SKIN AND MUSCULOSKELETALKristin Clephane MSN, RN, CPN

SKIN

Functions of the Skin: Protection Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption/excretion Production of Vitamin D

LAYERS OF THE SKIN

Epidermis

Dermis

Subcutaneous Layer

EPIDERMIS- PROTECTIVE LAYER

Epidermis: Top of skin, rugged, protective barrier.

Contains melanocytes (pigmentation of skin) Keratin- makes up most of epidermis- tough, strong.

Dead keratinized cells are shed constantly. (completely replace epidermis every 4 wks).

AVASCULAR- no blood vessels, nourished by the dermis.

Three color sources: Affected by thickness of skin and edema. Brown pigment: melanin Yellow-orange pigment: carotene Red-purple: vascular bed.

EPIDERMAL APPENDAGES Hair:

Vellus- fine, faint hair Terminal- thick, dark hair.

Sebaceous glands: Produce Sebum- oils and lubricates skin, prevents water loss.

Sweat glands: Eccrine- make sweat Apocrine-make thick milky secretion, bacteria love it and the bacteria

make you stink!

Nails: HARD- made of keratin. Pink color due to highly vascular cells. Lunula- white opaque at proximal end, lies over nail matrix where new

keratinized cells are formed Cuticle- covers and protects nail matrix

DERMIS- SUPPORTIVE LAYER

Dermis- mostly connective tissue or collagen. Collagen- fibrous protein that resists tearing, and allows skin

to stretch.

Contains: nerves, sensory receptors, blood vessels, and lymphatics.

Epidermal appendages extend down into dermis. (hair follicle, sebaceous glands, sweat glands,nails)

SUBCUTANEOUS LAYER-THE CUSHION Subcutaneous layer- Consists of adipose tissue (FAT)

Prevents injury by cushioning. Stores fat for energy. Provides insulation for temperature control. Gives skin increased mobility over structures underneath.

ASSESSING SKIN, SUBJECTIVE DATA 1ST: HISTORY

Skin History of skin disease. Change in pigmentation or moles. Excessive dryness or moisture. Pruritis (itching) Bruising Rash or Lesion Medications Hair loss Change in nails Environmental/occupational hazards Skin cancer assessment Self-care behaviors

SUBJECTIVE DATA COLLECTION: AGING ADULT

Changes in last few years?

Delayed wound healing?

Skin pain?

Change in feet, toenails, bunion-can you wear shoes?

Frequent falls?

Diabetes or Peripheral Vascular Disease?

How do you care for your skin?

SKIN, OBJECTIVE DATA: GETTING READY Inspection and palpate the skin.

Skin tells you A LOT about a patient.

Know the person’s “normal” skin coloring.

Touch non-threatening areas first (hands and arms).

Look at the person as a whole (preferrably undressed), then look at specific areas/rashes.

Remove shoes/socks.

OBJECTIVE DATA

Remember to Palpate- Darker-skinned individuals, more difficult to see color variations (sometimes the only way to know there is a rash is to touch it).

Also look at mucous membranes.

Don’t forget to look in the warm, moist, dark places: Skin folds, under breast, in groin, etc.

NORMAL OBJECTIVE FINDINGS: COLOR

General Pigmentation- Overall skin tone.

Benign Findings: A: Freckles- small, flat macule of brown melanin on sun-

exposed skin. Mole (nevus)- proliferation of melanocytes- tan-brown, flat or

raised. B: Junctional nevus- macular only, children and adolescents. C: Compound nevi- macular and papular, adults.

Birthmarks- tan or brown in color

COLOR CHANGES: ABNORMAL Remember to look under tongue, buccal mucosa,

palpebral conjunctiva and sclera, and nail beds.

Pallor- White/PaleErythema- REDCyanosis- BLUE Jaundice- Yellow

ABNORMAL: PALLOR

Blood with oxygenated hemoglobin (in the arteries) are shifted away from the surface due to underlying issue.

Can look yellowish-brown in brown-skinned.

Can look ashen or gray in black

Caused by: vasoconstriction.

