"Please describe the hair distribution and thickness" - Normally hair is distributed over the scalp, eyebrows, eyelashes, axilla, pubic area and limbs. It may be sparse or absent elsewhere. - Hair thickness varies in different body areas. Scalp hair is usually coarse. Eyelashes and eyebrows are fine. Axillary and pubic hair is coarse. Leg and arm hair is fine. - Note any areas of alopecia (hair loss) or hirsutism (excess hair growth in women in male-pattern areas like face, chest). 12/9/2022 51 Henok L. Assessment of the Integumentary system... 

1. Assessment of the
Integumentary system
by
Henok L. (Bsc, Msc in Adult Health
Nursing)
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2. Assessment of the Integumentary system
Includes
• Skin
• Hair
• Nails
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3. Anatomy Overview
Skin
 Composed of three layers (epidermis, dermis and the
subcutaneous tissue)
 A physical barrier that protects the underlying tissues and
structures.
Hair
– consists of layers of keratinized cells found over much of the
body [except for the lips, nipples, soles of the feet, palms of
the hands, labia minora and penis.]
Nails
– located on the distal phalanges of fingers and toes, are hard,
transparent plates keratinized epidermal cells that grow from
a root underneath the skin fold called the cuticle.
Assessment of the Integumentary system…
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4. Anatomy Overview…
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5. Anatomy Overview…
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6. Subjective Data:
• Skin rashes, lesions, itching, dryness, oiliness, bruising, Changes
in skin color
• Precipitating factors: stress, weather, drugs, exposure to
allergens
• Methods of relief: medications, lotions
• History of skin disorders / Surgical excision of skin lesions/
Tattoos/.Body piercings
• Changes in condition of nails and cuticles / Nail-breaking,
splitting; nail enamel used / Cuticle inflammation
• Skin, hair and nail care habits, bathing patterns, soaps and
lotions used/ Shampoo, hair spray, coloring used, Exposure to
chemicals
Assessment of the Integumentary system…
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7. Assessment of the Integumentary system…
 The assessment technique used are inspection and palpation
Equipment needed:
• Adequate lightening
• Comfortable room temperature
• Dermoscope
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8. Assessment of the Integumentary system…
Inspection
Exposed the body part to be inspected
A . Inspect skin for generalized color
• Normally: in white skin person the color is light to
dark pink and in black skin person the color is light to
dark brown, olive
• Birthmarks-may be chocolate to brown color
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9. Assessment of the Integumentary system…
Inspection…
 Advice anyone with moles or birthmarks to perform
periodic skin self-examinations ,and watch for danger
signs such as
– Sudden enlargement
– Change in color
– Change in sensation( itching, tenderness)
– Change in the surrounding skin (redness , swelling)
– Ulceration or bleeding in mole(late sign)
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10. Birth marks…
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Stork-bite, “angel’s kiss” Strawberry mark

