Transcript Integumentary System

Integumentary System
N210
Rachel Natividad, RN, MSN
Variations across the lifespan: Infancy
ACROCYANOSIS
MONGOLIAN SPOT
JAUNDICE
Variations across the lifespan:
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Pregnancy
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Adolescence
Striae
Acne
Cherry Angioma
Variations across the lifespan: Elderly
Changes R/T Aging
Physiological change
↓ SQ tissue
Loss of collagen and elastic
fibers
↑ Capillary fragility
↓ sweat gland activity
Over exposure to sun
Loss of or inefficiency of
melanocytes
Physical Findings
Elderly: Seborrheic keratoses
Elderly: Senile Lentigines (Liver spots )
WRINKLES
PURPURA
LIVER SPOTS
LIVER SPOTS
Assessing Skin Turgor
Assessment
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Subjective data
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SWIPE
Objective data
Physical assessment
 Inspection and palpation
 Draw picture or take photo if possible
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Skin Lesions Types
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Primary: (Initial lesions) Appear in response to
external or internal environment of skin.
Vesicle,
Bulla
Primary Lesions
Wheal
Nodule
Papule
Tumor
Vesicle
Bulla
Skin Lesion Types
Secondary Lesions: Are a
result of trauma,
chronicity, or infection
of primary lesion.
Secondary Lesions
Crust
Scale
Fissure
Keloid
Lichenification
Vascular Lesions
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Appear as red pigmented lesion. Could be indicative
of bleeding
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Hemangiomas
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Telangiectasias
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port wine stain; strawberry mark-mature hemangioma
spider angioma with pregnancy or liver disease; venous
lake
Purpuric Lesions
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Petechiae
Ecchymoses
purpura
Vascular Lesions
HEMANGIOMA
Petechiae
Ecchymosis
Spider Angioma
Venous Lake
TELANGIECTASIA
Purpura
Shapes and Configurations
EXERCISE
Documentation of Skin Lesions
COLOR
SHAPE/CONFIGURATION
TYPE
SIZE
(L x W x D) in cm
DISTRIBUTION/
PATTERN
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EXUDATES
 Amount
 Color/consistency
 Serous
 Serosanguinous
 Sanguinous
 Purulent
Pattern Injury from Physical Abuse
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Lesions due to trauma or
abuse
Bruise or wound whose
shape suggests the
instrument or weapon
that caused it
Physical signs with
history that does not
match the severity or
type of injury indicates
abuse
Pattern Injuries
Pattern Injury: Distribution
Diagnostic Tests
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Culture
Skin Biopsies
Punch
 Shave
 Excisional
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Woods Light
Diascopy
Skin Testing
Parasitic Infestations
Cause
Pediculosis
Scabies
Symptom &
Location/
areas
affected
Treatment
Parasitic Infestations
CAPITIS
CORPORIS
PUBIS
Infestations cont.
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Scabies
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A contagious disease
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Transmission: close and
prolonged contact or
infected bedding
Infestations Cont.

Scabies lesion
distribution
Pressure Ulcers
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Tissue damage caused by the skin and
underlying soft tissue are compressed between
bony prominence and an external surface for an
extended period.
Pressure Ulcers
Pressure Ulcers
CAUSES (6)
RISKS (4)
PREVENTION (5)
Staging of Pressure Ulcers
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Pressure ulcers and their features are classified
and assessed in 4 stages:
Stage 1
 Stage 2
 Stage 3
 Stage 4
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Staging of Pressure Ulcers- Cont.
Stage
Stage 1
Stage 2
Stage 3
Stage 4
Eschar
Description
Stage 1 Pressure Ulcer
Stage 2 Pressure Ulcer
Stage 3 Pressure Ulcer
Stage 4 Pressure Ulcer
Stage 4 with Necrosis
Eschar- cannot be staged
Ulcer Assessment
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Describe ulcer
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Appearance
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Stage
Location
Size
Shape
Drainage
Odor
Stage
Presence of infection
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Foul smell
Purulent drainage
Heat, extreme redness, edema
Stage the ulcer