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
– 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. • Wound repair through cell replacement
• Allows excretion of metabolic wastes as
minerals
• Provides identity through skin color and facial
features
7. The skin is the body's
largest
organ, covering the entire
body.
8. • The skin is the largest organ of the body
comprising 15 percent of total body weight.
• Layers of the skin
A. Epidermis B. Dermis
C. Subcutaneous tissue
10. 1. Sweat Gland
Eccrine sweat glands: are widely
distributed and open directly onto the
skin surface
Apocrine sweat glands: open into hair
follicle in axillary and genital areas
2. Sebaceous glands: Produce sebum(oily
secretion)
11. • Epidermis: the most superficial layer, then,
devoid of blood vessels
• Epidermis depends on the underlying dermis
for its nutrition
12. • The dermis is well supplied with blood. It
contains connective tissue, sebaceous
glands, sweat glands and hair follicles.
• It merges below with subcutaneous or
adipose tissue, also known as fat.
16. The color of normal skin depends on
four pigments:
• Melanin
• Carotene
• Oxyhemoglobin
• deoxyhemoglobin
17. • The amount of melanin, the brownish
pigment of the skin, is genetically
determined and is increased by exposure to
sunlight.
• Carotene is a golden yellow pigment that
exists in subcutaneous fat, palms and sole
18. • Oxyhemoglobin, a bright red pigment,
predominate in the arteries and capillaries. An
increase in blood flow through the arteries to the
capillaries causes a reddening of the skin, whereas
the opposite change usually produces pallor.
• The skin of light-colored people is normally redder
on the palms, soles, face, neck, and upper chest.
19. • Deoxyhemoglobin, a darker and somewhat
bluer pigment.
• An increased concentration of
deoxyhemoglobin in cutaneous blood
vessels gives the skin a bluish cast known as
cyanosis.
20. Adult have two types of hair:
• Vellus hair: short, fine, and relatively
unpigmented
• Terminal hair: thicker, and usually pigmented (
scalp, eyebrows)
21. • Nails protect the distal end of the fingers and toes.
• The firm and usually curving nail plate gets its pink
color from the vascular nail bed to which the plate
is firmly attached.
• One forth of the plate (nail root) is covered by the
proximal nail fold.
22. • The cuticle extends from the fold and functioning
as a seal, protects the space between the fold and
the plate from external moisture
• Lateral nail folds cover the sides of the nail plate
• Fingernails grow approximately 0.1mm daily;
toenails grow more slowly.
23.
24.
25. • Sebaceous glands produce sebum, a fatty substance
secreted onto the skin surface through the hair
follicle.
• These glands are present on all the skin surfaces
except the palms and soles.
• The sebum lubricate hair and skin and reduces
water loss through the skin.
26. Are of two types:
• Eccrine glands: are widely distributed, open
directly onto the skin surface, and by their sweet
production help to control body temperature.
• Apocrine glands: are found chiefly in the auxiliary
and genital regions, usually open into hair follicles
27.
28. The purpose of integumentary history is to identify the
following:
• Disease of the skin
• Systemic disease that have skin manifestations
• Physical abuse
• Risk for pressure ulcer
• Need for health promotion education regarding skin
• Promote wound healing
• Prevent skin breakdown and/or additional
wounds
29. Past History
• Are you having experience of skin problem, such as
rashes, lesion
• Have you noticed any changed in your ability to feel
pain, pressure, light touch, or temperature changed?
• Have you had any hair loss or change in the
condition of your hair?
• Have you had any change in the condition or
appearance of your nails?
• Describe any previous problem within the skin, hair
or nails ( past history)
• Have you ever had any allergic skin reaction to food,
medication, plants?
30. Family history
• Has anyone in your family had a recent illness,
rash, or other skin problem?
• Do any family members have the same or
similar symptoms?
• Does anyone have allergies?
31. Lifestyle and personal habits
• Describe your bathing
• Have you changed product brands recently?
• Do you wear false nails or wigs?
