Assessing Clients with Skin Disorders

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Assessing Clients with Skin Disorders

• Chapter 44

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Integumentary System

• Functions
• 1. Protects body from injury
• 2. Provides a barrier to loss of fluids
• 3. Sensory - touch, pressure,pain, and
  temperature
• 4. Regulates body temperature via sweat glands
• 5. Production of vitamin D

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Skin

• 2 Layers
• Epidermis
• outer layer, protection, stores melanin
• epithelial cells
• Dermis
• inner layer, temperature regulation
• connective tissue, contains hair follicle, sweat
  glands and sebaceous glands

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Layers of the Skin
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Skin Color

• 1. Erythema
• reddening of the skin
• fever, inflammation, sunburn, drug reaction
• 2. Cyanosis
• bluish discoloration
• poor oxygenation of hemoglobin

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Skin Color

• 3. Pallor
• paleness of skin
• shock, fear, anemia or hypoxia
• 4. Jaundice
• yellow-to-orange skin color
• hepatic disorders

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• 3 Types
• Sebaceous - Oil
• to soften and lubricate the skin
• Sudoriferous - Sweat
• to regulate body temperature by excretion of
  sweat
• Ceruminous - located in external ear canal
• secrete cerumen, sticky trap for foreign materials

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The Hair and Nails

• Protective Function
• Hair
• cushions the scalp
• eyelashes and eyebrows protect the eyes
• provides insulation in cold weather
• Nails
• protects fingers, toes, aid grasping

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The Health Assessment Interview

• Determine problems with the integumentary system
• Describe any skin problems or injuries, nail
  problems or scalp problems you have had.
• Is your skin and/or scalp dry or oily?
• Do you have any skin pain, burning or itching?

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The Physical Assessment

• Can be part of head-to-toe or focused assessment
• Assessment through inspection and palpation
• Assess for
• color, lesions, temperature,texture, moisture,
  turgor and edema

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Assessments?
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The Physical Assessment

• Inspect color
• pallor
• cyanosis
• jaundice
• Inspect for lesions
• irregular skin, rash, hives, psoriasis - scaly
  red patches

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The Physical Assessment

• Palpate the skin for temperature
• warm with fever
• cool in shock or decreased blood flow
• Palpate skin for texture
• smooth or coarse
• Palpate skin for moisture
• dry, moist, diaphoretic - M.I., shock

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The Physical Assessment

• Palpate for Turgor
• pinching skin over collar bone or back of hand
• decreased in dehydration tenting
• increased in edema
• Assess for edema
• accumulation of fluid in body tissues
• depress skin over ankle

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The Physical Assessment

• Rate the Edema
• 1 slight pitting
• 2 deeper pit
• 3 obvious pit, extremities are swollen
• 4 the pit remains
• Edema occurs in cardiovascular disease, renal
  failure and cirrhosis of liver

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Lymph Edema
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The Physical Assessment

• Hair
• inspect distribution and quality
• palpate for texture
• inspect the scalp for lesions
• Nails
• inspect for curvature, color and thickness

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Variations in the Older Adult

• Loss of subcutaneous tissue
• wrinkles, sagging, decreased turgor
• Skin tags
• small flaps of excess skin
• Decreased hair and nail growth
• Liver spots
• small flat brown macules

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Primary Skin Lesions

• Macule
• flat color change in the skin - freckle
• Papule
• elevated palpable mass with circumscribed boarder
  - elevated mole
• Nodule
• elevated, solid mass extending deeper - lipoma

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Primary Skin Lesions

• Vesicle
• fluid filled with thin translucent walls -
  blister
• Wheal
• larger than vesicle - insect bite, hives
• Pustule
• pus filled vesicle - acne
• Cyst
• elevated, encapsulated mass - sebaceous cyst

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Skin Lesions
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Secondary Skin Lesions

• Atrophy
• translucent, dry, paperlike skin resulting from
  thinning or wasting away due to loss of elastin
• Ulcer
• deep crater-like, irregular shaped area of skin
  loss extending into the dermis
• Fissure
• cracks with sharp edges - corner of mouth, feet

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Vascular Skin Lesions

• Port-wine stain
• lg. Flat mass of blood vessels on skin surface
• Strawberry mark
• bright red, raised cluster of immature
  capillaries
• Petechiae
• flat, red-purple freckles caused by tiny
  hemorrhages

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Vascular Skin Lesions

• Ecchymosis
• bruising - release of blood into surrounding
  tissues
• trauma, hemophilia, liver disease
• Hematoma
• similar to ecchymosis but is raised, swollen

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Documenting general appearance
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What terms describe this skin?
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Lymphaedema
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What would you document?
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Skin our protector our whole life!