Occurs in: High-stress states (metabolic/respiratory/fear/anxiety) Shock

ABNORMAL: ERYTHEMA

Intense Redness (excessive blood near surface).

Expected in: Fever Local inflammation Emotional reactions (blushing) Certain medical conditions: infection, systemic viral

processes

ABNORMAL: CYANOSIS

Hemoglobin does not have oxygen!!! (turns red when oxygen is bound to it).

Indicates hypoxemia (decreased O2 to tissues)

Occurs in: Shock Heart Failure Chronic Bronchitis Congenital Heart Disease

Hard to see in dark-skinned individuals.

ABNORMAL: JAUNDICE

Caused by increased billirubin in blood.

First seen in mouth (hard palate) and sclera.

As billirubin increases jaundice is then seen over the rest of the body.

NORMAL VS. ABNORMAL FINDINGS Temperature:

Use the backs of your hands. Hypothermia- Generalized coolness.

Induced in surgery. Localized coolness in immobility, casts, IV infusion.

Hyperthermia- Generalized heat. Increased metabolic rate, fever, exercise.

NORMAL VS. ABNORNMAL FINDINGS Moisture:

Perspiration occurs on face, hands, axilla, and skinfolds. Diaphoresis- PROFUSE perspiration. In setting of Dehydration- look in oral mucous membranes.

NORMAL FINDINGS

Texture Smooth and firm and even surface.

Thickness Thicker over palms and soles (callus). Uniform over rest of body.

NORMAL VS. ABNORMAL FINDINGS

Mobility and Turgor Pinch a large fold of skin on anterior chest under clavicle. Mobility- ease of the skin rising off the chest. Turgor- ability of the skin to return to place immediately Tenting: skin recedes slowly after pinched

NORMAL VS. ABNORMAL FINDINGS Vascularity or Bruising:

Cherry (senile) angiomas- small (1-5 mm), smooth, slightly raised bright red dots (common after age 30).

Bruising- should be consistent with trauma. Also document any tatoos.

ABNORMAL FINDINGS: LESIONS Lesions (lesions are not normal but are commonly found

and can be benign).

ALWAYS wear gloves when palpating a lesion!!

Note the following: Color Elevation Pattern/Shape Size Location and distribution Any exudate.

ABNORMAL FINDINGS: LESIONS Lesions- Assessment

Roll nodule between thumb and index finger to assess depth. Gently scrape a scale to see if it will come off (watch for

bleeding). Note surrounding skin temperature. Does the lesion blanch or stretch? Use a magnifier and light for closer inspection. Wood’s light to detect fluorescing lesions.

ABNORMAL FINDINGS: EDEMA Edema Scale: 1+: Slight edema, skin rapidly returns to normal after depressed.

2+: 4 mm or ¼ inch depression and returns to normal in 10-15 seconds.

3+: 6 mm or ¼-1/2 inch depression and returns to normal in 1-2 minutes

4+: 8 mm or ½-1 inch depression and returns to normal in 2-5 minutes.

Edema masks the normal color of the skin (obscures cyanosis and jaundice).

NORMAL FINDINGS: HAIR

Color

Texture

Distribution

Lesions

NORMAL VS. ABNORMAL FINDINGS: NAILS Shape and Contour

Normal 160 degrees Curved 160 degrees or less CLUBBING 180 degrees.

Consistency Smooth and regular (not brittle) Uniform and attached to nail bed.

Color Translucent window to pink nail bed.

Capillary Refill Blanche nail, and color should return in less than 3 seconds.

NORMAL FINDINGS: INFANT

Fetus and Pre-term Birth Covered with Lanugo (fine downy hair). Replaced at 3

months of age.

Birth- Vernix caseosa- thick, cheesy substance made of sebum

and shed epithelial cells.

Newborns Skin is thin, smooth, elastic More permeable. Sebum (few weeks) causes cradle cap and milia (tiny white

papules). Eccrine (sweat) glands- do NOT function (few months) Pigment system may be inefficient at birth.

NORMAL FINDINGS: INFANT

Mongolian Spot: Hyperpigmentation (dark) spot in blacks, Asian, American Indian, and Hispanic newborns. (fades during first year) Often mistaken for bruising (abuse).

