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Assessing Clients with Skin Disorders Chapter 44
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
