chapter

Patient Assessment: Integumentary System
JOAN DAVENPORT

51

History Physical Examination Inspection Palpation Assessment of Pressure Ulcers Assessment of Skin Tumors Assessment of the Skin in Older Adults Assessment of the Skin in Children

objectives
Based on the content in this chapter, the reader should be able to: ■ Identify the assessment skill necessary for the critical care nurse to use when evaluating the health of a patient’s skin. ■ Identify expected differences in skin color related to racial or skin tone characteristics. ■ Describe and recognize abnormal changes in skin color. ■ Recognize and describe skin lesions resulting from increased vascularity. ■ Describe the significance of rashes related to infection or to allergic reaction. ■ Identify the pitting and nonpitting edema. ■ Explain the cause of pressure ulcers and at least one scale used to assess a patient for pressure ulcer development. ■ Describe the features of malignant skin diseases.

he skin of a critically ill person is exposed to insults ranging from diminished blood flow and the resultant risk of pressure ulceration to rashes from hypersensitivity drug reactions and opportunistic infections. There is often ample opportunity for the critical care nurse to assess the skin—the intimacy involved in providing care to someone who is critically ill, the relative level of undress of the patient, and the attention to detail implicit in critical care nursing make integument assessment an ongoing and vital process.

T

PHYSICAL EXAMINATION
The assessment techniques necessary for an evaluation of the integument involve inspection and palpation.

Inspection
Inspection of the general appearance of the skin includes assessment of color; determination of the presence of lesions, rashes, or increased vascularity; and assessment of the condition of the nails and hair. COLOR Skin color is expected to be uniform over the body, except for the areas with greater degrees of vascularity. The genitalia, upper chest, and cheeks may appear pink or have a reddish tone in people with light skin. These same areas may appear darker in people with dark skin. Additional normal variations in skin color include those listed in Table 51-1.

HISTORY
When caring for patients with skin disorders, it is important to obtain information from the health history (Box 51-1). The information is useful in guiding the physical examination and in determining appropriate interventions.
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the lips. The amount of melanin is genetically determined and produces varying degrees of dark skin tone. the skin appears very pale. and soles of the feet. manifest differently depending on the person’s normal skin tone (Table 51-2). It is indicative of increased skin temperature caused by inflammation. is in subcutaneous fat and is most evident in those areas with the most keratin. shape. Finally. hard palate. may be flat or raised Silver or pink. The degree of oxygenation affects skin color.CHAPTER 51 Patient Assessment: Integumentary System 1201 box 51-1 Patient History—Skin Disorders Patient history relevant to skin disorders may be obtained by asking the following questions: When did you first notice this skin problem? (Also investigate duration and intensity. or general appearance (Table 51-3). In those with darker skin. Erythema may be expected when associated with a surgical wound. LESIONS Skin lesions are variously described by their color. such as pallor. transports oxygen to the tissues. Erythema manifests as a reddish tone in light-skinned people and a deeper brown or purple tone in dark-skinned people. such as cellulitis. lips. p 1645. asthma. In people with darker skin.1 In light-skinned people. color. In addition. the earlobes. Bickley and Szilagyi recommend using a transparent slide pressed against the lips to “blanch out the red color. eczema. jaundice is seen as a yellow coloration of the skin. salve) have you put on the lesion (including over-the-counter medications)? What skin products or cosmetics do you use? What is your occupation? What in your immediate environment (plants. oral mucous membranes. carotene. the length of time the lesion has . chemicals. raised. infections) might be precipitating this disorder? Is there anything new. the erythema is indicative of inflammation. Skin color abnormalities.) Has it occurred previously? Are there any other symptoms? What site was first affected? What did the rash or lesion look like when it first appeared? Where and how fast did it spread? Do you have any itching. and underside of the tongue. In lightskinned people. or brown Skin color is determined by the presence of four pigments: melanin. cause. or sunken. Bare BG: Brunner: Suddarth’s Textbook of Medical–Surgical Nursing (10th Ed). As hemoglobin gives up its oxygen to the tissues. distribution. burning. it is important to note the anatomical location. a yellow pigment. in turn. and the mucous membranes. hemoglobin. more prevalent in people with dark skin Generally flat marks anywhere on the body. and erythema. and deoxyhemoglobin. the nail beds. 2004.2 The yellowish hue of jaundice is indicative of liver disease or of hemolysis of red blood cells. due to the inflammatory process inherent in any tissue trauma. A diminished flow of oxyhemoglobin through the cutaneous circulation results in pallor. When deoxyhemoglobin is present in the cutaneous circulation. the hemoglobin changes to deoxyhemoglobin. attached to red blood cells. The process of inflammation increases vascularity of the tissues and this. hives. jaundice is seen as a yellowish-green color in the sclera. cyanosis may be seen as a grayishblue color. In either case. In people with light skin. jaundice. or are there any changes in the environment? Does anything touching your skin cause a rash? How has this affected you (or your life)? Is there anything else you wish to talk about in regard to this disorder? From Smeltzer SC. the skin takes on a blue cast and the individual is said to be cyanotic. should be noted. They are considered abnormal conditions and arise from many factors. had you recently consumed alcohol? What relation do you think there may be between a specific event and the outbreak of the rash or lesion? What medications are you taking? What topical medication (ointment. In general. palms of the hands. Lippincott Williams & Wilkins. especially in the palms and soles of the feet. produces the color alteration seen with erythema. pallor manifests as a yellowish-brown or ashen appearance (again. Carotene. as well as whether the lesion is flat. cyanosis evidences itself as an ashen-gray color seen easiest in the conjunctiva. because the usual pink undertones are lost). table 51-1 ■ Normal Variations in Skin Color Normal Variation Moles (pigmented nevi) Stretch mark (striae) Freckles Vitiligo Birthmarks Description Tan to dark brown. the palms and soles of the feet. cyanosis. may be caused by weight gain or pregnancy Flat macules anywhere on the body Unpigmented skin area. or allergies? Who in your family has skin problems or rashes? Did the eruptions appear after certain foods were eaten? Which foods? When the problem occurred.1 Another skin color abnormality is erythema. without the usual pink undertones. and pattern of any abnormal skin lesion. red. Philadelphia. or crawling sensations? Is there any loss of sensation? Is the problem worse at a particular time or season? How do you think it started? Do you have a history of hay fever. and nail beds. size.” making the yellow of jaundice more easily seen. sclera. may be tan. It is also seen in disease processes affecting the skin. animals. cream. Hemoglobin. tingling. details about the lesion’s borders or edges. In dark-skinned people.

