Physical Assessment of Physical Assessment of the Integumentary Systemthe Integumentary System

• Integument means covering.Integument means covering.

• The skin and its accessory organs, The skin and its accessory organs, hair, nails and glands comprise the hair, nails and glands comprise the integumentary system of the body.integumentary system of the body.

• The skin is composed of several The skin is composed of several different tissue types and is different tissue types and is considered an organ .considered an organ .

Functions of the IntegumentFunctions of the Integument

• ProtectionProtection

• Physical BarrierPhysical Barrier

• PerceptionPerception

• Temperature RegulationTemperature Regulation

• IdentificationIdentification

• CommunicationCommunication

Functions of the Integument Functions of the Integument continuedcontinued

• Wound RepairWound Repair

• AbsorptionAbsorption

• ExcretionExcretion

• Vitamin D ProductionVitamin D Production

The Three Layers of the The Three Layers of the IntegumentIntegument• Epidermis - the outermost layer of the Epidermis - the outermost layer of the

skin, made of stratified squamous skin, made of stratified squamous epithelium .epithelium .

• Dermis - the inner layer of the skin, made Dermis - the inner layer of the skin, made of dense fibrous connective tissue . of dense fibrous connective tissue .

• Subcutaneous tissue - thick, fat-Subcutaneous tissue - thick, fat-containing tissue. Below the skin; the containing tissue. Below the skin; the tissues between the dermis and the tissues between the dermis and the muscles.muscles.

Epidermal AppendagesEpidermal Appendages

• Hair is threads of keratinHair is threads of keratin• Sebaceous glands secrete the oil, Sebaceous glands secrete the oil,

sebumsebum• Sweat glandsSweat glands

– Eccrine glands secrete sweatEccrine glands secrete sweat– Apocrine glands secrete thicker, milky Apocrine glands secrete thicker, milky

secretion as in anogenital, nipples, and secretion as in anogenital, nipples, and illae areas illae areas

• Nails are hardened keratinNails are hardened keratin

Receptors in the skinReceptors in the skin

• The sensory receptors in the dermis The sensory receptors in the dermis are for cutaneous sensations which are for cutaneous sensations which include: touch, pressure, heat, cold, include: touch, pressure, heat, cold, and pain.and pain.

• The purpose of sensory receptors is The purpose of sensory receptors is to provide the CNS with information to provide the CNS with information about the external environment and about the external environment and its effect on the skin. its effect on the skin.

InterviewInterview

• Chief ComplaintChief Complaint– Recent Changes Recent Changes – Pruritus (itching)Pruritus (itching)– Dryness (xerosis)Dryness (xerosis)– Rashes (identify primary site, migration, pattern Rashes (identify primary site, migration, pattern

and evolutionand evolution– LesionsLesions– Ecchymoses (bruising)Ecchymoses (bruising)– Masses or lumpsMasses or lumps

• Symptom analysis Symptom analysis – Pages 225-229, JarvisPages 225-229, Jarvis

Interview (cont.)Interview (cont.)

• Past Health HistoryPast Health History– Example:Example:

• Immunologic, Endocrine, Collagen, Vascular, Immunologic, Endocrine, Collagen, Vascular, Renal, HepaticRenal, Hepatic

– Previous exposure to insects, infectious Previous exposure to insects, infectious diseasedisease

– Previous trauma & surgical interventionPrevious trauma & surgical intervention– History of past allergic reactionsHistory of past allergic reactions

Interview (cont.)Interview (cont.)

• MedicationsMedications– SensitivitiesSensitivities– Photosensitizing drugsPhotosensitizing drugs– Ask about self treatment with herbal Ask about self treatment with herbal

remediesremedies

• AllergiesAllergies– Medications & FoodsMedications & Foods

Interview (cont.)Interview (cont.)

• Family Health HistoryFamily Health History– Helps determine genetic predisposition Helps determine genetic predisposition

to skin disordersto skin disorders

• Psychosocial HistoryPsychosocial History– Particularly important in long-term & Particularly important in long-term &

chronic processes.chronic processes.– Determine & correct any misconceptions Determine & correct any misconceptions

about skin problems.about skin problems.

Interview (cont.)Interview (cont.)

• DietDiet– Excessive dryness may indicate Vitamin A Excessive dryness may indicate Vitamin A

deficiency.deficiency.

• Occupation & TravelOccupation & Travel– What have they been exposed to.What have they been exposed to.

• HabitsHabits– Frequency of hygiene practices.Frequency of hygiene practices.– Exercise & Sleep PatternsExercise & Sleep Patterns

• Affects circulation, nourishment, & repair of the skin.Affects circulation, nourishment, & repair of the skin.

– Is there prolonged exposure to sun, unusual cold, Is there prolonged exposure to sun, unusual cold, or other skin damaging conditions.or other skin damaging conditions.

