Assessment and diagnostic evaluation of integumentary system

Assessment and diagnostic evaluation of integumentary systemNiteshKumawatrakcon

IntroductionSkin is the largest organ system of the body. It forms a barrier between the internal organ and the external environment and participates in many vital functions.Because skin disorders are readily visible, dermatologic complaints are commonly the primary reason that a patient seeks health care.

ANTOMY AND PHYSIOLOGY OVERVIEW:-Skin composed of three layer-Epidermis Dermis Sub cutaneous layerGlands in skins are-Sweat gland Sebaceous glandAppendages of skin are-Hairs and nails

Contd.Function of skin are-Protection from micro organismAct as a physical barrierFluid balanceRegulation of body temperatureVitamin productionImmune response

ASSESSMENTHealth historyWhen caring for the patient with dermatological disorders, the nurse obtains important information through the health history and direct observation.During the health history interview, the nurse ask about-Any family history of skin disorderAny family or personal history of skin allergies.Allergic reaction to food, medications, and chemicals.Previous skin problems and skin cancer.The names of cosmetics, soaps, shampoos and other personal hygiene products.The health history contains specific information about the onset, signs, and symptoms , location, and duration of any pain itching, rash, or other discomfort.

Nurse may ask several questions to patients for obtain history, they are:- When did you first note this skin problem?Has it occurred previously?Are there any other symptoms?What site was affected first?What did the rash or lesion look like when it first appeared?Where and how fast did it spread?Do you have any itching , burning, tingling sensation?Is there any loss of sensation?Is the problem worse in any particular time or seasons?Do you have any history of hay fever fever, asthma, eczema or allergies?

BACK

CondWho in your family has skin problem or rashes?Did the eruption appear after certain food were eaten? Which food?What medication are you taking?What topical medication have you put on the lesion?What skin products or cosmetics do you use?What is your occupation?Does anything touching your skin cause a rash?How has this affected you (or your life)?

Physical assessmentAssessment DescriptionExpected causes General appearance by observation of color, temperature, moisture, dryness, skin texture, lesions, vascularity, mobility and the condition of the nails.Skin turgor, possible edema and elasticity are assessed by palpation.

ErythemaRedness of the skin,In light skinned people easily observed. Caused by congestion of capillaries.Inflammation is determined by palpation for increased warmth.PolycythemiaCarbon monoxide-poisoningVenous stasis

Increase smoothnessEdema HardnessIntracellular infiltrationRash Due to pruritus or itching, the patient is asked to indicate what areas of the body is involved.Pointing penlight laterally across the skin may highlight the rashes.Patient mouth and ears also examined.Skin infection, Dermatitis, eczema, scabies.

Rubeola or measels

Cyanosis Bluish discoloration of the skin result from a lack of oxygen in the blood.Other indication of cyanosis are cold clammy skin, a rapid thready pulse and rapid shallow respiration.Shock or with respiratory or circulatory compromise.Expose to cold, AnxityColor changesHypopigmentationLight skin then normalFungal infection, eczema and vitiligo

Cyanosis

Hyperpigm-entation Pallor

Dark yellow colorAbnormal dark skin

Yellow sclera, hard palate and mucous membrane and whole skinSun injury, or result of ageing.

Anemia, shock, local arterial insufficiency, albinism and vitiligo

Jaundice

Yellow-Orange tinge in forehead, palm and sole and nasolabial folds, but no yellow color of sclera mucous membraneOrange-Green or gray overlying pallor may also have ecchymoses and purpuraVitamin A poisoning, carotenemia

Uremia Ecchymoses and PurpuraBleeding in to skinPlatelet disorders, vessel fragility

UrticariaScales WhealsPlaques with hardness (on front of knee)Infection, allergic reaction PsoriasisPlaques and nodules Cutaneous lesions: blue red or dark brown plaques and nodulesKaposis sarcomaUlcerated lesionPainless chancre Syphilis

Urticaria

Kaposis sarcoma

VascularityVascular change include location, distribution, color, size, and the presence of pulsation.Petechiae, Ecchymoses, Purpura, angiomasHydration Dehydration

Over-hydration Lack of body water volume and dry skin

Increase in body water volume and smooth skinHemorrhage, vomiting, diarrhea and loss of body water.

Inappropriate use of I.V. infusion.

Temperature Hypothermia

Hyperthermia Decrease body Temperature

Increase body temperatureExposure to cold, brain injury, hypervolemiaInfection, metabolic disorderSKIN LESIONSPrimary skin lesionSkin lesions are the most prominent characteristics of dermatologic conditions. They vary in size, shape, and cause and are classified according to their appearance and origin.They may be primary or secondary.they are original lesion arising from previously normal skin.