• How much sun exposure do you receive daily?
• Diet
• Sunscreen
32. • For example, if the patient report a rash, the
nurse can use the OLD CART mnemonic to ask
follow-up questions in order to obtain a full
description of the condition
• Onset: when did it start?
• Location: where is it located?
• Duration: how long have you had it?
• Characteristic symptoms: describe your rash
33. • Associated manifestations: does it itch? Is there
any discharge?
• Relieving/ exacerbating factors: have you used
or done anything that seems to make it better:
• Treatment: have you put anything on it to treat
it?
34.
35. • Adequate lighting
• Good visualization
• Explain assessment process to patient
• Head-to-toe assessment
• Remove necessary cloths while providing
respect, warmth and privacy
• Appropriate client positions
36. Inspection of the Skin
• Follow head-to-toe approach
• Supine position to inspect anterior surfaces
• Special attention to skin folds
• Side-lying position to inspect posterior
surfaces
Copyright 2002, Delmar, A
division of Thomson Learning
38. Equipment
• Magnifying glass
• Good lighting, natural light preferred
• Penlight
• Clean gloves
• Small centimeter rule
39. Inspections and palpation of skin
Color
Moisture
Temperature
Thickness
Turgor
Edema
Lesions
Skin odors are usually noted in the skin fold.
39
40. • Skin color varies from body part to body part and
from person to person.
• Pallor easily perceived in the mouth mucosa
particularly in individuals with dark skin.
• Cyanosis readily seen in area of least
pigmentation e.g. lips, nail beds, conjunctiva,
soles and palm.
40
41. • Central cyanosis: if the oxygen level in the
arterial blood is low and indicate decreased
oxygenation in the patient
• Central cyanosis is best identified in the lips, oral
mucosa and tongue
42. • Peripheral cyanosis: the oxygen level is normal.
occurs when cutaneous blood flow decreases and
slows and tissues extract more oxygen than usual
from the blood. May be a normal response to
anxiety or a cold environment
• Cyanosis of the nails, hand and feet may be
central or peripheral in origin
43. • Jaundice or Yellow seen in client’s sclera, skin and
conjunctiva.
• Erythema may indicate circulatory changes
45. moisture of skin
• Skin is normally smooth and dry to touch without flaking
or cracking.
• Skin folds e.g. axillae are normally moist.
• In presence of lesions or ooze fluid, nurse must wear
gloves to prevent exposure to infections
• Carefully inspect skin folds where moisture may cause
skin breakdown
• Moisture indicates: Degree of client’s hydration
Dryness: Vitamin A def., hypothyroidism
Oily: Acne
45
46. Temperature
• Temperature of skin depends on the amount of blood
circulating through dermis.
• Generalized warmth: (Fever, Hyperthyroidism)
• Local warmth: (Inflammation)
• Coolness: (Hypothyroidism, Hypothermia, Shock, Low
cardiac output)
• Palpation of skin with dorsum of the hand.
• Assessment of skin is critical point in some conditions
such as: after cast application, or after vascular surgery.
46
47. Texture
• Note the roughness or smoothness of the skin
• Texture of skin normally smooth, soft and flexible
• If any abnormalities in texture found you must ask
the client is he exposed to any recent injury to the
skin?
• Nurse determines whether the client’s skin is
smooth or rough, thin or thick, tight or flexible.
• Rough: (Hypothyroidism)
47
48. • Turgor: is the skin elasticity diminished by edema or
dehydration.
• Assessment of turgor done by lift a fold of skin
between the thumb and forefinger and released.
• Note the ease with which it lifts up (mobility) and the
speed with which it returns into place (turgor)
• Normally skin return immediately to its position.
• Failure of this process means dehydration.
• Decreased mobility in edema and Scleroderma
• Decrease in turgor predisposes the client to skin
breakdown.
