Transcript Inspections and palpation of skin

Chapter (6)
Assessment of Skin, Hair and Nails
Faculty of Nursing-IUG
Structure of the Integument
 The skin is the largest organ of the body comprising 15 percent of total
body weight.
 Layers of the skin
A. Epidermis
B. Dermis
C. Subcutaneous tissue
Epidermal appendages
 Hair
 Nails
 Glands: two types of skin glands:
1. Sweat Gland
Eccrine sweat glands: are widely distributed and open directly onto the
skin surface
Apocrine sweat glands: open into hair follicle in axillary and genital
areas
2. Sebaceous glands: Produce sebum(oily secretion)
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Functions of skin and epidermal appendages
 Barrier to water and electrolyte loss
 Regulation of body heat
 Sensory organ for touch, temperature, and Pain
 Production of protective skin film by eccrine and sebaceous
glands
 Participation in production of vitamin
 Wound repair
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Assessing the Integument
1. Subjective data
 Skin infection, rashes, lesions, itching.
 Precipitating factors: stress, weather, drugs
 Changes in skin color, lesions
 Amount of sun exposure
 Scalp lesions, itching, and infections.
 Changes in texture and amount of hair.
 Changes in nails and cuticles nail breaking
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2. History of current symptom
 Are you having experience of skin problem, such as rashes, lesion
 Describe any birthmarks, tattoos, or moles
 Have you noticed any changed in your ability to feel pain, pressure,
light touch, or temperature changed?
 Have you had any hair loss or change in the condition of your hair?
 Have you had any change in the condition or appearance of your
nails?
 Describe any previous problem within the skin, hair or nails ( past
history)
 Have you ever had any allergic skin reaction to food, medication,
plants?
 Has anyone in your family had a recent illness, rash, or other skin
problem? (Family history)
3. Physical Assessment
 Equipment
Penlight Tongue depressor
Magnifying glass Flashlight
Centimeter rule
Wood’s lamp
Gloves
 Technique to examination of skin
Inspection
Palpation
Inspections and palpation of skin
Color
Moisture
Temperature
Turgor
Vascular changes
Edema
Skin odors are usually noted in the skin fold.
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Thickness
Lesions
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Inspection color of skin
 Skin color varies from body part to body part and from person to
person.
 Assessment first involves area of skin not exposed to the sun e.g.
palms of the hands.
 Pallor easily perceived in the buccal “mouth” mucosa particularly in
individuals with dark skin.
 Cyanosis readily seen in area of least pigmentation e.g. lips, nail beds
conjunctiva and palm.
 Jaundice orYellow seen in client’s sclera.
 Erythema may indicate circulatory changes
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Palpation moisture of skin
 Skin is normally smooth and dry.
 Skin folds e.g. axillae are normally moist.
 In presence of lesions or ooze fluid, nurse must wear gloves to
prevent exposure to infections drainage
 Moisture indicates:
1- Degree of client’s hydration
2- Condition of the outer lipid layer of the skin surface
Dry (xerosis):Vitamin A def. and Myxedema
Oily: Acne
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Palpation of Temperature
 Temperature of skin depends on the amount of blood circulating
through dermis.
 Generalized warmth: (Fever, Hyperthyroidism)
 Local warmth: (Inflammation)
 Coolness: (Hypothyroidism, Frost bite, Hypothermia, Shock, Low
cardiac output)
 Palpation of skin with dorsum of the hand.
 Assessment of skin is critical point in some conditions such as: after
cast application, or after vascular surgery.
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Palpation of Texture
 Texture of skin normally smooth, soft and flexible
 If any abnormalities in texture found you must ask the client is he
exposed to any recent injury to the skin?
 Nurse determines whether the client’s skin is smooth or rough, thin
or thick, tight or supple (flexible).
 Very Soft: (Thyrotoxicosis)
 Tight: (Scleroderma = hard skin)
 Rough: (Hypothyroidism)
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Palpation of Turgor
 Turgor: is the skin elasticity
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diminished by edema or
dehydration.
Assessment of turgor done by
pinching skin between the
thumb and forefinger and
released.
Normally
skin
return
immediately to its position.
Failure of this process means
dehydration.
Decrease in turgor predisposes
the client to skin breakdown.
Palpation of Vascularity
 Vascularity: Assessment of circulation of skin E.g. petechiae may indicate
serous blood clotting disorders, drug reactions or liver disease.
Inspection and Palpation of Edema
 Edema : "Build up of fluid in tissues“
 Inspected for location, color, and shape.
 Palpates areas of edema to determine mobility, consistency, and
tenderness
Inspection and Palpation of Lesions
 Normally skin free of lesions except common freckles.
 If lesion present, inspection must done for distribution, arrangement,
morphology, color and size
 Palpation for lesion’s mobility, contour (flat, raised or depressed) and
consistency (soft or hard are indicated).
 Cancerous lesions frequently undergo changes in color and size.
Hair and Scalp
 Assessment done for distribution, thickness, texture, and lubrication
of the hair.
 Some events which affect the distribution of hair over the body e.g.
client with hormone disorders, woman with hirsutism
 Amount of hair covering extremities may be reduced as a result of
aging and arterial insufficiency especially in lower limbs.
 Scaliness or dryness of the scalp is frequently caused by dandruff or
psoriasis.
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Nails Assessment
 Nails reflect an individual's general
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state of health, state of nutrition, and
occupation.
Nails are normally transparent,
smooth, and convex, with a nail bed
angle of about 160 degrees.
The surrounding cuticles are
smooth, intact and without
inflammation.
Nail bed is normally firm on
palpation.
Nails normally grow at a constant
rate.
Abnormal condition of nail
 Anonychia: complete absence of nails
 Platunychia: flatting nails
 Koilonychia : nails like spoon shape (iron deficiencies anemia)
 Racket nail: fattened and expanded nails
 Onycholysis: separation of nail form nail bed (thyrotoxicosis)
 Melanoychia: presence of brown color in nails plate
 Paronychia: inflammation of tissue surrounding the nail
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