Assessment of the Integumentary

 Identify manifestations of impaired integumentary

system with adult and geriatric clients III.Subcutaneous- Layer below dermis;
 Review basic integumentary anatomy -loose connective tissue /adipose (fatty) tissue
 Review functions of Integumentary system  Anchors skin to underlying muscle
 Identify alterations to skin
Normal Aging Changes
Skin Function  Thinning of skin (atrophy)
 Largest organ of the body  Uneven pigmentation
 Protection  Wrinkling, skin folds, and decreased elasticity
 Sensation  Dry skin
 Fluid balance  Diminished hair
 Temperature regulation  Increased fragility and increased potential for injury
 Vitamin D production  Reduced healing ability
 Immune response
 Absorption Decreased collagen
 Elimination Decreased skin turgor – tenting
 Psychosocial Increased risk for skin tears, pressure ulcers

Anatomic Structures of the Skin Assessment of the Skin

I. Epidermis-stratified squamous
epithelium:
 basal layer – innermost layer
 basal cells pushed up, older cells to t surface
melanocytes- produce pigment (melanin),color to the skin
squamous layer – outermost layer
Function
1.Protection – keratin forms barrier protecting internal organs
from the environment; Sun light, bacteria, fungus, viruses,
protozoans, parasites
2.Sensation – Dermatome chart; CNS = touch, pressure,
temperature, pain; ANS = blood vessels, sweat and oil glands
3.Fluid balance – sweat through skin, loss of H2O and Na+, poor
skin turgor is indicator of dehydration
4.Temperature regulation – convection, conduction, radiation,
and evaporation; Hypothalamus, sweat, “goose bumps”
5.Vitamin D – synthesis of cholecalciferol (Vit. D3) in skin from
cholesterol – dependent on UVB radiation from sunlight – 5 to 20
minutes per day – darker skin = more time;
food sources – salmon, sardines, tuna, eel, mushrooms, eggs
6.Immune response – Langerhans cells, macrophages, T-
lymphocytes, cytokines, leukocytes, mast cells
7.Absorption – medications – topical – creams, lotions, patches;
intradermal – TB skin test;
subcutaneous – insulin, lovenox, epinephrine, imitrex;
tanning – melanin
8.Elimination –
Eccrine sweat glands – urea, sodium, sugars, ammonia;
Sebaceous glands – oils (sebum)
9.Psychosocial – Body image, self-esteem
-Pigmentation comes from melanocytes – excessive sun exposure
can cause hyperpigmentation
Normal Flora- constitute protective host defense mechanism by
occupying ecological niche
- bacteria, fungus, protozoa – living in “harmony”
 Preparation of the patient: explain purpose,
provide privacy and coverings
 Assessment questions
 Inspect entire body, including mucosa (mouth andeyes), scalp,
hair, and nails, between fingers,toes, heels, behind ears, coccyx
region, under skin folds
Note: skin color, warmth, tone, scars, lesions,wounds, bruising,
hair distribution, nails
-Photographs MUST be taken of all pressure wounds
If abnormal finding during skin assessment, ask patient if they are
aware
 Wear gloves as appropriate (PPE)
 Wounds and lesions may require measurements
 Photographs may be used to document nature and extent of
skin conditions and to document progress resulting from
treatment. Photographs may also be used to track moles.
Skin Appearance
 Erythema
 Rash
 Cyanosis
 Jaundice
 Pruritus: itching
Erythema – superficial redness of skin
Rash – irritated or swollen skin
Cyanosis – deoxygenation;
Peripheral – fingers and toes; Central – mucous membranes,
tongue;
Carbon monoxide poisoning – CO has higher affinity to Hgb than
O2 (fire smoke, exhaust, natural gas, paint and varnish fumes)
Jaundice – liver disease which involves sclera;
Vitamin A toxicity (beta carotene) (carrots, sweet potatoes, kale,
spinach) – stored in adipose tissue, does not involve sclera
Pruritus – itchiness of skin

II.Dermis- Connective tissue layer

 blood, lymphatic vessels
 nerves/ nerve endings
 glands hair follicles
 elastic /COLLAGEN fibers- elasticity / toughness

