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ASSESSMENT OF THE INTEGUMENTARY

SYSTEM

Nesredin Ahmed
Msc, Adult Health Nursing
 Anatomy Overview
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Skin
 composed of three layers ( epidermis, dermis and the subcutaneous
tissue)
 a physical barrier that protects the underlying tissues and structures.
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 Epidermis
 consists of live, continuously dividing cells covered on the surface

by dead cells
 The dead cells contain large amounts of keratin, an insoluble,

fibrous protein that forms the outer barrier of the skin and has the
capacity to repel pathogens and prevent excessive fluid loss from
the body
 Melanocytes are the special cells of the epidermis that are

primarily involved in producing the pigment melanin, which

colors the skin and hair.
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 Dermis
 The dermis makes up the largest portion of the skin, providing

strength and structure.

 The dermis is also made up of blood and lymph vessels, nerves,

sweat and sebaceous glands, and hair roots.

 The dermis is often referred to as the “true skin.”

 Subcutaneous Tissue

 The subcutaneous tissue, or hypodermis, is the innermost layer of

the skin.
 The subcutaneous tissues and the amount of fat deposited are

important factors in body temperature regulation

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Hair
 Consists of layers of keratinized cells found over much of the body

except for the lips, nipples, soles of the feet, palms of the hands, labia
minora and penis.
 Hair color is supplied by various amounts of melanin within the hair

shaft.
Nails
-located on the distal phalanges of fingers and toes, are hard, transparent
plates keratinized epidermal cells that grow from a root underneath the
skin fold called the cuticle.
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Glands of the Skin

 There are two types of skin glands: sebaceous glands and sweat glands

 The sebaceous glands are associated with hair follicles.

 The ducts of the sebaceous glands empty sebum onto the space

between the hair follicle and the hair shaft, thus lubricating the hair
and rendering the skin soft and pliable.
 Sweat glands are found in the skin over most of the body surface, but

they are most heavily concentrated in the palms of the hands and soles
of the feet.
 Assessment of skin
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 Involves the entire skin area,

including the mucous
membranes, scalp, hair, and  Physical examination
nails. inspect and palpate for
 History taking focusing on
 Color, temperature,
Medication Hx
Trauma
 Moisture, elasticity,
Surgery  Turgor, texture, lesions,
Prior skin disease
Jaundice
 Vascularity, mobility, and
Delayed wound healing  The condition of the hair,
Allergies
nails and odor may be also
Sun exposure
Family Hx helpful.
Subjective data

 History of Present Health Concern

Skin
 Are you experiencing any current skin problems such as rashes,

lesions, dryness, oiliness, drainage, bruising, swelling, or changes in

skin color?
 What aggravates the problem? What relieves it?

 Are you experiencing any pain, itching, tingling, or numbness?

 Are you taking any medications (prescribed or “over the counter”),

using any ointments or creams, herbal or nutritional supplements, or

vitamins? How long have you been taking each of these?
 Do you have any tattoos?
 Subjective data
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Hair
 Have you had any hair loss or change in the condition of your

hair? Describe
Nail
 Have you had any change in the condition or appearance of your

nails? Describe
 COLLECTING OBJECTIVE DATA
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Equipment
 Examination light

 Penlight

 Mirror for client’s self-examination of skin

 Magnifying glass

 Centimeter ruler

 Gloves

 Wood’s light

 Examination gown or drape

 Braden Scale for Predicting Pressure Sore Risk

Physical Assessment
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When preparing to examine the skin, hair, and nails, remember these
key points:
 Inspect skin color, temperature, moisture, texture.
 Check skin integrity.
 Be alert for skin lesions.
 Evaluate hair condition; loss or unusual growth.
 Note nail bed condition and capillary refill
Skin assessments
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Six observation to make in assessing the skin

1.Color
2.Moisture
3.Temprature
4.Texture
5.Moblity and turgor
6.Presence of lesion
 1. Color
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 Advice anyone with moles or birthmarks to perform periodic

skin self-examinations ,and watch for danger signs such as
A. Sudden enlargement
B. Change in color
C. Change in sensation( itching, tenderness)
D. Change in the surrounding skin (redness, swelling)
E. Ulceration or bleeding in mole(let sign)
 A. General pigmentation
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 Normally it is consistent with the

genetic background and varies from
light to dark brown
 Normal skin color:
– light to dark pink in white skin
person and,
– light to dark brown, in black
skin person
 Hypopigmentation may be caused by a
fungal infection, eczema, or vitiligo;
 Hyperpigmentation can occur after sun

injury or as a result of aging.