the nail beds. . may be associated with vesicles. and nail beds Underlying Cause Decreased blood flow (decreased oxyhemoglobin flow to tissues) Increased deoxyhemoglobin in the cutaneous circulation Cyanosis Grayish-blue color of the palms and soles of the feet. and the mucous membranes Yellow color of the sclera. elevated lesion less than 5 mm in diameter Raised.1202 PART 11 INTEGUMENTARY SYSTEM table 51-2 ■ Skin Color Abnormalities Skin Color Abnormality Pallor Manifestation in Light-Skinned People Excessively pale skin Manifestation in Dark-Skinned People Yellowish-brown or ashen color to the skin Ashen-gray color of the conjunctiva. bullae. oral mucous membranes. or pustules Semisolid or fluid-filled mass. lips. encapsulated in deeper layers of skin Shedding or loss of debris on skin surface Loss of epidermis. less than 5 mm in diameter Solid. Curry. flattened lesion greater than 5 mm in diameter Papule containing purulent exudate Skin debris on the surface of the epidermis Solid mass. extending into dermis or deeper Raised wheal-like lesion Small fluid-filled lesion. 2000. the lips. usually extends to dermis Loss of epidermis. or pustules Epidermal erosion usually caused by scratching Crack in the epidermis usually extending into the dermis Flat area of skin with discoloration. the earlobes. called blackhead or whitehead Dried exudate over a damaged epithelium. less than 1 cm in diameter Transient. bullae. and hard palate Reddish tone Jaundice Increased red blood cell hemolysis. 5 mm to 5 cm in diameter Solid. elevated lesion or mass. liver disease Inflammation Yellow-green color of the sclera and palms and soles of the feet Deeper brown or purple tone Erythema table 51-3 ■ Types of Skin Lesions Lesion Blister Bulla Comedo Crust Cyst Desquamation Erosion Excoriation Fissure Macule Nodule Papule Plaque Pustule Scale Tumor Ulceration Urticaria Vesicle Wheal Description Fluid-filled vesicle or bulla Blister larger than 1 cm Plugged and dilated pore. irregular pink elevation with surrounding edema From Allwood. may be associated with vesicle. larger than 5 cm in diameter.