Primary Skin Lesions
1.Macule – circular, flat discoloration – red, brown, blue
(Mongolian spot)hypopigmented – EBV, syphilis, HIV,German
measles, Rubella
2.Papule – raised skin < 0.5cm, solid, skin color, red, white –
impacted oil gland
3.Plaque – raised skin > 1cm, solid, flat eg.psoriasis
4.Bulla – raised skin > 1 cm filled with serous or sero-purulent
fluid – 2nd degree burn
5.Vesicle – raised skin < 1 cm filled with serous fluid - chickenpox
6.Wheal – irregular round shaped, pallor in middle – hives –
allergic reaction – urticaria – caused by what substance cellular?
7.Nodule - raised > 1 cm, extends into dermis - irregular growth
of skin cells, may be tumorous
8.Cyst – sac filled with fluid, blood, serous, purulent, or gas –
abscess, ganglion cyst, ovarian cyst, bartholin gland cyST
Secondary Skin Lesions
1.Atrophy – Thinning of skin, appears shinier or translucent –
arterial insufficiency
2.Erosion – loss of epidermis after ruptured bulla or vesicle
3.Ulcer – loss of epidermis and dermis layer – venous stasis,
diabetes, pressure
4.Fissure – linear opening in epidermis, skin splits – dry skin,
cracking – heel fissures
5.Crust – dried blood over damaged skin – scabbing
6.Scar – thick fibrous tissue replacing damaged dermis, white,
pink, red - healed wound
7.Keloid – raised scar
8.Lichenification – thickened or roughened skin – rubbing,
scratching - Eczema, chronic dermatitis
Scales – accumulation of dead skin cells – Ichthyosis vulgaris –
“fish scale” disease
9.Petechiae – red or purple spots, minor bleeding into skin –
broken capillary vessels, use of blood pressure cuff
10.Purpura – purple-colored spots, damaged blood vessels, blood
pooling – ITP – Idiopathic Thrombocytopenic Purpura – low
Platelets
Vascular Skin lesions
1.Spider angioma – swollen blood vessel in epidermis, contains
central red spot. It is a vascular lesion characterized by anomalous
dilatation of end vasculature found just beneath the skin surface.
The lesion contains a central, red spot and reddish extensions
which radiate outward like a spider's web.
2.Cherry angioma – collection of small blood vessels – Also known
as senile angioma or Campbell de Morgan spot
3.Venous Star – dilated veins due to  intravenous pressure
4. Varicose Veins - enlarged, swollen, and twisting superficial veins
that you can see just under the skin, often appearing blue or dark
purple. They happen when faulty valves in the veins allow blood
to flow in the wrong direction or to pool.
Integumentary Infections
1. Lichen Planus – autoimmune disease that affects skin
 Tx:Corticosteroids (Prednisone),Immunosuppressive drugs
(Cyclosporine) ,Antihistamines (Hydroxyzine)
 Linear appearance , flat rash
2.Herpes Simplex-Grounded (clustered),tx: Acyclovir
- Bells Palsy
Herpes simplex can cause Bell’s palsy – facial symptoms mimic a
stroke – speech and swallowing can be altered – the eye of
affected side may need eye patch; extremity strength equal with
no other neurological deficits – virus has affected facial nerve –
treat with acyclovir and prednisone
Bells Palsy deficits may be permanent or can improve
3.Varicella(Chicken Pox)-varicella-zoster virus (VZV).
-blister-like rash,itching, tiredness, and fever.
- prevented by a vaccine- Varicella-zoster
tx: relieving symptoms
 Pain relievers Anti-itch Colloidal Oatmeal
 High-risk groups may receiveantiviral medications.
4.Shingles (Herpes Zoster)- dermatone linear along nerve route
tx: Antiviral (Acyclovir),Corticosteroid (Prednisone),
-5.Scabies- tx:(Permethrin)- topical
6.Erythema gyratum repens(EGR)
tx:Immunosuppressive-Hydroxychloroquine(used to treat malaria)
7. Lyme’s Disease: Target lesion (bull’s eye)
