Integumentary Assessment

Kozier Ch 30
What are the Functions of the
Integumentary System?
 Functional Review
Protector and barrier between internal
organs and external environment
Barrier against foreign body intrusions
against invading bacteria and foreign matter
Transmits sensation nerve receptors
allows for feelings of temperature, pain, light
touch and pressure
 Skin Functions
Regulates body temperature
regulates heat loss
Helps regulate fluid balance
absorbs water
prevents excessive water & electrolyte loss.
Slow loss up to 600 ml daily by evaporation
Immune Response Function
inflammatory process
 Skin Functions
Vitamin production
exposure to UV light allows for the conversion
of substances necessary for synthesizing
vitamin D
Necessary to prevent osteoporosis, rickets
 Skin Assessment
Visual inspection
Palpation
Olfactory senses
Adequate lighting
Remove necessary clothing while
providing respect and privacy
Appropriate client positions p.568
 Visual inspection
Skin color:
Palor
Cyanosis
Jaundice
Erythema
Hyperpigmentation
Hypopigmentation vitiligo
 Visible changes if the Skin
Changes in skin color texture
Eczema, infections
Assess the vascularity & hydration of skin
Edema swelling, pitting edema
1+ 2 mm 3+ 6 mm
2+ 4 mm 4+ 8 mm p.579

Nails configuration, consistency, color p.579

Hair color and distribution, aloplecia,

location
 Gerontology Considerations
Watch for significant changes in aging:
Decrease immunity functions
Susceptibility to infections
Poor nutrition
Decrease collagen production loss of
subcutaneous
Thinning of epidermal skin layers
Increase skin problems
 Gerontology Considerations
Taking more medications
Excessive environmental exposure
Dryness, wrinkling
Uneven pigmentation
Various proliferative lesions
 Assessing light to dark skin
Description Light skin Dark skin
Cyanosis - bluish Bluish tinge Ashen gray
Pallor - paleness Loss of rosy glow Ashen gray (drk skin)
Yellowish brown (brown
skin)
Erythema - redness Visible redness Diffused; rely on palpation
of warmth or edema
Petechiae small Purplish Usually invisible; check
size pinpoint pinpoints oral
ecchyumosis Mucosa, conjunctiva,
eyelids, conjunctiva
covering eyeballs.
 Assessing light to dark skin
Description Light skin Dark skin
Jaundice - yellow Yellow sclera, Reliable on sclera, hard
skin, fingernails, palate, palms and soles.
soles, palms, oral
mucosa
Ecchymosis large Purplish to Difficult to see, check
diffused bluish black yellow-green mouth or conjunctiva
Brown-Tan cortisol Bronze; Easily masked.
deficiency, increased Tan to light
melanin production brown
 Assessing Lesions
Vary in size, shape and cause
Primary vs. Secondary
Erruptions: cysts, wheals, bullous, pustules,
psoriasis, eczyma, vesicles, bullae, nodules,
papules
Discoloration: macules (caf-au-lait),
Disorders Affecting the Skin
 Skin Lesions p.755

Etiology
Infections herpes, impetigo, HIV, melanoma
Toxic chemicals: skin irritation
Physical trauma: burns, lacerations
Hereditary factors
External factors: allergens, contact dermitis
Systemic diseases: measles, lupus, nutritional
deficiency
 Skin Lesions
Nursing Process Care:
Assessment: descriptions; pt. history, causative
factors
Evaluation of skin identify problem
Nursing Diagnosis
Interventions for skin care to promote healing
and prevent further injury
Pain management & comfort
Infection control
Nursing evaluation & reassessment
 Systemic Skin Diseases:
Skin Disorders in Diabetes
Diabetes Dermapathy shin spots, caused
by break- down of small vessels that supply
the skin.
Stasis Dermatitis compromises circulation
to the distal extremities due to damage of
larger vessels.
Problem: Injuries heal slow; increase risk for
ulcerations; risk for skin infections
 Fungal infections of the Skin
Tinea Pedis (athletes foot)
Tinea Corporis (ringworm of the body)
Tinea Capitis (scalp ringworm)
Tinea Cruris (ringworm of the groin)
Jock itch jock, common in diabetes.
Tinea Unguium (ringworm of the nails)
onychomycosis
 Parasitic Infections
Pediculosis capitis - lice
Pediculosis corporis/pubis
Sarcoptes scabiei scabies
Raised burrows found between fingers, wrists,
elbows, nipples, feet, groin, gluteal folds, penis,
scrotum
Poor hygienic living conditions
Increase; contagious
Secondary lesions: vesicles, papules, crust,
excoriations
 Parasitic Infections
Appear 4 wks after exposure
Elderly patients from long term facilities
Lindane, crotamiton (Eurax), permethrin
 Nursing Diagnosis
Skin Impairment r/t:
GOAL:
Protect the skin
Prevent secondary infections
Promote healing
 Skin Care

Review of wound dressings

 Wound Dressings
Occlusive airtight cover applied to skin
lesions
Wet (obsolete) wet compresses applied on
acute weeping, inflamed lesions
Moisture-retentive more efficient wet drsg
for removing excudate: impregnated with
saline, petrolatum, zinc-saline, hydrogel,
antimicrobial agents.
Avoids maceration , less infections,
scarring & reduces pain.
 Wound Dressings
Hydrogels polymers with 90% water
content
superficial wounds, abrasions, skin graft
sites, draining venous ulcers
Hydrocolloids impermeable to water, O2
Remain intact during bathing.
Produce foul-smelling yellowish covering
May leave on wound for 7 days
Promote debridment & granulation tissue
 Wound Dressings
Foam hydrophilic absorption and
hydrophobic backing to prevent leaking of
exudate
Nonadherent; require secondary dressing
Used over bony areas and weeping wounds
Calcium alginates absorbent fiber packing
made from seaweed.
Absorbes exudate, best for macerated
wounds, packing deep wounds, sinus
tracking, heavy drainage - nonadherent