RASHES Rashes identified during inspection may indicate infection or a reaction to drug therapy. irregular patch caused by capillary dilation in the dermis of the skin Irregular. Hair that is thin and brittle occurs in table 51-4 ■ Vascular Lesions: Normal Variations Normal Variation Nevus flammeus (port-wine stain). also known as thrush. neck. These lesions are often pruritic. raised. Ecchymoses are bruises. noting the hair’s quantity.2 Petechiae result from tiny hemorrhages in the dermal or submucosal layers. The edema associated with urticaria is a result of local vasodilation and inflammation. purpura. They may be seen on the oral mucosa and in the conjunctiva. or upper trunk (see Fig. Other drugs.6 Hirsutism or increased facial. Some of these rashes are identified by the names listed in Table 51-3. immature hemangioma (strawberry mark) Cherry angioma Capillary hemangioma Telangiectasis Description Range from dark red to pale pink in color and are considered birthmarks Small. Hair loss in the critical care setting can be associated with pharmacotherapy. They do not disappear when pressure is applied to them. or pubic hair growth is an abnormal finding in the examination of women and children. They may appear as purple to yellowish-green rounded or irregular lesions. manifests as a whitish coating of the oral mucosa. a whitish pseudomembrane. 51-1C). are also noted. These findings may indicate disease or injury and warrant further investigation by the critical care nurse. The development of urticaria is often associated with food or drug reactions. Vascular changes considered to be normal variants include nevus flammeus (port-wine stain). which is followed by transudation of serous vascular fluid into the surrounding tissue. aspergillosis) that invade the underlying tissues. Alopecia refers to hair loss and can be diffuse. Petechiae are purple or red. Hirsutism has a familial pattern and is associated with menopause. patchy. Chemotherapy used in oncology treatment produces alopecia.” Oral candidiasis. increase in size and number with advancing age Red. spider angiomas. and certain pharmacotherapies (e. CONDITION OF THE HAIR The patient’s terminal hair is inspected daily. distribution. and texture. especially the tongue. and capillary hemangioma (Table 51-4).to 3-mm) lesions easily seen on light-skinned individuals and more difficult to see in those with dark skin (Fig. Purpura may appear brownish-red. telangiectasis. slightly raised. Abnormal vascular findings include petechiae.2 Urticaria is a reddened or white. Scalp hair should be resilient and evenly distributed. Identifying the type of lesion may help in identifying the cause of the rash. moniliasis resulting from Candida albicans infection) to deep fungal infections (e. and patient scratching may precipitate secondary skin abrasions. and may range from superficial tinea pedis (athlete’s foot) to intermediate yeast infections (e.3 Vascular lesions can be either a normal variation or an abnormal finding. and urticaria (hives). which can place the patient at risk for localized skin infections. Spider angiomas are fiery red lesions that are most often located on the face.g. This painful condition may produce fissures on the tongue and often restricts a patient’s oral intake. Antibiotics and corticosteroids place the patient at risk for these infections. endocrine disorders.”1 These lesions are most often associated with liver disease and vitamin B deficiency. Most often in the critical care setting. Skin infections are most often caused by fungi or yeasts. neck.. Purpura are very similar to petechiae. The lesion often changes shape and size during the course of the reaction. 51-1B). Ecchymoses occur as a result of trauma.CHAPTER 51 Patient Assessment: Integumentary System 1203 been present. corticosteroids and androgenic medications). Spider angiomas are seldom seen below the waist. when blood leaks from damaged blood vessels into the surrounding tissue. used for a prolonged time may also be responsible for hair loss. and peripheral papules and pustules.g.. body. fine red lines caused by permanent dilation of a group of superficial vessels .. Attention to the development of a rash in association with a change in pharmacotherapy is essential to help identify the occurrence of an allergic hypersensitivity reaction. and trunk. or complete. They have a central body that is sometimes “raised and surrounded by erythema and radiating legs. only larger. arms. Urticaria usually resolves completely over days to several weeks as the excess local fluid is reabsorbed. and any environmental or medication exposure that may be considered contributory. fungal and yeast infections are of the intermediate type and are the result of an opportunistic infection by normal flora. cherry angioma. small (1. 51-1A).g. and are more easily seen in people with light skin (see Fig. ecchymoses. such as heparin. nonpitting plaque that often occurs as a result of an allergic reaction. further compromising the patient from a nutritional perspective. Candidiasis presents in the groin and under the breasts of female patients with “erythema.2 A change in the hair’s texture may indicate ongoing health concerns. immature hemangioma (strawberry mark). bright red lesions on the face.