Café au lait spot: Large, round, oval patch of light brown pigmentation (coffee with milk).

Harlequin color change: Lower half of body turns red and upper half blanches (when in side-lying position).

Erythema toxicum: Rash, also called “flea bite” or newborn rash. Occurs at 3-4 days old. Tiny, punctate, red macules and papules on cheeks, trunck, chest, back, and buttocks.

NORMAL FINDINGS: INFANT

Acrocyanosis: bluish color around lips, hands and fingernails. Disappears with warming.

Cutis marmorata- transient mottling in trunk and extremeties.

Physiologic Jaundice: Yellowing of skin, sclera and mucous membranes (occurs on 3rd or 4th day).

Carotenemia: yellow-orange color in light-skinned people. Caused by ingesting large amounts of carotene foods.

Storkbite- flat, irregularly shaped red or pink patch on the forehead, eyelid or upper lip.

NORMAL FINDINGS: CHILD/PUBERTY Child:

Epidermis thickens, toughens, darkens and becomes lubricated.

Hair growth increases.

Puberty Apocrine (smelly) glands increase secretion (B.O.) Sebaceous glands more active (oily and acne) Subcutaneous fat increases (more in girls) Females- areola enlarges and darkens, breast tissue

develops, and coarse pubic and axillary hair. Males- Pubic, axillary and facial hair develops.

NORMAL FINDINGS: PREGNANCY Pregnancy

Increased pigment in areola, nipples, vulva and abdomen. Linea Nigra (abdomen) Chloasm (face)- brown patches Striae gravidarum (stretch marks)- abdomen, breasts and

thighs. Increased fat deposits in buttocks and hips.

NORMAL FINDINGS: AGING ADULT Epidermis- thins and flattens

Dermis- thins and flattens (loss of collagen and elastin)- causes wrinkles, makes skin easier to teat.

Sweat and sebum decreases- dry skin

Loss of subcutaneous fat- cold easier, easier to injure.

Senile purpura- dark, red discolored areas related to vascular fragility.

Hair matrix- decreased melanocytes (white/grey hair)

Hair decreases (balding- decreased testosterone in men).

Decreased estrogen causes facial hair in wormen.

CULTURAL DIFFERENCES

Whites- 20 times more likely to develop melanoma than blacks, 4 times more likely than Hispanics.

Asian and American Indians- less body odor. Hair tends to be straight and silky.

Inuit- sweat more on face, less on body.

Blacks- Keloids (scars), pigmentary disorders, pseudofolliculitis (ingrown hair), melasma- (pregnancy mask) Hair more fragile, dry, wide variety of textures.

ABNORMAL VASCULAR LESIONS: PETECHIAE.

ABNORMAL VASCULAR LESIONS: ECCHYMOSIS (BRUISE)

SHAPES OF LESIONS: ANNULAR

CONFIGURATION OF LESIONS: CONFLUENT

DISCRETE TARGET

ZOSTERIFORM

PLEASE ALSO STUDY THE FOLLOWING TERMS: P 232-233 Macule:

Plaque:

Papule:

Nodule:

Tumor:

Vesicle:

Bulla

Cyst:

Pustule:

Crust:

Scale:

Urticaria (Hives):

SKIN:Abrasion AKA Scrape

Wound from superficial damage to skin (no deeper than epidermis)

Characteristics

Color

Approximate vs. measured size

Drainage

Texture

ABRASION

LACERATION

Defined

A cut in the skin’s surface

Characteristics Superficial

Moderate

Deep

Can be defined by the layer(s) of skin involved: depth

Drainage

Well-Approxmated

Jagged

Approximate vs. measured size

Causal agent

LACERATION

SKIN TEAR

Defined

Damaged to skin from: shearing, force, friction

Characteristics

Superficial

Moderate

Deep

Can be defined by the layer(s) of skin involved: depth

Drainage

Well-Approxmated

Jagged

Approximate vs. measured size

Causal agent

SKIN TEAR

MUSCULOSKELETAL SYSTEM: CHP 22 Contains: bones, joints, muscles

Functions: Support Movement Protect Produce RBC’s Reservoir for storage of minerals (calcium, phosphorus)

MUSCULOSKELETAL: JOINTS

Nonsynovial- Fibrous tissue/cartilage. Immovable.