MACULE, PATCHFlat, nonpalpable skin color change (color may be brown, white, purple, red)Macule : < 1 cm, circumscribed borderPatch : > 1 cm, may have irregular borderFlat moles, petechia, rubella, vertigo, port wine stains

PAPULE, PLAQUEElevated palpable, solid mass with circumscribed borderPlaque may be coalesced papules with flat topPapule ; < 0.5 cm

Plaques ;> 0.5 cmwarts and lichen planus

psoriasis, actinic keratosis

MACULE, PATCH

NODULE, TUMORElevated, palpable, solid mass that extends deeper in to the dermis.Nodule;0.5-2 cm circumscribedTumor: >1-2 cm not always have sharp borderlipoma, squamous cell carcinoma, poorly absorbed injection

carcinomaVESICLE, BULLACircumscribed, elevated, palpable mass containing serous fluidVesicle:< 0.5 cm

Bulla : > 0.5 cmherpes simplex, chickenpox, poison, second degree burnpemphigus, contact dermatitis, large burn blisters

VESICLE back

BULLA back

WHEALElevated mass with transient borders, often irregular, size and color vary, caused by movement of serous fluid into the dermisurticarial, insect bitesPASTULE

CYSTPus-filled vesicles or bulla

Encapsulated fluid filled or semisolid mass in the subcutaneous tissue or dermisAcne, impetigo

Sebaceous cyst

PASTULE

Secondarylesion

EROSION

ULCER

FISSUREThey result from changes in primary lesionLoss of superficial epidermis, does not extend to dermis, depressed, moist areaskin loss extending past epidermisnecrotic tissue lossbleeding and scarring possible linear crack in the skinmay extend to dermisRuptured vesiclesScratched marks

Pressure ulcer

Athletes foot

SCALES

CRUST

SCAR desquamated dead epitheliumcolor varies (silvery , white)texture varies (thick, fine)dried residue of sebum, blood, or pus on the skin surfacelarge, adherent crust is scabskin mark left after healing of a wound represent replacement by connective tissueyoung scar is red or purplemature scar is white Dandruff, psoriasis, dry skin

Rupture of vesicles: impetigo, herpes, eczemaHealed wound or surgical incision

KELOID

ATROPHY hypertrophied scar tissueelevated irregular redthin, dry, transparent appearance of epidermisloss of surface markingsecondary to loss of collagen and elastin underlying vessels may be visible.Keloid of ear

Aged skin, arterial insufficiency

Keloid of ear

ASSESSMENT OF NAILSAssessmentDescriptionExpected causes Beaus lines

Spoon nailTransvers depressionSpoon shaped nailsSevere illnessLocal trauma

Beaus lines

Spoon nail

Paronychia

Pitting

Clubbing of nailInflammation of the skin around nailSmall depressions in the nailStraightening of normal angle (180 degree or greater) and softening of the nail base.Infection and tauma

Compromised blood circulation for nails.

Paronychia

Clubbing of nail

ASSESSMENT OF HAIRNatural hair color range from black to white. Hair assessment is carried by inspection and palpation.Gloves are worn by the examiner and examiner room should well lighted. Spreading the hair so that the condition of the skin underneath can be easily seen, the end of a cotton swab can be used to make small parts in the hair so that the scalp can be inspected.Any abnormal lesions, evidence of itching, inflammation, scaling or signs of the infestation are documented.

Contd..Texture of scalp hair range from fine to coarse, silky to brittle, oily to dry, and shiny to dull.Hair can be straight, or curly. Dry, brittle hair may result from overuse of hair dyes , hair dryer, and curling irons or from endocrine gland disorders.Male pattern hair distribution may be seen in some women at the time of menopause, when the hormone estrogen is no longer produced by the ovaries

In women with hirsutism, excessive hair may grow on the face, chest, shoulders and pubic area. When menopause is ruled out as the underlying cause, hormonal abnormalities related to pituitary or adrenal dysfunction must be investigated.Some condition may subjects the patient to a protracted illness, leading to feeling of depression, frustration, self consciousness, poor self-image and rejection. Itching and skin, which are feature of many skin diseases may be constant annoyance.

This discomfort may result in loss of sleep, anxiety and depression, all of which reinforce the general distress and fatigue that frequently accompany skin disorders.

ANTOMICAL DISTRIBUTION OF COMMON DISORDERContact dermatitis :- mainly at shoes, face (cosmetics, perfumes, earings)Seborrheic dermatitis :- frontal area, around lips, chest, around umbilicus, pubic area, scalp, back

DIAGNOSTIC EVALUATIONSkin biopsy ImmunofluorescencePatch testingSkin scarpingTzanck smearWoods light examinationClinical photographs

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