Assessing Clients with Skin Disorders

Chapter 44

Integumentary System

Functions1. Protects body from injury2. Provides a barrier to loss of fluids3. Sensory - touch, pressure,pain, and temperature4. Regulates body temperature via sweat glands5. Production of vitamin D

Skin

2 LayersEpidermis

outer layer, protection, stores melaninepithelial cells

Dermisinner layer, temperature regulationconnective tissue, contains hair follicle, sweat glands and sebaceous glands

Layers of the Skin

Skin Color

1. Erythema reddening of the skin

– fever, inflammation, sunburn, drug reaction

2. Cyanosisbluish discoloration

– poor oxygenation of hemoglobin

Skin Color

3. Pallorpaleness of skin

– shock, fear, anemia or hypoxia

4. Jaundiceyellow-to-orange skin color

– hepatic disorders

3 TypesSebaceous - Oil

to soften and lubricate the skin

Sudoriferous - Sweatto regulate body temperature by excretion of sweat

Ceruminous - located in external ear canalsecrete cerumen, sticky trap for foreign materials

The Hair and Nails

Protective FunctionHair

cushions the scalpeyelashes and eyebrows protect the eyesprovides insulation in cold weather

Nailsprotects fingers, toes, aid grasping

The Health Assessment Interview

Determine problems with the integumentary system

“Describe any skin problems or injuries, nail problems or scalp problems you have had.”“Is your skin and/or scalp dry or oily?”“Do you have any skin pain, burning or

itching?”

The Physical Assessment

Can be part of head-to-toe or focused assessmentAssessment through inspection and palpationAssess for

color, lesions, temperature,texture, moisture, turgor and edema

Assessments?

The Physical Assessment

Inspect colorpallorcyanosisjaundice

Inspect for lesionsirregular skin, rash, hives, psoriasis - scaly red patches

The Physical Assessment

Palpate the skin for temperaturewarm with fevercool in shock or decreased blood flow

Palpate skin for texturesmooth or coarse

Palpate skin for moisturedry, moist, diaphoretic - M.I., shock

The Physical Assessment

Palpate for Turgorpinching skin over collar bone or back of handdecreased in dehydration tentingincreased in edema

Assess for edemaaccumulation of fluid in body tissuesdepress skin over ankle

The Physical Assessment

Rate the Edema1+ = slight pitting2+ = deeper pit3+ = obvious pit, extremities are swollen4+ = the pit remains

Edema occurs in cardiovascular disease, renal failure and cirrhosis of liver

Lymph Edema

The Physical Assessment

Hairinspect distribution and qualitypalpate for textureinspect the scalp for lesions

Nailsinspect for curvature, color and thickness

Variations in the Older Adult

Loss of subcutaneous tissuewrinkles, sagging, decreased turgor

Skin tagssmall flaps of excess skin

Decreased hair and nail growth“Liver spots”

small flat brown macules

Primary Skin Lesions

Maculeflat color change in the skin - freckle

Papuleelevated palpable mass with circumscribed boarder - elevated mole

Noduleelevated, solid mass extending deeper - lipoma

Primary Skin Lesions

Vesiclefluid filled with thin translucent walls - blister

Wheallarger than vesicle - insect bite, hives

Pustulepus filled vesicle - acne

Cystelevated, encapsulated mass - sebaceous cyst

Skin Lesions

Secondary Skin Lesions

Atrophytranslucent, dry, paperlike skin resulting from thinning or wasting away due to loss of elastin

Ulcerdeep crater-like, irregular shaped area of skin loss extending into the dermis

Fissurecracks with sharp edges - corner of mouth, feet

Vascular Skin Lesions

Port-wine stainlg. Flat mass of blood vessels on skin surface

Strawberry markbright red, raised cluster of immature capillaries

Petechiaeflat, red-purple “freckles” caused by tiny hemorrhages

Vascular Skin Lesions

Ecchymosisbruising - release of blood into surrounding tissues trauma, hemophilia, liver disease

Hematomasimilar to ecchymosis but is raised, swollen

Documenting general appearance

What terms describe this skin?

Lymphaedema

What would you document?

Skin our protector for life!

NCLEX

The nurse assessing a dark skinned client for cyanosis knows that in which of the following would cyanosis be more visible in a dark skinned individual?A. ScleraB. MM and nail bedsC. Generalized skin colorD. Palms of the hands and feet

NCLEX

A nurse assessing an elderly thin client notes the skin turgor over the client’s clavicle is decreased. The nurse interpretes this finding as which of the following?A. Client is dehydratedB. Client has edemaC. This is a normal finding for this clientD. The client has experienced a recent weight loss.

NCLEX

When performing a screening and assessment on a 44 year old female, the nurse notes a patch of hair loss.The nurse suspects which of the following?A. DandruffB. AlopeciaC. Scalp ringworm (tinea capitis)D. head lice

NCLEX

When inspecting a client’s nails the nurse notes that the angle of the nail base is greater than 180 degrees. What is this condition called?A. AlopeciaB. edemaC. tentingD. clubbing

NCLEX

When working with an older person, you would keep in mind that the older adult is most likely to experience which of the following changes with aging?A. thinning of the epidermisB. thickening of the epidermisC. oiliness of the skinD. Increased elasticity of the skin

NCLEX

Which of the following glands plays a role in killing bacteria?A. sebaceous (oil) glandsB. Eccrine sweat glandsC. Apocrine sweat glandsD. Ceruminous glands