Assessing Clients with Skin Disorders

1. Assessing Clients with Skin Disorders Chapter 44

2. Integumentary System • Functions • 1. Protects body from injury • 2. Provides a barrier to loss of fluids • 3. Sensory - touch, pressure,pain, and temperature • 4. Regulates body temperature via sweat glands • 5. Production of vitamin D

3. Skin • 2 Layers • Epidermis • outer layer, protection, stores melanin • epithelial cells • Dermis • inner layer, temperature regulation • connective tissue, contains hair follicle, sweat glands and sebaceous glands

4. Layers of the Skin

5. Skin Color • 1. Erythema • reddening of the skin • fever, inflammation, sunburn, drug reaction • 2. Cyanosis • bluish discoloration • poor oxygenation of hemoglobin

6. Skin Color • 3. Pallor • paleness of skin • shock, fear, anemia or hypoxia • 4. Jaundice • yellow-to-orange skin color • hepatic disorders

7. 3 Types • Sebaceous - Oil • to soften and lubricate the skin • Sudoriferous - Sweat • to regulate body temperature by excretion of sweat • Ceruminous - located in external ear canal • secrete cerumen, sticky trap for foreign materials

8. The Hair and Nails • Protective Function • Hair • cushions the scalp • eyelashes and eyebrows protect the eyes • provides insulation in cold weather • Nails • protects fingers, toes, aid grasping

9. The Health Assessment Interview • Determine problems with the integumentary system • “Describe any skin problems or injuries, nail problems or scalp problems you have had.” • “Is your skin and/or scalp dry or oily?” • “Do you have any skin pain, burning or itching?”

10. The Physical Assessment • Can be part of head-to-toe or focused assessment • Assessment through inspection and palpation • Assess for • color, lesions, temperature,texture, moisture, turgor and edema

11. Assessments?

12. The Physical Assessment • Inspect color • pallor • cyanosis • jaundice • Inspect for lesions • irregular skin, rash, hives, psoriasis - scaly red patches

13. The Physical Assessment • Palpate the skin for temperature • warm with fever • cool in shock or decreased blood flow • Palpate skin for texture • smooth or coarse • Palpate skin for moisture • dry, moist, diaphoretic - M.I., shock

14. The Physical Assessment • Palpate for Turgor • pinching skin over collar bone or back of hand • decreased in dehydration tenting • increased in edema • Assess for edema • accumulation of fluid in body tissues • depress skin over ankle

15. The Physical Assessment • Rate the Edema • 1+ = slight pitting • 2+ = deeper pit • 3+ = obvious pit, extremities are swollen • 4+ = the pit remains • Edema occurs in cardiovascular disease, renal failure and cirrhosis of liver

17. Lymph Edema

18. The Physical Assessment • Hair • inspect distribution and quality • palpate for texture • inspect the scalp for lesions • Nails • inspect for curvature, color and thickness

20. Variations in the Older Adult • Loss of subcutaneous tissue • wrinkles, sagging, decreased turgor • Skin tags • small flaps of excess skin • Decreased hair and nail growth • “Liver spots” • small flat brown macules

21. Primary Skin Lesions • Macule • flat color change in the skin - freckle • Papule • elevated palpable mass with circumscribed boarder - elevated mole • Nodule • elevated, solid mass extending deeper - lipoma

22. Primary Skin Lesions • Vesicle • fluid filled with thin translucent walls - blister • Wheal • larger than vesicle - insect bite, hives • Pustule • pus filled vesicle - acne • Cyst • elevated, encapsulated mass - sebaceous cyst

23. Skin Lesions

24. Secondary Skin Lesions • Atrophy • translucent, dry, paperlike skin resulting from thinning or wasting away due to loss of elastin • Ulcer • deep crater-like, irregular shaped area of skin loss extending into the dermis • Fissure • cracks with sharp edges - corner of mouth, feet

25. Vascular Skin Lesions • Port-wine stain • lg. Flat mass of blood vessels on skin surface • Strawberry mark • bright red, raised cluster of immature capillaries • Petechiae • flat, red-purple “freckles” caused by tiny hemorrhages

26. Vascular Skin Lesions • Ecchymosis • bruising - release of blood into surrounding tissues • trauma, hemophilia, liver disease • Hematoma • similar to ecchymosis but is raised, swollen

27. Documenting general appearance

28. What terms describe this skin?

29. Lymphaedema

30. What would you document?

32. Skin our protector for life!

33. NCLEX • The nurse assessing a dark skinned client for cyanosis knows that in which of the following would cyanosis be more visible in a dark skinned individual? • A. Sclera • B. MM and nail beds • C. Generalized skin color • D. Palms of the hands and feet

34. NCLEX • A nurse assessing an elderly thin client notes the skin turgor over the client’s clavicle is decreased. The nurse interpretes this finding as which of the following? • A. Client is dehydrated • B. Client has edema • C. This is a normal finding for this client • D. The client has experienced a recent weight loss.

35. NCLEX • When performing a screening and assessment on a 44 year old female, the nurse notes a patch of hair loss. • The nurse suspects which of the following? • A. Dandruff • B. Alopecia • C. Scalp ringworm (tinea capitis) • D. head lice

36. NCLEX • When inspecting a client’s nails the nurse notes that the angle of the nail base is greater than 180 degrees. What is this condition called? • A. Alopecia • B. edema • C. tenting • D. clubbing

37. NCLEX • When working with an older person, you would keep in mind that the older adult is most likely to experience which of the following changes with aging? • A. thinning of the epidermis • B. thickening of the epidermis • C. oiliness of the skin • D. Increased elasticity of the skin

38. NCLEX • Which of the following glands plays a role in killing bacteria? • A. sebaceous (oil) glands • B. Eccrine sweat glands • C. Apocrine sweat glands • D. Ceruminous glands