Health Assessment 02-19-2022

WEEK 5 : INTEGUMENTARY SYSTEM

The integumentary system consists of the skin, hair,and nails
● The skin, hair, and nails provide clues about general health, reflect changes in environment, and signal
internal ailments stemming from other organs.

SKIN
➔ The largest organ of the body and the easiest of all systems to assess.
➔ A physical barrier that protects the underlying tissues and organs from microorganisms, physical
trauma, ultraviolet radiation (UVR), and dehydration.
➔ Provides individual identity to a person's appearance.
➔ Thicker on the palms of the hands and soles of the feet.
➔ Continuous with the mucus membranes at the orifices of the body.
➔ The outer visible layer contains keratin that is extremely tough and it is a protective protein substance
that causes tissue to become horny.
➔ The outermost layer consists of dead keratinized cells and the innermost layer is the only layer that
undergoes cell division.
➔ Contains melanin and keratin – forming cells.

Dermis
01. Made up of proteins and mucopolysaccharides. It is a thick,
Plays a vital role in :
gelatinous material that provides a supporting matrix for nerve
★ Temperature maintenance tissue, blood vessels, sweat and sebum glands, and hair follicles.
★ Fluid and electrolyte
balance 02. Well – vascularized, contains collagen, elastic fibers, nerve endings,
★ Absorption
lymph vessels and the origin of sebaceous and sweat glands.
★ Excretion
★ Sensation
★ Immunity
Subcutaneous Tissue
★ Vit. D synthesis ● Loose connective tissue containing fat cells, blood vessels, nerves,
and the remaining portion of sweat glands and hair follicles.
● Stores fat as an energy reserve and provides insulation to conserve
internal body heat. Serves as a cushion to protect bones and internal
organs
 HAIR
➔ Made up of keratinized cells and found over most of the body.
➔ Grows from hair follicles supplied by blood vessels located in the dermis.
➔ Hair provides protection by covering the scalp and filtering dust and debris away from the nose, ears,
and eyes.

Hair Changes
★ Anagen
➔ The active growth phase of hair follicles during
which the root of the hair is growing rapidly.
During this phase the hair grows about 1 cm every
28 days.
★ Telogen
➔ Resting stage of the growth cycle.

Alopecia
➔ Probably the most distressing change in hair that can occur because of its cosmetic effect not only
refers to scalp hair but also to body hair.

★ Non-Cicatricial
- Nonscarring
- Hormonal changes
- Medications
- Infectious diseases / Thyroid
- Follicles may remain intact and reverse process

★ Cicatricial
- Scarring
- Burns
- Radiations
- Traction
- Irreversible damage to hair follicles
 NAILS
➔ Made up of hard, keratinized cells and grow from a nail root under the cuticle.
➔ Protecting the distal portions of the digits enhances precise movement of the digits aid in picking up
objects.
NAIL ASSESSMENT
Inspect fingernail plate shape, curvature and angle
➔ Normal

- Colorless and convex curve

- Angle between nail and nail bed: usually 160 degree.

➔ Deviations from normal

- Concave
- Clubbed fingernails s (>180o ) due to chronic tissue
- hypoxia

★ Inspect and palpate finger and toenail bed color

➔ Normal

- Highly vascular and pink in light skinned

- In dark skinned may look brown or black

● Deviations from normal

- Bluish or purplish tinges

- Pale

★ Inspect tissues surrounding cells

● Normal
- Intact epidermis

● Deviations from normal

- Hangnails
- Inflammation of surrounding tissues

★ Perform blanch test

● Normal
- prompt return or pink/useal color, less than 4 seconds

● Deviations from normal

- Delayed return of color. Usually >4 seconds
SYMPTOM ANALYSIS

★ Itching - Pruritus
➔ Itching arises from free nerve endings (nonmyelinated), which are especially abundant in the flexor
aspects of the wrist and ankles. It occurs as a result of a spinal reflex and external stimuli, such as
heat, dryness, inflammation, and vasodilation.

● Pruritus
- Severe itching
- It may be localized or generalized and caused by a dermatologic problem
or underlying systemic problem.
★ Rashes
➔ Like itching, may be localized or generalized acute or chronic, and caused by an obvious
dermatologic problem or an underlying systemic problem.

★ Seasonal skin disorders

● Cold Urticaria
- Temperature fluctuations

● Warm Weather Skin Rash

- Air humidity

● Cutaneous Anthrax
- Exposure to contaminants

★ Non - healing sore or chronic ulceration

➔ Often associated with underlying diseases.
➔ The most common types are caused by vascular disease or pressure or by diabetes.

