assessing the integumentary

7/29/2019 Assessing the Integumentary

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Assessing the IntegumentarySystem

Mrs.Helena R.Joseph,M.Sc(N),Associate Professor,

Medical Surgical Nursing Department

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Composition of the integumentarysystem Skin

Hair

Nails

Is the largest organ of the body and the easiest ofall systems to assess

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Mrs. Mahdia SamahaKony


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Anatomy and Physiology Review9/13/2013

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Epidermis Covers, protects, and waterproofs. Contains four main layers:

Stratum corneum: Keratinized layer. Prevents loss orentry of water; protects against pathogens andchemicals.

Stratum lucidum: Found only on palms of hands andsoles of feet; protects against UV sunrays to prevent

sunburn.1.Stratum granulosum2.Stratum germinativum. The innermost layer of epidermis,

is the only layer that undergoes cell division & containsmelanin & 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 hemoglobin3. 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 thestratum germinativum; also contains nerve endings,touch receptors, and fingerprint pattern; double layer onhands and feet.

Reticular Layer: Contains connective tissue withcollagen and elastic fibers, blood and lymphatic vessels,nerves, free nerve endings, fat cells, sebaceous glandsand hair roots, deep pressure receptors, and smoothmuscle fibers.

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DermisSweat 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 helpsregulate 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; whenapocrine secretions react with bacteria, bodyodor results.

Ceruminous glands are a type of apocrine glandfound in the external ear canal.

They secrete cerumen, which prevents drying ofthe ear drum and traps foreign substances.

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Sebaceous Glands: Produce sebum, whichlubricates and protects skin and hair.

Cholesterol: Converts to vitamin D whenexposed 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 andfiltering dust and debris away from the nose, ears,and eyes.

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The Nails

Nails are made up of hard, keratinized cellsand growfrom a nail root under the cuticle.

The nail bed, or epithelial layer of skin: vascularsupply gives the nail a pink color

The lunula, the proximal part of the nail. Thenailbeds .

The purpose of the nails is to protect the distalportions of the digits and aid in picking up objects

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Relationship of the IntegumentarySystem 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 sweatglands.

Adrenal hormones affect dermal blood supplyand mobilize lipids from adipocytes.

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Relationship of the IntegumentarySystem to Other Systems 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 andphosphorous absorption.

Supplies nutrients while skin stores lipids.

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Relationship of the IntegumentarySystem to Other Systems 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 andphosphorus absorption.

Skeletal system provides a framework for skin.

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Relationship of the IntegumentarySystem to Other Systems 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 moremacrophages 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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Relationship of the Integumentary System

to Other Systems MUSCULAR Skin synthesizes vitamin D needed for calcium

absorption for muscle contraction. Gives shape to and supports skin.

Contraction of facial muscles allows communicationthrough 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.

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Symptom Analysis9/13/2013

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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 ChronicUlceration A nonhealing wound or chronic irritation is often

associated with an underlying disease.

The most common types of nonhealing wounds orchronic skin ulcerations are caused by vasculardisease or pressure or by diabetes.

Pruritus : is severe itching. May be localized or generalized

Caused by a dermatologic problem or underlyingsystemic problem. Pruritus is often accompanied by a rash. Itching,

when not associated with a rash, may be indicativeof 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, caninfluence the perception of itching, whichexplains 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 oran underlying systemic problem.

Seasonal Skin Disorders

Seasonal skin problems include those caused bytemperature fluctuations, air humidity, andexposure 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, Pityriasisrosea, Urticaria, Acne flare-ups

Winter: Contact dermatitis of hands, Senilepruritus/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- 100strands 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 hairfollicles)

Nonscarring(resulting from hormonal changes, medications,infectious diseases, or thyroid disease, in which the folliclesremain intact with a potential to reverse the process).

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Nail Changes

Changes in the nails also often reflect anunderlying systemic problem

Changes in color and texture are frequentcomplaints.

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Assessing Lesions

Primary lesion is one that appears inresponse to some change in the internal or

external environment of the skin and is notaltered by trauma.

