2 integumentary system

THE SKIN

Maria Carmela L. Domocmat, RN, MSN

STEP 1


STEP 2

Confirm that the
skin is clean
and free from
body odor.


STEP 3

Cyanosis Carotenemia

Jaundice


Inspecting the
palms is an
opportunity to
assess overall
coloration.


STEP 4

Inspect the skin for even
pigmentation over the body.


Freckles Versicolor

Nevus

Vitiligo Vitiligo


STEP 5

Determine
the Client’s
skin
temperature


STEP 6

Assess the amount
of moisture
on the skin
surface and
texture.

STEP 7

Palpate to assess thickness

STEP 8

Palpating to assess skin elasticity
and mobility.

Assessing skin turgor

Testing for skin tenting

Tenting


STEP 9

Palpate Edema of the
hand
to
detect Pitting Edema

edema


STEP 10
Spider Angioma

Inspect the
skin for
superficial Venous
Star

arteries and Spider Vein

veins


STEP 11
Inspect and palpate the skin for
lesion.
Referral

Suspect physical abuse. Be especially
If you notice drainage
sensitive if client is fearful and has a history from any lesion, put
of previous injuries. Obtain medical assistance on gloves before
proceeding with the
and follow your states’ legal requirements to assessment.
notify the police or local protective agency.


STEP 12

Palpate the skin for sensitivity


Evaluating Skin Lesions
A – (assymetrical)
B – (borders)
C – (color)
D – ( diameter)
E – (elevation)

PRIMARY LESIONS
MACULE, PATCH

Freckles
Nevus

Vitiligo

Petechiae

Chloasma
Ecchymosis Mongolian
spot

Rubella Purpura


Papule, Plaque

Lichen Planus

Eczema
Warts


Psoriasis


Nodule, tumor

Tumor

(café-au-lait spot)
Nodule Patch

A combination typical of neurofibromatosis

Vesicle, Bulla

Atopic
Dermatitis

Vesicle


Erythema multiforme

Bulla

Chicken Pox

Pemphigus

Wheal

Wheal in a drug
eruption in an
infant
Urticaria


Pustule

Pustular psoriasis

Furuncle

Impetigo


Acne


Cyst


Secondary Skin Lesions

Lichenification

Atrophy

Striae

Aged Skin


Ulcer

Ulcer from
Venous
Stasis


Erosion

Apthous Ulcer


Fissure

Fissured Tongue Athlete’s Foot


Crust

Ruptured
vesicles
of herpes
simplex


Keloid

Keloid of
ear piercing


Cancerous Skin Lesions
Nodule

Tumor

Telengiectasia
Ulcer


Cancerous Skin Lesions
Nodule

Tumor Uler

Telengiectasia


Kaposi’s
Sarcoma


Malignant Superficial Spreading
Melanoma

Nodular

Serious Type of
Skin Cancer


Common Skin Variations
in Older Clients

Cutaneous Tags


Cherry Angiomas

Cutaneous Horn

Senile Lentigines


Hair Assessment


Inspect the
scalp and
hair
STEP 1
Confirm that the scalp and hair are clean.
Examine strands of hair that are loose or undone.
Part and divide the hair at 1-inch intervals and
observe.


STEP 2 STEP 3
Observe the client’s Assess the texture
hair color of the hair
Varies according to Roll a few strands of hair
the level of melanin between your thumb and
production forefinger.
Graying is Hold a few strands of hair
influenced by taut with one hand while you
genetics slide the thumb and forefinger
Graying in patches of your other hand along the
may indicate a length of the strand.
nutritional deficiency.


STEP 4 Male Pattern Balding

> Observe the
amount and
distribution of
the hair
throughout the
scalp – varies with
age, sex, and overall
health.


STEP 5

Inspect the Regions of infection will
fluoresce when exposed
scalp for to the ultraviolet light
of a Wood’s lamp.
lesions.

Dim the room light and shine a Wood’s lamp on the
client’s scalp as you part the hair.


Palpation of Hair
1. Palpate the hair between your
fingertips.
2. Note the condition of the hair
form the scalp to the end the
hair.


Abnormalities of
Hair and Scalp

Pediculosis
Capitis
(head lice)


Hirsutism -excess body hair in females, following
the male pattern. Typically due to
endocrine or metabolic dysfunction, or
idiopathic.

Side-effect of
Cyclosporin


Alopecia Areata


Constant feature of
Kwashiorkor
but may also be seen in
Marasmus.

Dry hair; lacks normal lustre


The ‘flag-sign’ or signa de
bandera

-alternating darker and lighter
bands when held up.

Trichotillomania


Tinea Capitis

Seborrheic Dermatitis


Lanugo hair

Symptoms of Scurvy
-hairs on most parts of the body
become corksrew-shaped


Sparse and brittle hair Menke’s kinky hair
in this sex-linked syndrome
disorder
caused by a defect in
intestinal copper
absorption


Assessing
the
Nails


STEP 1

Inspect nail grooming and cleanliness

STEP 2

Inspect nail color and markings.


STEP 3

Assess capillary refill


STEP 4

Inspect and
palpate the
nails for
shape and
Schamroth
Technique
contour.


Curvature of the normal nail

Clubbing of the nail

Spoon nail


STEP 5
Palpate the nails to determine
thickness, regularity, and
attachment to the nail bed.
STEP 6
Inspect and palpate the cuticles.


Common Nail Disorders

Clubbing of the finger

In clubbing, the distal phalanx of each finger is rounded
and bulbous. The nail plate is more convex, and the
angle between the plate and the proximal nail fold
increases to 180º or more. The proximal nail fold, when
palpated, feels spongy or floating. Causes are many,
including chronic hypoxia and lung cancer.


Paronychia


ONYCHOLYSIS

With Hyperkeratosis


Beau’s Lines

Are transverse depressions in the nails associated
with acute severe illness. The lines emerge from under
the proximal nail folds weeks later and grow gradually
out with the nails.


Terry’s
Nails
Mostly whitish with a distal band of reddish brown
Lunulae may not be visible
Seen with aging and people with chronic diseases
* Liver Cirrhosis
* Congestive Heart Failure
* Non-Insulin-Dependent Diabetes


Transverse White Lines
(Mees’’Lines) Curves are similar to those of the
lunula, not the cuticle, and may follow
an acute or severe illness.


Onycho- Psoriasis Subungal Hematoma
cryptosis

Eggshell Nail
Onychomycosis
Longitudinal
Melanonychia


Onychauxis Leukonychia Onychatrophia

Onychophagy Onychorrhexis Pteryigium


Palpation of the Hair
Texture
Inspection of the Nails
Color
Shape and Configuration
Palpation of the Nails
Texture


2 integumentary system

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