★ Nail changes
➔ Changes in the nails also often reflect an underlying systemic problem.
➔ Changes in color and texture are frequent complaints.
SKIN COLOR ASSESSMENT
★ Normal
➔ Varies from light to deep brown, from ruddy pink to light pink

★ Deviations from normal

➔ Pallor
❖ Decrease in color of the skin caused by lack of oxygen in the body. Best observed around
fingernails, lips, palpebral conjunctiva, and oral mucosa; likewise, on the palms of hands
and soles of feet
➔ Cyanosis
❖ Bluish discoloration of the skin due to lack of oxygen or poor tissue perfusion
❖ Best observed on the lips and nail beds
❖ 2 Types of cyanosis
➢ Central
- Cause by diseases of heart and lungs.
- Bluish discoloration of tongue and linings of the mouth.
➢ Peripheral
- Results from decreased peripheral circulation.
- Seen at the arms and legs.

➔ Jaundice
❖ Also known as icterus; a yellowish appearance of the skin, sclera, mucous membranes, and
excretions related to hepatobiliary disorders or hemolytic diseases.

➔ Erythema
❖ Redness of the skin due to congestion of the capillaries

SKIN COLOR UNIFORMITY

★ Normal
➔ Generally uniform except in areas exposed to sun. And in areas of lighter pigmentation in dark
skinned.

★ Deviations from normal

➔ Hyperpigmentations
❖ BIRTHMARKS
- Abnormal destruction of the melanin
➔ Hypopigmentation
❖ VITILIGO
- Destruction of melanocytes in the area
 ❖ ALBINISM
- Complete or partial lack of melanin

SKIN ODOR
★ Unusual body odor
- Poor hygiene or underlying disease
★ Odors from excessive sweating (hyperhydrosis)
- Possible thyrotoxicosis (excess thyroid hormone)
★ Odors from night sweats o Possible tuberculosis
- Urine odor o Incontinence problem
★ Mousy odor
- Liver disease

SKIN EDEMA
★ Excessive accumulation of fluid in body tissues – cardiovascular problem.
★ Note the degree to which the skin remains indented or pitted when pressed by a finger

➔ 1+
- Barely detectable
➔ 2+
- indentation of less than 5 mm
➔ 3+
- indentation of less than 5 - 10 mm
➔ 4+
- indentation of more than 10 mm

INSPECT, PALPATE, AND DESCRIBE SKIN LESIONS

★ According to location, distribution, color, configuration, size, shape, type or structure
★ Types

➔ Primary skin lesions

❖ Initial alteration in the skin
❖ Abscess, ulcer, tumor, open wound
➔ Secondary skin lesions
❖ Arises from a change in primary lesion
❖ Crusts, keloids, scars
➔ The ABCDE of lesions
❖ Useful for assessment of skin cancers
 - Asymmetry
- Border irregularity
- Color variations
- Diameter
- Elevation

PRIMARY SKIN LESIONS

★ Macule and Patch
➔ Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red).
Macules are less than 1cm with a circumscribed border. Whereas patches are greater than 1 cm,
and may have an irregular border
➔ Examples of Macule:
❖ Cherry Angioma
- The collection of blood vessels
❖ Lentigines
- Small brown patches on skin (typically with old people)
❖ Petechiae
- Tiny circular bleeding under the skin
❖ Scarlet fever
- bright red rash that covers most of the body, bacterial illness that develops in people
with strep throat

★ Papule and Plaque

➔ Elevated, palpable, solid mass
➔ Palpable, Raised, but Superficial
➔ Papules have a circumscribed border and are less than 0.5 cm
➔ Plaques are greater than 0.5 cm
➔ Examples of Papules
❖ Elevated Nevi
❖ benign (noncancerous) moles, also known as dysplastic nevi
❖ Warts
❖ growths on skin caused by an infection with humanpapilloma virus, or HPV

★ Wheal
➔ Elevated mass with transient borders that is often irregular. Size and color vary. Collection of
edema fluid into the dermis. Raised, superficial, and temporary.
➔ Examples
❖ Hives
❖ Insect bites
★ Nodule and Tumor
➔ Elevated, solid, palpable mass that extends deeper into dermis than a papule
 ➔ Nodules are <2 cm and circumscribed
➔ Tumors are >2 cm and do not always have sharp borders
➔ Examples of Nodules
❖ Lipoma
- lump of fatty tissue between your skin and the underlying muscle
- it feels rubbery, and you may be able to move it around a bit
- usually painless, harmless, and not cancerous
❖ Squamous cell carcinoma
- the second most common form of skin cancer
- usually found on areas of the body damaged by UV rays from the sun or tanning
beds
❖ Dermatofibroma
- superficial benign fibrous histiocytoma
- a common cutaneous nodule of unknown etiology that occurs more often in women
- frequently develops on the extremities (mostly the lower legs) and is usually
asymptomatic, although pruritus and tenderness can be present
★ Cyst
➔ Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis
➔ 1 cm or larger elevated
➔ Palpable, solid with depth into dermis

★ Vesicle and bulla

➔ Palpable, fluid filled
➔ Vesicles are less than 0.5 cm
➔ Bullas are greater than 0.5 cm
➔ A circumscribed, round or oval, thin translucent mass filled with serous fluid or blood
➔ Examples of Vesicles
❖ Herpes simplex
❖ Varicella
❖ Poison ivy rash
❖ Second degree burns
➔ Examples of bulla
❖ Pemphigus
❖ Contact dermatitis
❖ Large burn blisters
❖ Bullous impetigo
★ pustule