Treat with supportive care-topical steroids
8.Toxic Epidermal Necrolysis-30% of body surface area
potentially life-threatening dermatologic disorder
- widespread erythema, necrosis, and bullous detachment of the
epidermis and mucous membranes, resulting in exfoliation and
possible sepsis and/or death
Steven-Johnson Syndrome - <10% of body surface area
first signs/symptoms : fever, unexplained widespread skin pain,
red or purple skin rash that spreads blisters on your skin and the
mucous membranes of your mouth, nose, eyes and genitals. -
Shedding of skin within days after blisters form.
Cause: sulfa; phenytoin,carbamazepine; piroxicam or allopurinol.
-15 to 30% of body surface area is considered SJS/TEN overlap.
9..Psoriasis-Polycyclic lesions
tx: Corticosteroids Anti-inflammatories NSAIDS
Immunosuppressive (Enbrel)
9.Urticaria
10.Hand-FootMouth-(Coxsackievirus)  Gels
 Viral Infection ; painful rash form blisters; Very Contagious  Paste
 Treatment: NSAIDs, supportive care for symptoms  Ointment
 Sprays
11.Head Lice-Parasites;tx: Permethrin Shampoo  Surgical
Shave head 2.Systemic – oral and intravenous
Excessive heat kills eggs
12.Athletes foot(Tinea pedis)-Antifungal -Clotrimazole Goal of Dermatologic Drug Therapy
13.Tinea Corpis(Ringworm)- Annular and arciform (circular or  Relieve symptoms
arcing); Topical Miconazole  Eradicate or improve lesions
14.Nail fungus-Onychomycosis;tx: Antifungal -Lamisil  Promote healing and repair
15.Candida Albicans (Oral Thrush) Fluconazole  Restore skin integrity
 Oral Nystatin (swish and swallow)  Prevent recurrence
 Common after course of broad spectrum antibiotics –why  Specific goals depend on the condition being treated.
16.Nail Clubbing Chronic low levels of o2 in blood (Hypoxemia)
Prevention
Infection resistant organisms  Aware of environment (exposure)
MRSA- Tx: Bactrim DS  Sunscreens
 Clindamycin  Lotions
 Doxycycline  Good hygiene
 Vancomycin  Good nutrition – protein, vitamins , minerals for healing
VRE (VancomycinResistantEnterococci)  Mobility
tx: Doxycycline  Proper hydration
 Chloramphenicol  Handwashing
 Rifampin  Strong immune system (Good sleep)
 High dose Ampicillin
 Nitrofurantoin Nursing Diagnoses
 Linezolid  Acute pain
 Unasyn  Impaired skin/tissue integrity
 Disturbed body image
-Anatomic Distribution of Common Skin Disorders  Deficient fluid volume
Diagnostic Procedures  Deficient knowledge
1. Skin biopsy – detect cancer
2.Immunofluorescence – detect antibodies Skin Injuries
3.Patch testing - allergies SUPERFICIAL VS DEEP LACERATION
4.Skin scrapings – collect skin cells AVULSION
5. Tzanck smear – blistering skin conditions
 ex: Pemphigus vulgaris (autoimmune disorder)
6.Wood’s light examination – black light illuminates Common Wound/Incisional Healing Methods
bacteria and fungus -stitches, staples, steri strips
Common repair techniques of lacerations and avulsions
Bacitracin – a bacteriostatic ointment - is commonly applied to
Dermatologic Drug Therapy closed wounds as these to decrease bacterial growth on skin
 Applied topically to skin, mucous membranes for local effect around wound
 When systemic absorption undesirable
Purposes Abrasion-Falls against rough surface
 Improve barrier function; soften,remove scaly lesions Punctures: Nails, GSW, stabbing
 Alter skin inflammation, blood flow Excoriation from scratching
 Exert antimicrobial effects, affect proliferating cells Skin Tear
-Burns
Types of Dermatologic Drugs
 Antimicrobials,
 Antibiotics, Antifungals, Antivirals,Antiseptics
 Corticosteroids, immunosuppressants
 Emollients and moisturizers
 Enzymes
 Keratolytics
 Retinoids

Forms of Dermatologic Drug Therapy

1.Topical, transdermal
 Creams
 Lotions
 Suspensions
 Powders