Synovial Joint cavity filled with lubricant (synovial fluid) Layer of cartilage covers opposing bones. Ligaments strength joint and prevent movement in the wrong

direction. Bursa- enclosed sac filled with synovial fluid.

Occurs in areas of friction. Helps muscles and tendons glide over bones.

MUSCULOSKELETAL: MUSCLES Muscles make up 40-50% of body wt.

Three Types of Muscles: Skeletal/Voluntary (Only ones we are talking about) Smooth Cardiac

THINGS TO KNOW:

Differentiate between synovial & nonsynovial joints

List motions allowed by the TMJ: Hinge open and close. Glide for protrusion/retraction. Glide for side-to-side movement.

Describe shape & surface landmarks of the spine: C7 & T1 (Base of Neck) T7 & T8 (Scapula) L4 (Iliac crest) Sacrum (Dimples or posterior superior iliac spines)

LANDMARKS OF THE SPINE.

SUBJECTIVE ASSESSMENT/HISTORY

Do you have a history of…:

Problems or pain in your joints, bone, muscles? If so, Location (where), Quality (what does it feel like),

Onset (when did it start), Timing (when and how long does it occur)?

Do you have any stiffness (joints), swelling, heat, crepitus, redness, cramping (muscles), or weakness (muscles), clicking on joint movement, limitation of movement?

Any deformities, hx/o trauma or accident? Can you perform functional ADLs? (bathing, toileting,

dressing, grooming, eating, mobility, communication)

SUBJECTIVE ASSESSMENT/HISTORY

What are your self-care behaviors? Occupational hazards (nursing is full of them) Heavy lifting Repetitive motion Chronic stress to joints Exercise patterns. Wt. gain Medications (anti-inflammatories)

MUSCULOSKELETAL SYSTEM

Developmental Considerations

1. Infants/Children: Skeletal contour changes- Spinal changes Growth plates- epiphyses

2. Pregnant female: (Postural changes) Lordosis- shifts wt back so you don’t fall

over.

3. Aging adult: osteoporosis, postural changes, decreased height, bony prominence marked

MUSCULOSKELETAL SYSTEM

Transcultural Considerations

Bone density - higher in black males, hip width 1.6cm smaller in black female than white female

LORDOSIS IN PREGNANCY, KYPHOSIS IN ELDERLY.

SCOLIOSIS

MUSCULOSKELETAL: OBJECTIVE ASSESSMENT Inspection

Palpation

Range of motion

Equipment needed: Tape measure Skin marking pen Ganiometer (APRN typically)

PHYSICAL EXAMINATION: OBJECTIVE INSPECTION: PERFORMED ON ALL PATIENTS

Skeleton & extremities note: posture, alignment of extremities, contour, symmetry, size,

presence of any gross deformities

Muscles note: size, symmetry, contour

Joints and skin over bones note: color, presence of edema, size and color of joint, masses or

deformity.

Gait note: conformity, symmetry and rhythm

PHYSICAL EXAMINATION: OBJECTIVE PALPATION: PERFORMED ON ALL PATIENTS!!

Muscles, bones, joints note: Presence of tenderness, heat, edema or masses.

Over joints during movement note: Presence of crepitus or clicking sounds.

PHYSICAL EXAMINATION: OBJECTIVE RANGE OF MOTION (ROM):

Active: PERFORMED ON ALL PATIENTS!! The patient moves the limb/joint, and the nurse stabilizes (if

needed).

Passive: PERFORMED WHEN PATIENT HAS OR A MUSC ISSUE IS SUSPECTED!! The nurse moves and stabilizes limb/joint.

Active and Passive ROM should be the SAME.

Done in order: head to toe

Documentation: Normal: Full ROM against gravity.

MUSCULOSKELETAL: MOVEMENTS P.567

Flexion- Bending limb at joint

Extension- Straightening limb at joint.