49. Edema
• Edema : "Build up of fluid in the interstitial
spaces“
• Inspected for location
• may be localized due to injury Or systematic as
in heart failure
• Systematic edema most often occurs in the
dependent portions of the body such as feet, legs
and sacral area
• Edema may be pitting or nonpitting
• The skin appears puffy and feels tight
52. Lesions
• Normally skin free of lesions except common
freckles.
• If lesion present, inspection must done for their
anatomic location and distribution, arrangement,
morphology, color and size
• Palpation for lesion’s mobility, contour (flat, raised
or depressed) and consistency (soft or hard).
• Cancerous lesions frequently undergo changes in
color and size.
53. Assessment of Lesions
• Color
• Shape
• Size in cm
• Elevation (flat or raised)
• Location and distribution on body
• Exudate (color, odor)
54. • Cyanosis
• Jaundice
• Carotenemia: is the presence in blood of the
orange pigment carotene from excessive intake of
carrots or other yellow fruits or vegetables . unlike
jaundice it does not affect the sclera, which remain
white
55.
56. • Vitiligo: s a condition that
causes depigmentation of
parts of the skin. It occurs
when skin pigment cells die
or are unable to function
57. • Psoriasis: meaning "itching condition" or "being
itchy. Appears mainly on extensor surfaces
58. • atopic eczema or eczema is a type of
dermatitis,, relapsing, non-contagious and itchy
skin disorder. Appears mainly on flexor surfaces
64. • Papule : up to 1 cm. A papule is a circumscribed,
solid elevation of skin with no visible fluid
• Plaque: elevated superficial lesion 1cm or larger,
often formed by coalescence of papules
65.
66. • Nodules: are solid, raised areas in or under the
skin that are larger than 0.5 centimeters. Firmer
than papule
67. • Cyst: nodule field with expressible material,
either liquid or semisolid
•
68. • Wheal: somewhat irregular, relatively transient
superficial area of localized skin edema
75. • Fissure: a linear crack in the skin, often
resulting from excessive dryness
• Ulcer: a deeper loss of epidermis and
dermis
76. • Petechia: is a small (1-3
mm) red or purple spot
on the skin, caused by a
minor hemorrhage
(broken capillary blood
vessels)
77. • ecchymosis: is the escape of blood into the tissues
from ruptured blood vessels. The term also applies
to the subcutaneous discoloration resulting from
seepage of blood within the contused tissue. (>
3mm)
78.
79. • Assessment done for distribution, thickness,
texture, and lubrication of the hair.
• Some events which affect the distribution of hair
over the body e.g. client with hormone disorders,
woman with hirsutism
• Amount of hair covering extremities may be
reduced as a result of aging and arterial
insufficiency especially in lower limbs.
79
80. • Scaliness or dryness of the scalp is frequently
caused by dandruff or psoriasis.
• Color of hair depends on the amount of melanin
present and varies from pale blond to black
• Inspect the scalp for lesions and parasites by
separating the hair
81. • Nails reflect an individual's general state of
health, state of nutrition, and occupation.
• Nails are normally transparent, smooth, and
convex, with a 160 degrees angle between nail
base and skin.
82. • The surrounding cuticles are smooth, intact and
without inflammation.
• Nail bed is normally firm on palpation.
• Nails normally grow at a constant rate.
• Note their color and shape and any lesions
83. Assessment of Nails
• Shape and contour: slightly curved or flat and
smooth, 160 degrees.
• Consistency- surface smooth and regular, not
brittle or splitting, uniform thickness.
• Capillary Refill- depress nailbed color
blanches , color should return <1-2 seconds
88. Koilonychia : nails like spoon shape
(iron deficiencies anemia)
• It refers to abnormally
thin nails (usually of the
hand) which have lost
their convexity,
becoming flat or even
concave in shape. In a
sense, koilonychia is the
opposite of nail
clubbing.
93. Considerations as the nurse…
•Is the patient nutritionally challenged?
•Is the patient immobile?
•Does the skin appear paper-like or fragile?
