helps protect against penetration o Helps with perception, temperature regulation, communication, wound repair o Helps in the production of Vitamin D Hair Sebaceous glands Swear glands o Important for fluid balance and thermoregulation o Eccrine glands o Apocrine glands

Developmental Competence: Infants, Children, and Adolescents 

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Newborn Infants o Lanugo: fine, downy hair of newborn infant o Vernix caseosa: thick, cheesy substance  protection for fetus while in utero from all of the amniotic fluid o Sebum: holding water in the skin producing milia  Milia look like white head pimples  just the sebum of the skin Children o Epidermis thickens, darkens, and becomes lubricated o Hair growth accelerates Adolescents o Secretions from apocrine sweat glands increase  increase in acne o Subcutaneous fat deposits increase o Secondary sex characteristic

Developmental Changes in Pregnancy  

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Striae gravidarum (stretch marks associated with pregnancy)  abdomen, breasts, thighs o Different from striae Linea nigra o Increased pigmentation of the midline of the abdomen o More pronounced more in darker skinned individuals Chloasma o Discoloration across the face o “mask of pregnancy”

Developmental Changes in Older Adults 

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Changes in elasticity o Skin folds become more pronounced o Skin will sag more Decrease in number of sweat and sebaceous glands  skin will be more dry More senile prepula o Increased capillary fragility o Capillaries are more easy to break o Older patients will say “old people skin” Increase in skin breakdown Changes in hair matrix o Fine, grey hair

History of Present Illness: Skin             

Changes in skin, hair, or nails Sequence of events Symptoms Location  specify Associated symptoms Recent exposure o Allergens, sun, caustic substances Apparent cause Travel history Treatment response Adjustment to problem Medications  some medications can cause photosensitivity Trauma Bites

Past Medical History 

Skin o Previous skin problems o Lesions, treatments o Tolerance to sunlight, number of sunburns, tanning history  Cumulative effect of sun exposure  Evaluate the risk for skin cancer

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o Diminished or heightened sensitivity to touch o Cardiac, respiratory, liver, endocrine, or other systemic disease o Pruritis  itching o Any reactions? Exposure to toxic substances? Hair o Previous hair problems o Systemic problems Nails o Previous nail problems o Nail injury o Bacterial, viral, or fungal infection Systemic problems o Associated skin disorder o Congenital anomalies o Respiratory, cardiac, endocrine, hematologic, or other systemic diseases

***ARE THERE ANY UNDERLYING DISEASES IN THE ENDOCRINE SYSTEM, CARDIAC FUNCTIONING, RESPIRATORY, LIVER***

History for Pregnant Patients  

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Weeks of gestation or postpartum Hygiene practices o Because we are talking specifically about skin o How will this affect their integumentary system?  specifically the perineum Presence of skin problems before pregnancy Effects of pregnancy on preexisting conditions Rashes

History of Special Populations 

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Infants o Temperature o Birth marks o Allergies o Bathing and hygiene practices o Sun exposure o Attire o Temperature of the home o Nutrition  Feeding and eating habits Children and adolescents o Food allergies o Allergic reactions o Sun exposure o Exposure to infectious diseases o Rashes o Pet or animal exposure

o Exposure to outside environment

Physical Examination  

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Adequate lighting is essential Body sweep o Consider each organ system  Color of the skin can let us know about circulation Exposure o Only expose what you need to expose at that time Draping Hygiene Color and uniform appearance Skin lesions  be detailed!!! o Be precise in measurements o Measure in all dimensions o Note shape o Measure in centimeters o Make sure there is adequate lighting Thickness Symmetry Palpation of the skin surfaces for o Moisture o Temperature o Texture o Turgor o Overall elasticity Inspect hair o Color o Texture o Overall density o Placement Palpate the head o Texture o Fragility o Expected differences among different ethnic groups Inspect nails o Coloration of nails and nailbeds o Length o Symmetry o Surface changes  Rigid, beading, pealing, pitting Inspect and palpate proximal and lateral nail folds o Warts o Cysts o Tumors o Redness, swelling, pain

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Look at nail base angle Observe cuticles

Assessment of Skin Lesions 

Characteristics of lesion o Size (measure all dimensions)  Be very precise in measurements  Measure in a flexible ruler that is clear  MEASURE IN CENTIMETERS o Shape o Color o Blanching o Texture o Elevation or depression o Attachment at base o Exudates o Configuration o Location and distribution o Tools  Wood’s lamp for fungal lesions  Fluorescing lesions o Ring worm  Clear ruler