Abduction- Move away from midline.

Adduction- Move toward midline.

Pronation- Turning forearm palm down.

Supination- Turning forearm palm up.

Circumduction- Arm in circle around shoulder.

Inversion- Sole of foot inward at ankle.

Eversion- Sole of foot outward at ankle.

Rotation- Move head on central axis.

Protraction- Forward and parallel to ground.

Retraction- Backward and parallel to ground.

Elevation- Raising.

Depression- Lowering.

SKELETAL MUSCLE MOVEMENTS.

ROM ABNORMAL OR SPECIFIC AREAS If ROM is outside of normal limits per degrees noted (you

would just see this, observe it with your eyes and touch) you could then specify the abnormality with a…

Ganiometer:

You Tube: How to use a goniometer

You Tube: An App!...think it's reliable?

You Tube: Quick Demo, goniometer

PHYSICAL ASSESSMENT: OBJECTIVE Muscle Strength: Test the prime mover muscle groups

for each joint. Ask patient to perform same motion as ACTIVE ROM and hold

against opposing force (nurse applies the opposing force).

Documentation: Normal: Equal bilaterally with full resistance, strength 5 /0-5.

Where 0 is no movement, and 5 is full movement against resistance and gravity.

PHYSICAL ASSESSMENT: OBJECTIVE

Grading Muscle Strength Grade Description 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM with gravity 2 Full ROM with gravity removed (passive motion) 1 Slight contraction 0 No contraction

HEAD TO TOE PHYSICAL ASSESSMENT: TMJ

Temporomandibular joint: Inspect area just anterior to the ear. Palpate (2 fingers) in front of ears Bilaterally. ROM: Ask pt to:

1. Open mouth maximally: normal is 3-6 cm (can measure or use 3 fingers)

2. Partially open mouth and protrude lower jaw and move side to side: normal is 1-2 cm

3. Stick out lower jaw: shouldn’t deviate Palpate contracted temporalis and masseter muscles with

clenched teeth. Strength: Ask pt to:

1. Move jaw forward and laterally against resistance.2. Open mouth against resistance.3. Document using 0-5 scale

TEMPOROMANDIBULAR JOINT

PHYSICAL ASSESSMENT: SPINE

Spine - Cervical Spine Inspect alignment of head and neck. Palpate the spinous processes, and sternomastoid, trapezius

and paravertebral muscles.

ROM: Ask pt. to:1. Touch chin to chest: flexion2. Lift chin toward ceiling: extension3. Touch each ear to shoulder. (don’t lift up shoulder): lateral

BENDING4. Turn chin to each shoulder: rotation

Strength: 1. Repeat ROM with opposing force.2. Document on 0-5 scale

CERVICALSPINE

PHYSICAL ASSESSMENT: SPINE Thoracic & Lumbar Spine

1. Inspect if spine in straight vertical line. Also inspect curvature from the side. (kyphosis-thoracic curve, Lordosis- Lumbar curve). Scoliosis.

2. Palpate spinous processes and paravertebral muscles.

ROM: Ask pt to:1. Bend forward and touch toes: flexion2. Bend sideways: lateral bending3. Bend backwards: extension4. Twist should to one side then the other:

rotation5. Raise straight leg up (laying position): if

positive produces sciatic pain Do Not Assess Strength for Thoracic and Lumbar Spine.

SPINE

SPINE

PHYSICAL ASSESSMENT: SHOULDER Shoulders

Inspect and compare both shoulders for size and contour of joint, and equality of bony landmarks.

Palpate both shoulders for spasm, atrophy, swelling, heat, masses or tenderness.

ROM: Ask pt to:1. Move both arms forward and up in wide arcs and then back

(arms extended): forward flexion vs. extension2. Rotate are internally behind back and place as high toward

scapulae as possible: internal rotation3. Raise arms from sides, (palms together) over head:

abduction4. Touch both hands behind head with elbows flexed:

external rotation Strength: Ask pt to:

1. Shrug shoulders against resistance.2. Flex forward and up against resistance.3. Abduct against resistance.4. Document using 0-5 scale

SHOULDERS

PHYSICAL ASSESSMENT: ELBOW

Elbows:1. Inspect the size and contour of the elbow (flexed

and extended). 2. Palpate olecranon process and bursa.

