Transcript B75 Chapter 44 - Assessing Skin Disorders

Assessing Clients with Skin
Disorders
Chapter 44
Integumentary System
Functions
1. Protects body from injury
2. Provides a barrier to loss
of fluids
3. Sensory - touch,
pressure,pain, and
temperature
4. Regulates body
temperature via sweat glands
5. Production of vitamin D
Skin
2 Layers
Epidermis
outer layer, protection, stores melanin
epithelial cells
Dermis
inner layer, temperature regulation
connective tissue, contains hair follicle,
sweat glands and sebaceous glands
Layers of the Skin
Skin Color
1. Erythema
reddening of the skin
– fever, inflammation, sunburn, drug reaction
2. Cyanosis
bluish discoloration
– poor oxygenation of hemoglobin
Skin Color
3. Pallor
paleness of skin
– shock, fear, anemia or hypoxia
4. Jaundice
yellow-to-orange skin color
– hepatic disorders
3 Types
Sebaceous - Oil
to soften and lubricate the skin
Sudoriferous - Sweat
to regulate body temperature by excretion of
sweat
Ceruminous - located in external ear
canal
secrete cerumen, sticky trap for foreign
materials
The Hair and Nails
Protective Function
Hair
cushions the scalp
eyelashes and eyebrows protect the
eyes
provides insulation in cold weather
Nails
protects fingers, toes, aid grasping
The Health Assessment
Interview
Determine problems with the
integumentary system
“Describe any skin problems or injuries,
nail problems or scalp problems you
have had.”
“Is your skin and/or scalp dry or oily?”
“Do you have any skin pain, burning or
itching?”
The Physical Assessment
Can be part of head-to-toe or focused
assessment
Assessment through inspection and
palpation
Assess for
color, lesions, temperature,texture,
moisture, turgor and edema
Assessments?
The Physical Assessment
Inspect color
pallor
cyanosis
jaundice
Inspect for lesions
irregular skin, rash, hives, psoriasis scaly red patches
The Physical Assessment
Palpate the skin for temperature
warm with fever
cool in shock or decreased blood flow
Palpate skin for texture
smooth or coarse
Palpate skin for moisture
dry, moist, diaphoretic - M.I., shock
The Physical Assessment
Palpate for Turgor
pinching skin over collar
bone or back of hand
decreased in dehydration
tenting
increased in edema
Assess for edema
accumulation of fluid in body
tissues
depress skin over ankle
The Physical Assessment
Rate the Edema
1+
2+
3+
4+
= slight pitting
= deeper pit
= obvious pit, extremities are swollen
= the pit remains
Edema occurs in cardiovascular
disease, renal failure and cirrhosis of
liver
Lymph
Edema
The Physical Assessment
Hair
inspect distribution and quality
palpate for texture
inspect the scalp for lesions
Nails
inspect for curvature, color and
thickness
Variations in the Older Adult
Loss of subcutaneous tissue
wrinkles, sagging, decreased turgor
Skin tags
small flaps of excess skin
Decreased hair and nail growth
“Liver spots”
small flat brown macules
Primary Skin Lesions
Macule
flat color change in the skin - freckle
Papule
elevated palpable mass with
circumscribed boarder - elevated mole
Nodule
elevated, solid mass extending deeper lipoma
Primary Skin Lesions
Vesicle
fluid filled with thin translucent walls - blister
Wheal
larger than vesicle - insect bite, hives
Pustule
pus filled vesicle - acne
Cyst
elevated, encapsulated mass - sebaceous
cyst
Skin Lesions
Secondary Skin Lesions
Atrophy
translucent, dry, paperlike skin resulting from
thinning or wasting away due to loss of elastin
Ulcer
deep crater-like, irregular shaped area of skin
loss extending into the dermis
Fissure
cracks with sharp edges - corner of mouth,
feet
Vascular Skin Lesions
Port-wine stain
lg. Flat mass of blood vessels on skin
surface
Strawberry mark
bright red, raised cluster of immature
capillaries
Petechiae
flat, red-purple “freckles” caused by tiny
hemorrhages
Vascular Skin Lesions
Ecchymosis
bruising - release of blood into
surrounding tissues
trauma, hemophilia, liver disease
Hematoma
similar to ecchymosis but is raised,
swollen
Documenting general
appearance
What terms describe this skin?
Lymphaedema
What would you document?
Skin our protector for life!
NCLEX
The nurse assessing a dark skinned client for cyanosis
knows that in which of the following would cyanosis be more
visible in a dark skinned individual?
A. Sclera
B. MM and nail beds
C. Generalized skin color
D. Palms of the hands and feet
NCLEX
A nurse assessing an elderly thin client notes the skin turgor
over the client’s clavicle is decreased. The nurse interpretes
this finding as which of the following?
A. Client is dehydrated
B. Client has edema
C. This is a normal finding for this client
D. The client has experienced a recent weight loss.
NCLEX
When performing a screening and assessment on a 44 year
old female, the nurse notes a patch of hair loss.
The nurse suspects which of the following?
A. Dandruff
B. Alopecia
C. Scalp ringworm (tinea capitis)
D. head lice
NCLEX
When inspecting a client’s nails the nurse notes that the
angle of the nail base is greater than 180 degrees. What is
this condition called?
A. Alopecia
B. edema
C. tenting
D. clubbing
NCLEX
When working with an older person, you would
keep in mind that the older adult is most likely to
experience which of the following changes with
aging?
A. thinning of the epidermis
B. thickening of the epidermis
C. oiliness of the skin
D. Increased elasticity of the skin
NCLEX
Which of the following glands plays a role in killing
bacteria?
A. sebaceous (oil) glands
B. Eccrine sweat glands
C. Apocrine sweat glands
D. Ceruminous glands