ABCDE Skin Assessment      

Promoting health and self-care Dark pigmentation of skin helps with protection against skin cancer  melanin Increased likelihood of skin cancer in Caucasian patients Most severe environmental risk factor for developing skin cancer is exposure to UV radiation from sun and tanning sources Increases risk for melanoma depending on the amount of sunburns you get in your lifetime Certain skin presentations are associated with different ethnic groups  teach about skin selfexaminations o A: asymmetry  What is the shape of the lesion?  Round lesions  not as concerned o B: border  Regular or irregular o C: color o D: diameter o E: elevation and enlargement

Physical Examination: Pregnant Patients 

Skin Inspection o Striae gravidarum (stretch marks associated with pregnancy) o Telangiectasis/hemangiomas

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Hemangiomas: Collection of capillaries at the surface level  seen on infants heads or arms; can grow or go away on their own; will bleed if bumped  Telangiectasis: seen in geriatric patients around their ankles; almost like a starburst pattern o Cutaneous tags o Increased pigmentation  Chloasma  mask of pregnancy  Linea Nigra  dark line down the abdomen o Palmar erythema o Itching o Altered hair growth Infants, children, adolescents o Document any birthmarks, lesions, contour distortions o Evaluate skin turgor, blanching o Acne, maturational changes Older adults o Look for skin breakdown over bony prominences

Shapes and Configurations of Lesions  

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TABLE 9.6; PAGE 148-149  NEED TO KNOW Annular and circular o Round, active margin with a clearing center o Tinea corporis  ring worm Confluent o Joining or running together o Urticaria  hives Discrete o Well demarcated or defined borders Grouped o Grouped lesions Gyrate o Arranged in rings or convulutions Target or iris o Pink macules with a purple central papule o Erythema multiform Linear o In a line formation o Poison ivy Polycyclic o Interlocking or coalesced circles

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o Urticaria Zosteriform o Follows a dermatome o Shingles

Primary Skin Lesions  

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MEMORIZE!!! Macules o Flat, nonpalpable circumscribed o Less than 1 cm diameter o Freckle Papules o Elevated, palpable, firm, circumscribed o Less than 1 cm o Wart Patches o Flat, nonpalpable irregular borders o Greater than 1 cm o Vitiligo Plaques o Elevated, flat top, firm, rough o Greater than 1 cm o White or grey in color o Psoriasis Nodules o Elevated, firm, circumscribed, deeper in the dermis o 1-2 cm in diameter o Lipoma Wheals o Elevated, circumscribed, irregular shaped, cutaneous edema o Insect bite o Intradermal injections  TB test Tumors o Similar to a nodule o Not as demarcated; deeper and less defined o Greater than 2 cm Urticaria (hives) Vesicles o Elevated, circumscribed, superficial o Filled with serous fluid o Less than 1 cm o Varicella /chicken pox o Can be grouped

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Cysts o elevated, circumscribed, palpable, incapsulated o Filled with liquid or semisolid material o Sebaceous cyst Bullas o Elevated, superficial o Filled with serous fluid o Greater than 1 cm o Blister Pustules o Elevated, superficial, filled with purulent fluid o Acne

Secondary Skin Lesions 

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Debris on skin surface o Crusts  Dried serum, blood, or purulent exudate  scab o Scales  Flakey, exfoliation, or dry skin Break in continuity of the skin o Fissures  Deep linear crack or break from the epidermis to the dermis  Athlete’s foot o Erosions  Loss of epidermis, depressed and moist  Ex. Varicella after rupture o Ulcers  Loss of epidermis and dermis  Concave  Will vary in size  Exudative o Excoriations  Linear or hollowed out loss of dermis  Repetitive scratching o Scars  Thin to thick fibrous tissue replacing injured dermis o Atrophic scars  Older striae  Silver in color  Can feel the texture  thinner o Lichifications  Rough, thickened epidermis caused by repetitive rubbing or irritation o Keloids  Irregularly shaped, progressively enlarging scar  Genetic feature

 More common in darker skinned individuals  Hypertrophic scar o Slough  Peeling or falling away of the epidermis or the dermis