ROM: Ask pt to:1. Bend and straighten elbow: flexion & extension2. Move 90 degrees in pronation and supination.

Strength: Ask pt to:1. Flex and extend elbow against resistance.2. Document using 0-5 scale

ELBOWS

ELBOWS

MUSCLE STRENGTH - ELBOW

PHYSICAL ASSESSMENT HAND/WRIST Wrists/Hands

1. Inspect for swelling, position, shape, redness, and deformity.

2. Palpate each joint in wrist and hands. Use thumbs on hand and wrist, use thumb and forefinger on finger joints.

ROM: Ask pt. to:1. Bend hand up and down at the wrist:

extension/flexion2. Bend fingers up and down:

hyperextesion/flexion3. Hands flat- move in: radial deviation & out:

ulnar deviation4. Spread fingers apart and make a fist.5. Touch thumb to each finger and base of little

finger.

PHYSICAL ASSESSMENT: HAND/WRIST

Wrist/Hands Strength: Ask the pt to:

Place arm palm up on table and flex wrist up against resistance, document using 0-5 scale

Phalen’s Test: Hold both hands back to back (wrists at 90 degrees) for 60 seconds. (should have no pain/numbness)

Tinel’s Sign: Direct percussion of median nerve at wrist. (should have no symptoms).

HANDS AND WRISTS ROM

PHYSICAL ASSESSMENT: HIP Hip

1. Inspect symmetrical iliac crests, gluteal folds, and buttocks. Smooth, even gait.

2. Palpate the joints. Should be stable and symmetric.

ROM: Ask the pt to:1. Raise each leg with knee extended: flexion2. Bend each knee up to chest with other leg straight:

hip flexion w/ knee flexed3. Bend knee (foot flat on bed) and rotate knee in:

internal rotation and out: external rotation4. Straighten leg and swing foot laterally: abduction

and medially: adduction5. Stand and swing straight leg back behind body.

HIPS

PHYSICAL ASSESSMENT: KNEE

Inspect skin smooth, no lesions. Lower leg alignment. Shape, contour, swelling, and atrophy.

Palpate- muscles should feel solid and joint smooth, no warmth, no tenderness, no thickening, no nodules. Some crepitus in knee is NOT abnormal. If swelling check BULGE sign-

Firmly stroke up on medial aspect of the knee 2-3 times.

Tap the lateral aspect. Watch the medial side in the hallow

for a bulge from a fluid wave. Ballottement of Patella-

With left hand compress suprpatellar pouch.

With right hand, push the patella sharply against femur. (patella should already be snug against femur/shouldn’t move).

PHYSICAL ASSESSMENT: KNEE

Knee ROM: Ask pt to:

1. Bend each knee: flexion2. Extend each knee: extension3. Check ROM walking.

Muscle Strength: Ask pt to:1. Maintain flexion while attempting to pull leg

forward.2. Extension- success in rising from seated

position in low chair or from squat without using hands.

3. Document using 0-5 scale

KNEE

PHYSICAL ASSESSMENT: ANKLE/FOOT

Inspection for equal symmetry, contour and skin characteristics. Weight-bearing on middle of foot. Toes should be straight. Skin smooth, even coloring. Note calluses or bursal reactions.

Palpate the ankle with thumb. Joints should feel smooth and depressed. Use thumb on top of foot and fingers on bottom for metatarsophalangeal joints. Use pinching motion of thumb and forefinger for toes.

PHYSICAL ASSESSMENT: ANKLE/FOOT ROM: Ask pt to:

1. Point toes toward the floor: plantar flexion2. Point toes to nose: dorsiflexion3. Turn soles of feet out: eversion and in: inversion4. Flex and straighten toes.

Muscle Strength: Ask pt to:1. Maintain dorsiflexion and plantar flexion against resistance. (toes

up and down)2. Document using 0-5 scale

ANKLE AND FOOT

THE END!