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Assessment and Diagnostic Tests - Integumentary
Assessment and Diagnostic Tests - Integumentary
Assessment and Diagnostic Tests - Integumentary
Contd..
Melanocytes are present in the deep basal layer of
the epidermis
Contain melanin pigment color to the skin and hair
and protects the body from damaging ultraviolet rays
Sunlight and hormones stimulate the melanosome (
within the melanocyte) to produce melanin
Contd..
If new cells slough off too rapidly, the skin will appear
thin and eroded
If new cells form faster than the old cells are shed,
the skin becomes scaly and thickened
Changes in the cell cycle account for many skin
problems - Psoriasis
Skin Appendages
Hair; Nails ; Glands sebaceous and Sweat glands
(apocrine sweat glands , eccrine sweat glands,
ceruminous)
Develop from the epidermal layer and receive
nutrients, electrolytes, and fluids from the dermis
Hair and nails form from specialized keratin that
becomes hardened
Contd..
Controls heat regulation by responding to changes in
internal and external temperature
Helps to maintain hemostasis through fluid and
electrolyte balance
Endogenous synthesis of vitamin D ( critical to
calcium and phosphorus balance)
Absorption
Asthetic functions
Gerontologic considerations
Undergoes many physiological changes associated with
normal aging
Excessive sun exposure, systemic diseases and poor
nutrition
Loss of :
subcutaneous tissue,
substances of elastin,
collagen, and fat diminishes the protection and cushioning of
underlying tissues and organs decreases muscular tone and
results in the loss of the insulating properties of fat
Contd..
Dermal layers thin and skin becomes fragile and
transparent
Capillary loops decrease in number- contribute to
delayed wound healing
Sweat and sebeaceous glands decrease( hormonal
changes) in number and functional capacity leading
to dry and scaly skin
Contd..
Hair growth diminishes
Thinning of hair in the scalp axilla and pubic areas
Photoaging profound wrinkling, increased loss of
elasticity, mottle, pigmented areas, cutaneous
atrophy and benign or malignant lesions
Increased chances of developing bedsores on
dependent areas
Assessment
Begins at the initial contact with the patient and
continues throughout the examination
Specific areas of the skin are examined - unless the
chief complaint is that of a dermatologic nature
A general statement of the physical condition of the
skin should be recorded and specific problem should
be noted under the appropriate system
Health history questions should be asked when a skin
problem is noted
Subjective Data
Important health Information
Past health history
Will indicate previous trauma, surgery or prior disease that
involves the skin
Any changes in the skin color
Specific information related to food , pet, and drug
allergies and skin reactions to insect bites and stings
Chronic and unprotected exposure to UV light, radiation
treatments
Medications used like vitamins, corticosteroids, hormones,
antibiotics and antimetabolites etc. including OTC
medications
Contd..
Elimination Pattern
Have you noticed changes in your skin related to
excessive sweating, dryness or swelling /
Contd..
Cognitive perceptual pattern
Do you have any unusual sensations of heat cold or
touch?
Do you have any pain associated with your skin
condition?
Do you have any joint pain?
Contd..
Have you changed your lifestyle because of your skin
condition?
Are there any environmental skin irritants at your
current or previous work place or home?
Contd..
Do you feel that stress plays a role in your skin condition
How do you handle stress?
Objective data
Physical examination
Primary skin lesions develop on previously unaltered
skin
Some of the common characteristics of primary and
secondary skin lesions are (given in the hand out )
General principles
Private examination room of moderate temperature
with good lighting daylight preferred
Ensure patient is comfortable and in a gown that
allows easy access to all skin areas
Be systematic and proceed from head to toe
Compare symmetric parts
Perform general inspection and then a lesion specific
examination
Use the metric system while taking measurements
Use appropriate terminology and nomenclature when
reporting or documenting
Inspection
General color and pigmentation, vascularity or
bruising and the presence of lesions or discolorations
A skin color that is normal of a particular patient can be
a sign of a pathologic condition in another patient
Color depends on the amount of melanin(brown),
carotene (yellow), oxyhaemoglobin (red) and reduced
haemoglobin ( bluish red)
Contd..