Vascular Lesions 

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Hemangiomas o port-wine stain (nevus flammeus)  noted on birth in the newborn nursery o capillary hemangioma  red capillary patched caused by dilation of dermal capillaries  seen a lot of times on the head or arms  very fragile, bleeds easy Telangiectasia o Fine irregular red lines caused by dilated capillaries  Bluish, irregularly shaped  Does not blanch with pressure o Spider or star angioma  Red central body with “legs”  Does blanch with pressure o Venous lake  Collection of vessels Purpuric lesions o Petechiae  Pinpoint  Red, purple, brown in color  Less than ½ cm  Non-blanching o Purpura  Red, purple  Greater than ½ cm o Ecchymosis  variable in size  Flat  Greater than 1 cm Lesions caused by trauma or abuse o Pay attention to patterns o Documentation is important o Do not offer an opinion o Chart what we see  BE VERY DETAILED o Be detailed in your history o If you can take a picture, it is worth a thousand words o Hematomas  Large collection of blood-filled space o Scalp petechiae o Cigarette burns o Hand marks

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Scratches Belt marks Ligature from rope or cord Scolding Bruises

Nails      

Fungal infection o Aunico mycosis Clubbing from chronic hypoxia o Angle of the nailbed is dramatically increased Pitting of nail bed o Associated with psoriasis Ingrown nail o Aunico cryptosis Subungual hematoma o Blood under the nail In elderly patients o Thick brittle nails are prone to fungal infections  Hard to get rid of o Longitudinal ridges are prone to splitting

Hair 

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Pediculosis o Lice o Nits Alopecia o Different types Receding hairline Remember that skin, hair, and nail changes can be a disease process all by themselves, but can also signal systemic problems o Be mindful what we see!!!

Eczematous Dermatitis  

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Most common inflammatory skin disorder Can be from o Irritant o Allergic o Atopic Non-specific term to describe epidermal changes Scratching!!!!

Folliculitis and Furuncle (Boil)  

Inflammation and infection of hair follicle and surrounding dermis Furuncle o Deep seated infection of the pilosebaceous unit

Cellulitis o Diffuse, acute infection of skin and subcutaneous tissues o Red, warm, swollen o Can get so tight that it can begin to weep

Tinea (Dermatophytosis) o o o o

Group of noncandidal, fungal infection that involve the stratum cornidium, nails, or hair Tinea capidus  ring worm Jock itch Athlete’s foot

Pityriasis Rosea & Rosacea o Pityriasis Rosea o Self-limiting inflammation of unknown cause o Patch o Rash disappears on its own  Lasts 6-8 weeks  Scaly papules and plaques that begin with a single herold patch  Christmas tree rash o Rosacea o Chronic inflammatory skin disorder o Redness of the face

Psoriasis   

White, silver scaley plaques Chronic disease Increased proliferation of keratinocyte

Drug Eruptions & Acanthosis Nigricans  

Drug eruptions o Cutaneous reactions to medications Acanthosis Nigricans o Think of Tina o Non-specific reaction pattern associated with obesity, endocrine syndromes, or even malignancies o Can be inherited disorder o Skin condition characterized by dark, velvety skin discoloration in skin folds and skin creases  Affected skin becomes thickened o Most often affects armpits, groin, and neck

Risks for Skin Cancer    

Age (over 50) Fair, freckled complexion Exposure to sunlight or UV radiation Light-colored hair or eyes

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Sunburn easily Exposure to arsenic, creosote, tar, petroleum  work or environmental exposure; occupational hazards Family history of skin cancer Radium exposure Equator or high altitude Precancerous dermatoses

Melanoma  

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Skin cancer that develops from melanocytes Signs of melanoma (ABCDE Rule) o A: asymmetric in shape; one half unlike the other o B: irregular border o C: color variability/variegated  shades of brown, black, grey, red, and white o D: diameter greater than 6 mm  Pencil eraser o E: evolving  the lesion is changing in size, shape, or shade of color The four major types of melanoma o Superficial spreading o Nodular o Lentigo maligna o Acral lentiginous

Basal Cell Carcinoma      

Most common type of skin cancer; most common cutaneous malignant neoplasm Caused by sun exposure Shiny “pearly” papule or nodule Umbilicated center and telangiectasis Grows slowly Usually occurs on sun-exposed areas

Squamous Cell Carcinoma      

Second most common skin cancer BLEEDS EASILY!!!!  KEY INDICATOR o Pt will present with a sore that “won’t heal” and bleeds all the time More common in immunosuppressed or transplant patients Hyperkeratotic lesion with crusting and ulceration Can be more aggressive than Basal Cell Carcinoma Usually occurs on sun-exposed areas

Kaposi Sarcoma    

Malignant tumor of the endothelium Common tungstic infection of HIV Purpley dark areas all over Very distinguishable...