 Color…

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B. Widespread change( secondary to systemic disorder)

 Such as pallor(white),Erythema (red),cyanosis(blue) and

jaundice(yellow).
 In dark skinned people the amount of normal pigment may mask color

changes
 Lips and nail beds show some color change, but they vary with the

person’s skin color and may not always be accurate signs.

Pallor: whitish discoloration due to reduction of RBC
 The more reliable sites are those with the least pigmentation. such as

under the tongue. the buccal mucosa, the pulpebral conjunctiva, and the
sclera
 Color..

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 Erythema: an intense redness of the skin due to excess

blood(hyperemia) in the dilated superficial capillaries.
 This is a sign that is to be expected with fever inflammation, or with

emotional reactions.

 Cyanosis: a bluish mottled color that signifies decreased perfusion

with oxygenated blood.

 Jaundice:- yellow color indicating rising amounts of bilirubin in the

blood
 Jaundice is first noted in the junction of the hard and soft palate the

mouth and sclera

  Acanthosis nigricans:- roughening and darkening of skin in
localized areas, especially the posterior neck
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 Palpation of the skin

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 Palpate the skin for texture, temperature, and moisture, turgor and
edema
 Normal skin has a generalized warmth and smooth to touch.

 Skin is normally dry without excessive perspiration

 Testing for skin turgor will reveal the moisture content & mobility of

the tissue .
 Poor skin turgor is present with dehydration, also commonly found in

elderly clients
 Palpation of the skin...

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2.Temprature & moisture:-

 Use the back(dorsa) of your hands and check bilaterally
 Normal finding:-

skin has warm temperature and dry moisture

 Deviation from normal:-

Extremely cold or warm temperature ;wet , oily moisture.

Perspiration appears on the face, hands, axilla, and skin folds in
response to activity, a warm environment, or anxiety
Diaphoresis or profuse perspiration accompanies an increased
metabolic rate, such as on fever.
Dehydration is evident in the oral mucus membrane
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4.Texture
Normally skin feels smooth, soft and firm, with an even surface ;
(rough, thick indicates deviation from normal)
5. Mobility and turgor
 Pinch up a large fold of skin on the anterior chest under the

clavicle
 Mobility is the skin’s ease of rising, and turgor is its ability to

return to place promptly when released

 This reflects the elasticity of the skin

 Mobility is decrease when edema is present

 Poor turgor is evident in sever dehydration or extreme weight

loss and also commonly found in elderly clients

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 Sever dehydration
Edema

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Edema :press firmly for 5- 10 seconds over tibia and ankles

 Normally: no swelling, pitting or edema

 Deviation from normal: swollen ;shallow to deep pitting ;ascites

Classify edema if present

 1+ shallow pit formed by thumb pressure(2mm)

 2+ deep pit formed by thumb pressure(4mm)

 3+ signs of pitting independent part of the body(eg. Limb) 6mm

 4+ generalized deep pitted edema accompanied by ascites(as in

sever CHF),8mm
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6. Lesion
 Assess lesion of the skin and document its characteristics as:

1. color: pink, red, yellow, brown, black

2. Type: macule, papule, wheal, scale, ulcer, scar…
3. Pattern: annular, linear,
4. Location: generalized, skin fold, extensor surface of the
joint
5. size: width, length & depth.
6. Mobility: fixed or movable
7. Consistency:- hard, firm, soft
 If any exudates-note its color or odor
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Types of skin lesion- two basic types

 Primary: are original lesions arising from previously unaltered

skin.
 Secondary: can originate from primary lesions

 progression of the primary disease to a different appearance.

Result from external cause such as

 Scratching
 Trauma
 Changes in primary lesions
 Infections
 Types of skin lesion

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 1. Primary lesions:
A. Non palpable lesion:
Macule : flat and circumscribed discoloration of the skin on exposed
surface(hands ,forehead)
B. Palpable lesions with out fluid
Papule: solid, elevated ,superficial lesion(<1cm)(e.g mole)
Tumor: solid, elevated and deep ;has dimension of depth (e,g epithelioma)
Wheal: localized edema (e.g insect bite)
C. palpable lesions with fluid:
Vesicle: elevated and filled with clear fluid (e.g blister)
Bulla : large vesicle or blister larger than 1 cm in diameter (e.g 2nd degree
burn)
Pustule: elevated and filled with pus(e.g. acne)
Nodules :elevated and firm has dimension of depth
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 Types of skin lesion...

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2. Secondary lesions:
Are changes that take place in primary lesion and

possibly modified of them.