94. Diabetics are at high risk for
slow healing wounds due to
vascular changes leading to
arteriosclerosis (thickening,
loss of elasticity, and
calcification of arterial walls).
99. Age Spots:
(Liver Spots) Part of the skin’s
normal aging process. Appear as
flat gray, brown or black spots.
They vary in size and usually
appear on the face, hands,
shoulders and arms; areas most
exposed to the sun.
105. Copyright 2002, Delmar, A
division of Thomson Learning
Wound Evaluation
• Location
• Color
• Drainage
• Odor
• Size
• Depth
• Measure the borders
106. Safety Tips for the Elderly
• Identify environmental hazards and
minimize risk
• Interventions to decrease risk for
thermal injuries
• Interventions to maintain skin integrity
and prevent damage
Copyright 2002, Delmar, A
division of Thomson Learning
107. Risk factors for pressure sores
People are at risk of developing pressure sores if they
have difficulty moving and are unable to easily
change position while seated or in bed. Immobility
may be due to:
• Generally poor health or weakness
• Paralysis
• Injury or illness that requires bed rest or wheelchair
use
• Sedation
• Coma
108. Age. The skin of older adults is generally more
fragile, thinner, less elastic and drier than the
skin of younger adults. Also, older adults usually
produce new skin cells more slowly. These
factors make skin vulnerable to damage.
109. • Lack of sensory perception. Spinal cord injuries,
neurological disorders and other conditions can
result in a loss of sensation. An inability to feel
pain or discomfort can result in not being aware
of bedsores or the need to change position.
110. • Weight loss. Weight loss is common during
prolonged illnesses, and muscle atrophy and
wasting are common in people with paralysis.
111. • Poor nutrition and hydration. People need
enough fluids, calories, protein, vitamins and
minerals in their daily diet to maintain healthy
skin and prevent the breakdown of tissues.
112. • Excess moisture or dryness. Skin that is moist
from sweat or lack of bladder control is more
likely to be injured and increases the friction
between the skin and clothing or bedding. Very
dry skin increases friction as well
113. • Bowel incontinence. Bacteria from fecal
matter can cause serious local infections and
lead to life-threatening infections affecting the
whole body.
114. • Medical conditions affecting blood flow.
Health problems that can affect blood flow,
such as diabetes and vascular disease, increase
the risk of tissue damage.
115. The Braden scale assesses a patient's
risk of developing a pressure ulcer by
examining six criteria:
116. 1-Sensory perception
This parameter measures a patient's ability to
detect and respond to discomfort or pain
that is related to pressure on parts of their
body.
117. 2- Moisture
• Excessive and continuous skin moisture can
pose a risk to compromise the integrity of the
skin by causing the skin tissue to become
macerated and therefore be at risk for
epidermal erosion. So this category assesses
the degree of moisture the skin is exposed to.
118. 3- Activity
This category looks at a clients level of physical
activity since very little or no activity can
encourage atrophy of
119. 4- Mobility
This category looks at the capability of a
client to adjust their body position
independently. This assesses the physical
competency to move and can involve the
clients willingness to move.
120. 5- Nutrition
The assessment of a clients nutritional status
looks at their normal patterns of daily
nutrition. Eating only portions of meals or
having imbalanced nutrition can indicate a
high risk in this category.
121. 6- Friction
Friction looks at the amount of assistance a client
needs to move and the degree of sliding on beds or
chairs that they experience. This category is assessed
because the sliding motion can cause shear which
means the skin and bone are moving in opposite
directions causing breakdown of cell walls and
capillaries.[5]
122. • Each category is rated on a scale of 1 to 4,
excluding the 'friction category which is rated on
a 1-3 scale. This combines for a possible total of
23 points, with a higher score meaning a lower
risk of developing a pressure ulcer and vice-versa.
The Braden Scale assessment score scale:
• Very High Risk: Total Score 9 or less
• High Risk: Total Score 10-12
• Moderate Risk: Total Score 13-14
• Mild Risk: Total Score 15-18
• No Risk: Total Score 19-23