➔ Pus-filled vesicle or bulla

➔ Examples
❖ Acne
❖ impetigo
SECONDARY SKIN LESIONS

★ Lichenification
➔ Thickening and scaling with increased skin markings, ex. Eczema

★ Scales
➔ Shedding of dead skin cells
➔ Can be either dry or oily
➔ Flaking of the skin surface
➔ Maybe adherent or loose o Variable in color
➔ Ex. Psoriasis
★ Crust
➔ Dried exudates, dried serum, blood or pus on the surface of the skin, Ex. Impetigo
★ Scar
➔ Skin mark left after healing of wound or lesion that represents replacement by connective tissue of
the injured tissue
➔ Young scars are red or purple, whereas mature scars are white or glistening
➔ Ex. Trauma scar
★ Keloid
➔ Hypertrophic scarring because of excess collagen formation
➔ Raised and irregular
★ Excoriations
➔ Abrasion or other loss that does not extend beyond the superficial epidermis
➔ Loss of outer skin layers from scratching or rubbing
➔ Ex. Scabies
★ Erosions
➔ Loss of superficial epidermis that does not extend to the dermis
➔ Ex. Dermatophyte
★ Fissures
➔ Linear crack in the skin that may extend to the dermis and may be painful
➔ Ex. Chapped lips
★ Ulcers
➔ Skin loss extending past epidermis, with necrotic tissue loss.
➔ Bleeding and scarring are possible
➔ Ex. Stasis ulcer
★ Atrophy
➔ Thinning of skin with transparent appearance
➔ Ex.Thinning of skin due to aging
-
VASCULAR LESIONS
➢ Lesions are associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic
disease, among other problems

★ Ecchymosis - round or irregular lesion; varies and changes: black, yellow, and green hues
★ Petechia - Secondary to blood extravasation; Caused by steroids, vasculitis, systemic diseases
★ Cherry angioma - Papular and round, red or purple lesion found on the trunk or extremities; It may
blanch with pressure
★ Spider Angioma - Red arteriole lesion with a central body with radiating branches; ass. w/ liver disease
★ Telangiectasis - It does not blanch when pressure is applied; Associated with increased venous pressure
states (varicosities)
★ Hematoma - A localized collection of blood creating an elevated ecchymosis; It is associated with trauma
★ Capillary hemangioma - red color; irregular shaped patch; strawberry marks
★ Post - wine stain - red color; Seen with dilation of dermal capillaries

COMMON ABNORMALITIES OF THE SKIN

★ Acne vulgaris
★ Actinic keratosis
★ Contact dermatitis
★ eczema/atomic dermatitis
★ Herpes simplex
★ Intertrigo
★ Pityriasis rosea
★ Psoriasis
★ Rosacea
★ Seborrhea
★ Seborrheic keratosis
★ Stasis dermatitis
★ Tinea capitis
★ Tinea corporis
★ Tinea cruris
★ Tinea pedis
★ Tinea manus

3 MOST COMMONLY DEETCTED SKIN CANCER

★ Melanoma - An invasive, cancerous skin tumor with strong potential for metastasis to both regional and
distant sites and organs
★ Squamous cell carcinoma - A form of skin cancer occurring mainly in the squamous cells
★ Basal cell carcinoma - An epidermoid cancer, one of the most common malignant skin diseases
 Observe and palpate skin moisture Palpate skin temperature
➔ Done by touching or palpating the skin of the ➔ Done by touching or palpating the skin of the
extremities. extremities.
❖ Normal ❖ Normal
- moist - Uniform; within normal range
❖ Deviations from normal ❖ Deviations from normal
- Excessively dry - Generalized or localized; hyperthermic
or hypothermic

RISK FACTORS FOR PRESSURE ULCERS &

★ Impaired mental status
★ Impaired nutritional status
★ Sensory deficits
★ Immobility
★ Mechanical forces
★ Shearing and friction
★ Increased by temperature
Excessive exposure to moisture from bodily secretions, such as urinary and fecal incontinence.

Bed ridden individuals can develop pressure sores in number of areas, including:
★ Back or sides of the head
★ Rims of the ears
★ Shoulder or shoulder blades
★ Hipbones
★ Lower back tailbone
★ Backs or sides of the knees
★ Heels, ankles and toes.

GRADING PRESSURE ULCER

★ Grade 1 - Nonblanchable erythema of intact skin; Indicates potential for ulceration

★ Grade 2 - Partial-thickness loss involving both epidermis and dermis; Ulcer is still superficial and appears
as a blister, abrasion or very shallow crater
★ Grade 3 - Full-thickness loss involving subcutaneous tissue; A deep crater that may undermine adjacent
tissues
★ Grade 4 - Full-thickness loss with extensive involvement of muscle, bone, or supporting structures
★ Undetermined - Ulcers that are covered with eschar cannot be staged without débridement