Ulcer: formed by local destruction of epidermis and

part or all of the underlying dermis (e.g pressure ulcers)

Crust :covering formed from serum, blood or pus

drying on the skin

Scale : thin , flaky skin (e.g dandruff , dry skin)
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 Diagnostic Evaluations
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 Clinical photographs
 Skin biopsy
 Skin Scrapings
 Skin culture
 Immunofluorescence
 Patch testing: to identify substances allergen
 Smear: to examine cells from blistering skin.
 Diagnostic evaluation of skin
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Skin Biopsy
 Skin Biopsy is indicated for deeper infections, suspicious lesions, or

for evaluation of current treatment.

 A biopsy is an excision of a small piece of tissue for microscopic

examination.
 Biopsies are performed on skin nodules, plaques, blisters, and other

lesions to rule out malignancy and to establish an exact diagnosis

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 Three common types of skin biopsies

 A punch biopsy uses a small round cutting instrument, called a
punch, to cut a cylinder shaped plug of tissue for a full-thickness
specimen.
 A shave biopsy removes just the area that has risen above the rest of
the skin.
 An incisional biopsy is performed with a scalpel to make a deep
incision and almost always requires sutures for closure.
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 Skin Scrapings
 Tissue samples are scraped from suspected fungal lesions with a
scalpel blade moistened with oil so that the scraped skin adheres to
the blade.
 The scraped material is transferred to a glass slide, covered with a
coverslip, and examined microscopically.
 The spores and hyphae of dermatophyte infections, as well as
infestations such as scabies, can be visualized.
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Skin cultures
 Skin cultures are done to determine the presence of fungi,

bacteria, and viruses.

 When a fungal infection is suspected, gently scrape scales from

the lesion into a Petri dish or other indicated container.

 The specimen is then treated with a 10% potassium hydroxide

solution to make fungi more prominent.

 Bacterial cultures may be collected with a sterile swab or wound

culture kit
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 Immunofluorescence (IF) is a common laboratory technique, which is

based on the use of specific antibodies which have been chemically
conjugated to fluorescent dyes.
 Designed to identify the site of an immune reaction, it combines an antigen
or antibody with a fluorochrome dye.
 A patch test is a method used to determine whether a specific
substance causes allergic inflammation of a patient's skin.
 Any individual suspected of having allergic contact dermatitis or atopic

dermatitis needs patch testing.

 Hair
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Inspection & palpation of Hair

 Inspect distribution ,thickness, lubrication, Color & texture
 Graying of hair-(indicating albinos, sign of aging, dyes)
 Oiliness of hair-puberty, hyperfunction of sebaceous glands
 Febrile illness or scalp disease sometimes result in hair loss
 In addition inspect for infestation of scalp
 Body hair is usually very fine, pubic & axillary hair is coarse
 The male pubic hair resembles a diamond, the female pubic hair patter
is like an inverted triangle.
 Inspection & palpation of Hair...
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Dry brittle hair- hypothyroidism/excessive use of hair

dyes
shiny of hair in AIDS

A total absence of body hair- hypopitutarism, poor

nutrition, serious illness, chemotherapy, radiotherapy

Inspect and palpate the scalp: for symmetry,

deformity, lesions etc

Normally scalp is smooth and firm in texture and has

no lesion
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 Nails
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Inspection & palpation of nails

 The condition of the nails reflects general health, state of nutrition,
a persons occupation,& level of self care.
 Inspect the nail beds color, the thickness & shape of the nail
 Palpate for texture & check capillary refill.
 The normal color of the nail is a pinkish white.
 With aging, trauma or decreased circulation the nails will become
thicker than normal.
 Inspection & palpation of nails...

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 Shape of nail:
 Normal:

round nail with 160 degree nail

base
Texture : round and hard ( in dark
skin may be thick)
 Deviation from normal:

nail jagged, soft, and spooned

 Inspection & palpation of nails…

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 Nails normally grow about 0.1mm/day

 The nails grow more slowly, become thick & yellow when

lymphatic circulation is obstructed.

 Spoon nails- iron deficiency anemia.

 Pitting of the nails- psoriasis, fungal disease of the nails

 Brittle,frayed nails- malnutrition, thyrotoxicosis, iron & calcium

deficiency, & with X-ray irradiation.

 Pallor is associated with anemia, shock, anxiety fear, syncope

 Cyanosis & clubbing is due to chronic hypo perfusion (COPD,

CHF), & also spongy up on palpation

 Decreased capillary refill indicates peripheral vascular disease or

anemia.
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 Quiz 1

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1. List danger signs of moles or birthmarks

2. What is Jaundice?
3. What is Pallor ?
4. What is Spoon nails?
5. Poor turgor is evident in_______________