oily. MOISTURE The skin may be described as dry. In this case. and edema. should indicate a return of the pink tones in less than 3 seconds. as in Parkinson’s disease. the skin may be noticeably cooler distal to an occluding lesion. the skin is expected to lift up easily and quickly return into place. Skin turgor is decreased in the patient with dehydration. is associated with irondeficiency anemia. When assessed centrally. Skin mobility may be decreased in scleroderma or in a patient with increased edema. It requires gentle palpation to assess.1 hypothyroidism. congestive heart failure. louse eggs. or clammy. Fig. Chronic disease states such as cirrhosis. Petechiae/purpura B. sores. A spoonshaped nail. Hyperhidrosis is the term given to excessive perspiration. can be overlooked in the rush of critical care nursing. and type 2 diabetes mellitus. used with permission from Marks R: Skin Disease in Old Age.) Palpation The skin is palpated for texture. Philadelphia. Lippincott Williams & Wilkins. Philadelphia. called koilonychias. seen in people with chronic diseases C. p 110. In addition. lice. Ecchyrriosis figure 51-2 Terry’s nails. the hair is parted in several areas to reveal the underlying scalp. When the angle of the nail is 180 degrees or greater. done by blanching the nail beds and then releasing the pressure. Bands across the nails. B. JB Lippincott. 51-2). 2003. The nail bed is very vascular and is an excellent location for assessing the adequacy of the patient’s peripheral circulation.7 Also not to be overlooked is the presence of infection or infestation of the scalp and hair. p 106. C.1204 PART 11 INTEGUMENTARY SYSTEM A. TEXTURE Texture refers to the smoothness of the skin surface. Dry skin may be seen in the patient with hypothyroidism. Nail beds that are bluish or purplish in tint may be indicative of cyanosis.) such as cirrhosis. Skin is oily with acne and with increased activity of the sebaceous glands. may indicate protein deficiency. (A. (Used with permission from Bickley L: Bates’ Guide to Physical Examination and History Taking [8th Ed]. MOBILITY AND TURGOR Mobility and turgor provide information about the health of the skin and may yield information about the patient’s fluid volume balance. during palpation any evidence of discomfort arising from the areas palpated is noteworthy.7 During the inspection. TEMPERATURE Temperature is usually assessed with the dorsal surface of the hand to identify the general skin temperature as warm or cool. Clubbing is attributed to chronic hypoxemia. The skin’s temperature can also be used to assess the possibility of reduced blood flow from an arterial insufficiency. and type 2 diabetes mellitus may affect the nails by producing Terry’s nails. like hair. Diaphoresis may be a response to increased temperature or increased metabolic rate. 2003. Spider angioma figure 51-1 Abnormal vascular lesions. Philadelphia. used with permission from Bickley L: Bates’ Guide to Physical Examination and History Taking [8th Ed]. In those with severe protein malnutrition. clubbing is said to be present (see Chapter 24. 24-2). White spots on the nails are associated with zinc deficiency. and the lunulae may not be visible (Fig. used with permission from Kelley WN: Textbook of Internal Medicine. especially in the older adult. the hair color may appear reddish or bleached and the hair texture is described as coarse and dry.7 .1 These nails are whitish with a distal band of dark reddish-brown color. Bromhidrosis refers to foul-smelling perspiration. The capillary refill test. CONDITION OF THE NAILS Nails. Philadelphia. over the clavicles. diaphoretic. mobility and turgor. JB Lippincott. temperature. nail beds that are pale may indicate reduced arterial blood flow. Rough skin occurs in patients with hypothyroidism. a careful inspection as part of the “routine” assessment can reveal information about the patient’s general state of health. The patient’s scalp and body hair is inspected regularly for evidence of flaking. Low cardiac output states may produce skin that is referred to as clammy. Lippincott Williams & Wilkins. heart failure. Other shapes that the nail takes on may provide clues to deficient nutritional states of the patient. 1989. and ringworm. 1987. moisture. however.

mobility. 51-4). such as that caused by hypotension. scapula.9 The Braden Scale for Predicting Pressure Sore Risk. In addition. Nonpitting edema is that which does not depress with palpation. by the amount of time it takes the pit to rebound (Table 51-5). The back of the neck of the patient with a tracheostomy tube must be assessed because the tube holder may be applied too tightly. patients with sedation or frequent analgesic dosing are at increased risk for problems related to their immobility. Lack of movement then serves only to accelerate the process of pressure ulcer development. from brain or spinal cord injury or from a peripheral neuropathy such as that caused by diabetes) are at greater risk for ulceration because they do not recognize the discomfort from being in one position for extended periods.8. It is the pressure applied by the weight of the body that causes a reduction in arterial and capillary blood flow. and toes. Pitting edema is identified as edema that retains the depression made when palpated. Common pressure ulcer points include the occiput. recommended in the guidelines set forth by the U. Agency for Health Care Policy and Research and widely used in hospital settings. resulting in reduced blood flow. or peripheral vascular insufficiency. In addition to the edema. and warm. Dressing devices and wound appliances can place pressure on underlying skin.g. but a score of 18 best predicts pressure ulcer risk for both groups. Pressure ulceration on the toes occurs as a result of the pressure of the bed linen on the feet. heels. heart failure. ASSESSMENT OF PRESSURE ULCERS The development of pressure ulcers in the critically ill patient is a preventable complication. activity. Patients with decreased sensation (e. leading to these ischemic events.12 During assessment of the skin. the skin is usually red. the nurse must be vigilant for signs of skin breakdown (Fig. The difficulty arises in the patient with multiple-system dysfunction with concomitant fluid. requires the daily assessment of six parameters and provides a numerical score ranging from a very high risk score of 6 to a very limited risk or minimal risk score of 2310 (Fig. frequent position changes are required to prevent the development of pressure ulcers.CHAPTER 51 Patient Assessment: Integumentary System 1205 EDEMA Edema is classified as either nonpitting or pitting. moisture. and therefore are at very high risk for the development of pressure ulcers.. ischium. occasionally. Adults with a score below 16 (18 for older adults) are considered at risk and specific interventions to prevent the development of ulceration are recommended. benign skin lesions. This type of edema can be further classified by the depth of the depression and. which are debilitating and expensive to treat. Infectious matter in wound drainage or feces increases the risk that an ulcer will progress and become a major source of sepsis. and nutritional deficiencies. keeping the skin clean and dry is requisite in the prevention of pressure ulceration. Pitting edema is usually in the skin of the extremities and in dependent body parts.11 A 2002 study by Bergstrom and Braden compared cut-off scores for black and white populations and found no difference between scores. tender. Assisting the patient with frequent position changes is crucial in preventing pressure ulcers from developing. nutrition. 51-3). Therefore. Moisture increases the risk for maceration of the skin and promotes its breakdown. There has been some work done to establish the relative risk among those with darkerpigmented skin using a higher cut-off score of 18. Nonpitting edema is seen in patients with a local inflammatory response and is caused by capillary endothelial damage. electrolyte. Problems with sensory perception. The tape securing a nasogastric tube must be regularly removed and the condition of the tip of the nose and nares assessed for changes resulting from pressure from the tube. ASSESSMENT OF SKIN TUMORS Benign nevus and seborrheic keratosis are common. Similarly. Recognizing that there are certain features that increase a patient’s risk for development of pressure ulcers allows the critical care nurse to increase surveillance and implement preventative treatment modalities. Patients with poor circulation.S. The benign nevus or mole appears in the first two to three decades and its appearance remains unchanged table 51-5 ■ Pitting Edema Scale Scale (1+ to 4+) 1+/4 2+/4 3+/4 4+/4 Measurement 2 mm 4 mm 6 mm 10 mm Description Barely detectable Deeper pit Deep pit Very deep pit Time to Rebound Immediate Few seconds 10–20 sec > 20 sec . Identifying those individuals most at risk for pressure ulcer development is a focus of assessment. are also at higher risk because of the underlying possibility of tissue hypoxia. Many tools for assessing pressure ulcer risk use a point system. buttocks. and friction and shearing forces increase the patient’s risk for development of pressure ulcers. sacrum. Critically ill patients are among those with the most significant limitations of these parameters.