11. Assessment of the Integumentary system…
Inspection…
B. Widespread change
• Such as pallor(white), Erythema (red), cyanosis(blue) and
jaundice(yellow)
• In dark skinned people ,the amount of normal pigment
may mask color changes
 Lips and nail beds show some color change, but they vary
with the person’s skin color and may not always be
accurate signs.
 The more reliable sites are those with the least
pigmentation. such as under the tongue. the buccal
mucosa, the pulpebral conjunctiva, and the sclera
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12. Assessment of the Integumentary
system…
Inspection…
Deviation from the normal:
• In white: extreme pallor, yellow (jaundice)
• In black skin:
– lose of red tones in pallor
– bluish colored palms soles, lips, earlobes with
cyanosis
– yellow colored palms ,soles, sclera ,oral mucosa
with jaundice
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13. Assessment of the Integumentary system…
Palpation
• Palpate the skin for texture, temperature, and moisture, turgor
and edema
1.Temprature & moisture
• Use the back(dorsa) of your hands to palpate the person and
check bilaterally
 Normal finding: skin has warm temperature and dry moisture
– Deviation from normal: extremely cold or warm temperature
;wet, oily moisture.
• Perspiration appears normally on the face, hands, axilla, and
skin folds in response to activity, a warm environment, or
anxiety
– Diaphoresis or profuse perspiration accompanies an
increased metabolic rate, such as on fever. dehydration is
evident in the oral mucus membrane
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14. Assessment of the Integumentary system…
Palpation…
2.Texture
• Normally skin feels smooth, soft and firm, with an even
surface; (rough, thick indicates deviation from normal)
3.Mobility and turgor
• Mobility is the skin’s ease of rising, and turgor is its
ability to return to place promptly when released. (This
reflects the elasticity of the skin)
– Mobility is decrease when edema is present
 Pinch up a large fold of skin on the anterior chest under
the clavicle
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15. Assessment of the Integumentary system…
Palpation…
• Normally: no swelling, pitting or edema
– Deviation from normal: swollen ;shallow to deep
pitting
• Edema: Press firmly for 5- 10 seconds over tibia and
ankles
• Classify edema if present
1+ : Shallow pit formed by thumb pressure(2mm)
2+ : Deep pit formed by thumb pressure(4mm)
3+ : Signs of pitting independent part of the body(eg.Limb),
6mm
4+: Generalized deep pitted edema accompanied by ascites
(as in sever CHF),8mm
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16. Assessment of the Integumentary system…
4.Lesion…
 Types of skin lesion
1. Primary lesions
 A. Non palpable lesion
– Macule: flat and circumscribed discoloration of the skin on
exposed surface (hands, forehead)
– Patch: Lesion is flat and >1 cm
 B. Palpable lesions with out fluid
– Papule: solid, elevated, superficial lesion(<1cm)(e.g mole)
– Plaque: Lesion is raised, >1 cm,
– Tumor: solid, elevated and deep; has dimension of depth
(e,g epithelioma)
– Wheal: localized edema (e.g insect bite). have irregular
sizes/shapes and may come & go
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17. Assessment of the Integumentary system…
4.Lesion…
1. Primary lesions…
 C. Palpable lesions with fluid:
– Vesicle: elevated and filled with clear fluid (e.g blister)
– Bulla: large vesicle or blister larger than 1 cm in
diameter (e.g 2nd degree burn)
– Pustule: elevated and filled with pus (e.g. acne)
– Nodules :elevated and firm has dimension of depth
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18. Assessment of the Integumentary system…
4.Lesion…
2. Secondary lesions
• Are the changes that take place in primary lesion and
possibly modify them.
– Ulcer: formed by local destruction of epidermis and part or
all of the underlying dermis (e.g pressure ulcers)
– Crust: covering formed from serum, blood or pus drying on
the skin
– Scale: thin, flaky skin (e.g dandruff , dry skin)
– Excoriation: scratches that may break the skin, often linear
and caused by fingernails
– Lichenification: occurs when the epidermis becomes
thickened and rough due to chronic scratching or rubbing
of the skin
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19. Types of skin lesion
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20. 12/9/2022 20
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21. ( Primary Skin Lesions)
Papule : Elevated and superficial ( Example: wart)
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22. (Primary Skin Lesions)
Pustule : Elevated and filled with pus
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23. (Secondary Lesions)
Crust: Dried pus or blood
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24. ( Secondary Lesions)
Scale: Thin, flaky skin
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25. ( Secondary Skin Lesions )
Keloid: Hypertrophied Scar
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26. Assessment of the Integumentary system…
Palpation…
4.Lesion:
 Document characteristics of skin lesions as:
– Color: pink, red, yellow, brown, black
– Type: macule, papule, wheal, scale, ulcer, scar
– Pattern/configuration: annular, linear, circular, oval
– Location/distribution: generalized, skin fold, extensor
surface of the joint
– Size: width, length & depth
– Mobility: fixed or movable
– Consistency: hard, firm, soft
– Any exudates: note its color or odor
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27. Assessment of the Integumentary system…
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Configuration

28. Assessment of the Integumentary system…
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Distribution

29. Describing Skin Findings
• Primary lesion: Primary lesions are flat or raised
• Number: Lesions can be solitary or multiple. If multiple,
record how many (Also consider estimating)
• Size: Measure with a ruler in millimeters or centimeters.
For oval lesions, measure in the long axis, then
perpendicular to the axis
• Shape: “circular,” “oval,” “annular” (ring-like, with central
clearing), “nummular” (coin-like, no central clearing), and
“polygonal.”
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30. Describing Skin Findings…
• Color: start with tan, light brown, and dark brown if you
are having trouble
• Texture: Palpate if it is smooth, fleshy, verrucous or
warty, or scaly (fine, keratotic, or greasy scale)
• Location: Be as specific as possible. For single lesions,
measure their distance from other landmarks (e.g., 1 cm
lateral to left oral commissure)
• Configuration: Although not always necessary,
describing patterns is often very helpful. (grouped,
annular, linear)
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31. Describing Primary Skin Lesions…
12/9/2022 Henok L. 31
Multiple 3–8-mm erythematous confluent
round macules on arms; [morbilliform drug
Eruption]

32. Describing Primary Skin Lesions…
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Solitary dark brown, blue-gray, and red 7-mm macule
with irregular borders and fingerlike projections of
pigment,on right forearm; [malignant melanoma]

33. Describing Primary Skin Lesions…
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Large confluent completely depigmented patches on
dorsal hands and distal forearms; [vitiligo]

34. Describing Primary Skin Lesions…
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Multiple 2–4-mm soft, fleshy skin-colored to light brown
papules on lateral neckin skin folds; [skin
tags/acrochordon]

35. Describing Primary Skin Lesions…
12/9/2022 Henok L. 35
Scattered erythematous to bright pink well-circumscribed
flat-topped plaques on extensor knees, with overlying
silvery scale; [plaque psoriasis]

36. Describing Primary Skin Lesions…
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Multiple round coin-like eczematous plaques on arms,
with overlying dried transudate crust; [nummular
Dermatitis]

37. Describing Primary Skin Lesions…
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Multiple 2–4-mm vesicles and pustules on erythematous
base, grouped together on left neck; [herpes simplex virus]

