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Integumentary Assessment

Integumentary Assessment. Kozier Ch 30. What are the Functions of the Integumentary System?. Functional Review. Protector and barrier between internal organs and external environment Barrier against foreign body intrusions against invading bacteria and foreign matter

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Integumentary Assessment

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  1. Integumentary Assessment Kozier Ch 30

  2. What are the Functions of the Integumentary System?

  3. Functional Review • Protector and barrier between internal organs and external environment • Barrier against foreign body intrusions • against invading bacteria and foreign matter • Transmits sensation – nerve receptors • allows for feelings of temperature, pain, light touch and pressure

  4. Skin Functions • Regulates body temperature • regulates heat loss • Helps regulate fluid balance • absorbs water • prevents excessive water & electrolyte loss. • Slow loss up to 600 ml daily by evaporation • Immune Response Function • inflammatory process

  5. Skin Functions • Vitamin production • exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D • Necessary to prevent osteoporosis, rickets

  6. Skin Assessment • Visual inspection • Palpation • Olfactory senses • Adequate lighting • Remove necessary clothing while providing respect and privacy • Appropriate client positions p.568

  7. Visual inspection Skin color: • Palor • Cyanosis • Jaundice • Erythema • Hyperpigmentation • Hypopigmentation – vitiligo

  8. Visible changes if the Skin • Changes in skin color texture • Eczema, infections • Assess the vascularity & hydration of skin • Edema – swelling, pitting edema 1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm p.579 • Nails – configuration, consistency, color p.579 • Hair – color and distribution, aloplecia, location

  9. Gerontology Considerations Watch for significant changes in aging: • Decrease immunity functions • Susceptibility to infections • Poor nutrition • Decrease collagen production – loss of subcutaneous • Thinning of epidermal skin layers • Increase skin problems

  10. Gerontology Considerations • Taking more medications • Excessive environmental exposure • Dryness, wrinkling • Uneven pigmentation • Various proliferative lesions

  11. Assessing light to dark skin

  12. Assessing light to dark skin

  13. Assessing Lesions • Vary in size, shape and cause • Primary vs. Secondary • Erruptions: cysts, wheals, bullous, pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules • Discoloration: macules (café-au-lait),

  14. Disorders Affecting the Skin

  15. Skin Lesions p.755 • Etiology • Infections –herpes, impetigo, HIV, melanoma • Toxic chemicals: skin irritation • Physical trauma: burns, lacerations • Hereditary factors • External factors: allergens, contact dermitis • Systemic diseases: measles, lupus, nutritional deficiency

  16. Skin Lesions • Nursing Process Care: • Assessment: descriptions; pt. history, causative factors • Evaluation of skin – identify problem • Nursing Diagnosis • Interventions for skin care to promote healing and prevent further injury • Pain management & comfort • Infection control • Nursing evaluation & reassessment

  17. Systemic Skin Diseases: Skin Disorders in Diabetes • Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin. • Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels. Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections

  18. Fungal infections of the Skin • Tinea Pedis (athlete’s foot) • Tinea Corporis (ringworm of the body) • Tinea Capitis (scalp ringworm) • Tinea Cruris (ringworm of the groin) • Jock itch jock, common in diabetes. • Tinea Unguium (ringworm of the nails) • onychomycosis

  19. Parasitic Infections • Pediculosis capitis - lice • Pediculosis corporis/pubis • Sarcoptes scabiei – scabies • Raised burrows found between fingers, wrists, elbows, nipples, feet, groin, gluteal folds, penis, scrotum • Poor hygienic living conditions • Increase; contagious • Secondary lesions: vesicles, papules, crust, excoriations

  20. Parasitic Infections • Appear 4 wks after exposure • Elderly patients from long term facilities • Lindane, crotamiton (Eurax), permethrin

  21. Nursing Diagnosis • Skin Impairment r/t: • GOAL: • Protect the skin • Prevent secondary infections • Promote healing

  22. Skin Care Review of wound dressings

  23. Wound Dressings • Occlusive – airtight cover applied to skin lesions • Wet –(obsolete) wet compresses applied on acute weeping, inflamed lesions • Moisture-retentive –more efficient wet drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. • Avoids maceration , less infections, scarring & reduces pain.

  24. Wound Dressings • Hydrogels – polymers with 90% water content • superficial wounds, abrasions, skin graft sites, draining venous ulcers • Hydrocolloids –impermeable to water, O2 • Remain intact during bathing. • Produce foul-smelling yellowish covering • May leave on wound for 7 days • Promote debridment & granulation tissue

  25. Wound Dressings • Foam – hydrophilic absorption and hydrophobic backing to prevent leaking of exudate • Nonadherent; require secondary dressing • Used over bony areas and weeping wounds • Calcium alginates – absorbent fiber packing made from seaweed. • Absorbes exudate, best for macerated wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent

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