urine. Rarely eats more than 1/3 of any food offered. MOBILITY Ability to change and control body position 1. OR receives less than optimum amount of liquid diet or tube feeding. Chairfast: Ability to walk severely limited or nonexistent. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Protein intake includes only 3 servings of meat or dairy products per day. but for very short distances. Usually eats a total of 4 or more servings of meat and dairy products. 4. etc. or grasp) to fully to pressure-related painful stimuli. Never eats a complete meal. Precancerous lesions (actinic keratoses) are thick. Spasticity.” These lesions require attention because there is a risk for development of squamous cell carcinoma.4 1 LINE . moist. and round or oval in shape. ACTIVITY Degree of physical activity 2. OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs. Occasionally will take a dietary supplement.) over time. No Limitations: Makes major and frequent changes in position without assistance. 3. 4. Cannot communicate discomfort except by moaning or restlessness. 1988. requiring an extra linen change approximately once a day. Total Score NPO: IV: TPN: Nothing by Mouth Intravenously Total parenteral nutrition figure 51-3 The Braden Scale is a widely used screening tool to identify people at risk for pressure ulcers. Maintains relatively good position in chair or bed most of the time but occasionally slides down. OR is NPO and/or maintained on clear liquids or IVs for more than 5 days. The nevus is periodically assessed for changes because a change may indicate dysplasia of the tissue and the risk of melanoma. Occasionally will refuse a meal. restraints. 51-5B).1206 PART 11 INTEGUMENTARY SYSTEM Braden Scale FOR PREDICTING PRESSURE SORE RISK Patient's Name Evaluator's Name 2. Date of Assessment 4. 2. Constantly Moist: Skin is kept moist almost constantly by perspiration. dairy products) each day. Very Poor. Potential Problem: Moves feebly or requires minimum assistance. 3. Dampness is detected every time patient is moved or turned. linen only requires changing at routine intervals. rough patches that develop on sun-exposed areas of the skin. but not always. MOISTURE Degree to which skin is exposed to moisture 1. 3. 4. Occasionally eats between meals. contractures or agitation leads to almost constant friction. Slightly Limited: Responds to verbal commands. Does not take a liquid dietary supplement. Rarely Moist: Skin is usually dry. but will usually take a supplement if offered. Occasionally Moist: Skin is occasionally moist. Maintains good position in bed or chair at all times. Adequate: Eats over half of most meals. but cannot always communicate discomfort or need to be turned. During a move skin probably slides to some extent against sheets. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. 51-5A). 1. Spends majority of each shift in bed or chair. Complete lifting without sliding against sheets is impossible. Walks Occasionally: Walks occasionally during day. especially in fair-skinned people (see Fig. Very Limited: Responds only to painful stimuli. 3. scaly keratotic (horny) lesions on the exposed areas of the body. yellow to brown lesions that are described as velvety when touched1 (Fig. Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Bedfast: Confined to bed 4. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Excellent: Eats most of every meal. Eats 2 servings or less of protein (meat or dairy products) per day. OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body 2. (Courtesy of Barbara Braden and Nancy Bergstrom. No Impairment: Responds to verbal commands. Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.moan. chair. with or without assistance. 2. FRICTION AND SHEAR 1. Takes fluids poorly. Never refuses a meal. Problem: Requires moderate to maximum assistance in moving. Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Completely Immobile: Does not make even slight changes in body or extremity position without assistance. These lesions have clearly defined borders. flinch. Braden Scale Scores 1 = Highly Impaired 3 or 4 = Moderate to Low Impairment Total Points Possible: 23 Risk Predicting Score: 16 or Less 3. SENSORY PERCEPTION 1. or other devices. They are described as “white. Eats a total of 4 servings of protein (meat. Copyright. Reprinted with permission. Cannot bear own weight and/or must be assisted into chair or wheelchair. due to discomfort diminished level of consciousness or sedation. Does not require supplementation. Seborrheic keratoses are common. Completely Limited: Unresponsive (does not Ability to respond meaning. Very Moist: Skin is often. These lesions are often multiple and often symmetrically distributed on the trunk and face. NUTRITION Usual food intake pattern 1. OR limited ability to feel pain over most of body surface. requiring frequent repositioning with maximum assistance. are uniform in color. 2. Linen must be changed at least once a shift. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. Frequently slides down in bed or chair. 3.