Secondary lesions result from changes in

primarylesions. They either add to or takeaway from an existing primary lesion.

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Pressure Ulcers

Pressure ulcers are a type of secondary lesioncaused by unrelieved pressure.

Assessment begins with identifying those at riskfor pressure ulcer development and developing aplan to prevent pressure ulcer formation.

If a pressure ulcer develops, assessment focuseson staging pressure ulcers and developing andevaluating pressure ulcer treatment plans.

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Clinical Description of LesionsSize: 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 ofassigned grad

Shape Macules, wheals, and vesicles are circumscribed.

Fissures are linear.

Irregular borders are associated with melanoma.

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Clinical Description of Lesions

ColorVariegated-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 whiteTexture

Macules are smooth. Warts are rough. Psoriasis is scaly.

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Clinical Description of Lesions

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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ExudateClear 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 thanvesicles, as seen with second-degree burns.

Yellow pus exudates: Pustules, as seen withimpetigo or acne. Tenderness or Pain associated with a lesion

depends on the underlying cause. May be associatedwith bullae from a burn or ecchymoses (bruise).

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Clinical Description of LesionsPetechiae or Purpura

Extravasations of blood into skin.

Caused by steroids, vasculitis, systemic diseases.

Does not blanch.

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Vascular LesionsEcchymosis

Extravasation of blood intoskin layer.

Caused by trauma/injury.

Does not blanch.

Petechiae or Purpura Extravasations of blood into skin.

Caused by steroids, vasculitis, systemicdiseases. Does not blanch.

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Vascular LesionsVenous 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 ofcapillaries.

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Vascular Lesions

Spider Angioma

Red color, type oftelangiectasis.

Looks like a spider, with

central body and fine radiatinglegs.

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:


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Primary LesionsRaised, Superficial,

Temporary

Examples:

Allergic reaction

Hives (urticaria)

Insect bite

Palpable, Solid With

Depth Into Dermis

Examples:

Bartholins cyst

Erythema nodosum

Lipoma

Nodule:2 cm

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Primary LesionsVesicle (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 LesionsLichenification: Thickening

and Scaling With IncreasedSkin Markings

Examples:

Contact dermatitis

Eczema

Lipoma

Psoriasis


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Secondary Lesions Scales: Shedding, Dead Skin

Cells; Scales Can Be Either Dryor 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

FormationsExamples:

Surgical site

Trauma site


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Secondary Lesions Keloid: Hypertrophic

scarring because of

excess collagenformation; raised andirregular

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 thesuperficial 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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Secondary lesions that take awayFissure: Linear breaks in the skin

with well-defined borders, mayextend to the Dermis

Examples:

Athletes foot

Cheilitis

Hand dermatitis (chappedhands)

Syphilis


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Secondary lesions that take away Ulcer: Irregularly

shaped loss extending to

or through the dermis;may be Necrotic

Examples:

Pressure ulcer


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Secondary lesions that take away Atrophy: Thinning of

skin with transparent

appearance and loss ofmarkings

Examples: Aging

Arterial insufficiency

Topical corticosteroids


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Common Abnormalities9/13/2013Mrs. Mahdia Samaha

Kony

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Acne Vulgaris Caused by sebaceous gland overactivity with plugging of

hair follicles and retention of sebum,

resulting in comedones, papules, and pustules. Onset istypically 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 orpustules.

Cysts may develop and leave

extensive scarring.

Most common on face, back,

and shoulders. Bacillus is cause.

Lesions may be sore andpainful.


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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 rolledborder.

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 permanentlyaltered.

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 erythematousbase.

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 regionalnodes.


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Herpes Zoster

Also called shingles; an acute, infectious diseasecaused by the varicella zoster virus.

Postzoster neuralgia discomfort can last formonths.

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 painfulgrouped 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 withimpaired 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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PsoriasisNails 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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TineaTinea 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 CrurisJock 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 PedisAthletes 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 onpalms.

Tinea pedis occurs in interdigital folds between toes oron soles of feet.


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Vitiligo

Characterized by white patches of skin surroundedby 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.


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