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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
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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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[Link] & 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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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_______________