Dermatologic Assessment Dermatologic Assessment History History

• Chief complaintChief complaint

• Definition of problem (onset, Definition of problem (onset, location)location)

• DurationDuration

• Accompanying manifestationsAccompanying manifestations

• Evolution of lesion or eruptionEvolution of lesion or eruption

• Aggravating & relieving factorsAggravating & relieving factors

Dermatologic Assessment Dermatologic Assessment History History

• Medical interventionMedical intervention

• Self-treatmentSelf-treatment

• Compliance & treatment factorsCompliance & treatment factors

Preparation for the Physical Preparation for the Physical ExaminationExamination

• Strong direct lighting, natural Strong direct lighting, natural sunlight is bestsunlight is best

• Small centimeter rulerSmall centimeter ruler

• PenlightPenlight

• GlovesGloves

• Wood’s light (ultraviolet light) may Wood’s light (ultraviolet light) may be needed for special proceduresbe needed for special procedures

InspectionInspection

• Color, Page 249 JarvisColor, Page 249 Jarvis– PallorPallor– CyanosisCyanosis– ErythemaErythema– JaundiceJaundice– Document presence of tattoosDocument presence of tattoos

• General pigmentationGeneral pigmentation• Areas of hypopigmentation or Areas of hypopigmentation or

hyperpigmentationhyperpigmentation• Abnormal color changesAbnormal color changes

Hair and scalp InspectionHair and scalp Inspection

• Inspect distribution & qualityInspect distribution & quality• TextureTexture• Inspect the Scalp:Inspect the Scalp:

– LesionsLesions– ExcoriationsExcoriations– LumpsLumps– BruisesBruises– Lice Lice

NailsNails

• Color, Shape & ContourColor, Shape & Contour

• TextureTexture

• IntegrityIntegrity

• ThicknessThickness

• Capillary refillCapillary refill

PalpationPalpation

• TemperatureTemperature– Assess with dorsum of handAssess with dorsum of hand– Warmth reflects circulationWarmth reflects circulation– Compare sidesCompare sides

• MoistureMoisture– Refers to the skin’s hydration level in terms of Refers to the skin’s hydration level in terms of

both wetness & oilinessboth wetness & oiliness– Diaphoresis, dehydrationDiaphoresis, dehydration

• TextureTexture– Should feel smooth, soft, & resilientShould feel smooth, soft, & resilient

Palpation continuedPalpation continued

• TendernessTenderness• ThicknessThickness

– CallusCallus– AtrophicAtrophic

• EdemaEdema– Not a “normal finding”Not a “normal finding”– Common in some disordersCommon in some disorders

• CardiovascularCardiovascular• Renal failureRenal failure• Cirrhosis Cirrhosis

Edema gradingEdema grading

– May be pittingMay be pitting– 1+ Barely Visible1+ Barely Visible– 2+ Indentation < 5mm2+ Indentation < 5mm– 3+ Indentation of 5 to 10mm3+ Indentation of 5 to 10mm– 4+ Indentation of 10mm or >4+ Indentation of 10mm or >

Palpation continuedPalpation continued

• TurgorTurgor– Reflection of skin’s elasticity & hydrationReflection of skin’s elasticity & hydration– Turgor is decreased (less elasticity) as Turgor is decreased (less elasticity) as

the skin “tents” and stands by itselfthe skin “tents” and stands by itself

• Hygiene, odorHygiene, odor

• Vascularity or bruisingVascularity or bruising

Lesion TypesLesion Types

• Types of LesionsTypes of Lesions– Primary - those developing from Primary - those developing from

previously unaltered skinpreviously unaltered skin– Secondary – those which develop over Secondary – those which develop over

time because of a factor such as time because of a factor such as scratching or infection scratching or infection

If any Lesions present, note If any Lesions present, note the:the:• ColorColor

• Shape and configurationShape and configuration

• SizeSize

• ElevationElevation

• ExcudateExcudate

• Location and distributionLocation and distribution

• Table 12-3 to 12-11, pages 250-265, JarvisTable 12-3 to 12-11, pages 250-265, Jarvis

Self-Care BehaviorsSelf-Care Behaviors

Teach skin self-examination, using the Teach skin self-examination, using the ABCDE ruleABCDE ruleA—asymmetryA—asymmetry

B—borderB—border

C—colorC—color

D—diameterD—diameter

E—elevation and enlargementE—elevation and enlargement

Developmental Developmental ConsiderationsConsiderations

• InfantsInfants– Lanugo (fine downy hair) from 3 months Lanugo (fine downy hair) from 3 months

gestation to a few months after birthgestation to a few months after birth– Thin, smooth, highly permeable and Thin, smooth, highly permeable and

elastic skinelastic skin– Increased sebum through the first few Increased sebum through the first few

weeks of lifeweeks of life– Temperature regulation inefficientTemperature regulation inefficient

Developmental Developmental ConsiderationsConsiderations• Aging AdultsAging Adults

– Skin loses elasticity and underlying fat Skin loses elasticity and underlying fat reservesreserves

– Vascularity diminishesVascularity diminishes– Decreased response of sweat glandsDecreased response of sweat glands– Lifetime of environmental traumaLifetime of environmental trauma– Wound healing decreasedWound healing decreased– Melanocytes decreases melanin productionMelanocytes decreases melanin production– Loss of self-esteemLoss of self-esteem