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 for life!
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NCLEX

• The nurse assessing a dark skinned client for
  cyanosis knows that in which of the following
  would cyanosis be more visible in a dark skinned
  individual?
• A. Sclera
• B. MM and nail beds
• C. Generalized skin color
• D. Palms of the hands and feet

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NCLEX

• A nurse assessing an elderly thin client notes
  the skin turgor over the clients clavicle is
  decreased. The nurse interpretes this finding as
  which of the following?
• A. Client is dehydrated
• B. Client has edema
• C. This is a normal finding for this client
• D. The client has experienced a recent weight
  loss.

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NCLEX

• When performing a screening and assessment on a
  44 year old female, the nurse notes a patch of
  hair loss.
• The nurse suspects which of the following?
• A. Dandruff
• B. Alopecia
• C. Scalp ringworm (tinea capitis)
• D. head lice

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NCLEX

• When inspecting a clients nails the nurse notes
  that the angle of the nail base is greater than
  180 degrees. What is this condition called?
• A. Alopecia
• B. edema
• C. tenting
• D. clubbing

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NCLEX

• When working with an older person, you would keep
  in mind that the older adult is most likely to
  experience which of the following changes with
  aging?
• A. thinning of the epidermis
• B. thickening of the epidermis
• C. oiliness of the skin
• D. Increased elasticity of the skin

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NCLEX

• Which of the following glands plays a role in
  killing bacteria?
• A. sebaceous (oil) glands
• B. Eccrine sweat glands
• C. Apocrine sweat glands
• D. Ceruminous glands