premalignant. Basal cell carcinomas are found exclusively in light-skinned people. Philadelphia. As it develops. The tumors have irregular borders. ASSESSMENT OF THE SKIN IN OLDER ADULTS With aging there are some expected changes to the integument (Box 52-2). or blue?). B is for borders (are they irregular. and those with a family history of melanoma. 2003. The worldwide frequency of malignant melanomas is growing more rapidly than any other cancer except lung cancer. p 133. Springhouse. or blurred?). red. it is possible to do a thorough assessment for suspect skin lesions that may be cancerous. Springhouse. refer the patient to a dermatologist or oncologist. With loss of underlying fat tissue and decreased vascularity of the dermal layer.13 (see Fig. These cancers can be invasive and are more malignant than basal cell cancers if not treated promptly. white. Illustrations used with permission from Makelbust J. the carcinoma takes on a hyperkeratotic appearance and may ulcerate and bleed3 (see Fig. depressed centers. . C is for color (dark brown or black. and arise from the hair follicles on the head and neck. Radiation and tissue damage from scars. Kelley J: Health Assessment in Nursing [2nd Ed]. PA. It is estimated that 40% to 50% of those who live to age 65 years will be diagnosed with skin cancer at least once.14 The most common location for the development of these lesions is on the trunk in men and on the legs in women.CHAPTER 51 Patient Assessment: Integumentary System 1207 figure 51-4 Stages of pressure ulcers. those prone to sunburn. are dark brown or black. ragged. The American Cancer Society (ACS) recommends a monthly self-assessment for melanoma using the “ABCDs. ulcers. and malignant lesions. Like basal cell cancers. the primary cause is exposure to ultraviolet light.) LONG Skin cancer is the most common type of cancer in the United States. and have treatment initiated much sooner than would otherwise be the case. Those at highest risk include those with fair com- plexions. notched. These tumors are slow growing and rarely metastasize but do cause local skin destruction and disfigurement. Malignant melanomas are highly metastatic lesions that come from the melanin-producing cells of the body. and D is for diameter. Sieggreen MY: Pressure Ulcers: Guidelines for Prevention and Management. Lippincott Williams & Wilkins.”15 A is for asymmetry. (Used with permission from Weber J. and fistulas may give rise to squamous cell carcinomas. Basal cell carcinomas appear with pearly borders. While in a critical care setting. Squamous cell carcinomas affect the skin and the mucous membranes. 2001. 51-5D).14 Basal cell and squamous cell cancers are often grouped as nonmelanoma skin cancers. the skin thins. Figure 51-5 provides pictures and descriptions of these benign. Prolonged and cumulative exposure to the sun is recognized as the cause of basal cell carcinoma. and are usually larger than 6 mm. 51-5C). and rolled edges3.