38. Describing Primary Skin Lesions…
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Several tense bullae on lower legs; [insect bites]

39. Describing Primary Skin Lesions…
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∼30 2–5-mm erythematous papules and pustules on frontal,
temporal, and parietal scalp; [bacterial folliculitis]

40. Describing Primary Skin Lesions…
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Many variably sized (1–10-cm) whealson lateral neck,
shoulder; [urticaria]

41. Vascular Lesions
• Spider Angioma:
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Color and Size Fiery red; from very small to
2 cm
Shape Central body, sometimes raised,
surrounded by erythema and radiating legs
Pulsatility and
Effect
of Pressure
Often seen in center of the spider when
pressure with a glass slide is applied;
pressure on the body causes blanching of
the spider
Significance Single spider angiomas are normal and are
common on the face and chest; also seen
in pregnancy and liver disease

42. ( Vascular Lesions)
Spider angioma: Bright red with radiating legs
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43. Vascular Lesions…
• Spider Vein:
12/9/2022 Henok L. 43
Color and Size Bluish; size variable, from very small to
several inches
Shape Variable; may resemble a spider or be linear,
irregular
Pulsatility and
Effect of
Pressure
Absent; pressure over the center does not
cause blanching, but diffuse pressure
blanches the veins
Significance Often accompanies increased pressure in the
superficial veins, as in varicose veins

44. Vascular Lesions…
• Spider Vein…
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45. Vascular Lesions…
• Cherry Angioma:
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Color and Size Bright or ruby red; may become purplish
with age; 1–3 mm
Shape Round, flat, or sometimes raised; may be
surrounded by a pale halo
Pulsatility and
Effect of
Pressure
Absent; may show partial blanching,
especially if pressure applied with edge of a
pinpoint
Significance None; increases in size and numbers with
aging

46. ( Vascular Lesions)
Cherry angioma: Ruby red: flat or raised
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47. Vascular Lesions…
• Petechia/Purpura:
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Color and Size Deep red or reddish purple, fading away
over time; petechia, 1–3 mm; purpura are
larger
Shape Rounded, sometimes irregular; flat
Pulsatility and
Effect of
Pressure
Absent; no effect from pressure
Significance Blood outside the vessels; may suggest a
bleeding disorder or, if petechiae, emboli to
skin; palpable purpura in vasculitis

48. ( Vascular Lesions)
Petechiae/Purpura: Round red or purple macules.
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49. Vascular Lesions…
• Ecchymosis:
12/9/2022 Henok L. 49
Color and Size Purple or purplish blue, fading to green,
yellow, and brown with time; variable size,
larger than petechiae, >3 mm
Shape Rounded, oval, or irregular; may have a central
subcutaneous flat nodule (a hematoma)
Pulsatility and
Effect
of Pressure
Absent; no effect from pressure
Significance Blood outside the vessels; often secondary to
bruising or trauma; also seen in bleeding
disorders

50. ( Vascular Lesions)
Ecchymosis: Round or irregular macular lesion; larger than
Petechiae
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51. Assessment of the Integumentary system…
 Hair
Inspection & palpation
• Inspect distribution, thickness, lubrication, color & palpate
for texture
– Body hair is usually very fine, pubic & axillary hair is coarse
• The male pubic hair resembles a diamond, the female pubic
hair patter is like an inverted triangle
– Graying of hair: albinos, sign of aging, dyes
– Oiliness of hair: puberty, hyperfunction of sebaceous
glands
– Febrile illness or scalp disease sometimes result in hair
loss
• In addition inspect for infestation of scalp
51
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52. Assessment of the Integumentary system…
 Hair…
Inspection & palpation…
• Dry brittle hair: hypothyroidism/excessive use of hair dyes
• Shiny of hair in AIDS
• A total absence of body hair: hypopitutarism, poor nutrition,
serious illness, chemotherapy, radiotherapy
52
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53. Assessment of the Integumentary system…
 Nails
Inspection & palpation
 The condition of the nails reflects general health, state of nutrition,
a persons occupation, & level of self care.
• Inspect the nail beds color, the thickness & shape of the nail
• The normal color of the nail is a pinkish white
– With aging, trauma or decreased circulation the nails will
become thicker than normal.
• Shape of nail:
 Normal: round nail with 160 degree nail base
Deviation from normal:
– Clubbing:180 degree or more nail base
• Palpate for texture & check capillary refill
53
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54. Assessment of the Integumentary system…
 Nails…
Abnormal
• The nails grow more slowly & become thick & yellow
when lymphatic circulation is obstructed
• Spoon nails: iron deficiency anemia
• Pitting of the nails: psoriasis, fungal disease of the nails
• Brittle, frayed nails: malnutrition, thyrotoxicosis, iron &
calcium deficiency, & with X-ray irradiation.
• Pallor is associated with anemia, shock, anxiety fear,
syncope
• Cyanosis & clubbing is due to chronic hypo-perfusion
(COPD, CHF), & also spongy up on palpation
54
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55. Nails…
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56. END
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