Protection & Adaptation – Integumentary System Overview  The skin is the body’s largest organ, comprising 15% of the total body weight.  The skin (1) acts as a protective barrier against disease-causing organisms, (2) is a sensory organ for pain, temperature, and touch, and (3) synthesizes vitamin D.  Injury to the skin poses risks to safety and triggers a complex healing response.  Knowing the normal healing pattern will assist in recognizing alterations that require intervention. Integumentary System  Refers to skin, hair, scalp, nails  Begin with health history (subjective data)  Followed by the physical examination (objective data) – visible surfaces  Sight, smell, and touch – inspection and palpation  Patient’s health status – oxygenation, circulation, nutrition, local tissue damage, and hydration Integumentary Assessment  Adequate lighting  Equipment - gloves, penlight, and small centimeter ruler  Room temperature  Inspection  Skin odors Subjective Data  Health History Questions – Table 31-7, 31-10, 31-11 o Past history of skin disease, allergies, hives, psoriasis, or eczema? o Change in pigmentation or color? o Change in mole size, shape, color, tenderness? o Excessive dryness or moisture? o Pruritus or skin itching? o Excessive bruising? o Rash or lesions? o Medications: prescription and over-the-counter? o Hair loss? o Change in nails’ shape, color, or brittleness? o Environmental or occupational hazards? o Self-care behaviors?  Additional history for infants and children o Does child have any birthmarks? o Any change in skin color as a newborn?  Physiologic jaundice?  Cyanosis? o Does child have any rash or sores? o Does child have diaper rash? o Does child have any burns or bruises?  Where?  How did it happen? o Has child been exposed to:  Contagious skin conditions: scabies, impetigo, lice?  Communicable diseases: measles, chicken pox, scarlet fever?  Toxic plants: poison ivy? o Does child have habits such as nail biting or twisting hair? o What steps are taken to protect child from sun exposure?  Additional history for adolescents o Skin problems such as pimples, blackheads?  Additional history for aging adults o What changes have you noticed in your skin in last few years? o Any delay in wound healing? o Any change in feet: toenails; bunions, wearing shoes? o Falling: bruises, trauma? o History of diabetes or peripheral vascular disease? Objective Data: Physical Examination - Color  Varies but usually uniform over the body  Pigmentation o Ivory or light pink to ruddy pink in light skin o Light to deep brown or olive in dark skin o Older adults – increases unevenly causing discoloration  Cyanosis  Jaundice  Erythema Objective Data: Physical Examination - Moisture  Refers to wetness and oiliness  Normally smooth and dry  Skin folds e.g. axillae – moist  Minimal perspiration or oiliness  Use ungloved fingertips to palpate skin surfaces  Observe for dullness, dryness, crusting, and flaking – lightly rubbed  Excessive dryness – older adults, soap, lack of humidity, exposure to sun, smoking, stress, excessive perspiration, and dehydration 2 Objective Data: Physical Examination - Temperature  Depends on the amount of blood circulating o Increased – localized erythema or redness o Decreased – pallor  Color variations – Table 31-8  Cold exam room – temperature and color  Palpate with the dorsum or back of the hand - warm o Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status o Hands and feet may be slightly cooler in a cool environment  Hypothermia  Hyperthermia Objective Data: Physical Examination - Texture  Character of the surface of the skin and how the deeper layers feel  Palpate lightly with the fingertips o Normally smooth, soft, even, and flexible o Thicker texture over the palms of the hand and soles of the feet o Older adults – wrinkled and leathery  Palpation o Smooth or rough o Thin or thick o Tight or supple o Indurated (hardened) or soft Objective Data: Physical Examination - Turgor  Elasticity of skin  Aging – diminished elasticity (edema, dehydration)  Grasp a fold of skin on the back of the forearm (don’t use back of hand) or sternal area with the fingertips and release  Lifts easily and falls immediately  Poor turgor stays pinched and shows tenting Objective Data: Physical Examination - Vascularity  Circulation of the skin affects color  Localized pressure areas when patients remain in one position  Appears reddened, pink or pale  Aging – capillaries become fragile and more easily injured  Petechiae – nonblanching, pinpoint-size, red or purple spots 3  Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse  Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein Objective Data: Physical Examination - Edema  Swollen or edematous from buildup of fluid in the tissues  Causes - Direct trauma and impairment of venous return  Inspect for location, color, shape  Appears stretched and shiny  Palpate to determine mobility, consistency, and tenderness  Pitting edema – Press the edematous area firmly with the thumb for several seconds and release, record depth Objective Data: Physical Examination - Lesions  Any unusual finding of the skin surface  Free of lesions, except for common freckles or age-related changes (skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts  Box 31-6 o Macule - freckle o Papule - mole o Nodule - wart o Tumor – solid mass o Wheal – hive o Vesicle – chicken pox o Pustule - acne o Ulcer – venous stasis ulcer o Atrophy – arterial insufficiency  Inspect and palpate skin o Lesions: if any are present note:  Color  Elevation  Pattern or shape  Size – in cm (height, width, & depth)  Location and distribution on body  Any exudate: note color and odor  Use additional lighting Question?  What do the ABC and D stand for in the mnemonic to assess for skin cancer?  ABCD: o Asymmetry o Border irregularity