■ Decreased sebaceous and sweat gland activity leads to dry and flaking skin. Purple patches or macules from blood leaking into the tissues after minimal injury may appear. B. occurs in the hair of the nares and on the tragus of men’s ears. Mobility restrictions over time may result in an unkempt appearance of nails in the older patient and may require attention and care by a podiatrist. Dry and flaking skin results from decreased sebaceous and sweat gland activity and is not unexpected in the older adult patient. loss of skin turgor. Basal Cell Carcinoma D. C. and have a tendency to split into layers. hair color often transitions to gray because of diminished melanin. American Cancer Society.4 In the older adult. (A. p 107. 2003. pressure ulcers in this population heal more slowly and are often complicated by the older patient’s diminished immune response. ■ Reduced hormone levels lead to thinning of the hair and transition from terminal to vellus hair. Malignant Melanoma figure 51-5 Benign. the opposite change. Seborrheic Keratosis B.2 Decreased peripheral circulation produces changes in the nails. JB Lippincott. ASSESSMENT OF THE SKIN IN CHILDREN The assessment of a child’s skin is much the same as that of an adult’s. ■ Decreased peripheral circulation leads to slowed nail growth and brittle nails that split easily. They grow more slowly but are often thicker and more brittle. sometimes called “liver spots. increased wrinkling.) wrinkles. However. but it is important to recognize that some findings take on a different significance because of the nature of . Philadelphia. Actinic Keratosis C. 1985. The risk of pressure ulcer formation in the older adult is increased because of greater mobility limitations and impaired peripheral circulation from cardiovascular.1. ■ Sun exposure over a long period of time leads to yellowing and thickening of the skin and the development of solar lentigo. Bickley L: Bates’ Guide to Physical Examination and History Taking [8th Ed]. and D courtesy of Sauer GC: Manual of Skin Diseases [5th Ed]. Reduced hormone levels result in a change in the size of the hair follicle and produce the change from coarse terminal hair to softer vellus hair and the thinning of hair seen in both sexes. Philadelphia. Lippincott Williams & Wilkins. Once developed. from vellus to terminal. flat macules and may be seen in isolation or in clusters on sun-exposed areas of the face or hands. and metabolic disorders.1208 PART 11 INTEGUMENTARY SYSTEM A. E. and actinic purpura.2 Solar lentigo. Prolonged or repeated sun exposure results in a yellowed or thickened appearance. dark brown. and loses turgor.” appear as light to box 51-2 Expected Changes in the Integument of Older Patients ■ Loss of underlying fat tissue and decreased vascularity of the dermal layer lead to thinning of the skin. neurological. Squamous Cell Carcinoma E. These lesions are called actinic purpura and occur because the underlying capillaries lose the protection from hypodermal fat. ■ Decreased melanin leads to graying of the hair. premalignant. and malignant skin lesions.