The skin is examined for possible problems related to
vascularity, such as areas of bruising and vascular and
purpuric lesions such as angiomas
If lesions are found then the
Color
Size
Distribution
Location
Shape - should be recorded
Palpation
Palpated to provide information about the temperature,
turgor and mobility , moisture and texture
Temperature back of hands
Skin should be warm without being hot
Temperature of skin increases when blood flow to dermis is
increased
Decreased body temperature occurs when in shock, chilling,
or emotional distress
Contd..
Moisture of skin
Texture
Refers to the fineness or coarseness of the skin
Skin should feel smooth and firm with the surface
evenly thin in most areas
Contd..
More difficult to assess than lighter skin
Assessment is more easily made in areas where the
epidermis is thin and pigmentation is lighter, such as
Lips
Mucous membrane
Palms
Nail beds
Diagnostic tests
Before diagnostic testing / procedure , perform an
assessment and document the findings
Nursing interventions for diagnostic procedures
includes explaining the procedure to the client and
significant others and allowing them to ask questions
and express concerns
Contd..
Explain appropriate wound care and indications of
possible side effects and complications that should be
reported
Provide instructions for follow up appointment
Documentation of diagnostic procedures and the
specific location of the lesion must be completed
Skin biopsy
Removal of skin tissue for histologic (cellular
microscopic) assessment or immunofluorescence
Punch , excisional , incisional
Local anesthesia is generally used, small gauge 26-30
gauge needle is recommended
Procedure is usually quick and almost painless
Skin nodules
Plaques
Blisters
And other lesions to rule out malignancy and establish
an exact diagnosis
Pre-procedure
Instruct the client
Avoid using asprin and products containing asprin for 48 hrs
before the biopsy to avoid prolonged bleeding time
If client is taking anticoagulants notify the physician
Review clients medical history for liver malfunction, which
affects clotting time
If history of cardiac valve replacement prophylactic antibiotics
need to be given
Obtain informed consent
Client can eat a light meal before the procedure to avoid
syncope
Post Procedure
Cover biopsy sites with an antibiotic ointment and a
clean bandage or dry dressing unless ordered
otherwise
Non-adhesive type of dressings in clients with a
fragile or sensitive skin and clients with Latex allergy
Remind client that a follow-up assessment is
necessary and appointment should be taken for
suture removal
Inform the number of days required for getting the
results
Immunofluorescence
Designed to identify the site of an immune reaction
Combines an antigen antibody with a fluorochrome
dye
Antibodies can be made fluorescent by attaching
them to a dye
Direct immunofluorescence technique to detect
auto antibodies directed against portions of the skin
Contd..
Indirect immunofluorescence detects specific
antibodies in the patients serum
Procedure
Fine scales from edge of the site are scrapped with a
number 15 scalpel blade or the edge of a glass slide
onto a 2nd glass slide
A drop of 10% - 20% potassium hydroxide is added to
the scale, and a coverslip is placed over the specimen
Gentle pressure is applied to flatten the scales
Slide is gently heated to dissolve keratin more quickly
Contd..
The scrapings are then observed under microscope
Culture scrapings are implanted in the appropriate
culture medium
For a nail culture an altered dystrophic nail is snipped
and implanted in the medium
Patch testing
Attempt to identify substances that produce allergic
skin responses
Painless procedure
Done to differentiate between an irritant contact
dermatitis and an allergic contact dermatitis
Procedure
Small amounts of various substances or allergens are
applied to the skin using commercially prepared tapes
containing allergens
The client and significant others need to understand
that low concentration are used
Should not be performed if acute dermatitis is
present or if the client is taking substantial amounts
of oral steroids
Tzancks Smear
Used for microscopic assessment of fluids and cells
rom vesicles or bullae
An intact recently evolved vesicle top is removed and
its base scrapped with a curette
The debris is smeared onto a labeled slide and sent
for cytological examination
Presence of a multinucleated giant cell establishes a
diagnosis of viral infection such as herpes simplex or
herpes zoster infection
Contd..
Lesions that still contain melanin almost disappear
under ultraviolet light
Lesions that are devoid of melanin increase the
whiteness with ultraviolet light
Reassure patient that the light is not harmful to skin
or eyes