Ch 30- Integumentary Assessment

7/29/2019 Ch 30- Integumentary Assessment

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What are the Functions of theIntegumentary System?


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Functional Review

Protector and barrier between internalorgans and external environment

Barrier against foreign body intrusions

against invading bacteria and foreign matter

Transmits sensationnerve receptors

allows for feelings of temperature, pain, light

touch and pressure


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Skin Functions

Regulates body temperatureregulates heat loss

Helps regulate fluid balance

absorbs water

prevents excessive water & electrolyte loss.

Slow loss up to 600 ml daily by evaporation

Immune Response Functioninflammatory process


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Skin Functions

Vitamin productionexposure to UV light allows for the conversion

of substances necessary for synthesizing

vitamin D

Necessary to prevent osteoporosis, rickets


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Skin Assessment

Visual inspection

Palpation

Olfactory senses Adequate lighting

Remove necessary clothing while

providing respect and privacy Appropriate client positions p.568


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Visual inspection

Skin color: Palor

Cyanosis

Jaundice

Erythema

Hyperpigmentation

Hypopigmentationvitiligo


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Visible changes if the Skin

Changes in skin color texture

Eczema, infections

Assess the vascularity & hydration of skin

Edemaswelling, pitting edema

1+ 2 mm 3+ 6 mm

2+ 4 mm 4+ 8 mm p.579

Nailsconfiguration, consistency, color p.579

Haircolor and distribution, aloplecia,location


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Gerontology Considerations

Watch for significant changes in aging:

Decrease immunity functions

Susceptibility to infections

Poor nutrition

Decrease collagen productionloss ofsubcutaneous

Thinning of epidermal skin layers

Increase skin problems


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Taking more medications

Excessive environmental exposure

Dryness, wrinkling

Uneven pigmentation

Various proliferative lesions

Gerontology Considerations


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Assessing light to dark skin

Description Light skin Dark skin

Cyanosis - bluish Bluish tinge Ashen gray

Pallor - paleness Loss of rosy glow Ashen gray (drk skin)

Yellowish brown (brown

skin)Erythema - redness Visible redness Diffused; rely on palpation

of warmth or edema

Petechiaesmall

size pinpoint

ecchyumosis

Purplish

pinpoints

Usually invisible; check

oral

Mucosa, conjunctiva,

eyelids, conjunctiva

covering eyeballs.


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Assessing light to dark skin

Description Light skin Dark skin

Jaundice - yellow Yellow sclera,

skin, fingernails,

soles, palms, oral

mucosa

Reliable on sclera, hard

palate, palms and soles.

Ecchymosislarge

diffused bluish black

Purplish to

yellow-green

Difficult to see, check

mouth or conjunctiva

Brown-Tancortisol

deficiency, increasedmelanin production

Bronze;

Tan to lightbrown

Easily masked.


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Assessing Lesions

Vary in size, shape and cause

Primary vs. Secondary

Erruptions: cysts, wheals, bullous, pustules,

psoriasis, eczyma, vesicles, bullae, nodules,papules

Discoloration: macules (caf-au-lait),


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Disorders Affecting the Skin


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Skin Lesions p.755

EtiologyInfectionsherpes, impetigo, HIV, melanoma

Toxic chemicals: skin irritation

Physical trauma: burns, lacerationsHereditary factors

External factors: allergens, contact dermitis

Systemic diseases: measles, lupus, nutritionaldeficiency


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Skin Lesions

Nursing Process Care:

Assessment: descriptions; pt. history, causative

factors

Evaluation of skinidentify problem

Nursing Diagnosis

Interventions for skin care to promote healing

and prevent further injury

Pain management & comfortInfection control

Nursing evaluation & reassessment


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Systemic Skin Diseases:Skin Disorders in Diabetes

Diabetes Dermapathyshin spots, caused

by break- down of small vessels that supply

the skin. Stasis Dermatitiscompromises circulation

to the distal extremities due to damage of

larger vessels.

Problem: Injuries heal slow; increase risk for

ulcerations; risk for skin infections


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Fungal infections of the Skin

Tinea Pedis (athletes foot)

Tinea Corporis (ringworm of the body)

Tinea Capitis (scalp ringworm)

Tinea Cruris (ringworm of the groin)

Jock itch jock, common in diabetes.

Tinea Unguium (ringworm of the nails)

onychomycosis


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Parasitic Infections

Pediculosis capitis - lice Pediculosis corporis/pubis

Sarcoptes scabieiscabies

Raised burrows found between fingers, wrists,elbows, nipples, feet, groin, gluteal folds, penis,

scrotum

Poor hygienic living conditionsIncrease; contagious

Secondary lesions: vesicles, papules, crust,

excoriations


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Parasitic InfectionsAppear 4 wks after exposure

Elderly patients from long term facilities

Lindane, crotamiton (Eurax), permethrin


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Nursing Diagnosis

Skin Impairment r/t:

GOAL:

Protect the skinPrevent secondary infections

Promote healing


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Skin Care

Review of wound dressings


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Wound Dressings

Occlusiveairtight cover applied to skinlesions

Wet(obsolete) wet compresses applied on

acute weeping, inflamed lesions Moisture-retentivemore efficient wet drsgfor removing excudate: impregnated withsaline, petrolatum, zinc-saline, hydrogel,

antimicrobial agents.Avoids maceration , less infections,

scarring & reduces pain.


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Wound Dressings

Hydrogelspolymers with 90% water

content

superficial wounds, abrasions, skin graft

sites, draining venous ulcers

Hydrocolloidsimpermeable to water, O2

Remain intact during bathing.

Produce foul-smelling yellowish coveringMay leave on wound for 7 days

Promote debridment & granulation tissue


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Wound Dressings

Foam hydrophilic absorption andhydrophobic backing to prevent leaking ofexudate

Nonadherent; require secondary dressing

Used over bony areas and weeping wounds

Calcium alginatesabsorbent fiber packingmade from seaweed.

Absorbes exudate, best for maceratedwounds, packing deep wounds, sinustracking, heavy drainage - nonadherent

Ch 30- Integumentary Assessment

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