2003 2. Price SA: Cutaneous infections. Nurs Res 22(1):55. pearly border b.com/ agingskinnet/Q&A. REFERENCES 1. b. Louis. dorsal surface of the forearm. Over the past 5 days. Lippincott Williams & Wilkins. It manifests itself as a white. cradle cap. Wilson SF. 4. 2002 3. Rockville. Urticaria is best described as a a. and she is assisted by two caregivers with a pivot to a chair twice each day. Hooper’s family visits daily and helps her to communicate with a pencil and paper tablet. and nails. fiery red. smooth. Appl Nurs Res 12(2):60–68. St. b. 1. NJ. Skin that is excessively dry throughout the body may indicate a vitamin A deficiency or may be related to frequent bathing. pinpoint. b. Lyder CH. Mosby. Wilson LM (eds): Pathophysiology (6th Ed). numerous antibiotics. Szilagyi PG: The skin. dark lesions. 3. pp 257–287. Which of the following phrases describes basal cell carcinoma? a. at that time. Mrs. et al: The Braden Scale for pressure ulcer risk: Evaluating the predictive validity in black and Latino/ Hispanic elders. hair. dark black lesion with irregular border d. peripherally over the patient’s forearms and shins. and dopamine for blood pressure support during her first 3 days in the ICU. Cyanosis in an African-American patient can best be identified by assessment of the a. d. and benzodiazepine sedation) affect Mrs. pp 837–873. it changes color from purplish to greenish. and slightly dry. 2. Yu C. Prentice-Hall. Which one of the following statements about oral candidiasis clinical applicability challenges Self-Challenge: Critical Thinking Mrs. rolled edge. Giddons JF (eds): Health Assessment for Nursing Practice (2nd Ed). It is a painful white coating of the oral mucosa and tongue. c. Berman AJ. She has a continuous bladder catheter and an incontinence fecal bag in place draining liquid stool. Hooper’s integument status? is true? a. 2000 8. Philadelphia. Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in Adults: Prediction and Prevention. Henze RL (eds): Focus on Pathophysiology. She has a triple-lumen central venous access catheter. conjunctiva and oral mucous membranes. b. pp 1087–1096. Hooper? 2. What are Mrs. 1992 11. MD: Agency for Health Care Policy and Research. c. increased tissue vascularity. et al. Kozier B. d.com. Agency for Health Care Policy and Research. 2000 4. . irregular lesion caused by tissue trauma. pp 531–629. raised inflamed lesion with transu- date vascular fluid in the surrounding tissue. Public Health Service. In Bickley LS (ed): Guide to Physical Examination and History Taking (8th Ed). St. Mosby. peripherally at the nail beds. the skin is assessed for any rashes that may indicate bacterial or viral infection. et al: Health assessment. U. What is the role of the critical care nurse in the prevention of pressure ulcers for Mrs. Hooper is scheduled for a tracheostomy tomorrow and. considered an expected finding in an older adult. Louise Hooper. a 62-year-old widow. c. increased oxyhemoglobin content.S. c. 1987 9. 1999 7. 1973 10. Light brown lesion that feels velvety when touched 6. d. American Academy of Dermatology: Agingskinnet. Physical therapy consultation was made on day 3. decreased interstitial pressures. Bickley LS. type 2 diabetes mellitus. In Gutierrez K (ed): Pharmacotherapeutics: Clinical Decision-Making in Nursing. raised lesion with a central body and radiat- ing legs. c. Accessed July 1. Laguzza A. Philadelphia. Berman AJ. pp 95–113. (eds): Fundamentals of Nursing (6th Ed). As a bruise ages. et al: The Braden Scale for predicting pressure sore risk. Large. Braden BJ. or diaper rash. Mrs. and chronic obstructive pulmonary disease (COPD). She has been intubated and on mechanical ventilation. 2003 6. Bruises in a child may indicate nonaccidental trauma and attention is paid to the location of the bruises and to the color. She has received continuous enteral feedings through a nasogastric tube. In Wilson SF. has been in the medical-surgical intensive care unit (ICU) for the past 2 weeks after a diagnosis of respiratory failure and pneumonia. Clinical Practice Guideline no.skincarephysicians. Louis. Hooper’s risk factors for development of pressure ulcers? 3.CHAPTER 51 Patient Assessment: Integumentary System 1209 the child’s skin. Gosnell DJ: An assessment tool to identify pressure sores. In Price SA. Lippincott Williams & Wilkins. Bergstrom N. d. numerous antibiotics. Depressed center. pp 774–789. How might the medications indicated (dopamine. In Bullock BA. Skin that is locally very dry may indicate eczema. In Kozier B. Philadelphia. AHCPR publication no. This patient’s medical history includes obesity. Nurs Res 36:205–210. It is the result of systemic Staphylococcus infection. Mrs. Normally. d. will also have a percutaneous gastric feeding tube inserted. 1999 Study Questions 1. Curry K: Normal and altered functions of the skin. earlobes. purple. The critical care nurse must be sure that special attention is paid to the skin of children in critical care settings related to lesions from infectious disease. Upper Saddle River. 5. Hooper has received a benzodiazepine for sedation at least once per day. 92-0047.16 Because of reduced total sun exposure. Buttry TS: Anticoagulant and antiplatelet drugs. Giddons JF: Skin. may indicate a malignant change in a child. Scaly white lesion c. nonblanching lesion. WB Saunders. Available at http://www. Allwood J. reddened or white. small. Department of Heath and Human Services. Erb G. 15. 2003 5. decreased hemoglobin levels. palms of the hands and soles of the feet. the skin of a child is soft. 2000. centrally over the trunk. Skin turgor is best assessed a. It is a painless manifestation of an opportunistic infection. crusty lesion of the patient’s lips and hard palate. Erb G. In Skincare physicans. Stawiski MA. Emerling J. The color change of erythema is related to a. centrally over the patient’s clavicles. b.

Dermatol Nurs 13(4):289. (eds): Wong’s Nursing Care of Infants and Children (7th Ed).1210 PART 11 INTEGUMENTARY SYSTEM 12. Available at http://www. 2003 OTHER SELECTED READING Byers PH.cancer. Mosby. Huether SE: Structure. 2001 Hayes KVD: Skin wellness and illness. Winkelstein ML. American Cancer Society: Detecting skin cancer. National Cancer Institute: What you need to know about skin cancer? 2002. Braden BJ: Predictive validity of the Braden Scale among black and white subjects. 2002 13. In Condon MC (ed): Women’s Health. Available at http://www. In McCance KL.org. Accessed July 1. 2000 Cuzzell JZ: Wound assessment and evaluation. Reynolds P: Diagnosing skin malignancy: Assessment of predictive clinical criteria and risk factors. Louis. 2002 14. Accessed July 1. Prentice-Hall. Mosby. 2003 . Upper Saddle River. St. function. 2003 15.cancer. 2004 Finch A: Assessment of skin in older people: As the largest organ in the body. Hockenberry MJ. J Fam Pract 53:210. Nurs Older People 15(2):29. Nurs Res 51:398–403. St. Huether SE (eds): The Biological Basis for Disease in Adults and Children (4th Ed). Wilson D. Adv Skin Wound Care 13:115.gov/cancerinfor/wyntk/ skin. et al. the skin can offer valuable information about the general health of an older person. 2003. Louis. Bergstrom N. 2003 Strayer SM. pp 1434–1468. and disorders of the integument. Carta SG. NJ. 2003 16. Mayrovitz HN: Pressure ulcer research issues in surgical patients.

between refs.Chapter 51—Author Queries 1. 13 and 14. 3 and 5. 2. 4 in the text. . in numerical order. but presumably it should be cited first between refs. It is cited later. 13 and 14 were switched to preserve numerical order of citation. Please cite ref. Refs.

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