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

II.Dermis- Connective tissue layer

 blood, lymphatic vessels
 nerves/ nerve endings
 glands hair follicles
 elastic /COLLAGEN fibers- elasticity / toughness
 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
Primary Skin Lesions 3.Varicella(Chicken Pox)-varicella-zoster virus (VZV).
1.Macule – circular, flat discoloration – red, brown, blue -blister-like rash,itching, tiredness, and fever.
(Mongolian spot)hypopigmented – EBV, syphilis, HIV,German - prevented by a vaccine- Varicella-zoster
measles, Rubella tx: relieving symptoms
2.Papule – raised skin < 0.5cm, solid, skin color, red, white –  Pain relievers Anti-itch Colloidal Oatmeal
impacted oil gland  High-risk groups may receiveantiviral medications.
3.Plaque – raised skin > 1cm, solid, flat eg.psoriasis 4.Shingles (Herpes Zoster)- dermatone linear along nerve route
4.Bulla – raised skin > 1 cm filled with serous or sero-purulent tx: Antiviral (Acyclovir),Corticosteroid (Prednisone),
fluid – 2nd degree burn -5.Scabies- tx:(Permethrin)- topical
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, 6.Erythema gyratum repens(EGR)
cracking – heel fissures tx:Immunosuppressive-Hydroxychloroquine(used to treat malaria)
5.Crust – dried blood over damaged skin – scabbing 7. Lyme’s Disease: Target lesion (bull’s eye)
6.Scar – thick fibrous tissue replacing damaged dermis, white, Treat with supportive care-topical steroids
pink, red - healed wound
7.Keloid – raised scar 8.Toxic Epidermal Necrolysis-30% of body surface area
8.Lichenification – thickened or roughened skin – rubbing, potentially life-threatening dermatologic disorder
scratching - Eczema, chronic dermatitis - widespread erythema, necrosis, and bullous detachment of the
Scales – accumulation of dead skin cells – Ichthyosis vulgaris – epidermis and mucous membranes, resulting in exfoliation and
“fish scale” disease possible sepsis and/or death
9.Petechiae – red or purple spots, minor bleeding into skin –
broken capillary vessels, use of blood pressure cuff Steven-Johnson Syndrome - <10% of body surface area
10.Purpura – purple-colored spots, damaged blood vessels, blood first signs/symptoms : fever, unexplained widespread skin pain,
pooling – ITP – Idiopathic Thrombocytopenic Purpura – low red or purple skin rash that spreads blisters on your skin and the
Platelets mucous membranes of your mouth, nose, eyes and genitals. -
Shedding of skin within days after blisters form.
Vascular Skin lesions
1.Spider angioma – swollen blood vessel in epidermis, contains Cause: sulfa; phenytoin,carbamazepine; piroxicam or allopurinol.
central red spot. It is a vascular lesion characterized by anomalous -15 to 30% of body surface area is considered SJS/TEN overlap.
dilatation of end vasculature found just beneath the skin surface.
The lesion contains a central, red spot and reddish extensions 9..Psoriasis-Polycyclic lesions
which radiate outward like a spider's web. tx: Corticosteroids Anti-inflammatories NSAIDS
2.Cherry angioma – collection of small blood vessels – Also known Immunosuppressive (Enbrel)
as senile angioma or Campbell de Morgan spot
3.Venous Star – dilated veins due to  intravenous pressure
9.Urticaria
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.
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